Time is essential for survival of critically injured casualties. A halving of the transfer time from the battlefield to the hospital - a concept known as "golden hour" - has resulted in a higher survival rate for servicemen in Afghanistan, according to a new study published in JAMA Surgery.
Minimizing time between critical injury and definitive care has long been a standard for trauma systems, particularly in war, where devastating injuries often result in death before hospital arrival.
The concept of the golden hour was pioneered by Dr. R. Adams Cowley 5 decades ago, at the University of Maryland Medical Center in Baltimore. Dr. Cowley recognized that the sooner trauma patients reached definitive care, particularly if they arrived within 60 minutes of being injured, the better their chance of survival.
In 2009, Secretary of Defense Robert M. Gates mandated a standard of 60 minutes or less, from call to arrival at the treatment facility, for prehospital helicopter transport of US military casualties with critical injuries, cutting in half the previous goal of 2 hours.
In a recent study, Dr. Russ S. Kotwal, of the US Army Institute of Surgical Research, Joint Base San Antonio-Ft. Sam Houston, and colleagues compared morbidity and mortality outcomes for casualties before and after the mandate, and for those who underwent prehospital helicopter transport in 60 minutes or less compared with more than 60 minutes.
Case fatality rate drops from 13.7% to 7.6%
The analysis included battlefield data for 21,089 US military casualties that occurred during the Afghanistan conflict from September 2001 to March 2014.
Before the mandate, the case fatality rate was 13.7%, or 469 out of 3,429 injured. After the mandate, case fatality rate decreased to 7.6%, or 1,344 out of 17,660 injured.
Of those killed in action, meaning on the battlefield, the fatality rate decreased from 16% to 9.9%. The number that died after reaching the hospital was unchanged, indicating a higher survival rate overall.
The decrease was associated with an increase in the percentage of casualties transported to treatment facilities in 60 minutes or less, and equates to 359 lives being saved.
In addition, the median time of transport after the mandate was reduced from 90 minutes to 43 minutes. Although not all transport was achieved within the hour, the percentage increased from 24.8% before the mandate to 75.2% after.
The decrease in prehospital helicopter transport time gave critical casualties, who would have previously died in the field, the opportunity to receive en route and facility-based care. Other casualties who previously would have died in treatment facilities were also afforded care earlier.
Commenting on the report, Dr. Todd E. Rasmussen, of Defense Trauma Registry, says:
"Reduction in the percentage killed in action following the 2009 policy change provides evidence of the effect of an enhanced capability during the 'golden hour' after injury."
Although the trauma centers were challenged by the increased number of critically wounded patients arriving, the chance of survival rose significantly.
Earlier this year, Medical News Today reported on the need to screen military personnel on returning home for mental health effects following the trauma of war.