EMERGENCY MEDICAL SERVICES/ORIGINAL RESEARCH

Emergency Medical Services Out-of-Hospital Scene and

Transport Times and Their Association With Mortality in
Trauma Patients Presenting to an Urban Level I Trauma Center
C. Eric McCoy, MD, MPH; Michael Menchine, MD, MPH; Sehra Sampson, MD; Craig Anderson, PhD;
Christopher Kahn, MD, MPH

Study objective: We determine the association between emergency medical services (EMS) out-of-hospital times
and mortality in trauma patients presenting to an urban Level I trauma center.
Methods: We conducted a secondary analysis of a prospective cohort registry of trauma patients presenting to a
Level I trauma center during a 14-year period (1996 to 2009). Inclusion criteria were patients sustaining traumatic
injury who presented to an urban Level I trauma center. Exclusion criteria were extrication, missing or erroneous out-
of-hospital times, and intervals exceeding 5 hours. The primary outcome was inhospital mortality. EMS out-of-hospital
intervals (scene time and transport time) were evaluated with multivariate logistic regression.
Results: There were 19,167 trauma patients available for analysis, with 865 (4.5%) deaths; 16,170 (84%)
injuries were blunt, with 596 (3.7%) deaths, and 2,997 (16%) were penetrating, with 269 (9%) deaths. Mean
age and sex for blunt and penetrating trauma were 34.5 years (68% men) and 28.1 years (90% men),
respectively. Of those with Injury Severity Score less than or equal to 15, 0.4% died, and 26.1% of those with a
score greater than 15 died. We analyzed the relationship of scene time and transport time with mortality among
patients with Injury Severity Score greater than 15, controlling for age, sex, Injury Severity Score, and Revised
Trauma Score. On multivariate regression of patients with penetrating trauma, we observed that a scene time
greater than 20 minutes was associated with higher odds of mortality than scene time less than 10 minutes
(odds ratio [OR] 2.90; 95% confidence interval [CI] 1.09 to 7.74). Scene time of 10 to 19 minutes was not
significantly associated with mortality (OR 1.19; 95% CI 0.66 to 2.16). Longer transport times were likewise not
associated with increased odds of mortality in penetrating trauma cases; OR for transport time greater than or
equal to 20 minutes was 0.40 (95% CI 0.14 to 1.19), and OR for transport time 10 to 19 minutes was 0.64
(95% CI 0.35 to 1.15). For patients with blunt trauma, we did not observe any association between scene or
transport times and increased odds of mortality.
Conclusion: In this analysis of patients presenting to an urban Level I trauma center during a 14-year period, we
observed increased odds of mortality among patients with penetrating trauma if scene time was greater than 20
minutes. We did not observe associations between increased odds of mortality and out-of-hospital times in blunt
trauma victims. These findings should be validated in an external data set. [Ann Emerg Med. 2013;61:167-174.]

Please see page 168 for the Editor’s Capsule Summary of this article.

A feedback survey is available with each research article published on the Web at www.annemergmed.com.
A podcast for this article is available at www.annemergmed.com.
0196-0644/$-see front matter
Copyright © 2012 by the American College of Emergency Physicians.
http://dx.doi.org/10.1016/j.annemergmed.2012.08.026

INTRODUCTION been recommended that the least amount of time required in

Debate continues over the “load and go” versus “stay and the out-of-hospital setting be spent, allowing only for
stabilize” approach to patient care in the out-of-hospital setting performance of essential procedures.1-3
because there is a paucity of supportive data for either Multiple elements compose an EMS system, each with
argument. The critical factor at the center of this debate is inherent qualities that may be reviewed, analyzed, and improved
emergency medical services (EMS) out-of-hospital time on if deficient.4 One component currently in debate and
(response time, scene time, and transport time) and its commonly scrutinized by administrators, elected officials, and
association with patient outcome, namely, morbidity and the public, and one potentially affecting patient care, is the
mortality. Although the optimal out-of-hospital intervals for association between out-of-hospital time and mortality in
EMS personnel have not been defined for major trauma, it has patients presenting to a trauma center.

