Y O R K

Health Economics C O N S O R T I U M

GSM ASSOCIATION

The Golden Hour and Mobile Phones

Final Report

PETER WEST, Director SARAH REDMOND, Consultant JUNE 2004

©GSMA

Market Square, University of York, Vanbrugh Way, Heslington, York YO10 5NH Tel: 01904 433620 Fax: 01904 433628 Email: [email protected] http://www.york.ac.uk/inst/yhec/

York Health Economics Consortium is a Limited Company Registered in England and Wales No. 4144762 Registered office as above.

Contents

Page No. Executive Summary

Acknowledgements

Section 1: Introduction 1 1.1 Objective 1 1.2 Background 1 1.3 Aims of the Study 2 1.4 Structure of the Report 3

Section 2: Methods 4 2.1 Literature Search 4 2.2 Assessment of Retrieved Articles 5

Section 3: Results 7 3.1 The ‘Golden Hour’ 7 3.2 Mobile Phones 10 3.3 Conclusions 12

Section 4: Conclusions 13 4.1 Main Findings 13 4.2 Conclusions 13

References

Appendices:

Appendix A Search Strategies: Golden Hour Appendix B Search Strategies: Mobile Phones for Calling Ambulance Services Appendix C Golden Hour Template Appendix D Mobile Phones

Executive Summary

1. OBJECTIVE

The overall objective of the study was to identify literature on the use of mobile phones for calling for ambulance services and to identify literature on the ‘golden hour’, the crucial medical reference period in clinical emergencies.

2. BACKGROUND

The ‘golden hour’ refers to the first 60 minutes after the onset of an acute illness. The chances of survival, if treatment is given, are greatest within this hour. The concept of the ‘golden hour’ had spread throughout the world with out-of-hospital care running on the principle of ‘scoop and run’ in order to get patients to hospital and treatment as fast as possible.

3. METHODS

Two separate literature searches were undertaken:

• To identify literature on the ‘golden hour’; • To identify literature on the use of mobile phones for calling for ambulance services.

Key databases were searched limited only by date range and restricted to 1996- 2004. The databases included MEDLINE, PubMed and EMBASE. The Internet was also searched using general search engines Copernic and Google. The literature search provided a list of potentially useful papers. The list was assessed and papers that met the aims and objectives of the study were obtained from on-line journals, where possible. Relevant information from the available papers was entered into a pro-forma template, such as:

• The complete reference; • The country the study was carried out in; • Any information related to the ‘golden hour’ or mobile phone use; • The objective of the study; • Whether the study was carried out in an urban or rural setting; • The response times; • The benefits of early treatment or the benefits of using a mobile phone to inform of an accident; • The conclusions.

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4. RESULTS AND CONCLUSIONS

The on-line journals search produced 62 papers related to the ‘golden hour’ and 11 papers related to mobile phones.

In conclusion the review found that there is a need for a quick response to traumas but this does not always have to be within an hour. In the case of cardiac arrests and myocardial infarctions, responses need to be within ten to fifteen minutes but for pneumonia it can be up to eight hours. There is a need to reduce response times further, especially for cardiac arrests and myocardial infarctions. Mobile phones have been shown to be used to call ambulance services but there is no information as to the health benefits this provides. It is unclear as to whether mobile phone use would enable the emergency services to reach patients any quicker than they currently do. Research should, therefore, focus on initiatives the emergency services could implement themselves to reduce response times, for example, by the use of targeted response systems and by increasing the number of ambulances. There is scope for mobile phone technology to be used by pre-hospital staff to reduce symptom-to-treatment times and research should focus on these areas.

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Acknowledgements

The authors would like to thank Steven Duffy (Information Specialist) for assistance with the literature search.

This research was conducted by York Health Economics Consortium Ltd for the GSM Association, however, the views expressed by the authors may not be those of the GSM Association or its members.

Contact at the GSM Association, Dr Jack Rowley, Director Environmental affairs.

Section 1: Introduction

1.1 OBJECTIVE

The overall objective of the study was to identify literature on the use of mobile phones for calling ambulance services and to identify literature on the ‘golden hour’, the crucial medical reference period in clinical emergencies.

1.2 BACKGROUND

The ‘golden hour’ refers to the first 60 minutes after the onset of an acute illness. The chances of survival, if treatment is given, are greatest within this hour [1]. The concept of the ‘golden hour’ has spread throughout the world with out-of-hospital care running on the principle of “scoop and run “ in order to get patients to hospital and treatment as fast as possible [1].

Lerner et al. [1] conducted a literature review, in 2001, to establish the origins of the ‘golden hour’. They concluded that Cowley was the first person to introduce the concept in 1975 when he stated that “the first hour after an injury will largely determine a critically-injured person’s chances of survival,” in a further article, in 1976, he goes on to mention the ‘golden hour’ directly.

Another early advocate of the ‘golden hour’ was Trunkey [2], who in his 1983 paper detailed the numbers of deaths from trauma in the US. In 1982 it was 165,000 people and $62 million per day was lost in wages as a result. Trunkey noted that, at the time of the article, “physicians, hospital administrators, government officials and the general public” largely neglected trauma. Trunkey detailed the three main peaks of deaths following a trauma:

• The first peak occurs very soon after trauma and is almost always not preventable. Here death is caused by lacerations to the brain or brain stem or spinal cord and by major blood loss; • The second peak occurs within the first few hours after a trauma and is treatable. The time between the trauma and treatment is critical in determining outcome. Here death is caused by internal haemorrhages of the head, respiratory system or abdominal organs or by severe blood loss;

Section 1 1

• The third peak occurs in people who die days or weeks after. Quality of medical care, rather than the initial speed of treatment, is crucial here, as death is caused by infection or multiple organ failure.

It is patients within the second peak that would benefit from a rapid response to treatment, especially but not exclusively during the first hour after a trauma.

The advanced trauma program is a course for doctors which provides details on the correct way to deal with an trauma [3]. This emphasises the point that the ‘golden hour’ is not limited to 60 minutes but to the first few hours after a trauma. They reiterate Trunkey’s point that trauma is a major cause of death and in 1997 they estimated trauma related costs (lost wages, medical expenses, insurance administration costs, property damage, fire loss, employer costs, and indirect costs) at $400 billion annually, in the US.

1.3 AIMS OF THE STUDY

This study aimed to search the literature for information concerning the ‘golden hour’ paying particular attention to:

• Benefits of rapid responses to trauma, for example, lives saved and any economic benefits; • Cardiac events and early response; • Reduced ambulance response times; • 999 research; • Urban versus rural outcomes; • Traffic accident notification.

The study also aimed to search the literature for information concerning mobile phones for calling ambulance services paying particular attention to:

• Emergency contacts, especially ambulance services; • Health benefits caused by mobile phones calling the emergency services; • 911, E911, EMS (Emergency Management Systems) and 999 research; • Information technology and emergency outcomes.

This study is focussed on potential areas of benefit so two areas within the mobile phones literature were excluded. These were:

• Driver distraction effects; • Possible health effects.

Section 1 2

1.4 STRUCTURE OF THE REPORT

The remainder of the report compromises the following sections:

• Section 2: Methods, detailing the literature search; • Section 3: Results, the findings of the literature review will be detailed; • Section 4: Conclusions, the conclusions will be summarised; • Appendices, the pro-forma used to summarise the articles are included.

Section 1 3

Section 2: Methods

2.1 LITERATURE SEARCH

Two separate literature searches were undertaken:

• To identify literature on the ‘golden hour’; • To identify literature on the use of mobile phones for calling ambulance services.

The database searches were limited by date range and restricted to 1996-2004; no further limitations by study design or language were used.

The following databases were searched for both questions:

MEDLINE (1996-2004) and PubMed (2004); EMBASE (1996-2004); Cinahl (1996-2004); Health Management Information Consortium (HMIC) (1996-2004) WebSPIRS); British Nursing Index (BNI) (1996-2004); Database of Abstracts of Reviews of Effects (DARE) (1996-2004); NHS Economic Evaluation Database (NHS EED) (1996-2004); Health Technology Assessment database (HTA) (1996-2004/03); Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials (CENTRAL) (1996-2004; OHE Health Economic Evaluation Database (HEED) (1996-2004); PsycINFO (1996-2004); Science Citation Index and Social Science Citation Index (1996-2004).

The Internet was also searched. General search engines Copernic (http://www.copernic.com/en/index.html) and Google (http://www.google.com/) were used. Details of the search terms used in the literature search for the ‘golden hour’ and mobile phones are provided in Appendix A and in Appendix B respectively.

Section 2 4

2.2 ASSESSMENT OF RETRIEVED ARTICLES

The literature search provided a list of potentially useful papers. This list was assessed and papers that met the aims and objectives of the study were obtained from on-line journals, where possible. Relevant information from the available papers was entered into a pro-forma template. The pro-forma template for the ‘golden hour’ and the mobile phones are provided in Tables 2.1 and 2.2 respectively.

Table 2.1: The ‘golden hour’ pro-forma

Reference Author. Title. Journal. Date; Issue: page number. Country The country the study was carried out in. Status Was an abstract or a full article reviewed? Directly related to the Golden Hour Explanation of whether the study is related to the golden hour. Study type Provide the study type. Objective Summarise the objective of the study. Urban / Rural Was the study carried out in an urban or a rural setting? Event Details of the event that has taken place that has caused assistance to be asked for, for example, a heart attack or a vehicle accident. Time before calling for help The amount of time from the onset of an event to when help is called for, either by the patients themselves or by a bystander. Response time The time it takes for help to arrive once assistance has been asked for. Technology used to inform of the accident Was EMS used? Help given The medical care given during the pre-hospital stages of care. This should include care from passers by and medical staff. Transport The mode of transport used to take patients to hospital. Benefits The added benefits from early treatment. For example, lives saved or economic benefits. Conclusions Summarise the author’s conclusions.

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Table 2.2: Mobile phones pro-forma

Reference Author. Title. Journal. Date; Issue: page number Country The country the study was carried out in. Status Was an abstract or a full article reviewed? Study type Provide the study type. Objective Summaries the objective of the study Technology Describe whether the study investigates a technology used for health care or if the study looks at the use of mobile phones directly. Emergency contacts This refers to what service was called for, for example, the ambulance service. Event Describe the event that has taken place that has caused assistance to be asked for, for example, a heart attack or a vehicle accident. Health benefits Describe the health benefits that arise from using a mobile phone to inform of an accident. Technology used to inform of the accident Was EMS, 911, E911 or 999 used? Conclusions Summarise the author’s conclusions. Reference to the ‘golden hour’ Are references made to the ‘golden hour’? Is the paper relevant to the ‘golden hour’?

The next section details the results of the review.

Section 2 6

Section 3: Results

3.1 THE ‘GOLDEN HOUR’

The ‘golden hour’ literature search identified 264 potential articles. The titles and abstracts, where available, were assessed and articles were discounted if they did not mention the golden hour and survival or health benefits. This reduced the number of potential papers to 184. Once papers were identified the Internet was searched for available papers. This produced 62 papers, of which 23 were not reviewed, as on closer inspection they were not relevant. Articles that were dismissed looked at ways to improve on the scene care but did not mention response times or health benefits, made no mention of the golden hour (directly or indirectly), looked at deaths from traumas but did not discuss improving response times, looked at out-of-hospital cardiac arrests but did not look at response times, looked at non urgent emergency calls or they reiterated the same points as other reviewed papers. The pro-forma for the ‘golden hour’ can be found in Appendix C.

Of the articles that were reviewed most looked at response times to cardiac incidents. Survival to discharge, at 6%, is low from such events [4]. A leading factor in this is long response times. Other events studied were road traffic accidents, any emergency event, pelvic fractures, severe burns and pneumonia.

3.1.1 Benefits of an Early Response to Trauma or Acute Health Problems

Many articles comment that the benefits from an early response to a trauma are likely to be an increased chance of survival and the potential for lives to be saved, but few give quantifying data. MacDonald et al. [5] looked at the records of 65 patients in Norway that had been taken to hospital via a helicopter following a trauma. A panel of experts reviewed the records to see if they would have benefited from an earlier response. They concluded that only 10 patients would have benefited from a reduction in response times leading to a gain of 18.3 quality adjusted life years (QALYs).

