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Identifying patients with time-sensitive injuries

Association of mortality with increasing prehospital time

Chen, Xilin MPH; Guyette, Francis X. MD, MPH; Peitzman, Andrew B. MD; Billiar, Timothy R. MD; Sperry, Jason L. MD, MPH; Brown, Joshua B. MD, MSc

Journal of Trauma and Acute Care Surgery: June 2019 - Volume 86 - Issue 6 - p 1015–1022
doi: 10.1097/TA.0000000000002251

BACKGROUND Trauma is a time-sensitive disease. However, recognizing which patients have time-critical injuries in the field is challenging. Many studies failed to identify an association between increasing prehospital time (PHT) and mortality due to evaluation of heterogenous trauma patients, as well as inherent survival bias from missed deaths in patients with long PHT. Our objective was to determine if a subset of existing trauma triage criteria can identify patients in whom mortality is associated with PHT.

METHODS Trauma patients 16 years or older transported from the scene in the National Trauma Databank 2007 to 2015 were included. Cubic spline analysis used to identify an inflection where mortality increases to identify a marginal population in which PHT is more likely associated with mortality and exclude biased patients with long PHT. Logistic regression determined the association between mortality and PHT, adjusting for demographics, transport mode, vital signs, operative interventions, and complications. Interaction terms between existing trauma triage criteria and PHT were tested, with model stratification across triage criteria with a significant interaction to determine which criteria identify patients that have increased risk of mortality associated with increasing PHT.

RESULTS Mortality risk increased in patients with total PHT of 30 minutes or less, comprising a study population of 517,863 patients. Median total PHT was 26 minutes (interquartile range, 22–28 minutes) with median Injury Severity Score of 9 (interquartile range, 4–14) and 7.4% mortality. Overall, PHT was not associated with mortality (adjusted odd ratio [AOR], 0.984 per 5-minute increase; 95% confidence interval [CI], 0.960–1.009; p = 0.20). Interaction analysis demonstrated increased mortality associated with increasing PHT for patients with systolic blood pressure less than 90 mm Hg (AOR, 1.039; 95% CI, 1.003–1.078, p = 0.04), Glasgow Coma Scale score of 8 or less (AOR, 1.047; 95% CI, 1.018–1.076; p < 0.01), or nonextremity firearm injury (AOR, 1.049; 95% CI, 1.010–1.089; p < 0.01).

CONCLUSION Patients with prehospital hypotension, Glasgow Coma Scale score of 8 or less, and nonextremity firearm injury have higher mortality with increasing PHT. These patients may have time-sensitive injuries and benefit from rapid transport to definitive care.

LEVEL OF EVIDENCE Prognostic/Epidemiologic III; Therapeutic/Care Management IV.

From the Division of General Surgery and Trauma, Department of Surgery (X.C., A.B.P., T.R.B., J.L.S., J.B.B.B), and Department of Emergency Medicine (F.X.G.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Submitted: November 21, 2018, Revised: February 13, 2019, Accepted: February 22, 2019, Published online: March 11, 2019.

These data were presented as a poster presentation at the 77th Annual Meeting of the American Association for the Surgery of Trauma, September 26-29th, 2018 in San Diego, CA.

Address for reprints: Joshua B. Brown, MD, MSc, Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213; email:

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© 2019 Lippincott Williams & Wilkins, Inc.