Volume , .  : February  Annals of Emergency Medicine 167

Emergency Medical Services Scene and Transport Times McCoy et al

Editor’s Capsule Summary Study Setting and Selection of Participants

This study was conducted in Orange County, CA, which is
What is already known on this topic composed of 34 cities within approximately 800 square miles
Uncertainty remains about the relationship between and is bordered by Los Angeles County to the northwest, San
emergency medical services (EMS) on-scene Bernardino County to the northeast, Riverside County to the
intervals and trauma patient outcomes. east, San Diego County to the southeast, and the Pacific Ocean
to the west-southwest. This metropolitan county has an
What question this study addressed approximate population of 3,036,712 million and is composed
What were the associations between EMS on-scene of 8.35% of the state of California’s resident population and
and transport time intervals and inhospital mortality more than 1% of the US resident population because fully 1 in
among 19,167 trauma center patients? 100 US residents resides in Orange County.8
Data were prospectively collected as part of the trauma
What this study adds to our knowledge registry at a university teaching hospital, which is the only Level
When on-scene intervals exceeded 20 minutes, there I trauma center servicing the entire county, receiving more than
were increased odds of mortality for patients with half of the county’s trauma patients; 2 Level II trauma centers
penetrating trauma but not for those with blunt also receive trauma patients. The trauma registry at the study
trauma. The transport duration did not matter. institution is an American College of Surgeons Level I Trauma
Potential confounding factors that may have Center patient registry and collects data on all trauma
extended on-scene times were not assessed. activations with mechanism of injury consistent with trauma, all
trauma activations with International Classification of Diseases,
How this is relevant to clinical practice Ninth Revision (ICD-9) codes between 800 and 959.9, and all
EMS on-scene intervals should be monitored for trauma patients without trauma activation who are admitted to
cases of penetrating trauma. Factors that cause the trauma service and have an ICD-9 code between 800 and
delays and their relationships to outcomes should be 959.9. The primary sample for this study was collected from
determined. consecutive data obtained from January 1, 1996, through
December 31, 2009. The study protocol was reviewed and
approved by the university’s institutional review board.
The primary study cohort consisted of consecutive patients
In the United States, trauma is the fifth leading cause of sustaining blunt or penetrating traumatic injury and presenting
death, claiming more than 121,500 lives annually.5,6 to the Level I trauma center during a 14-year period (1996 to
Unintentional injury is the leading cause of death for people 2009). Exclusion criteria were extrication, missing or erroneous
between the ages of 1 and 44 years and is responsible for more out-of-hospital times, intervals exceeding 5 hours, missing data,
years of life lost than stroke, cancer, and cardiovascular disease and nonblunt or penetrating injury (ie, burns, drowning,
combined.6,7 Given these facts and statistics, identifying factors hangings). Although the trauma registry at the study institution
associated with trauma-related mortality is a critical step in the records patient data on interfacility transfers and times when
process of medical systems evaluation and improvement. patients left the sending hospital, these times were excluded
Although many factors may contribute to mortality in the from our analysis.
acutely injured trauma patient, identifying those factors that Orange County’s EMS system is mostly urban, consisting of
are associated with mortality that have the potential to be 23 paramedic receiving centers, 22 private ambulance
systematically improved on within the EMS structure could companies, 1 air ambulance service, and 13 fire agencies, with
have tremendous implications for patient care and outcome. total transports of more than 50,000 per year. The system is fire
This study is designed to identify the association between based, with a combination of fire-based and private
out-of-hospital time and mortality in trauma patients transportation. Units are dispatched in a tiered fashion through
presenting to an urban Level I trauma center. This a structured protocol system; all first-in fire department
information may provide factors that can be improved on at apparatus are staffed with at least 1 paramedic.
the systems level to affect change (decrease mortality) at the
Methods of Measurement
population level.
EMS intervals were calculated from trauma registry data at
the university teaching hospital. Intervals were based on
MATERIALS AND METHODS standard EMS definitions and included scene time (time of
Study Design arrival of first EMS responding vehicle on scene to time leaving
We conducted a secondary analysis of a prospective cohort the scene) and transport time (time leaving the scene to vehicle
registry of trauma patients presenting to an urban Level I arrival at the receiving hospital).9 EMS call activation times are
trauma center during a 14-year period (January 1996 to not recorded in the trauma registry database and therefore
December 2009). response times were not calculated. Thus, “total time” in this

168 Annals of Emergency Medicine Volume , .  : February 

McCoy et al Emergency Medical Services Scene and Transport Times

study reflects the total scene and transport times and not the
“total out-of-hospital time” that describes response, scene, and
transport times. We categorized out-of-hospital times into 10-
minute intervals a priori with the intent of choosing an interval
that is operationally practical, clinically feasible, and politically
acceptable.
The additional variables considered in the analysis were those
known or thought to be associated with mortality in trauma
patients and included age, sex, blunt injury versus penetrating
injury, Revised Trauma Score, and Injury Severity Score. The
primary outcome was inhospital mortality.