For patients who suffer a cardiac arrest, survival is directly related to the speed of which treatment is given, the chances of survival reduce by between 5.5% and 10% for every minute that passes without treatment [6]. In Hong Kong immediate survival stands at 14.1% and survival to discharge at 1.25% [7]. Defibrillation is an important factor in survival but after two minutes from the arrest only two thirds of patients are amenable to defibrillation and this gets less with time with the potential for successful defibrillation being greatest during the first 10 minutes [8-10].

Section 3 7

Public access defibrillators are one method of reducing the time from symptoms to treatment. There is a debate in the literature as to whether money should be spent installing public access defibrillators or on training first responders, like police and fire fighters, in administering defibrillation. Pell et al. and Pell [9] [8] argue for first responders and Walker et al. [11] show that public access defibrillators only increase survival by 5 to 6.5%. There is an agreement that in areas where the probability of a cardiac arrest is high there is some merit, in terms of lives saved, of having public access defibrillators, such as in nursing home, dialysis centres, sports stadiums and aircrafts but first responders need to be trained in how to use them. MacDonald et al. [12] conducted a study at an airport where public access defibrillators had been installed and airport staff were trained in their use. They found that in 94.7% of cases the airport team provided care before an EMS team.

For patients who have suffered a myocardial infarction, 65 lives per thousand can be saved if the patient presents to medical staff within an hour of symptoms. This reduces to 26 per thousand for patients presenting within two to three hours, to 29 per thousand for patients who present in three to six hours, to 18 per thousand for patients who present within 6 to 12 hours and to nine per thousands for patients who present within 12 to 24 hours [13]. To provide the best chance of survival fibrinolytic therapy or thrombolysis treatment need to be administered quickly. For fibrinolytic therapy the benefit reduces by 1.6 lives per 1000 for each hour of delay [13]. If thrombolytic treatment is given within one hour of symptoms mortality is reduced by 45% and if treatment is given within the first three hours treatment mortality is reduced by 23%.

For pneumonia patients antibiotics need to be given in the first eight hours to increase survival rates.

3.1.2 Response Times and the ‘Golden Hour’

Response times to traumas are generally within the ‘golden hour’ but this is not always the case for door-to-needle times, the time from the patient arriving at the hospital to the time of treatment. Al-Gamdi [14] report that in Saudi Arabia the mean response times to traffic accident in urban areas, from the time the call is made to the time the patient arrives at the hospital is 35.85 minutes. Altintas and Bilir [15] report that the average time from call to arrival at hospital was 32.31 minutes in Turkey.

In 2003 Birkhead [16] conducted a myocardial infarction national audit project (MINAP), to see if targets had been met in terms of response times. The audit looked at 10,000 patient records. The national service target aimed to obtain door- to-needle times of 30 minutes by 2002, 20 minutes by 2003 and that care is given

Section 3 8

within 60 minutes of a call for help. The audit found that in 1993 eight percent of patients received help within 60 minutes of first calling for help and this had increased to 34% by 2002. In 1992 the median door-to-needle time was 53 minutes and this had fallen to 26 minutes in 2002. The audit found that 70% of patients received thrombolytic treatment within 30 minutes of getting to hospital but only 37% of patients received treatment within 60 minutes of calling for help. The authors suggest that better use of out-of-hospital staff could improve response times.

Response times to cardiac arrests are generally within the ‘golden hour’ but as Section 3.1.1 shows response times need to be within ten minutes. Pell et al. [4] showed that reducing the response time from 15 to 8 minutes increases the number of potential survivors from 6% to 8% and reducing the response times even further to five minutes increases survival to 11%.

Responses times to myocardial infarctions again are mostly within the golden hour with many under eight minutes; but door-to-needle times are still largely over one hour. Hourigan et al. [17] demonstrated that in Australia the mean door-to-call time in an emergency department was 110 mins and 141 in a coronary care unit. The mean door-to-needle time was 47 minutes in an emergency department and 88 minutes in a coronary care department. A UK study by Stoykova et al. [18] in 2004 looked at ambulance response times and national standards. They found that in 1996/97 96% of emergency calls had a response within 19 minutes and 45.3% within eight minutes. They found that in 2001 78.4% of emergency calls had a response within eight minutes, which is above the target of 75%. Rapid response teams used in 2002 had even faster response times, with 88.2% of emergency calls being reached within eight minutes.

3.1.3 999 Research

The use of enhanced 911 can help reduce response times. Athey [19] investigated the adoption of an enhanced 911 in Pennsylvania in 1991, linked to a caller identification, which is in turn linked to a location database. The immediate identification of patients’ whereabouts helped to speed up response times and this in turn increased patients’ welfare.

3.1.4 Urban Verses Rural

Of the papers reviewed seven were in an urban setting, four were in a rural setting and 13 looked at both urban and rural settings. For the rest of the papers the setting was not specified.

Section 3 9

Of the papers that looked at both urban and rural areas most found small differences in response times. Breen et al. [20] looked at response times to any emergency in Ireland. They found that in urban areas 44% of calls were responded to within nine minute whereas in rural areas 29% of calls were responded to within nine minutes.

Rawles et al. [21] looked at call-to-needle times after a myocardial infarction in Scotland. The results are shown in Table 3.1. The British Heart foundation recommends thrombolysis treatment should be given within 90 minutes of help being requested. The results of this paper suggest that to meet these targets prehospital staff should initiate treatment before the patient reaches the hospital in rural areas and patients in urban areas should go straight to a coronary care unit.

Table 3.1: Results from the paper by Rawles

Call to needle times, minutes Call-to-needle times, minutes (opiate given) (%in 90 mins) (Thrombolysis given) (%in 90 mins) In rural areas Care given by GP 30 (97) 45(93) Care given in hospital, (GP 35 (93) 150 (5) called first) Care given in hospital (999 88 (60) 102 (31) called) In urban areas Care given in hospital (GP 25 (95) 105 (37) called) Care given in hospital, (999 61 (75) 96 (38) called A&E then a coronary care unit) Care given in hospital (999 52 (94) 58 (81) called coronary care unit))

Svensson et al. [22] showed that in Sweden for patients who have suffered an acute myocardial infarction the median time from symptoms to the ambulance arriving at the hospital was 1 hour 10 minutes in urban areas and 1 hour 33 minutes in rural areas.

3.2 MOBILE PHONES

The mobile phones search identified 84 potential articles. On close inspection of the titles and abstracts, where available, this number was reduced to 45 articles. Articles were disregarded if they were concerned with image transmission to aid diagnosis or monitoring of patients, or if they were concerned with personal alarm systems that automatically alert the emergency services if the individual has been inactive for a certain length of time. The Internet search for articles found 11 papers,

Section 3 10

3 were discounted as they talked about phones and car drivers and crashes, telemedicine. As the number of article found was small six abstracts were also reviewed. The pro-forma for mobile phones can be found in Appendix D.

Chapman and Schofield [23] conducted a random telephone survey of 720 mobile phone users to access whether they had used them to inform of any medical emergency. The study found that:

• 1 in 8 mobile phone users had reported a road accident; • 1 in 16 people had reported a non-road medical emergency; • 1 in 100 reported a psychiatric crisis; • 1 in 720 had reported a heart attack, epileptic fits or diabetic comas; • 1 in 357 reported domestic violence.

The authors conclude that mobile phones are used to report dangerous situations and it, therefore, seems reasonable to assume they have saved lives. They comment that land lines, used to call the emergency services, have been shown to be associated with increased survival from out-of-hospital cardiac arrests and they say its reasonable to assume the same is true of mobile phones. The authors make the point that because mobile phones can be used to call for help individuals may put themselves in dangerous situations, for example, hazardous pursuits.

There has been an increase in inappropriate calls made to the emergency services through unintentional calling by mobile phones. Martens et al. [24] show that 37% of calls made to a Dutch emergency dispatch centre in 1997 were from global systems for mobile communications (GSM) and of these 82% were inappropriate. In 1998 the percentage of GSM calls had increased to 52% but of these 90% were inappropriate.

Many papers are concerned with other uses of mobile phones. One such paper is by Akella [25] and looks at automated collision notification (ACN). Akella shows response times and mortality rates can be reduced by ACN. The technology used in mobile phones can be used in the form of alarm systems attached to patients at risk of a cardiac arrest. These alarms alert passers-by and emergency staff that an arrest has occurred, thus helping to reduce response times [26]. Video systems can be used to monitor prehospital patients to enable the appropriate system to be in place when a patient arrives at hospital.

Perhaps the most useful way mobile technology can be used is in the transmission of ECGs from prehospital staff to emergency room staff. An ECG is essential before thrombolysis treatment can be administered and, therefore, if performed in the prehospital stages of care response times can be substantially reduced. Terkelsen

Section 3 11

et al. [27] conducted a study to see if physicians at remote hospitals can diagnose ST-segment-evaluation-AMI in patients with a suspected acute myocardial infarction, using an ECG transmitted via a global system for mobile communications. The authors showed that, although on-the-scene times were longer, the door-to- needle times were shorter. The use of technology such as ECG transmission will be especially important in circumstances involving long travel times to the hospital.

3.3 CONCLUSIONS

In conclusion, it can be seen that there is a need for quick responses to trauma, especially cardiac arrests and myocardial infarctions. There is an increase in mortality if treatment is delayed. The concept of a ‘golden hour’ seems to be misleading, with the critical time from symptoms to treatment varying for different acute problems, for example, defibrillation of myocardial infarctions should be given within 10 minutes and antibiotics for pneumonia needs to be given within eight hours. Not all acutely ill patients reach hospital within the recommended time frame. To address this ambulances could only serve a predefined area [14], and the number of ambulances could be increased, though to improve response times for the small proportion of time sensitive emergencies would require a large fleet expansion. To reduce the time from symptoms to treatment prehospital staff should be required to provide more treatment, such as CPR, thrombolysis treatment and defibrillation.

It is important to note that not all emergency calls warrant a rapid response; prioritisation of calls could help with this. Delay is also difficult to measure, for example, people do not always know or cannot remember when the symptoms of an acute event occurred.

There is no doubt that mobile phones are useful in summoning help. In 1996 half a million calls to 911 were made from mobile phones in Canada [24]. Chapman et al. discussed the potential for mobile phone to save lives but no evidence of this was provided. The benefits of mobile phones could lay elsewhere, in the use by medical staff in the monitoring and early diagnosis of prehospital patients and in automated collision or health problem notification.

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Section 4: Conclusions

4.1 MAIN FINDINGS

The main findings from the literature review are:

• For the ‘golden hour’: o An early response to a trauma increases the chances of survival to discharge; o For patients who have suffered a cardiac arrest, survival depends on prompt delivery of defibrillation. After ten minutes the chances of defibrillation being successful are greatly reduced; o After a myocardial infarction, the British Heart Foundation recommend thrombolysis treatment should be administered during the first 90 minutes to increase survival. Survival can be increased from 23%, if treatment is given after three hours, to 45%, if treatment is given in the first hour; o Pneumonia patients need to be treated during the first eight hours of symptoms; o Mean response times are mostly within an hour but this does not always translate to mean call to treatment times. • For Mobile phones: o The use of mobile phones to call the emergency services has the potential to save some lives; o There is no data on how many lives can be saved; o The number of inappropriate calls to emergency service via mobile phones is on the increase; o There is scope to use mobile technology for monitoring, image transmission, automatic vehicle collision transmission and alarm systems; o There is potential for the use of mobile communications in the transmission of ECG from pre-hospital staff to emergency room staff.

