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The impact of short prehospital times on trauma center performance benchmarking

An ecologic study

Byrne, James P. MD; Mann, N. Clay PhD, MS; Hoeft, Christopher J. MA; Buick, Jason MSc; Karanicolas, Paul MD, PhD; Rizoli, Sandro MD, PhD; Hunt, John P. MD, MPH; Nathens, Avery B. MD, PhD

Journal of Trauma and Acute Care Surgery: April 2016 - Volume 80 - Issue 4 - p 586–596
doi: 10.1097/TA.0000000000000974
AAST 2015 Plenary Papers

BACKGROUND Emergency medical service (EMS) prehospital times vary between regions, yet the impact of local prehospital times on trauma center (TC) performance is unknown. To inform external benchmarking efforts, we explored the impact of EMS prehospital times on the risk-adjusted rate of emergency department (ED) death and overall hospital mortality at urban TCs across the United States.

METHODS We used a novel ecologic study design, linking EMS data from the National EMS Information System to TCs participating in the American College of Surgeons' Trauma Quality Improvement Program (TQIP) by destination zip code. This approach provided EMS times for populations of injured patients transported to TQIP centers. We defined the exposure of interest as the 90th percentile total prehospital time (PHT) for each TC. TCs were then stratified by PHT quartile. Analyses were limited to adult patients with severe blunt or penetrating trauma, transported directly by land to urban TQIP centers. Random-intercept multilevel modeling was used to evaluate the risk-adjusted relationship between PHT quartile and the outcomes of ED death and overall hospital mortality.

RESULTS During the study period, 119,740 patients met inclusion criteria at 113 TCs. ED death occurred in 1% of patients, and overall mortality was 7.2%. Across all centers, the median PHT was 61 minutes (interquartile range, 53–71 minutes). After risk adjustment, TCs in regions with the shortest quartile of PHTs (<53 minutes) had significantly greater odds of ED death compared with those with the longest PHTs (odds ratio, 2.00; 95% confidence interval, 1.43–2.78). However, there was no association between PHT and overall TC mortality.

CONCLUSION At urban TCs, local EMS prehospital times are a significant predictor of ED death. However, no relationship exists between prehospital time and overall TC risk-adjusted mortality. Therefore, there is no evidence for the inclusion of EMS prehospital time in external benchmarking analyses.

From the Sunnybrook Research Institute (J.P.B., P.K., A.B.N.), and Department of Surgery (P.K., A.B.N.), Sunnybrook Health Sciences Center; Clinical Epidemiology Program (J.P.B., P.K., A.B.N.), Institute of Health Policy, Management and Evaluation, Division of General Surgery (J.P.B., P.K., S.R., A.B.N.), Rescu (J.B.), Li Ka Shing Knowledge Institute, and Department of Surgery (S.R.), St. Michael's Hospital, and Institute of Medical Science (S.R.), University of Toronto; and Sunnybrook Centre for Prehospital Medicine (J.B.), Toronto, Ontario, Canada; and National Emergency Medical Service Information System Technical Assistance Center (N.C.M.); and Department of Pediatrics (N.C.M.), University of Utah School of Medicine, Salt Lake City, Utah; Trauma Quality Improvement Program (C.J.H., A.B.N.), American College of Surgeons, Chicago, Illinois; and Department of Surgery (J.P.H.), Louisiana State University Health Sciences Center, Baton Rouge, Louisiana.

Submitted: September 3, 2015, Revised: January 3, 2016, Accepted: January 5, 2016, Published online: January 21, 2016.

This work was presented at the 74th annual meeting of the American Association for the Surgery of Trauma, September 9–12, 2015, in Las Vegas, Nevada.

Address for reprints: James P. Byrne, MD, Sunnybrook Research Institute, Sunnybrook Health Sciences Center, 2075 Bayview Ave, Room D-574, Toronto, Ontario, Canada, M4N 3M5; email:

© 2016 Lippincott Williams & Wilkins, Inc.