Primary Data Analysis

Descriptive statistics were used to describe the characteristics
of the patient population studied during the 14-year period.
The data were downloaded from the trauma database, converted
to Stata file format, and analyzed with Stata (version 12.0;
StataCorp, College Station, TX). We used logistic regression to
assess the association of scene and transport time with mortality,
controlling for variables known to influence mortality. A priori,
we determined that the intervals 0 to 9 minutes, 10 to 19
minutes, and greater than or equal to 20 minutes would be
operationally practical, clinically feasible, and politically
acceptable.

RESULTS
Characteristics of Study Subjects
Continuous data were obtained for all patients presenting to
the study facility during a 14-year period (January 1996 to
December 2009). Twenty-six thousand five hundred sixty-four
cases were eligible for review. Excluded cases consisted of 1,515
for extrication, 4,805 missing 1 or more time data items (scene
or transport times), 334 with scene or transport time less then
zero minutes or greater than 300 minutes, 2 missing final
outcome data (ie, mortality report), 418 not listed as “blunt” or
“penetrating” (ie, burns), 228 missing Injury Severity Score, 31
missing age, 2 missing sex, and 62 missing Revised Trauma
Score. After all exclusions, there were 19,167 cases available for Figure 1. Flow diagram showing of 26,564 cases yielding
19,167 available for analysis. ST/TT, Scene or transport
analysis (Figure 1).
time; ISS, Injury Severity Score; RTS, Revised Trauma
Score.
Main Results
Of the 19,167 trauma cases available for analysis, 865 (4.5%)
resulted in mortality. Of all injuries, 16,170 (84%) injuries were penetrating trauma, 1.3% of those with Injury Severity Score 0
blunt, with 596 (3.7%) deaths, and 2,997 (16%) were to 15 died and 40.9% of those with a score of 16 to 75 died.
penetrating, with 269 (9%) deaths. Mean age and sex for blunt Mean Revised Trauma Scores for blunt and penetrating traumas
and penetrating trauma were 34.5 years (68% men) and 28.1 were 7.5 and 7.1, respectively (Table 1).
years (90% men), respectively. Of those with Injury Severity Blunt trauma accounted for approximately 85% of all cases.
Score less than or equal to 15, 0.4% died, and 26.1% of those The median scene time for blunt trauma was 13 minutes, with
with a score greater than 15 died; 15.5% of patients with blunt an interquartile range (IQR) of 10 to 18 minutes. Median
trauma had an Injury Severity Score greater than 15 compared transport time for blunt trauma was 12 minutes (IQR 8 to 17
with 19.4% of patients with penetrating trauma with a score minutes), and the median total time for blunt trauma was 26
greater than 15. Among patients with blunt trauma, 0.2% of minutes (IQR 21 to 33 minutes).
those with Injury Severity Scores of 0 to 15 died and 22.6% of Penetrating trauma accounted for approximately 15% of all
those with a score of 16 to 75 died. Among patients with cases. The median scene time for penetrating trauma was 11

Volume , .  : February  Annals of Emergency Medicine 169

Emergency Medical Services Scene and Transport Times McCoy et al

Table 1. Characteristics of patient population studied during a

14-year period.
Blunt Penetrating
Patient Characteristics (nⴝ16,170) (nⴝ2,997)
Mean age, y 34.5 28.1
Male, % 68.2% 90.5%
ISS, %
0–15 84.5 80.7
16–75 15.5 19.4
Mean RTS (SD) 7.5 (1.13) 7.1 (1.90)
Death (ISS 0–15), % 0.2 1.3
Death (ISS 16–75), % 22.6 40.9

Figure 3. Histogram of transport time for blunt and

penetrating injuries.