4.2 CONCLUSIONS

There is a need for a quick response to traumas but this does not always have to be within an hour. In the case of cardiac arrests and myocardial infarctions, responses need to be within 10 to 15 minutes but for pneumonia it can be up to eight hours. There is a need to reduce response times further, especially for cardiac arrests and

Section 4 13 myocardial infarctions. Mobile phones have been shown to be used to call ambulance services but there is no information as to the health benefits this provides. It is unclear as to whether mobile phone use would enable the emergency services to reach patients any quicker than they currently do. Research should, therefore, focus on initiatives the emergency services could implement themselves to reduce response times, for example, by the use of targeted response systems and by increasing the number of ambulances. There is scope for mobile phone technology to be used by prehospital staff to reduce symptom-to-treatment times and research should focus on these areas.

Q:\wpwin60\smr\Reports\PAW119\FinalReport-June04.doc CIS/18.06.04

Section 4 14

References

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2. Trunkey D. Trauma: Accidental and international injuries account for more years of life lost in the US than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further research. Scientific American. 1983; 249 20-27.

3. Advanced Trauma Life Support. Students Course Manual. Sixth Edition. American College of Surgeons.C33N.St Clair, Chicago, IL, 60611. 1997; 19- 11.

4. Pell JP, Sirel JM, Marsden AK, Ford I, Cobbe SM. Effect of reducing ambulance response times on deaths from out of hospital cardiac arrest: cohort study [see comment]. Bmj. 2001; 322 (7299): 1385-8.

5. Hotvedt R Kristiansen IS. Does a shorter response time improve patient outcome in ambulance helicopter programmes? Pre-Hospital Immediate Care. 1999; 3(3) 136-9.

6. Heward A, Damiani M, Hartley-Sharpe C. Does the use of the Advanced Medical Priority Dispatch System affect cardiac arrest detection? Emergency Medicine Journal. 2004; 21 (1): 115-118.

7. Leung LP, Wong TW, Tong HK, Lo CB, Kan PG. Out-of-hospital cardiac arrest in Hong Kong. Prehospital Emergency Care. 2001; 5 (3): 308-11.

8. Pell JP. The debate on public place defibrillators: charged but shockingly ill informed. Heart. 2003; 89 (12): 1375-1376.

9. Pell JP, Sirel JM, Marsden AK, Ford I, Walker NL, Cobbe SM. Potential impact of public access defibrillators on survival after out of hospital cardiopulmonary arrest: retrospective cohort study. British Medical Journal. 2002; 325 (7363): 515-517.

10. Smith KL, McNeil JJ, Emergency Medical Response Steering C. Cardiac arrests treated by ambulance paramedics and fire fighters [see comment]. Medical Journal of Australia. 2002; 177 (6): 305-9.

11. Walker A, Sirel JM, Marsden AK, Cobbe SM, Pell JP. Cost effectiveness and cost utility model of public place defibrillators in improving survival after prehospital cardiopulmonary arrest. British Medical Journal. 2003; 327 (7427): 1316-1319.

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12. MacDonald RD, Mottley JL, Weinstein C. Impact of prompt defibrillation on cardiac arrest at a major international airport. Prehospital Emergency Care. 2002; 6 (1): 1-5.

13. Boersma E, Maas AC, Deckers JW, Simoons ML. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour [see comment]. Lancet. 1996; 348 (9030): 771-5.

14. Al-Ghamdi AS. Emergency medical service rescue times in Riyadh. Accident Analysis & Prevention. 2002; 34 (4): 499-505.

15. Altintas KH Bilir N. Ambulance times of Ankara emergency aid and rescue services' ambulance system. European Journal of Emergency Medicine. 2001; 8 (1): 43-50.

16. Birkhead J National Audit of Myocardial Infarction P. Where are we today? Early results from MINAP, the National Audit of Myocardial Infarction Project. Heart (British Cardiac Society). 2003; 89 (Suppl 2): 13-5.

17. Hourigan CT, Mountain D, Langton PE, Jacobs IG, Rogers IR, Jelinek GA, Thompson PL. Changing the site of delivery of thrombolytic treatment for acute myocardial infarction from the coronary care unit to the emergency department greatly reduces door to needle time [see comment]. Heart (British Cardiac Society). 2000; 84 (2): 157-63.

18. Stoykova B, Dowie R, Bastow P, Rowsell KV, Gregory RPF. Ambulance emergency services for patients with coronary heart disease in Lancashire: Achieving standards and improving performance. Emergency Medicine Journal. 2004; 21 (1): 99-104.

19. Athey S Stern S. The Impact of Information Technology on Emergency Health Care Outcomes. RAND Journal of Economics. 2002; 33 399-432.

20. Breen N, Woods J, Bury G, Murphy AW, Brazier H. A national census of ambulance response times to emergency calls in Ireland. Journal of Accident & Emergency Medicine. 2000; 17 (6): 392-5.

21. Rawles J, Sinclair C, Jennings K, Ritchie L, Waugh N. Call to needle times after acute myocardial infarction in urban and rural areas in northeast Scotland: prospective observational study [see comment]. Bmj. 1998; 317 (7158): 576-8.

22. Svensson L, Karlsson T, Nordlander R, Wahlin M, Zedigh C, Herlitz J. Safety and delay time in prehospital thrombolysis of acute myocardial infarction in urban and rural areas in Sweden. American Journal of Emergency Medicine. 2003; 21 (4): 263-70.

23. Chapman S Schofield WN. Lifesavers and Samaritans: emergency use of cellular (mobile) phones in Australia. Accident Analysis & Prevention. 1998; 30 (6): 815-9.

References 16

24. Martens P, Calle P, Cornet JP, Muller N. Inappropriate calls to an emergency medical despatch centre via cellular telephones--no impact of a once-only multimedia coverage. European Journal of Emergency Medicine. 1999; 6 (1): 5-7.

25. Akella MR, Bang C, Beutner R, Delmelle EM, Batta R, Blatt A, Rogerson PA, Wilson G. Evaluating the reliability of automated collision notification systems. Accident Analysis & Prevention. 2003; 35 (3): 349-60.

26. Miller B. Rationale and specifications for an automatic cardiac arrest-driven alarm and 911 caller ID (ACADA/911). Medical Hypotheses. 1997; 48 (5): 449-51.

27. Terkelsen CJ, Norgaard BL, Lassen JF, Gerdes JC, Ankersen JP, Romer F, Nielsen TT, Andersen HR. Telemedicine used for remote prehospital diagnosing in patients suspected of acute myocardial infarction. Journal of Internal Medicine. 2002; 252 (5): 412-20.

References 17

APPENDIX A

Search Strategies: Golden Hour

ELECTRONIC DATABASE SEARCHES

MEDLINE strategy (Ovid Gateway). Internet. 1996-2004/Mar week 4. 7th April 2004

The MEDLINE database was searched on the 7th April 2004. 1340 records were retrieved. PubMed was also searched for more recent references that have yet to be indexed in MEDLINE. This search found an additional 98 records.

1. golden hour.ti,ab. 2. (first hour or 1st hour or one hour or 1 hour or 1 hr or 60 minute$ or sixty minute$).ti,ab. 3. (response adj3 (time$ or rate$)).ti,ab. 4. 2 or 3 5. (interven$ or treatment$ or present$ or resuscit$ or admission or admit or arrival$ or hospital$ or delay$ or wait$ or hesitat$).ti,ab. 6. 4 and 5 7. exp Emergency Medical Services/ 8. Emergencies/ 9. exp AMBULANCES/ 10. emergenc$.ti,ab. 11. (accident$ or injur$).ti,ab. 12. trauma$.ti,ab. 13. ambulance$.ti,ab. 14. or/7-13 15. 1 or (6 and 14) 16. animal/ 17. human/ 18. 16 not (16 and 17) 19. 15 not 18

EMBASE strategy (Ovid Gateway). Internet. 1996-2004/week 14. 7th April 2004

The Embase database was searched on the 7th April 2004. 1209 records were retrieved.

1. golden hour.ti,ab. 2. (first hour or 1st hour or one hour or 1 hour or 1 hr or 60 minute$ or sixty minute$).ti,ab. 3. (response adj3 (time$ or rate$)).ti,ab. 4. 2 or 3 5. (interven$ or treatment$ or present$ or resuscit$ or admission or admit or arrival$ or hospital$ or delay$ or wait$ or hesitat$).ti,ab. 6. 4 and 5 7. emergency health service/ 8. emergency/ 9. ambulance/ 10. emergenc$.ti,ab. 11. (accident$ or injur$).ti,ab. 12. trauma$.ti,ab. 13. ambulance$.ti,ab. 14. or/7-13

Appendix A i

15. 1 or (6 and 14) 16. (rat or rats or mouse or mice or hamster or hamsters or animal or animals or dogs or dog or cats or bovine or sheep).ti,ab,sh. 17. exp Animal/ 18. nonhuman/ 19. exp Human/ 20. 16 or 17 or 18 21. 20 not (20 and 19) 22. 15 not 21

Cinahl Strategy (Ovid Gateway). Internet. 1996-2004/April week 1. 7th April 2004

The Cinahl database was searched on the 7th April 2004. 441 records were retrieved.

1. golden hour.ti,ab. 2. (first hour or 1st hour or one hour or 1 hour or 1 hr or 60 minute$ or sixty minute$).ti,ab. 3. (response adj3 (time$ or rate$)).ti,ab. 4. 2 or 3 5. (interven$ or treatment$ or present$ or resuscit$ or admission or admit or arrival$ or hospital$ or delay$ or wait$ or hesitat$).ti,ab. 6. 4 and 5 7. exp Emergency Medical Services/ 8. EMERGENCIES/ 9. exp AMBULANCES/ 10. emergenc$.ti,ab. 11. (accident$ or injur$).ti,ab. 12. trauma$.ti,ab. 13. ambulance$.ti,ab. 14. or/7-13 15. 1 or (6 and 14)

BNI strategy (Ovid Gateway). Internet. 1996-2004/03. 7th April 2004

The BNI database was searched on the 7th April 2004. 0 records were retrieved.

1. golden hour.ti,ab. 2. (first hour or 1st hour or one hour or 1 hour or 1 hr or 60 minute$ or sixty minute$).ti,ab. 3. (response adj3 (time$ or rate$)).ti,ab. 4. 2 or 3 5. (interven$ or treatment$ or present$ or resuscit$ or admission or admit or arrival$ or hospital$ or delay$ or wait$ or hesitat$).ti,ab. 6. 4 and 5 7. emergenc$.ti,ab. 8. (accident$ or injur$).ti,ab. 9. trauma$.ti,ab. 10. ambulance$.ti,ab.

Appendix A ii

11. or/7-10 12. 1 or (6 and 11)

HMIC strategy (Ovid WebSPIRS). Internet. 1996-2004/03. 7th April 2004

The HMIC database was searched on the 7th April 2004. 72 records were retrieved.

#1 golden hour in ti,ab #2 (first hour or 1st hour or one hour or 1 hour or 1 hr or 60 minute* or sixty minute*) in ti,ab #3 (response near3 (time* or rate*)) in ti,ab #4 #2 or #3 #5 (interven* or treatment* or present* or resuscit* or admission or admit or arrival* or hospital* or delay* or wait* or hesitat*) in ti,ab #6 #4 and #5 #7 emergenc* in ti,ab #8 (accident* or injur*) in ti,ab #9 trauma* in ti,ab #10 ambulance* in ti,ab #11 #7 or #8 or #9 or #10 #12 #1 or (#6 and #11

Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials (CENTRAL). Cochrane Library. Internet, Issue 1:2004. 1996-2004. 7th April 2004

The CDSR and CENTRAL were searched on the Cochrane Library on the 7th April 2004. 166 reviews were retrieved from the CDSR database, but none were relevant. 163 records were found on CENTRAL, but only 5 were retained as potentially relevant.

