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Original Investigation |

The Effect of a Golden Hour Policy on the Morbidity and Mortality of Combat Casualties

Russ S. Kotwal, MD, MPH1,2,3; Jeffrey T. Howard, PhD1; Jean A. Orman, ScD, MPH1; Bruce W. Tarpey, BS1; Jeffrey A. Bailey, MD1,2; Howard R. Champion, FRCS2; Robert L. Mabry, MD1; John B. Holcomb, MD4; Kirby R. Gross, MD1,2
[+] Author Affiliations
1Joint Trauma System, United States Army Institute of Surgical Research, Joint Base San Antonio–Ft Sam Houston, Texas
2Uniformed Services University of the Health Sciences, Bethesda, Maryland
3Texas A&M Health Science Center College of Medicine, College Station
4Center for Translational Injury Research, The University of Texas Medical School at Houston
JAMA Surg. 2016;151(1):15-24. doi:10.1001/jamasurg.2015.3104.
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Importance  The term golden hour was coined to encourage urgency of trauma care. In 2009, Secretary of Defense Robert M. Gates mandated prehospital helicopter transport of critically injured combat casualties in 60 minutes or less.

Objectives  To compare morbidity and mortality outcomes for casualties before vs after the mandate and for those who underwent prehospital helicopter transport in 60 minutes or less vs more than 60 minutes.

Design, Setting, and Participants  A retrospective descriptive analysis of battlefield data examined 21 089 US military casualties that occurred during the Afghanistan conflict from September 11, 2001, to March 31, 2014. Analysis was conducted from September 1, 2014, to January 21, 2015.

Main Outcomes and Measures  Data for all casualties were analyzed according to whether they occurred before or after the mandate. Detailed data for those who underwent prehospital helicopter transport were analyzed according to whether they occurred before or after the mandate and whether they occurred in 60 minutes or less vs more than 60 minutes. Casualties with minor wounds were excluded. Mortality and morbidity outcomes and treatment capability–related variables were compared.

Results  For the total casualty population, the percentage killed in action (16.0% [386 of 2411] vs 9.9% [964 of 9755]; P < .001) and the case fatality rate ([CFR] 13.7 [469 of 3429] vs 7.6 [1344 of 17 660]; P < .001) were higher before vs after the mandate, while the percentage died of wounds (4.1% [83 of 2025] vs 4.3% [380 of 8791]; P = .71) remained unchanged. Decline in CFR after the mandate was associated with an increasing percentage of casualties transported in 60 minutes or less (regression coefficient, –0.141; P < .001), with projected vs actual CFR equating to 359 lives saved. Among 4542 casualties (mean injury severity score, 17.3; mortality, 10.1% [457 of 4542]) with detailed data, there was a decrease in median transport time after the mandate (90 min vs 43 min; P < .001) and an increase in missions achieving prehospital helicopter transport in 60 minutes or less (24.8% [181 of 731] vs 75.2% [2867 of 3811]; P < .001). When adjusted for injury severity score and time period, the percentage killed in action was lower for those critically injured who received a blood transfusion (6.8% [40 of 589] vs 51.0% [249 of 488]; P < .001) and were transported in 60 minutes or less (25.7% [205 of 799] vs 30.2% [84 of 278]; P < .01), while the percentage died of wounds was lower among those critically injured initially treated by combat support hospitals (9.1% [48 of 530] vs 15.7% [86 of 547]; P < .01). Acute morbidity was higher among those critically injured who were transported in 60 minutes or less (36.9% [295 of 799] vs 27.3% [76 of 278]; P < .01), those severely and critically injured initially treated at combat support hospitals (severely injured, 51.1% [161 of 315] vs 33.1% [104 of 314]; P < .001; and critically injured, 39.8% [211 of 530] vs 29.3% [160 of 547]; P < .001), and casualties who received a blood transfusion (50.2% [618 of 1231] vs 3.7% [121 of 3311]; P < .001), emphasizing the need for timely advanced treatment.

Conclusions and Relevance  A mandate made in 2009 by Secretary of Defense Gates reduced the time between combat injury and receiving definitive care. Prehospital transport time and treatment capability are important factors for casualty survival on the battlefield.

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Figure 1.
Case Fatality Rate and Transport Time

Trend in case fatality rate (CFR) based on linear model where CFR = 0.183 + (−0.002 × quarterly time period). Model R2 = 0.625. Linear model projections (dashed line) surrounded by 95% CIs (dotted lines) predict a CFR of 10.3 (95% CI, 8.7-11.9) at the end of the study period compared with the CFR of 8.6 actually observed, for a difference of 1.7, which equates to potentially 359 lives saved. Logarithmic and higher-order polynomial models had inferior model fit characteristics compared with the linear model. Stratified regression analysis of transport time and CFR trends conducted separately for the periods before and after the mandate showed no association between transport time and CFR in the period before the mandate (regression coefficient, 0.058; P = .48), but they showed a highly significant association in the period after the mandate (regression coefficient, −0.141; P < .001) and an overall correlation coefficient of −0.96 (P < .001) for the association between transport time in 60 minutes or less and CFR.

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Figure 2.
Rates Adjusted for Injury Time Period (Before vs After Mandate) of Killed in Action (KIA) Mortality, Died of Wounds (DOW) Mortality, and Acute Morbidity, by Injury Severity Score (ISS) and Type of Medical Treatment Facility (MTF), Blood Transfusion, and Transport Time

The data provide 12 cases labeled as KIA who also received a massive transfusion; although these cases were dead on arrival to an MTF, heroic measures were undertaken. For blood transfusion, sample sizes were too small to evaluate prehospital transfusion (PHT) using the Cochrane-Mantel-Haenszel test. However, KIA mortality, DOW mortality, and acute morbidity (defined by presence of amputation, cardiac arrest, coagulopathy, and/or shock) were compared between patients who received PHT (n = 132) and patients who did not (n = 4410). Of patients who received PHT, 2.3% (3 of 132) were KIA, while 7.0% (308 of 4410) of patients who did not receive PHT were KIA (χ21 = 4.460; P = .04). Of patients who received PHT, 5.3% (7 of 132) were DOW, while 3.2% (141 of 4410) of patients who did not receive PHT were DOW (χ21 = 1.803; P = .18). Of patients who received PHT, 80.3% (106 of 132) experienced acute morbidity, while 14.4% (633 of 4410) of patients who did not receive PHT experienced acute morbidity (χ21 = 409.175; P < .001). Statistical comparisons are based on the Cochrane-Mantel-Haenszel test with adjustment for ISS and injury time period (before vs after the mandate).

aP < .01.

bP < .001.

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