Figure 2. Histogram of scene time for blunt and

penetrating injuries.

minutes (IQR 8 to 15 minutes). Median transport time for

penetrating trauma was 10 minutes (IQR 8 to 14 minutes), and Figure 4. Histogram of total time for blunt and penetrating
the median total time for penetrating trauma was 22 minutes injuries.
(IQR 17 to 28 minutes).
For both blunt and penetrating injuries (all cases), the
median scene time was 13 minutes (IQR 10 to 17 minutes), (95% CI 0.57 to 1.37) for greater than or equal to 20 minutes
median transport time was 12 minutes (IQR 8 to 16 minutes), and 0.88 (95% CI 0.65 to 1.18) for 10 to 19 minutes.
and the median total time was 26 minutes (IQR 20 to 32 Transport time ORs were 1.16 (95% CI 0.76 to 1.78) for
minutes) (Figures 2 to 4). greater than or equal to 20 minutes and 1.04 (95% CI 0.78 to
On multivariate regression of patients with penetrating 1.40) for 10 to 19 minutes (Table 2; Figure 5).
trauma, we observed that a scene time greater than or equal to All of the covariates that we postulated had an effect
20 minutes was associated with higher odds of mortality than on mortality showed statistically significant associations with
scene time less than 10 minutes, with an odds ratio (OR) of mortality in our sample and were controlled for in the
2.90 (95% confidence interval [CI] 1.09 to 7.74). Scene time of multivariate regression analysis. Men had a 1.31 odds of
10 to 19 minutes was not significantly associated with mortality mortality compared with women (95% CI 1.12 to 1.54). The
(OR 1.19; 95% CI 0.66 to 2.16). Longer transport times were odds of mortality increased in successive age groups with age
likewise not associated with increased odds of mortality in greater than 60 years (OR 3.56; 95% CI 2.87 to 4.42), 40 to 59
penetrating trauma cases; OR for transport time greater than or years (OR 1.46; 95% CI 1.17 to 1.82), and 20 to 39 years (OR
equal to 20 minutes was 0.40 (95% CI 0.14 to 1.19), and OR 1.27; 95% CI 1.04 to 1.55). The odds of mortality with
for transport time 10 to 19 minutes was 0.64 (95% CI 0.35 to patients having an Injury Severity Score greater than 15 was
1.15) (Table 2; Figure 5). 91.06 compared with those with less than 15 (95% CI 70.07 to
On multivariate regression of patients with blunt trauma, we 118.34) (Figure 6). The mortality associated with Injury
did not observe any association between scene or transport times Severity Score in our study (specifically that mortality is greater
and increased odds of mortality. Scene time ORs were 0.88 with Injury Severity Score greater than 15 compared with a

170 Annals of Emergency Medicine Volume , .  : February 

McCoy et al Emergency Medical Services Scene and Transport Times

Table 2. Multivariate logistic regression evaluating association

between out-of-hospital time and mortality.
Covariates OR (95% CI)
Scene time, min Blunt Penetrating
0–9 Reference Reference
ⱖ10–19 0.88 (0.65–1.18) 1.19 (0.66–2.16)
ⱖ20 0.88 (0.57–1.37) 2.90 (1.09–7.74)
Transport time, min Blunt Penetrating
0–9 Reference Reference
ⱖ10–19 1.04 (0.78–1.40) 0.64 (0.35–1.15)
ⱖ20 1.16 (0.76–1.78) 0.40 (0.14–1.19)
Men 1.31 (1.12–1.54)
Age, y
0–19 Reference
20–39 1.27 (1.04–1.55)
40–59 1.46 (1.17–1.82)
⬎60 3.56 (2.87–4.42)
ISS 0–15 Reference Figure 6. Scatterplot diagram of percentage of patients
ISS 16–75 91.06 (70.07–118.34) dying as a function of Injury Severity Score for blunt and
RTS ⬎7 Reference penetrating trauma.
RTS ⱕ7 78.20 (63.00–97.08)

