Golden hour policy improves combat survival

Organisation: Position: Deadline Date: Location:

A US mandate in 2009 that pre-hospital helicopter transport of critically injured combat casualties occur in 60 minutes or less (golden hour policy) has resulted in a reduction in time between critical injury and definitive care for combat casualties in Afghanistan and an improvement in survival, according to a new study.

Minimising time between critical injury and definitive care has long been a hallmark and metric of trauma systems, particularly in war, where devastating injuries result in death occurring predominantly before hospital arrival. In 2009, US Secretary of Defence Robert M Gates mandated a standard of 60 minutes or less, from call to arrival at the treatment facility, for pre-hospital helicopter transport of US military casualties with critical injuries, cutting in half the previous goal of 2 hours.

Dr Russ S Kotwal, of the United States Army Institute of Surgical Research, Joint Base San Antonio-Ft Sam Houston, and colleagues compared morbidity and mortality outcomes for casualties before vs after the mandate and for those who underwent pre-hospital helicopter transport in 60 minutes or less vs. more than 60 minutes. The analysis included battlefield data for 21,089 US military casualties that occurred during the Afghanistan conflict from September 2001 to March 2014.

For the total casualty population, the percentage killed in action (16% (386 of 2,411) vs 9.9% (964 of 9,755)) and the case fatality rate ((CFR) 13.7 (469 of 3,429] vs 7.6 (1,344 of 17,660) were higher before vs after the mandate, while the percentage died of wounds ((DOW) 4.1% vs 4.3%) remained unchanged.

Decline in CFR after the mandate was associated with an increasing percentage of casualties transported in 60 minutes or less, with projected vs actual CFR equating to 359 lives saved.

Among 4,542 casualties with detailed data, there was a decrease in median transport time after the mandate (90 min vs 43 min) and an increase in missions achieving pre-hospital helicopter transport in 60 minutes or less (24.8% vs 75.2%). 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 and were transported in 60 minutes or less, while the percentage died of wounds was lower among those critically injured initially treated by combat support hospitals.

“In summary, as transport time decreased and capabilities increased, casualties who would previously have been in the killed in action mortality group survived outright or survived long enough that they shifted to the DOW mortality group, and casualties who would previously have been in the DOW mortality group were also surviving. Decreasing the time from injury to arrival at the treatment facility challenged the full measure of the trauma system with more critically injured casualties who then benefited from the care they received,” the authors write.

Abstract
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.

JAMA material
JAMA Surgery abstract
JAMA Surgery commentary


Receive Medical Brief's free weekly e-newsletter



Related Posts

Thank you for subscribing to MedicalBrief


MedicalBrief is Africa’s premier medical news and research weekly newsletter. MedicalBrief is published every Thursday and delivered free of charge by email to over 33 000 health professionals.

Please consider completing the form below. The information you supply is optional and will only be used to compile a demographic profile of our subscribers. Your personal details will never be shared with a third party.


Thank you for taking the time to complete the form.