The Elusive Golden Hour: Barriers to Trauma Care in Rural Montana

Introduction: Most trauma guidelines are derived from data based in urban settings, where trauma patient transfers to a tertiary center average 60 minutes or less. However, this “golden hour” is an elusive goal in the rural Northwest, due to complex injury mechanisms, harsh weather, and varying levels of pre-hospital care. Further studies are required to describe the barriers to care.

Methods: A 10-year retrospective analysis (2012-2022) of the trauma registry at a rural Northwest tertiary trauma center was performed. Basic patient demographics, time and distance to definitive care, available providers and mortality were compared.

Results: Of the 4545 trauma activations included, transfer patients accounted for 47.3%. 81.5% of transfer patients were from areas with RUCA designation 7-10 (small and isolated small rural towns). For transfer patients, the EMS arrival time from injury was 57.5 (43.5, 71.2) minutes, time to arrival at the initial facility was 2.0 (1.9, 2.3) hours, time to arrival at the tertiary facility was 7.2 (6.8, 7.3) hours, and transportation distance to the tertiary facility was 188.4 (174, 192.7) miles. Overall transfer all-cause mortality was significantly higher than direct presentations on univariate regression (5.0% vs. 3.0%; p < 0.0001). Urban centers were more likely than isolated rural centers to have on-call general surgeons (93.5% vs 29.8%) and APPs (99.7% vs 89.3%).

Conclusion: This single-center 10-year retrospective analysis represents the largest real-world data examining trauma transfer and mortality outcomes in Montana. Transfers traverse significantly greater distances and take longer than what is described elsewhere.