between increasing Injury Severity Score and decreased scene

and transport times may be in part explained by EMS providers
recognizing that a patient is critically ill and moving with a
greater sense of urgency. Conversely, one can imagine longer
out-of-hospital times for patients with greater injury severity
and shorter out-of-hospital times for those with lower injury
severity. The discrepancy in previous studies with regard to
patient injury severity level and out-of-hospital times may be
explained by the paramedics’ assessment of a “sick” patient and
its relation to the rapidity with which they provide care and
transport. It is this variable of the paramedics’ assessment of the
injury severity that likely has a substantial influence on the
timeliness of patient care and transport. This variable is
practically impossible to quantify and may be a source of
omitted variable bias in our study. To date, we have found no
Figure 5. Graph of percentage of patients dying as a studies that have been able to measure this variable.
function of scene time for blunt and penetrating trauma. Exclusion of patients from the analysis, as well as those with
missing data, could have introduced bias to the results.
Exclusion of patients extricated in the field was chosen to
score ⬍15) is consistent with that of current national minimize the effect that prolonged out-of-hospital times in this
benchmarks, as well as the prevalent historic association of group would have on skewing the mean out-of-hospital times of
injury severity and mortality in the trauma literature.10,11 The the sample being studied. Given that these prolonged out-of-
odds of mortality with patients having a Revised Trauma Score hospital times or reasons for extrication could have an effect on
less than 7 was 78.20 compared with those with a score greater mortality, we also analyzed our data with this subgroup
than 7 (95% CI 63.00 to 97.08) (Table 2). included (data not shown) and found that it did not change our
final results. We excluded patients with missing or erroneous
LIMITATIONS out-of-hospital times because we wanted to evaluate a complete
Previous studies have shown an association between data set. We excluded out-of-hospital times exceeding 5 hours
increased out-of-hospital times and decreased mortality, as well because we believed that EMS personnel could travel the entire
as an association between increasing Injury Severity Score and distance of the county well within 3 to 4 hours, even with
decreased scene and transport times.3,12-17 The association maximum traffic. The extra hour was added as a cushion. We
between increased out-of-hospital times and decreased mortality chose this timeframe to capture all of the true out-of-hospital
may be in part explained by EMS providers moving with haste times and outliers while excluding out-of-hospital times that
for patients thought to have serious injury and taking more time were clearly erroneous (eg, a 23-hour transport time). We also
for patients recognized as having minor injuries. The association did not measure longer-term (eg, ⬎30-day) survival.

Volume , .  : February  Annals of Emergency Medicine 171

Emergency Medical Services Scene and Transport Times McCoy et al

Our study has the limitation of any EMS study attempting to supporting the argument that minimizing out-of-hospital times
evaluate large populations in that the heterogeneity of the decreases mortality.12-14,22,23 A recent study by Newgard et al24
population and treatment regimens may make it difficult to draw found no association between EMS out-of-hospital intervals and
useful conclusions and it may be that the external validity of any mortality among injured patients presenting with physiologic
particular EMS study has applicability only within similarly defined abnormality. Among the limitations they observed was the lack
geographic populations with similar EMS resources. Each system’s of detailed hospital-based information, including measures of
response intervals and times may need to be individually tailored to injury severity. In the field of out-of-hospital and trauma care,
meet the needs of the community within the financial and political injury severity has been substantially linked, intensively studied,
constraints inherent to that region. The trauma registry at the study and widely accepted as a significant predictor of mortality and
institution is an American College of Surgeons Level I Trauma patient outcome. Our study includes Injury Severity Score as
Center patient registry and collects data on scene and transport one of the variables measured and controlled for in our analysis,
times. In our study, we did not know the response times because thereby allowing the evaluation of the association between out-
they are not recorded in the trauma registry, and therefore we were