#1 (golden next hour) #2 ((first next hour) or (one next hour) or (sixty next minute*)) #3 ((response next time*) or (response next rate*)) #4 (#2 or #3) #5 (interven* or treatment* or present* or resuscit* or admission or admit or arrival* or hospital* or delay* or wait* or hesitat*) #6 EMERGENCY MEDICAL SERVICES explode tree 1 (MeSH) #7 EMERGENCIES single term (MeSH) #8 AMBULANCES explode tree 2 (MeSH) #9 emergenc* #10 accident* #11 trauma* #12 ambulance* #13 (#7 or #8 or #9 or #10 or #11 or #12 or #13) #14 (#1 or (#6 and #14))

Appendix A iii

DARE, HTA and NHS EED strategy. Internal CRD CAIRS interface. 1996- 2004/03. 7th April 2004

The DARE, HTA and NHS EED databases were searched on the 7th April 2004. 17 records were retrieved from DARE, 25 from NHS EED, and 0 records were retrieved from HTA. s golden(w)hour s first(w)hour or one(w)hour or sixty(w)minute$ s response(w)time* or response next rate* s s2 or s3 s intervene$ or treatment$ or present$ or resuscit$ or admission or admit or arrival$ or hospital$ or delay$ or wait$ or hesitat$ s s4 and s5 s emergenc$ s accident$ s trauma$ s ambulance$ s s7 or s8 or s9 or s10 s s1 or (s6 and s11)

PsycINFO strategy (Ovid WebSPIRS). Internet. 1996-2004/03 week 5. 7th April 2004

The PsycINFO database was searched on the 7th April 2004. 127 records were retrieved, but none were relevant.

#1 golden hour in ti,ab #2 (first hour or 1st hour or one hour or 1 hour or 1 hr or 60 minute* or sixty minute*) in ti,ab #3 (response near3 (time* or rate*)) in ti,ab #4 #2 or #3 #5 (interven* or treatment* or present* or resuscit* or admission or admit or arrival* or hospital* or delay* or wait* or hesitat*) in ti,ab #6 #4 and #5 #7 emergenc* in ti,ab #8 (accident* or injur*) in ti,ab #9 trauma* in ti,ab #10 ambulance* in ti,ab #11 #7 or #8 or #9 or #10 #12 #1 or (#6 and #11

Science Citation Index and Social Science Citation Index strategy (Web of Science). Internet. 1996-2004/04. 7th April 2004

The SCI and SSCI databases were searched on the 7th April 2004. 109 records were retrieved.

TS=golden hour TS=(first hour or 1st hour or one hour or 1 hour or 1 hr or 60 minute* or sixty minute* or response time* or response rate*)

Appendix A iv

TS=(intervene* or treatment* or present* or resuscit* or admission or admit or arrival* or hospital* or delay* or wait* or hesitat*) TS=(emergenc* or accident* or injur* or trauma* or ambulance*) #2 and #3 and #4 #1 or #5

OHE HEALTH ECONOMIC EVALUATION DATABASE (HEED). CD-ROM. 1996- 2004/04. 7TH APRIL 2004

The HEED database was searched on the 7th April 2004. 24 records were retrieved.

AX=golden hour AX=(first hour) or (1st hour) or (one hour) or (1 hour) or (1 hr) or (60 minute) or (60 minutes) or (sixty minute) or (sixty minutes) AX=(response time) or (response times) or (response rate) or (response rates) CS=2 or 3 AX=intervention or treatment or presentation or present or resuscitate or resuscitation or admission or admit or arrival or hospital or delay or wait or hesitate CS=4 and 5 AX=emergency or emergencies AX=accident or accidents AX=ambulance or ambulances AX=trauma CS=7 or 8 or 9 or 10 CS=6 and 11 CS=1 or 12 JD>=1996 CS=13 and 14

CITATION SEARCHES

Brief Citation searching was undertaken using an article already identified, and the lead author of this article.

Pell JP, Sirel JM, Marsden AK, Ford I, Cobbe SM. Effect of reducing ambulance response times on deaths from out of hospital cardiac arrest: cohort study. BMJ 2001;322:1385-8.

14 further references were retrieved.

INTERNET SEARCHES

The Internet searches using Copernic and Google search engines were as unsuccessful as the previous Internet searches for mobile phone and emergency service use. Totally irrelevant web sites were identified relating to music CDs, an Israeli evidence based medicine information site, and various companies using the name ‘Golden Hour’.

Appendix A v

APPENDIX B

Search Strategies: Mobile Phones for Calling Ambulance Services

ELECTRONIC DATABASE SEARCHES

MEDLINE strategy (Ovid Gateway). Internet. 1996-2004/Mar week 4. 6th April 2004

The MEDLINE database was searched on the 6th April 2004. 80 records were retrieved. PubMED was also searched for more recent references that have yet to be indexed in MEDLINE. This search found an additional 2 records.

1. exp Emergency Medical Services/ 2. exp AMBULANCES/ 3. EMERGENCIES/ 4. emergenc$.ti,ab. 5. accident$.ti,ab. 6. ambulance$.ti,ab. 7. ("911" or 9-1-1 or "999").ti,ab. 8. or/1-7 9. Cellular Phone/ 10. (mobile adj3 (phone$ or telephone$)).ti,ab. 11. (cell$ adj3 (phone$ or telephone$)).ti,ab. 12. cellphone$.ti,ab. 13. (car phone$ or carphone$).ti,ab. 14. (wireless adj3 (phone$ or telephone$)).ti,ab. 15. (cordless adj3 (phone$ or telephone$)).ti,ab. 16. or/9-15 17. 8 and 16

EMBASE strategy (Ovid Gateway). Internet. 1996-2004/week 14. 6th April 2004

The Embase database was searched on the 6th April 2004. 42 records were retrieved.

1. emergency health service/ 2. ambulance/ 3. emergency/ 4. emergenc$.ti,ab. 5. accident$.ti,ab. 6. ambulance$.ti,ab. 7. ("911" or 9-1-1 or "999").ti,ab. 8. or/1-7 9. mobile phone/ 10. (mobile adj3 (phone$ or telephone$)).ti,ab. 11. (cell$ adj3 (phone$ or telephone$)).ti,ab. 12. cellphone$.ti,ab. 13. (car phone$ or carphone$).ti,ab. 14. (wireless adj3 (phone$ or telephone$)).ti,ab. 15. (cordless adj3 (phone$ or telephone$)).ti,ab. 16. or/9-15 17. 8 and 16

Appendix B i

Cinahl strategy (Ovid Gateway). Internet. 1996-2004/April week 1. 6th April 2004

The Cinahl database was searched on the 6th April 2004. 81 records were retrieved.

1. exp Emergency Medical Services/ 2. Ambulances/ 3. exp Emergencies/ 4. emergenc$.ti,ab. 5. accident$.ti,ab. 6. ambulance$.ti,ab. 7. ("911" or 9-1-1 or "999").ti,ab. 8. or/1-7 9. Wireless Communications/ 10. (mobile adj3 (phone$ or telephone$)).ti,ab. 11. (cell$ adj3 (phone$ or telephone$)).ti,ab. 12. cellphone$.ti,ab. 13. (car phone$ or carphone$).ti,ab. 14. (wireless adj3 (phone$ or telephone$)).ti,ab. 15. (cordless adj3 (phone$ or telephone$)).ti,ab. 16. or/9-15 17. 8 and 16

BNI strategy (Ovid Gateway). Internet. 1996-2004/03. 6th April 2004

The BNI database was searched on the 6th April 2004. 0 records were retrieved.

1.ambulance services/ 2. ambulance$.mp. 3. emergenc$.ti,ab. 4. 1 or 2 or 3 6. (mobile adj3 (phone$ or telephone$)).ti,ab. 7. (cell$ adj3 (phone$ or telephone$)).ti,ab. 8. cellphone$.ti,ab. 9. (car phone$ or carphone$).ti,ab. 10. (wireless adj3 (phone$ or telephone$)).ti,ab. 11. (cordless adj3 (phone$ or telephone$)).ti,ab. 12. or/5-11 13. 4 and 12

Appendix B ii

HMIC strategy (Ovid WebSPIRS). Internet. 1996-2004/03. 6th April 2004

The HMIC database was searched on the 6th April 2004. 8 records were retrieved.

#1 emergenc* in ti,ab #2 accident* in ti,ab #3 ambulance* in ti,ab #4 ("911" or 9-1-1 or "999") in ti,ab #5 #1 or #2 or #3 or #4 #6 (mobile near3 (phone* or telephone*)) in ti,ab #7 (cell* near3 (phone* or telephone*)) in ti,ab #8 cellphone* in ti,ab #9 (car phone* or carphone*) in ti,ab #10 (wireless near3 (phone* or telephone*)) in ti,ab #11 (cordless near3 (phone* or telephone*)) in ti,ab #12 #6 or #7 or #8 or #9 or #10 or #11 #13 #5 and #12

Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials (CENTRAL). Cochrane Library. Internet, Issue 1:2004. 1996-2004. 6th April 2004

The CDSR and CENTRAL were searched on the Cochrane Library on the 6th April 2004. 3 completed reviews and 1 protocol were retrieved from the CDSR database. 3 records were found on CENTRAL.

#1 EMERGENCY MEDICAL SERVICES explode tree 1 (MeSH) #2 AMBULANCES explode tree 2 (MeSH) #3 EMERGENCIES single term (MeSH) #4 emergenc* #5 accident* #6 ambulance* #7 (#1 or #2 or #3 or #4 or #5 or #6) #8 CELLULAR PHONE single term (MeSH) #9 ((mobile near phone*) or (mobile near telephone*)) #10 ((cell* near phone*) or (cell* near telephone*)) #11 cellphone* #12 ((car next phone*) or carphone*) #13 ((wireless near phone*) or (wireless near telephone*)) #14 ((cordless near phone*) or (cordless near telephone*)) #15 (#8 or #9 or #10 or #11 or #12 or #13 or #14) #16 #7 and #15

Appendix B iii

DARE, HTA and NHS EED strategy. Internal CRD CAIRS interface. 1996- 2004/03. 6th April 2004

The DARE, HTA and NHS EED databases were searched on the 6th April 2004. 1 record was retrieved from DARE, 1 from NHS EED, and 0 records were retrieved from HTA. s emergenc$ s accident$ s ambulance$ s s1 or s2 or s3 s mobile(w3)(phone$ or telephone$) s cell$(w3)(phone$ or telephone$) s cellphone$ s car(w)phone$ or carphone$ s wireless(w3)(phone$ or telephone$) s cordless(w3)(phone$ or telephone$) s s5 or s6 or s7 or s8 or s9 or s10 s s4 and s11

PsycINFO strategy (Ovid WebSPIRS). Internet. 1996-2004/03 week 5. 6th April 2004

The PsycINFO database was searched on the 6th April 2004. 4 records were retrieved.

#1 "Emergency-Services" in DE #2 emergenc* in ti,ab #3 accident* in ti,ab #4 ambulance* in ti,ab #5 ("911" or 9-1-1 or "999") in ti,ab #6 #1 or #2 or #3 or #4 or #5 #7 (mobile near3 (phone* or telephone*)) in ti,ab #8 (cell* near3 (phone* or telephone*)) in ti,ab #9 cellphone* in ti,ab #10 (car phone* or carphone*) in ti,ab #11 (wireless near3 (phone* or telephone*)) in ti,ab #12 (cordless near3 (phone* or telephone*)) in ti,ab #13 #7 or #8 or #9 or #10 or #11 or #12 #14 #6 and #13

Appendix B iv

Science Citation Index and Social Science Citation Index strategy (Web of Science). Internet. 1996-2004/04. 6th April 2004

The SCI and SSCI databases were searched on the 6th April 2004. 91 records were retrieved.

(emergenc* or accident* or ambulance* ) and (mobile phone* or mobile telephone* or cell* phone* or cell* telephone* or cellphone* or car phone* or carphone* or wireless phone* or wireless telephone* or cordless phone* or cordless telephone*)

OHE Health Economic Evaluation Database (HEED). CD-ROM. 1996-2004/04. 6th April 2004

The HEED database was searched on the 6th April 2004. No relevant records were retrieved.

