Rethinking the Golden Hour of Trauma

What does the evidence really tell us?


Nearly all EMS providers can remember their first exposure to the concept of the Golden Hour—the idea that trauma patients have significantly better survival rates if they reach surgery within 60 minutes of their injury. But there is some question about where the Golden Hour originated and even more about whether it’s true.

In a 2001 literature review published in Academic Emergency Medicine, authors led by E. Brooke Lerner, PhD, attempted to determine the origin of the term.1 They cited a series of studies discussing the Golden Hour, but found those studies often referenced one another and were not accompanied by supporting data or references to other studies. Most frequently the phrase is attributed to emergency medicine pioneer R Adams Cowley, who used it in 1973 in reference to helicopter transport of injured patients in Maryland.2 Cowley observed that “care given in the first hour determines the extent of organ damage that the patient might sustain.” But Lerner and colleague Ronald Moscati were unable to find peer-reviewed studies to support the concept of the Golden Hour and attributed the idea to Dr. Cowley’s “experience and [the] opinion of one of the fathers of trauma surgery.”1 However it began, the term entered the lexicon of emergency medical services and stuck.

A Recent Review

In March 2010, a study led by Craig Newgard, MD, and published in the Annals of Emergency Medicine attempted to discover a statistical link between the total “EMS interval” (or the time from 9-1-1 call until hospital arrival) and patient survival (see Table I).3 The authors included adult patients (15 or older) with traumatic injuries transported by EMS. The patients also met physiologic trauma criteria linked to “serious” injury (systolic blood pressure ≤ 90 mmHg, GCS ≤ 12, respiratory rate < 10 or > 29/min or placement of an advanced airway). Patients not transported directly to a trauma center from the scene were excluded, as were field deaths.

In addition to the total EMS interval, the authors evaluated the times tracked on a typical 9-1-1 call, including activation, response, scene and transport times. They also recorded information about each call (mechanism, type of injury, patient demographics) as well as treatments given and transport methods (ground vs. helicopter, ALS vs. BLS). The patient outcome tracked in the study was death within the hospital, either in the emergency department or after admission.

The study ultimately included 3,656 patients over 16 months. For these patients, the average total EMS time was 36.3 minutes. The authors were not able to find an increase in mortality for each additional minute of EMS time. They also analyzed the patient sample in 10-minute blocks and again found no link to mortality. Particular intervals like response and scene times (the “Platinum 10 Minutes”) also showed no association with worse outcomes. To answer the question of the Golden Hour, patients with total prehospital times of less than 60 minutes were analyzed separately from those with times of 60 minutes or more. Those with the longer times showed no association with increased mortality.

While this paper established no link between time and mortality, every study has limitations that may affect how useful its findings are. As an example, for this study injury severity (and therefore inclusion) was determined by field documentation. Since in-hospital injury severity was not available to the researchers, only patients who appeared injured to EMS personnel were included, rather than patients whose injury severity was determined based on their discharge diagnosis. Additionally, the study only measured in-hospital mortality and did not look at later deaths or how much function patients retained after discharge.

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