of-hospital times and mortality irrespective of the degree of
unable to evaluate response time or total time from call to hospital
injury sustained by the patient.
and its association with mortality; however, the lack of this
There are many variables that may determine whether the
information did not preclude our ability to evaluate the effect of
true association between out-of-hospital times and mortality
scene and transport times on mortality.
Response time could potentially be a confounder if associated may be found. Newgard et al24 reported that it is possible that
with scene or transport time and also independently associated with other factors, such as unmeasured confounders or heterogeneity
mortality. Characteristics of response times that could, if significant in the sample, precluded their ability to show such an
enough, introduce bias into the analysis would be response times association. Indeed the heterogeneity of the patient population
that are nonuniform, with wide variation. Owing to this, we and EMS system and structure lends to the difficulty of teasing
contacted the county EMS agency to obtain general descriptive out which exposures or risk factors may have an effect on
information on county response times. For basic life support patient outcome. The North American EMS system developed
response, the median 90th percentile for system standard response precipitously in the early 1970s, with significant federal grant
times is 6 minutes 15 seconds (range 4 to 8 minutes). For advanced support and guidance that defined essential system components;
life support response, the median 90th percentile for system however, that guidance did not include a national organizational
standard response times is 6 minutes 5 seconds (range 4 minutes 28 model for providing EMS services. That decision was left to
seconds to 7 minutes 45 seconds). Although this information is not local communities, and thus, in contrast with many other
as comprehensive as having the response times on the 19,167 cases countries, local EMS systems in the United States vary
evaluated in our study, we believed it would provide better considerably in how they are organized and financed.25,26 Given
characterization of the EMS system and allow us to evaluate the challenges of providing out-of-hospital care to
whether the response times had characteristics that would lead us to heterogeneous populations through a heterogeneous delivery
believe this variable as a significant confounder. We believe this system, it is imperative that the medical community identify
general information, although limited, does not suggest response patients who may benefit from timely care before abandoning
time characteristics that would significantly limit our ability to the notion that faster is better for all patients in the out-of-
evaluate the association between scene or transport time and hospital setting.
mortality. There are subgroups of the population for which the medical
community has found survival benefit from decreased out-of-
DISCUSSION
hospital times. Studies by Gervin and Fischer27 and Ivatury et
In this secondary analysis of a prospective cohort registry of
al28 found that rapid transport to a trauma center for patients
trauma patients presenting to a Level I trauma center during a 14-
sustaining penetrating thoracic injuries was associated with
year period, we observed an association between longer out-of-
hospital times, in particular scene times, and mortality in patients increased survival. The data in our study are complementary to
with penetrating trauma and an Injury Severity Score greater than these findings and support the notion that patients with
15. This study is the first to our knowledge to analyze data penetrating injuries may be a subgroup who may benefit from
spanning more than a decade, including close to 20,000 patients, decreased out-of-hospital times. In the literature examining
with specific aims to evaluate the association between out-of- nontraumatic out-of-hospital times, shorter EMS response
hospital times and mortality in the urban setting. intervals have been shown to consistently improve survival in
Our results are consistent with those of previous studies nontraumatic cardiac arrest.29,30 Indeed, this was once a
supporting the argument that minimizing out-of-hospital times subgroup of a heterogeneous population for which sufficient
is considered beneficial for survival.1-2,18,19 Two studies by research was conducted to truly evaluate the association.
Sampalis et al20,21 found that increased out-of-hospital times Similarly, we believe those patients with traumatic injury are a
were associated with increased mortality among seriously heterogeneous population with subgroups amenable to
injured trauma patients. There are also previous studies not increased survival with decreased out-of-hospital times. We