AX=emergency or emergencies AX=accident or accidents AX=ambulance or ambulances CS=1 or 2 or 3 AX=(mobile phone) or (mobile phones) or (mobile telephone) or (mobile telephones) AX=(cell phone) or (cell phones) or (cellular phone) or (cellular phones) or (cell telephone) or (cellular telephones) AX=cellphone or cellphones AX=(car phone) or (car phones) or carphone or carphones AX=(wireless phone) or (wireless phones) or wireless telephone) or (wireless telephones) AX=(cordless phone) or (coreless phones) or (cordless telephone) or (cordless telephones) CS=5 or 6 or 7 or 8 or 9 or 10 CS=4 and 11 JD>=1996 CS=12 and 13

CITATION SEARCHES

Brief Citation searching was undertaken using an article already identified, and the lead author of this article.

Chapman S, Schofield WN. Lifesavers and Samaritans: emergency use of cellular (mobile) phones in Australia. Accident Analysis & Prevention 1998;30:815-9.

No further useful cited references were retrieved.

Appendix B v

INTERNET SEARCHES

Attempted Internet searches using Copernic and Google search engines were unsuccessful. Other than a number of references to work in Australia by Simon Chapman, which had already been retrieved in the database searches, the results were not relevant. Most hits referred to selling phones with emergency charging devices, ambulance services using mobile phones, transmission of images via mobile phones, as well as health problems related to mobile phone use, and accidents caused by drivers using mobile phones.

Appendix B vi

APPENDIX C

Golden Hour Template

Directly related to Urban / Time before Number Reference Country Status Study type Objective Event the Golden Rural calling for help Hour

Yes- authors Al-Ghamdi. comment To investigate rescue Emergency medical A study that times, the service Injuries service rescue times looking at 874 Saudi Full ambulance provided for road traffic caused by 1 in Riyadh. Accident emergency Urban Not stated Arabia article response accidents and performs road traffic Analysis and calls made times are a comparison with other accidents. Prevention. 2002; 34: over 20 days. linked to countries. 499-505. survival

Altintas and Bilir. Yes - Ambulance times of comments Ankara emergency that delays in Descriptive aid and rescue To determinate Full getting study carried 2 services ambulance Turkey ambulance response Urban Any Not stated article patients to out over a system. European times. hospital can year Journal of Emergency cause loss of Medicine. 2001; 8: life. 43-50.

Athey and Stern. The impact of information technology on To study enhanced 911 Yes - looks Model of emergency health Full and its impact on Cardiac 3 US at response emergency Both Not stated care outcomes. article speeding up emergency arrest times health care. RAND Journal of responses. Economics. 2002; 33: 399-432

Appendix C i

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident Mean time from receiving the call to the ambulance being back at The authors suggest that to the station was 61.19 minutes. ensure the ambulance The time from the call to the reaches the patients within patient arriving at the hospital the desired time 1 EMS First aid Ambulance Increased survival rates (rescue time) was 35.85 minutes. ambulances should only Mean response time was 10.23 serve a predefined radius minutes (ambulance dispatch to based on their expected arrival at scene). Mean time at speed of travel. scene was 15.20 minutes. Average time from calling for help to ambulance being dispatched was 2.49 minutes. Average time on the scene was 9.36 minutes. Average time from the ambulance There should be more being despatched and arriving ambulances to help reduce back at the station was 61.89 times. Monitoring of calls 2 minutes. Average time from the EMS Not stated. Ambulance Potential for lives to be saved. should improve. Digital station to the scene was 9.16 recording would help with minutes. The average time from this. the scene to the hospital was 13.28. The average total time was 32.31. The average arrival at the scene to patient contact time was 3.46 minutes.

E911 improves response times and patient welfare. 3 Not stated E911, 911 Not stated Not stated Not stated Only 20% of emergency calls are due to cardiac arrests

Appendix C ii

Directly related to Urban / Time before Number Reference Country Status Study type Objective Event the Golden Rural calling for help Hour

Birkhead. Where are 8% of patients we today? Early To investigate door-to- received Yes- looks at results from MINAP, needle times. The treatment within the time it An early look the national audit of Full target to be reached by Not Myocardial the first 60 4 UK takes for at the MINAP myocardial infarction article April 2002 is 30 minutes stated infarction. minutes of patients to project project. Heart. and by April 2003 is 20 calling for help receive care 2003; 89: minutes. in 1993 and supplement 2. 34% in 2002.

Boersma et al. Early thrombolytic Yes - A study treatment in acute treatment is looking at all myocardial To investigate the gains The Full only able to randomised Myocardial 5 infarction: from initiation of very Both Not stated Netherlands article be given if it trials between infarction. reappraisal of the early treatment. is initiated 1983 and golden hour. The early. 1993. Lancet. 1996; 348: 771-75

Appendix C iii

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident Via a call to the GP or the It takes 40 minutes for 50% of emergency Under 70% of patients patients who call an ambulance to services. received thrombolytic reach hospital. The median door- Those who treatment within the first 30 to-needle time in 1992 was 53 Thrombolytic 4 Not stated call 999 Not stated minutes of arrival at minutes and 26 minutes in 2002. treatment reach hospital. But only 37% In 2001 43% of patients received hospital within the first hour of calling treatment within 30 minutes of more quickly for help. arrival and 67% in 2002. than those calling the GP. For patients presenting within For up to 12 hours one hour the reduction in fibrinolytic therapy is mortality was the greatest, there beneficial. Fibrinolytic were 65 lives saved per 1000 therapy should be initiated treated patients. The lives per within the first 2 to 3 hours 1000 saved at 2-3 hours of symptoms. The use of Response times up to 24 hours Fibrinolytic presentation was 26, at 3-6 it 5 Not stated Not stated ECG by first responders can were looked at therapy. was 29, at 6-12 hours it was 18 provide a quick diagnosis and at 12-24 hours it was 9. which leads to rapid Mortality increased the longer initiation of thrombolytic the time from presentation. therapy. Survival rates are There is a reduction in benefit of improved by quick 1.6 lives per 1000 for each hour treatment. Fibrinolytic therapy is delayed.

Appendix C iv

Directly related to Urban / Time before Number Reference Country Status Study type Objective Event the Golden Rural calling for help Hour

Any Breen et al. A emergency national census of call- collapse, Yes - ambulance response cardiac arrest, discusses times to emergency To investigate response cardiac Full response Prospective 6 calls in Ireland. Ireland times and the factors Both (other), chest Not stated article times and the study. Journal of Accident that cause delays. pain, road likely effect and Emergency traffic on mortality Medicine. 2000; 17: accidents and 392-395. other accidents.

Brodie et al. Effect of treatment delay on outcomes on patients To investigate the Yes - with acute myocardial outcomes of patients transferring infarction transferred who present at a local patients from community Cohort study hospital with AMI but Full could delay 7 hospitals for primary US on 1841 who are transferred to a Rural AMI Not stated article treatment percutaneous patients. hospital with the times and coronary intervention. facilities to give effect The American percutaneous coronary survival Journal of intervention (PCI). Cardiology. 2002; 89: 1243-1247.

Appendix C v

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident Within nine minutes 38% of calls, The authors comment that 43% of on-duty calls and 11% of not all emergency calls on-call calls had a response. warrant rapid response. Within nine minutes 44% in urban There needs to be a method areas and 29% in rural areas had in place for prioritising calls. a response. In urban areas 81% Vehicles attending critical had a response within 15 minutes. incidents need to be In rural 55% had a response within properly equipped, 27 minutes. 46% of emergency Potential to save lives and gain 6 Not stated Not stated Ambulance prioritising will help with this. calls made within a five mile radius life years. The authors comment that of the ambulance station had a effective immediate care response within nine minutes. 5% (quick response times) are a of calls made within a six to ten cost effective use of mile radius were responded to resources and compare well within nine minutes. Only 27% of with other types of calls made more than 20 miles intervention (breast, cervical away were responded to in 27 cancer screening). minutes.

The initial delay of starting Transferred patients presented at primary PCI was 54 minutes the emergency department slightly in transferred patients. Mortality was similar in the earlier than non transferred Other clinical outcomes 7 Not stated PCI Ambulance transferred and non transferred patients. Their door-to-balloon (frequency of achieving groups. times were one hour longer than TIMI-3 flow, early and late the non-transferred patients. mortality) were similar in both groups.

Appendix C vi

Directly related to Urban / Time before Number Reference Country Status Study type Objective Event the Golden Rural calling for help Hour

Califf and Newby. How much do we Yes - the gain by reducing time earlier the To discuss the benefits to reperfusion Full treatment the Discussion of Not Myocardial 8 US of treating within the first Not stated therapy. American article better the issues relevant. infarction. hour. Journal of Cardiology. chances of 1996; 78 (supplement survival. 12A): 8-15.

Cardiac arrest Eng Hock Ong et al. caused by Cardiac arrest and To look at out-of- choking, resuscitation Yes - survival Prospective hospital cardiac arrests suffocation, Mean time was epidemiology in Full rates linked observational in Singapore and traffic 9 Singapore Urban 10.6 minutes Singapore (Care I article to the chain study with emergency medical accidents, (SD=13.1) Study). Pre-hospital of survival 548 patients. services (EMS) falls, Emergency Care. responses. drowning, 2003; 7: 427-4433 poisoning and other injuries

Appendix C vii

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident

There is an increase in Increased survival rates and mortality the longer reduced complications. FTT treatment is delayed from Myocardial analysis shows only 1.6 per 8 Not stated Not stated Not stated the onset of symptoms. The reperfusion. 1000 lives would be saved from major problem is in getting reducing time to treat by an people with symptoms to hour. present early.

The survival to hospital after having a pre-hospital arrest was 2%. The lower survival In 27.3% of patients the EMS was rate in urban settings is called before collapse. In 8.1% of 63 had a return of spontaneous thought to be due to longer patients the EMS was called at the circulation, 30 survived to response times. There is a time of collapse. Time from call to EMS run by hospital, 7 survived to hospital problem of people not ambulance dispatch was 0.7 the Civil discharge. If the arrest was 9 CPR Ambulance recognising a cardiac arrest minutes (SD=1.1). The mean Defence witnessed by a member of the and, therefore, not calling EMS response time was 10.3 Force ambulance crew, compared to a the ambulance. It is minutes (SD=4.3). Mean time bystander, they were more likely essential that cardiac arrest from call to defibrillation was 16.7 to survive sufferers receive early CPR. minutes (SD=7.2). Fast response times and EMS can significantly increase survival rates.

Appendix C viii

Directly related to Urban / Time before Number Reference Country Status Study type Objective Event the Golden Rural calling for help Hour

To investigate the relationship between Fan et al. Prognosis prognosis of out-of- of patients with Yes hospital cardiac arrest ventricular fibrillation defibrillation patients and the chain of in out-of-hospital Prospective needs to be survival (early access to cardiac arrest in Full descriptive Ventricular 10 Japan administered emergency medical Urban Not stated Hong Kong: article study , with fibrillation quickly to services (EMS), early prospective study. 320 patients. increase defibrillation and Hong Kong Medical survival rates advanced life support Journal. 2003;8:318- (ALS), early 21. cardiopulmonary resuscitation (CPR).)

Gibler et al. To examine two trials Persistence of delays which investigated in presentation and delays to hospital. treatment for patients Looked at Yes -early GUSTO I randomised with acute myocardial delays in 2 Acute Full treatment patients to 1 of four Not 11 infarction: the US multinational myocardial Not stated article decreases fibrinolytic regimens, if stated GUSTO-I and Gusto- randomised infarction/ mortality they presented within 6 III experience. trials hours. GUSTO III Annuals of compared two Emergency Medicine. regimens. 2003;39: 123:130.