172 Annals of Emergency Medicine Volume , .  : February 

McCoy et al Emergency Medical Services Scene and Transport Times

believe it is prudent for the medical community to identify Dr Menchine is currently affiliated with USC Keck School of
patients who may benefit from shorter out-of-hospital times. Medicine, Los Angeles, CA.
Our findings support the golden hour concept and are Author contributions: CEM and CK were responsible for
consistent with the previously demonstrated hospital-based synthesizing research questions and overseeing the study.
beneficial effect on survival.31 Specifically, our study found that CEM and SS were responsible for researching current literature.
out-of-hospital scene times greater than or equal to 20 minutes CEM was responsible for developing a method for testing the
were associated with increased odds of mortality in patients with research questions. CEM, CK, and MM were responsible for
analyzing the data. CEM and MM were responsible for
penetrating traumatic injury. Although not stating causation
interpreting the data. CEM, MM, and SS were responsible for
and needing validation in an external data set, this information writing the article. CK and MM were responsible for editing the
aids in the identification of patient groups who may benefit article. CA was responsible for statistical analysis. CEM takes
from decreasing out-of-hospital times. It is the identification of responsibility for the paper as a whole.
these patient groups that allows research to further study what
Funding and support: By Annals policy, all authors are required
specific risk factors or exposures are directly linked to mortality to disclose any and all commercial, financial, and other
in efforts to make change at the EMS systems level. In relationships in any way related to the subject of this article
particular, scene time is the out-of-hospital interval that EMS as per ICMJE conflict of interest guidelines (see www.icmje.
systems have the most power to control, given that this interval org). The authors have stated that no such relationships exist.
is composed of evaluation and management that is guided by Publication dates: Received for publication July 28, 2011.
local EMS policy, procedures, and protocols. Revisions received December 28, 2011, and May 26, 2012.
Our study did not find an association between transport Accepted for publication August 21, 2012. Available online
times and mortality. Previous studies have demonstrated a November 9, 2012.
survival benefit of treating seriously injured patients in Presented as an abstract at the American College of
trauma centers, suggesting that the time lost by bypassing Emergency Physicians 2010 Scientific Assembly, September
nontrauma centers is recouped by the benefits of receiving care 2010, Las Vegas, NV.
at trauma centers.32-35 One study found that although transport
Address for correspondence: C. Eric McCoy, MD, MPH, E-mail
times to trauma centers were higher for patients bypassing other
ericmccoymd@gmail.com.
local facilities, longer transport times were not associated with
adverse outcomes.36 Our findings support this conclusion and
further substantiate the practice of transporting patients REFERENCES
presumed to have serious injury to trauma centers, despite 1. Feero S, Hedges JR, Simmons E, et al. Does out-of-hospital EMS
time affect trauma survival? Am J Emerg Med. 1995;13:133-135.
longer transport times.24,36
2. Hedges JR, Feero S, Moore B, et al. Factors contributing to
Even as the debate on “load and go” versus “stay and paramedic onscene times during evaluation and management of
stabilize” continues, there remain public expectation, political blunt trauma. Am J Emerg Med. 1988;6:443-448.
pressure, and financial incentives to respond within out-of- 3. Spaite DW, Tse DJ, Valenzuela TD, et al. The impact of injury
hospital times defined by local EMS agencies. Providing EMS severity and prehospital procedures on scene time in victims of
major trauma. Ann Emerg Med. 1991;20:1299-1305.
services and meeting these expectations takes a considerable 4. Blackwell TH, Kaufman JS. Response time effectiveness:
amount of human and capital resources and can place EMS comparison of response time and survival in an urban emergency
providers, patients, and the public at risk.24,37-39 Accordingly, medical services system. Acad Emerg Med. 2002;9:288-295.
we believe it is imperative that the medical community continue 5. Heron MP, Hoyert DL, Murphy SL, et al. Deaths: Final Data for
2006. National Vital Statistics Reports; Vol 57 No 14. Hyattsville,
to research those factors associated with mortality in trauma MD: National Center for Health Statistics; 2009.
patients in an effort to use the available resources more effective 6. Centers for Disease Control and Prevention. Injury Prevention and
and efficiently. Control: Data and Statistics. Available at: www.cdc.gov/injury/
In this analysis of patients presenting to an urban Level I wisqars/dataandstats.html. Accessed September 5, 2009.
7. Mann NC, Mullins RJ, Mackenzie EJ, et al. Systematic review of
trauma center during a 14-year period, we observed increased published evidence regarding trauma system effectiveness.
odds of mortality among patients with penetrating trauma if J Trauma. 1999;47(3 suppl):S25-33.
scene time was greater than 20 minutes. We did not observe 8. Orange County Health Needs Assessment (OCHNA) Data Report.
Santa Ana, CA: OCHNA; 2005.
associations between increased odds of mortality and out-of- 9. Spaite DW, Valenzuela TD, Meislin HW, et al. Prospective
hospital times in victims of blunt trauma. These findings should validation of a new model for evaluating emergency medical
be validated in an external data set. services systems by in-field observation of specific time intervals
in prehospital care. Ann Emerg Med. 1993;22:638-645.
10. American College of Surgeons Committee on Trauma Leadership.
Supervising editor: Theodore R. Delbridge, MD, MPH National Trauma Data Bank 2011 Annual Report. Chicago:
American College of Surgeons; 2011. Available at:
Author affiliations: From the Department of Emergency http://www.facs.org/trauma/ntdb/pdf/ntdbannualreport2011.pdf.
Medicine, UC Irvine School of Medicine, Orange, CA. Accessed September 20, 2012.