Appendix C ix

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident

Median time from recognition to Time plays a large part in activation of the EMS for determining the success of ventricular and non-ventricular defibrillation, the chance of fibrillation was 1 minute. The success drops by 7 to 10% median time to CPR was 8 minute for every minute of delay. for ventricular fibrillation and 9 The chain of 41 patients received defibrillation Success is unlikely after 15 10 minutes for non-ventricular EMS survival was Ambulance before arriving at hospital. Two minutes. A 5-minute time to fibrillation. The median time to applied. survived to hospital discharge. defibrillation provides the defibrillation was 9 minutes for best chance of survival. ventricular fibrillation. The median The introduction of public time to ALS was 27 minutes for access defibrillation should ventricular and non-ventricular shorten the time to fibrillation. defibrillation

The time from symptom onset to hospital arrival was 1.4 (0.9,2.3) GUSTO-I found that the hours for GUSTO-I and 1.4 hours elderly, women, patients (0.8,2.3) for GUSTO-III. The time with diabetes and minorities form hospital arrival to treatment are susceptible to delays in was 1.1 hours (0.8,1.5) for Fibrinolytic treatment. Early arrival and 11 Not stated Not stated Increased survival rates GUSTO-I and 0.8 hours (0.6-1.2) therapy treatment was associated for GUSTO-III. The total time to with higher educated treatment was 2.7 hours (1.9,3.8) patient, private patients and for GUSTO-I and 2.3 hours patients with a professional (1.6,3.3) for GUSTO-III. occupation. (25th,75th percentiles).

Appendix C x

Directly related to Urban / Time before Number Reference Country Status Study type Objective Event the Golden Rural calling for help Hour

Heward et al. Does Yes - the use of the discusses To look at advanced Advanced Medical the fact that medical priority dispatch Priority Dispatch Full survival Before and system (EMPDS) and Cardiac 12 UK Both Not stated System affect cardiac article decreases after study whether this has arrest arrest? Emergency with every improved the detection Medicine. 2004; 21: minute after of cardiac arrests. 115-118. arrest

Hotvedt et al. Does a shorter response time A panel of improve patients Yes - looks experts outcome in at response To estimate the health Full provides their 13 ambulance helicopter Norway times and benefits from shorter Rural Any Not stated article opinions of 65 programmes? Pre- health response times. previous hospital Immediate outcomes cases. Care. 1999; 3: 136- 139.

Appendix C xi

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident DOH specifies that patients in immediate threat should be responded to within 8 AMPDS has increased cardiac minutes. By increasing the Cardiac arrest detection by 200%. number of bystanders who 12 Not stated AMPDS arrest Not stated Compliance with the protocol recognise a cardiac arrest ( detection increased the accuracy of by use of AMPDS) the cardiac arrest detection. numbers who undertake CPR increases and, therefore, survival increases. This was a small study which used experts Only 10 patients would have Mean response time was 19.7 opinions. There is scope to benefited from a reduced minutes, mean flying time was Helicopter or improve health outcomes by response time. If response time 13 26.5 minutes. Patients Not stated Not stated ground reducing response times, was reduced by 15 minutes, an transported in the helicopter 62 transport but the population served is average of 17.7 life years (18.3 minutes earlier than land transport. scattered and it is unlikely QALYS) would be gained. the helicopter can reach patients any quicker.

Appendix C xii

Directly related to Urban / Time before Number Reference Country Status Study type Objective Event the Golden Rural calling for help Hour

Mean time from pain to hospital Hourigan et al. door was 145 Changing the site of minutes in the delivery of emergency Comparative To initiate thrombolytic thrombolytic department and Yes - states observational treatment in the treatment for acute 138 in the that door-to- study with emergency department myocardial infarction Acute coronary care Full needle times prospectively and not the coronary 14 from the coronary Australia Urban myocardial unit. Mean pain article should be collected care unit. By doing this care unit to the infarction to needle time less than 60 data, 189 it was hoped that door- emergency was 193 minutes patients in to-needle times could department greatly minutes in the total. be reduced. reduces door-to- emergency needle time. Heart. department and 2000; 84: 157-163. 227 minutes in the coronary care unit.

Joyce et al. Epidemiology of paediatric EMS Yes - looks Retrospective practice: a multistate To look at the paediatric 15 US Abstract at response computer Both Any Not stated analysis. Prehospital emergency service. times analysis and Disaster Medicine. 1996; 11 (3): 180-187.

Appendix C xiii

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident

The mean door to decision time was 37 minutes in the emergency No significant difference in the The move from thrombolytic department and the coronary care overall mortally. The case treatment being given in the unit. The mean call to needle fatality rate was higher in the emergency department Thrombolytic time was 110 minutes in the emergency department. reduced door-to-needle and treatment 14 emergency department and 141 Not stated Not stated Inappropriate thrombolysis was pain-to-needle time. The given in minutes in the coronary care unit. given in three patients in the evidence suggests that the hospital The mean door-to-needle time emergency department and only quicker treatment is given was 47 minutes in the emergency one in the coronary care the greater the benefits to department and 88 minutes in the department. patient. coronary care unit.

Spinal immobilization, Mean response time was 9+/- 16 oxygen Ambulance minutes, mean time at scene was administration, The on the scene times 15 Not stated in 89% of Not stated 12+/-14 minutes and mean intravenous found were not excessive. cases transport time 14+/-20 minutes. access and ALS medication.

Appendix C xiv

Directly related to Urban / Time before Number Reference Country Status Study type Objective Event the Golden Rural calling for help Hour Layon et al. Utstein style analysis of rural out-of-hospital Yes - out-of- A study that cardiac arrest hospital To assess whether looked at all (OOHCA): total survival survival rates are out-of- cardiopulmonary US Full linked to how directly linked to the Cardiac 16 hospital Rural Not stated resuscitation (CPR) (Florida) article quickly speed of defibrillation arrest cardiac time inversely defibrillation and effective CPR given arrests during correlates with in by bystanders a year. hospital discharge administered. time. Resuscitation. 2003;56:59-66

Lerner et al. The To perform a literature golden hour: scientific Yes - a review on the golden fact or medical "urban Full literature Literature Not 17 UK hour to identify if it is Any Not relevant legend"? Academic article review on the review relevant based on medical Emergency Medicine. golden hour evidence. 2001; 8:758-760

Appendix C xv

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident

Increases in response times and bystander given CPR might improve survival rates. If emergency medical CPR and 16 Not stated EMS Ambulance Increased survival rates dispatch teams are utilised defibrillation then communications will improve that will allow EMS directed response to be dispatched.

Trunkey describes the need for a quick response, the time varies for different injuries but all are under an hour. Foster states that every 30 minutes after an accident There are no large well mortality triples. Cowely says that controlled studies in the rapid access to medical care is the civilian population that most important determinant of 17 Not relevant Not relevant. Not relevant. Not relevant support the golden hour. It outcome, in a further article he appears that the golden states the "first 60 minutes after an hour did not originate from injury determined a patients conclusive findings. resulting mortality". Frey and Hoffman suggest ambulance staff have more training but do not discuss response times and outcomes.

Appendix C xvi

Directly related to Urban / Time before Number Reference Country Status Study type Objective Event the Golden Rural calling for help Hour

Within one hour of symptoms only 25% of Review of patients had Leslie et al. Delay in medical Yes - delays made a call for calling for help during records for in calling for help. 41% had myocardial infarction: 228 men and To investigate why there help results called within reasons for the delay Full 85 women is a delay in seeking Myocardial 18 UK in delayed Urban two hours and and the subsequent article who had help after a myocardial infarction. treatment 60% within four pattern of accessing survived infarction. which effects hours. 12% of care. Heart. acute survival patients waited 2000;84:137-141. myocardial more than 24 infarction. hours. More calls were made by men.

Leung et al. Out-of- hospital cardiac Yes - looks Prospective arrest in Hong Kong. Hong Full To look at prehospital Cardiac 19 at response descriptive Both Not stated Prehospital Kong article resuscitation arrest times study Emergency Care. 2001; 5: 308-311.

Appendix C xvii

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident

To reduce the delay in seeking help the recognition Infarct size is reduced and of symptoms needs to be survival increased by the early improved. A GP was administration of a thrombolytic generally called as the first agent. If this is given within one point of contact with health hour of symptoms mortality is 18 Not stated Not stated Not stated Not stated service. Once the decision reduced by 45% and by 23% if had been taken to seek given within three hours. assistance 1/4 of patients Delaying the administration by made their own way to 30 minutes reduces life hospital, this denied them expectancy by one year. the benefits of prehospital care by ambulance crew.

On average the call to dispatch The overall survival is very time was 1.04 minutes, the call to The immediate survival was low. There are delays along 19 CPR was 9.82 minutes and the Not stated CPR Not stated 14.1% and the survival to the chain of prehospital care prehospital interval was 27.55 discharge was 1.25%. that need to be improved. minutes.

Appendix C xviii

Directly related to Urban / Time before Number Reference Country Status Study type Objective Event the Golden Rural calling for help Hour

MacDonald et al. Impact of prompt Yes - To access the impact of defibrillation on discusses Prospective trained first responders cardiac arrest at a Full the observational being used to provide Cardiac 20 US Airport Not stated major international article importance outcome defibrillation before the arrest airport. Prehospital of early study EMS team reach the Emergency Care. defibrillation airport. 2002; 6: 105.

Meighan et al. Pelvic Yes - early To assess whether A&E Questionnaire fractures: the golden UK Full treatment departments have the Pelvic 21 sent to A&E Both Not stated hour. Injury. 1998; (Scotland) article helps ability to deal with pelvic fracture. doctors. 29: 211-213. survival rates fractures.

Appendix C xix

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident

The longer time that elapses between symptoms and treatment the lower the In 94.7% of cases the airport chance of survival. Prompt The median time for the airport team proved care before the defibrillation is needed. team was 2 minutes, for the EMS EMS team. 21.1% of patients Most attacks occur in basic life support team the time survived to hospital discharge. 20 911 used Defibrillation Not stated private residence. For the was 5.29 and for the EMS In five to eight of the people who few in public areas there is advanced life support team it was survived to hospital discharge an advantage of having 8.07 minutes. the airport teams care alone trained responders (i.e. in provided the return to circulation. nursing homes, dialysis centres, sports stadiums and on aircrafts).

Pelvic fixator. The aim of the study was to Application give treatment within the of a MAST golden hour. Only 17 out of (military anti Pelvic movement is restricted the 35 hospitals has shock which prevents movement and experience in the 21 Not stated Not stated Not stated trouser) suit, bleeding, which can be life application of a pelvic embolisation saving. fixator. The authors or open suggest that all orthopaedic ligation of trainees are taught pelvic major stabilization techniques. vessels.

Appendix C xx

Directly Time before related to Urban / Number Reference Country Status Study type Objective Event calling for the Golden Rural help Hour

Norris et al. Effect of time from onset to coming under care Yes - on fatality of patients examines Not stated Prospective To investigate time of with acute delays in _ York, S Acute Full study over symptoms starting to 22 myocardial UK receiving Glarmorgan myocardial Not stated article two years. time of receiving infarction: effect of treatment and infarction. 2213 patients hospital care. resuscitation and and health Brighton thrombolytic outcomes treatment. Heart. 1998; 80: 114-120.

Osterwalder. Can the "Golden Hour of Yes- an Shock" safely be efficient All trauma extended in blunt trauma To investigate whether patients who polytrauma patients? system Prospective exceeding the golden were Prospective cohort Full depends on observational hour for pre-hospital 23 Switzerland Urban admitted to Not stated study at a level article minimal study with time in patients with the Central hospital in Eastern rescue 254 patients. blunt polytrauma Emergency Switzerland. Pre- periods and increase mortality department hospital and Disaster direct Medicine. treatment 2002;17:75-80

Appendix C xxi

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident

Delay is difficult to measure. Difficult to remember or define when symptoms start. Another study has 309 cases presented within an shown that the more serious hour, 555 between one and two For treatment that started within the infarction the earlier the hours, 504 between two and four, Resuscitation an hour on average 107 lives call for help. Results show 387 between 4 and 12 and 292 and 22 Not stated Not stated were saved. For treatment that the benefits of being over 12 hours. The median door- thrombolytic started after a delay of 12 hours treated within an hour relate to-needle time was 50 minutes, treatment. on average 21 lives were saved. more to resuscitation being the median symptoms to needle given than thrombolysis. time was 185 minutes. People need to be better equipped to recognise the symptoms of myocardial infarction.

Where the golden hour was exceeded no negative health effects were Ambulance 23 Not stated Not stated Not stated Not stated recorded. The sample size or helicopter was small and the authors recommend caution be taken.

Appendix C xxii

Directly Time before related to Urban / Number Reference Country Status Study type Objective Event calling for the Golden Rural help Hour

Pell et al. Effect of reducing ambulance response times on Yes - looks To investigate the deaths from out of UK Full at survival association between Cardiopulmonary 24 Cohort study Both Not stated hospital cardiac (Scotland) article and delayed ambulance response arrest arrest: cohort study. treatment times and survival. BMJ. 2001; 322: 1385-1388.

Pell et al. Potential impact of public access defibrillators Yes - looks on survival after out To look at public UK Full at surreal Retrospective 25 of hospital access defibrillators Both Cardiac arrest Not stated (Scotland) article and delayed cohort study. cardiopulmonary and survival treatment arrest: retrospective cohort study. BMJ. 2002; 325.

Appendix C xxiii

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident

3% of people who had response times over 15 minutes survived The shorter the response to discharge. The shorter the time the more likely the response time the more likely patient is to have that defibrillation was given. defibrillation and to survive For the arrests not witnessed the Survival also depended on there to discharge. The current response time was greater than 15 being a bystander. Reducing 24 Not stated Defibrillation. Ambulance guide is to reach 90% of minutes in 7% of cases. Of these the response time from 15 to 8 emergency calls within 14 61% had a GP present minutes increase potential minutes, the authors survivors from 6% to 8%. If the suggest that increasing this response time was reduced to 5 to 8 minutes would increase minutes the potential survival the number of survivors. would increase from 6% to 10 or 11%.

The overall survival of patients who arrested in sites not suitable for public access defibrillation was 4.2% There is limited impact from (predicted 4.2%), of patients who public access defibrillators 70.1% of patient reached in three arrested in possible suitable on the overall survival of minutes were defibrillated. 58.3% 25 Not relevant Defibrillation. Not relevant. sites survival was patients. First responders of patients reached over three 4.5%(predicted 8.3%), of may be a more effective minutes were defibrillated. patients who arrested in suitable way of administering early places survival was 8.7% defibrillation. (predicted 16.2%) and the survival of all sites was 5.0 % (predicted 6.5%).

Appendix C xxiv

Directly Time before related to Urban / Number Reference Country Status Study type Objective Event calling for the Golden Rural help Hour

To investigate the Yes - Pell. The debate on impact of defibrillation highlights the public place provided by the fire fact that the Discussion of defibrillators: service, trained first Full % of patients past studies Not Cardiovascular 26 charged but UK responders, trained lay Not stated article amenable to and current applicable arrest shockingly ill volunteers and the use defibrillation thinking. informed. Heart; of lay persons (using decreases 2003: 1375-1376. "intelligent over time. defibrillators")

Witnessed ventricular Persse et al. fibrillation (VF) Yes - To compare the Cardiac arrest cardiac arrest, targeted survival rates of survival as a function Retrospective due to trauma, response patients who received of ambulance review of all drug systems help EMS targeted response deployment strategy Full 1997 overdose, 27 US reduce the care and those who Urban Not stated in a large urban article ventricular temperature time it takes received a uniform care emergency medical fibrillation extreme, for of all advanced life services system. arrests. involved a assistance to support (ALS) Resuscitation. paediatric be given response (UR) model. 2003;59:97-104 patient or were of a cardiac etiology

Appendix C xxv

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident

The use of public access defibrillators is hampered by After two minutes from the arrest the fact that not all arrests only two thirds of patients are occur in a public place. 26 Not stated Not stated Defibrillation. Not stated amenable to defibrillation this More research needs to be gets less with time. Defibrillation done into the benefits of is an important factor in survival. public assess and first responder use of defibrillators.

In 45.9% of The chance of survival and cases Paramedic response time were the response times are EMS bystander shortest in the TR area. Time The chance of survival was improved with the TR EMS. compared to CPR was 27 from dispatch until care was given Ambulance greatest if a targeted response By being able to recognise the usual given in the was 15.2 minutes in the TR area was initiated. what is an urgent call system TR area and and 18.8 minutes in the UR area survival rates can be 62.5% in the improved. UR area

Appendix C xxvi

Directly related to Urban / Time before Number Reference Country Status Study type Objective Event the Golden Rural calling for help Hour

Rawles et al. Call to Yes - to needle times after increase acute myocardial survival infarction in urban Thrombolysis Prospective Acute and rural areas in UK Full treatment observational To access call to needle 28 Both myocardial Not stated northeast Scotland: (Scotland) article needs to be study, with times. infarction. prospective given within 1046 patients. observational study. 90 minutes of BMJ. 1998; 317: a call for 576-578. help.

To investigate the Selker et al. Time- "clinical implications of dependent predictors No - does not the time dependent of primary cardiac directly talk predictive features of arrest in patients with Prospective Full about the cardiac arrest in the TPI Not Cardiac 29 acute myocardial US study on 4911 Not stated article need for care cardiac arrest model." stated arrest infarction. The patients to be given Patients who presented American Journal of quickly to the emergency Cardiology. 2003; department were 91: 280-286. studied.

Appendix C xxvii

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident

In rural areas call-to-needle times were 30 minutes when GPs gave opiate, 60 minutes longer when not seen by a GP, and when GPs did not give the opiate the time Ambulance, was 130 minutes. In rural areas the median when thrombolytic was given by a travel time The provision of GP the call-to-needle time was 45 for the rural thrombolytic treatment is minutes, when not given until at Thrombolysis areas was very important and must be 28 Not stated Increased survival. the hospital the time was 105 or opiate. 47 minutes given quickly. It should minutes (on average). In urban and 10 ideally be given before the areas, when GPs gave opiate the minutes in patient is transported. call-to-needle was 25 minutes, the urban when not seen by a GP the time area. was almost 1 hour after the call. In urban areas thrombolytic were only given in the hospital and the time was on average 100 minutes.

The odds ratio (OR) of an cardiac arrest for patients who Patients who arrive at the arrived, at the emergency The mean time from chest pain Not stated emergency department after department, within 1/2 hour of onset to ECG was 1.5 hours +/- what pre- a longer time has elapsed 29 Not stated Not stated chest pain and who have an ST 1.0 for the cases and 2.1 hours+/- hospital help since chest pain are more elevation of 20mm was 3.37 1.3 hours for the controls. was given. likely to have survived the times that of an patient with an most dangerous hour. elevation of 5mm. At 1hour after chest pain the odds ratio is 1.18.

Appendix C xxviii

Directly Time before related to Urban / Number Reference Country Status Study type Objective Event calling for the Golden Rural help Hour

Skogvoll et al. Helicopter emergency medical To investigate the services in out-of- helicopter emergency Yes - looking hospital cardiac medical serves (HEMS) Full at response 30 arrest - a 10-year Norway Cohort study and how often they are Urban Cardiac arrest Not stated article times and population-based involved in cardiac survival study. Acta arrests and their Anaesthesiologica influence on survival. Scandinavica. 1999; 43: 972-979. Smith et al. Cardiac Yes - arrests treated by discusses ambulance the fact that paramedics and fire Describes the To look at a defibrillation fighters. The Full first year of programme concerned Cardiovascular 31 Australia is unlikely to Urban Not stated emergency medical article an with defibrillation and arrest be response program/ programme response times. successful Medicine and the after 10 Community. 2002: minutes 177: 305-309.

Appendix C xxix

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident For those patients where the HEMS arrived in 14 minutes, 6% were later discharged from No relationship between the hospital. Where the HEMS arrived Survival to discharge. Survival HEMS response time and in 15-19 minutes 6% survived to was achieved in 36 out of 424 patient outcome. The discharge. Where the HEMS 30 Not stated Not stated Helicopter patients but most had regained likelihood of survival was arrived in 20-24 minutes 7% their pulse before the helicopter the same if the HEMS survived to discharge. Where the had arrived. arrived within 15 or 35 HEMS arrived in 24-34 minute 9% minutes. survived to discharge and where it arrived after 35 minutes 8% survived to discharge. The mean response time of the ambulance and fire fighters was 6 minutes, of the first ambulance on the scene was 7.1 minutes, of the The potential for successful Fire fighters offer an 31 mobile intensive care ambulance Not stated Defibrillation Ambulance defibrillation is greatest in the effective way of patients was 8.7 minutes and of the fire first 10 minutes. receiving early defibrillation. fighters was 6.8 minutes. The mean time for defibrillation was 8.75 minutes for patients in VF.

Appendix C xxx

Directly related to Urban / Time before Number Reference Country Status Study type Objective Event the Golden Rural calling for help Hour

Yes - looks at the time it To compare the speed takes for at which patients with Sobie et al. ED antibiotics to pneumonia who are "hold" patients: is be given, waiting in the their care also being Full there is a link A descriptive emergency department 32 US Urban Pneumonia. Not stated held? Journal of article between comparison. for a bed (ED hold) and Emergency Nursing. increased those admitted straight 2000; 26: 549-553. survival and from the emergency quick department to a bed administration (ED direct). of drugs

Stiell et al. The Ontario trial of active To compare compression- No - talks compression- decompression about the one Randomised decompression (ACD) cardiopulmonary Cardiac 33 US Abstract hour survival controlled CPR and standard CPR Urban Not stated resuscitation for in- arrest of patients trial. on the outcomes of hospital and only hospital and pre- prehospital cardiac hospital patients. arrest. JAMA. 1996; 275:

Appendix C xxxi

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident

On the whole those patients who were sent straight to a The door to antibiotic time from the hospital bed received time of arrival was 7.65 hours (SD Increased survival rates, if the antibiotics one hour sooner 32 6.33) in the ED hold group and Not stated Antibiotics. Not relevant. antibiotics are given within 8 but the difference was not 6.52 hours (SD 4.25) in the ED hours of hospital arrival. significant. Both groups direct group. received care within the 8 hours needed to increase survival.

There was no difference in the one hour survival rate for the out of No difference in the survival 33 Not stated CPR Not stated Not stated hospital patients, or in the MMSE or neurological outcomes. scores of the survivors.

Appendix C xxxii

Directly related to Urban / Time before Number Reference Country Status Study type Objective Event the Golden Rural calling for help Hour A discussion Stone and Pape. Yes - of the EMSB Evolution of the discusses courses To discuss the EMSB emergency the need for aimed at courses aimed at management of Full early and addressing Not Severe 34 UK addressing the issue of Not relevant severe burns (EMSB) article effective the issue of relevant burns. the management of course in the UK. resuscitation the trauma care. Burns. 1999; 25: in burns management 262-264. victims. of trauma care. To look at ambulance Stoykova et al. response times in Ambulance 1996/97 and 2001 and emergency services see how they compare for patients with to national standards. coronary heart Yes - looks In 1996/97 50% of Acute disease in Full at ambulance Retrospective 35 UK urgent calls had to be Both myocardial Not stated Lancashire: achieving article response cohort study. reached in 8 minutes, in infarction standards and times. 2001 this was 75%. improving The time to hospital had performance. to be 30 minutes for Emergency Medicine. patients eligible for 2004; 21: 99-104. thrombolysis in 2001.

Appendix C xxxiii

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident

The golden hour forms the basis of these courses. 34 Not relevant Not relevant Not relevant. Not relevant. Reduced mortality. EMBS has been adopted by the military (1998).

In 1996/97 96% of emergency Rapid response vehicles are calls has a response time within ECG, IV a more effective way of 19 minutes, 45.3% were reached access, pain achieving response time in 8 minutes. In 2001 78.4% has relief, targets. The call to hospital 35 response times within 8 minutes. Not stated Ambulance Not stated oxygen, time was on average In 2001 rapid response vehicles thrombolysis greater than the 30 minutes had a significantly shorter mean treatment. target, at 35 minutes, in response time and 88.2% were 2001. reached in 8 minutes.