Volume , .  : February  Annals of Emergency Medicine 173

Emergency Medical Services Scene and Transport Times McCoy et al

11. Baker SP, O’Neil B, Haddon W, et al. The Injury Severity Score: a 26. Overton J, Stout J. System design. In: National Association of
method for describing patients with multiple injuries and EMS Physicians, eds. Prehospital Systems and Medical
evaluating emergency care. J Trauma. 1974;14:187-196. Oversight. Dubuque, IA: Kendall/Hunt; 2002.
12. Pons PT, Markovchick VJ. Eight minutes or less: does the 27. Gervin AS, Fischer RP. The importance of prompt transport in
ambulance response time guideline impact trauma patient salvage of patients with penetrating heart wounds. J Trauma.
outcome? J Emerg Med. 2002;23:43-48. 1982;22:443-448.
13. Lerner EB, Billittier AJ, Dorn JM, et al. Is total out-of-hospital time 28. Ivatury RR, Nallathambi MN, Roberge RJ, et al. Penetrating
a significant predictor of trauma patient mortality? Acad Emerg thoracic injuries: in-field stabilization vs. prompt transport.
Med. 2003;10:949-954. J Trauma. 1987;29:1066-1073.
14. Petri RW, Dyer A, Lumpkin J. The effect of prehospital transport 29. Eisenberg MS, Bergner L, Hallstrom A. Cardiac resuscitation in
time on mortality from traumatic injury. Prehosp Disaster Med. the community: importance of rapid provision and implications for
1995;10:24-29. program planning. JAMA. 1979;241:1905-1907.
15. Di Bartolomeo S, Valent F, Rosolen V, et al. Are pre-hospital time 30. De Maio VJ, Stiell IG, Wells GA, et al. Optimal defibrillation
and emergency department disposition time useful process response intervals for maximum out-of-hospital cardiac arrest
indicators for trauma care in Italy? Injury. 2007;38:305-311. survival rates. Ann Emerg Med. 2003;42:242-250.
16. Osterwalder JJ. Can the “golden hour of shock” safely be 31. Mackenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation
extended in blunt polytrauma patients? Prehosp Disaster Med. of the effect of trauma-center care on mortality. N Engl J Med.
2002;17:75-80. 2006;354:366-378.
17. Pons PT, Haukoos JS, Bludworth W, et al. Paramedic response
32. Mullins RJ, Veum-Stone J, Helfand M, et al. Outcome of
time: does it affect patient survival? Acad Emerg Med. 2005;12:
hospitalized injured patients after institution of a trauma system
594-600.
in an urban area. JAMA. 1994;271:1919-1924.
18. Honigman B, Rohweder K, Moore E, et al. Prehospital advanced
33. Mullins RJ, Mann NC, Hedges JR, et al. Preferential benefit of
trauma life support for penetrating cardiac wounds. Ann Emerg
implementation of a statewide trauma system in one of two
Med. 1990;19:145-150.
adjacent states. J Trauma. 1998;44:609-617.
19. Gervin AS, Fisher RP. The importance of prompt transport
34. Mullins RJ, Veum-Stone J, Hedges JR, et al. Influence of a
intervals in salvage of patient with penetrating heart wounds.
statewide trauma system on location of hospitalization and
J Trauma. 1982;2:443-448.
outcome of injured patients. J Trauma. 1996;40:536-
20. Sampalis JS, Denis R, Lavoie A, et al. Trauma care regionalization: a
process-outcome evaluation. J Trauma. 1999;46:565-581. 545.
21. Sampalis JS, Lavoie A, Williams JI, et al. Impact of on-site care, 35. Demetriades D, Martin M, Salim A, et al. The effect of trauma
prehospital time, and level of in-hospital care on survival in center designation and trauma volume on outcome in specific
severely injured patients. J Trauma. 1993;34:252-261. severe injuries. Ann Surg. 2005;242:512-519.
22. Pepe PE, Wyatt CH, Bickell WH, et al. The relationship between 36. Sloan EP, Callahan EP, Duda J, et al. The effect of urban
total prehospital time and outcome in hypotensive victims on trauma system hospital bypass on prehospital transport times
penetrating injuries. Ann Emerg Med. 1987;16:293-297. and Level I trauma patient survival. Ann Emerg Med. 1989;18:
23. Stiell IG, Nesbitt LP, Pickett W, et al. The OPALS Major Trauma 1146-1150.
Study: impact of advanced life-support on survival and morbidity. 37. Ambulance crash-related injuries among emergency medical
CMAJ. 2008;178:1141-1152. services workers—United States, 1991-2002. MMWR Morb
24. Newgard CD, Schmicker RH, Hedges JR, et al. Emergency Mortal Wkly Rep. 2003;52:154-156.
medical services intervals and survival in trauma: assessment of 38. Kahn CA, Pirrallo RG, Kuhn EM. Characteristics of fatal
the “golden hour” in a North American prospective cohort. Ann ambulance crashes in the United States: an 11-year
Emerg Med. 2010;55:235-246. retrospective analysis. Prehosp Emerg Care. 2001;5:261-
25. Boyd DR. The history of emergency medical services in the United 269.
States of America. In: Boyd DR, Edlich RF, Micik S, eds. Systems 39. Becker LR, Zaloshnja E, Levick N, et al. Relative risk of injury and
Approach to Emergency Medical Care. Norwalk, CT: Appleton- death in ambulances and other emergency vehicles. Accid Anal
Century-Crofts; 1983:1-82. Prev. 2003;35:941-948.

Did you know?

ACEP members now have free access to all ABEM LLSA articles.

Visit http://www.annemergmed.com/content/abemreading or
www.acep.org/llsa to find out more.

174 Annals of Emergency Medicine Volume , .  : February 