Appendix C xxxiv

Directly Time before related to Urban / Number Reference Country Status Study type Objective Event calling for the Golden Rural help Hour Svensson et al. Safety and delay tome in prehospital Thrombolysis of acute myocardial Decision time Yes - looks To look at the delay in Acute infarction in Urban Full Controlled was slightly 36 Sweden at delays in treatment from the Both myocardial and Rural areas of article cohort study. longer in rural treatment start of treatment. infarction Sweden. American areas. Journal of Emergency Medicine. 2003; 21: 263-270.

Walker et al. Cost Yes - effectiveness and To determine the cost Discusses cost utility model of effectiveness of public the life years public place A study with access defibrillators UK Full gained from cardiopulmonary 37 defibrillators in historical located in major Both Not stated (Scotland) article the public arrest improving survival controls. airports, railway access after prehospital stations and bus (early) cardiopulmonary stations. defibrillation. arrest. BMJ. 327.

Appendix C xxxv

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident

Urban patents had a lower Early prehospital mortality rate and a lower Thrombolysis reduces the cardiogenic shock occurrence time to Thrombolysis and Thrombolytic 36 Not stated Not stated Ambulance and less congestive heart failure. increases survival. Delay in treatment. Mortality at one year was 5% in between symptoms and urban areas and 17% in rural treatment was longer in ones. rural areas.

Without public access defibrillation the survival to the A&E department was 52.9%, to admission was 26.4% and to discharge was 14.7%. With Public access defibrillators public access defibrillation the are costly, trained first survival to the A&E department responders may produce was 66.7%, to admission was 37 Not stated Not stated Defibrillation. Not stated better results. The overall 33.3% and to discharge was survival increase from them 16.7%. 5.7 life years were in all public sites in Scotland gained per survivor. The gain in is only 5.0 to 6.5%. QALYs was 4.5 undiscounted and 4.1 discounted. There was a QALY gin of 0.44 per year with discounted cost per QALY gained of £41146.

Appendix C xxxvi

Directly related to Urban / Time before Number Reference Country Status Study type Objective Event the Golden Rural calling for help Hour

Yes - within Wood. Major one hour, of pulmonary embolism. pulmonary To provide a structured Review of a embolism, approach to diagnosis pathophysiologic two thirds of Discussion of and to resuscitation and Major approach to the Full patients will past studies Not 38 US therapeutic strategies. pulmonary Not stated golden hour of article die. and current relevant. There is a golden hour embolism. hemodynamically Therefore, it thinking. of care that will be significant pulmonary is essential looked at. embolism. CHEST. that early 2002; 121: 877-905. treatment is given.

Yes - comments that the Woollard. Public quicker a access defibrillation: cardiac a shocking idea? Full To look at public access Not Cardiac 39 UK arrest patient Discussion Not stated Journal of Public article defibrillators. relevant arrest receives Health Medicine. defibrillation 2001; 23: 98-102. the better their survival chances.

Appendix C xxxvii

Technology used to Number Response time Help given Transport Benefits Conclusions inform of the accident Chance of death within the first hour is high. It is, therefore, essential that a pulmonary embolism is recognised and treated Resuscitation accordingly. Echo and cardiology can be used for 38 Not stated Not stated thrombolytic Not relevant. lives saved. diagnosis as it is treatment, are transportable, thrombolytic recommended therapy is the recommended treatment, emboloctomy should be used on patients were thrombolysis is contraindicated. Mortality increases by 4% with every minute until the first shock is given. The use of bystanders could reduce the time until first shock. 74% of cardiac If half the number of cardiac arrests occur outside Ambulances currently have to get arrest patients who arrest in hospital and 75% of these 39 to 75% of patients within 8 Not stated Defibrillation. Not stated public places are reached within outside the home. 5000 minutes. 4 minutes , 400 additional cases of ventricular people may survive each year. fibrillation occur in public places in England each year. Therefore, many are witnessed. Further research should be done to compare this to implantable defibrillators.

Appendix C xxxviii

APPENDIX D

Mobile Phones

Emergency Number Reference Country Status Study type Objective Technology contacts

To investigate Akella et al. Evaluating the automated collision reliability of automated notification and the Automated collision notification systems. effects that a 1 US Full article Cohort study collision Ambulance . Accident Analysis and weakened signal can notification. Prevention. 2003; 35: 349- have on the ability of 360. a call being completed. Automatic Champion et al. Urgency for vehicle 2 a Safer America. Airmed. US Abstract Not stated Not stated Not stated collision 1999; 5: 18.23. notification A review of 720 Chapman and Schofield. mobile phone users to A random Emergency use of cellular see if they had used 3 Not stated Full article telephone Mobile phone Any (mobile) telephones. The their phones in an survey Lancet. 1998;351:650 emergency since 1987

Chapmen and Schofield. Lifesavers and Samaritans: Random To investigate the use emergency use of cellular telephone of mobile phones and 4 (mobile) phones in Australia. Australia Full article Mobile phone Any survey of 720 reduced notification Accident Analysis and people. times in emergencies Prevention. 1998; 30: 815- 819.

Appendix D i

Technology Reference to the golden Number Event Health benefits used to inform Conclusions hour of the accident

The automated collision Yes - authors mention that 1 Vehicle crashes. Not stated Not stated technology can enhance the reducing the time to hospital response to emergencies. can reduce mortality.

The use of automatic vehicle Automatic collision notification has the 2 Not stated Lives saved. vehicle collision Yes - response times potential to save lives and notification shorten response times.

Authors conclude that it is plausible that lives have been 3 Any Live saved. None No saved by mobile phones being used to call for help.

Mobile phones are used to report accidents and dangerous Estimated that 1 in 8 mobile situations. It seems reasonable phone users have reported a road Yes - mentions the golden to assume they have saved lives. accidents in this way. 1 in 16 hour. Comments that land Important to remember that people had reported a non-road lines (911,999,000)are Lives saved. Calling people may put themselves in medical emergency. 1 in 100 shown to be associated with 4 Increase chance of emergency more dangerous situations safe reported a psychiatric crisis. 1 in increased survival from out- survival. numbers in the knowledge that they have a 720 have reported a heart attack, of-hospital cardiac arrests, mobile phone to gain assistance. epileptic fit or diabetic comas. 1 could be the same for Mobile phones enable individuals in 357 have reported domestic mobile phones. to inform a large number of violence. others about dangers, i.e. traffic delays.

Appendix D ii

Emergency Number Reference Country Status Study type Objective Technology contacts

Ferguson et al. The prehospital 12-lead electrocardiogram: impact on management of the out-of- To look at ECG in the 5 Not stated Abstract Not stated ECG Not stated hospital acute coronary prehospital setting syndrome patient. American Journal of Emergency Medicine. 2003; 21; 136-42.

Hunt. Emerging communication technologies To look at enhanced in emergency medical 911 and automatic enhanced 911 Emergency 6 Not stated Abstract Not stated services. Prehospital crash notification and and ACN services Emergency Care. 2002; 6: mobile phones 131-6.

Jermyn. Reduction of the To look at the effect Before and call-response interval with ambulance base Not mobile after study in 7 ambulance base paging. UK Full article paging would have on phones - Ambulance an ambulance Prehospital Emergency the call-response response times service. Care. 2000; 1: 318-321. intervals Martens et al. Inappropriate calls to an emergency medical despatch centre via cellular telephones - no To investigate a once Prospective 8 impact of a once only Belgium Full article only multimedia Mobile phone Ambulance survey multimedia coverage. coverage. European Journal of Emergency Medicine. 1999; 5: 5-7.

Appendix D iii

Technology Reference to the golden Number Event Health benefits used to inform Conclusions hour of the accident

Information obtained by a Allows diagnosis and prehospital ECG reduces the indication that Yes - reduces time to 5 Acute myocardial infarction. Not stated time to hospital treatment without thrombolysis treatment much increase in EMS use or on- treatment is needed. scene time.

There is an increasing number of emergency calls being made from mobile phones. ACN can provide EMS staff details of Enhanced 911, Yes - likely to impact on 6 Any Not stated accidents as soon as they ACN response times. happen, thus helping to reduce response times. Priority should be given to develop this technology. Reduction in defibrillation times. Base paging reduces response Yes - discusses response 7 Any Lives saved. EMS times. The overall reduction in times Increased survival response time was 30 seconds. rates.

The number of inappropriate calls by GSM increased from 82% in 1997 to 90% in 1998. Of all the calls to the emergency services No - does not mention 8 Any Not stated Mobile phone about 50% are inappropriate calls response times from GSM. A once only multimedia coverage has no impact on this.

Appendix D iv

Emergency Number Reference Country Status Study type Objective Technology contacts

To investigate a Miller. Rationale and monitoring device that specifications for an has an alarm and an Randomised automatic cardiac arrest- automated call Automatic Ambulance or 9 Not stated Abstract controlled driven alarm and 911 caller systems that alerts device bystander help study ID. Medical Hypotheses. the emergency 1997; 48: 449-51. services when a cardiac arrest occurs.

Nagatuma. Development of To look at Emergency an emergency medical video Medical Video multiplexing transport system Multiplexing Transport Video aiming at the nation wide System (EMTS). Live 10 Not stated Abstract Not stated transmission Not stated prehospital care on videos of prehospital via satellite. ambulance. Journal of patients are sent to Medical Systems. 2003; 27: emergency doctors in 133-40. remote hospitals. Pieske et al. ACN (automatic collision notification) - reducing fatalities in traffic accidents To look at automatic 11 by automated accident Germany Abstract Not stated ACN Not stated collision notification. reporting. Kongressband/Deutsche Gesellscaft fur Chirurgie. 2002; 119: 546-8

Appendix D v

Technology Reference to the golden Number Event Health benefits used to inform Conclusions hour of the accident

Alerts bystanders A global positioning device could and emergency also be attached to enable Yes - discusses early 9 Cardiac arrest services, allowing Alarm emergency services staff to find responses early care to be patients. given

Enables videos of the patient to Yes - impacts on treatment 10 Not stated Not stated Not stated be transmitted to the doctor times before arrival at the hospital.

The time from accident and the A predicted call for help can be reduced using reduction in road Yes - looks at response 11 Not stated ACN the automatic crash notification. traffic fatalities of times There could be an economic 15%. benefit of 561 million.

Appendix D vi

Emergency Number Reference Country Status Study type Objective Technology contacts

Ambulance - To investigate Terkelsen et al. traditional ones whether physicians at Telemedicine used for and ones a remote hospital can remote prehospital equipped with a Study with diagnose ST- diagnosing in patients global system for 12 Sikeborg Full article perspective segment-evaluation- Telemedicine. suspected of acute mobile controls AMI in patient who myocardial infarction. communications have a suspected Journal of Internal Medicine. (GSM) that linked AMI. This was done 2002;252: 412-420. to a computer at using a telemedicine the university.

Vaisanen et al. Prehospital Comparison of ECG ECG transmission: A comparison transmission from Advanced comparison of advanced of two different prehospital to a table mobile phone mobile phone and facsimile 13 Finland Full article methods of facsimile and to a for the use of Helicopter devises in an urban receiving mobile phone, prehospital Emergency Medical Service ECGs situated on a staff System. Resuscitation. helicopter. 2003; 57: 179-185.

Appendix D vii

Technology Reference to the golden Number Event Health benefits used to inform Conclusions hour of the accident

The use of prehospital diagnosis (by an ECG) lead to longer on Yes - concerned with scene times but shorted door-to- reducing time from Prehospital needle times. This reflects the 12 AMI Not stated symptoms to treatment in diagnosis fact that doctors at the waiting acute myocardial infarction hospital were alerted to the patients. condition of the patient before they arrived.

The phone is as good as a facsimile at receiving an ECG. The delay in The large distance to a hospital in receiving the ECG, Finland make it essential that Yes - discusses the Transmission of which is needed in thrombolysis is started as soon importance of giving 13 Acute myocardial infarction. ECG to a mobile order to start as possible, the mobile phone thrombolysis as soon as or a facsimile treatment, is makes this possible. There is a possible. potentially reduced. problem that overloads in the networks could lead to delayed transmissions.

Appendix D viii