Domain 1. Time as a Determinant of Outcome

Multiple international studies have described time dependency as a function of road-crash response, ^{Reference Ma, Zhang and Yan18} specifically time to scene rather than time on scene. Byrne, et al found that longer response times were associated with higher rates of mortality post-motor-vehicle accident in both rural and urban settings. ^{Reference Byrne, Mann and Dai19} In an analysis conducted by Lee, et al investigating Fatal Traffic Crash-Reporting and Reporting-Arrival Time Intervals of Emergency Medical Services (EMS), it was found that whilst 90% of fatal crashes were reported to EMS within ten minutes, average reporting time in rural areas was greater than that in urban areas, and importantly, freeways required longer time for EMS arrival (8.3 minutes) compared with conventional road (6.8 minutes). ^{Reference Lee, Abdel-Aty, Cai and Wang20} Further to this, a retrospective review of over 1,400 road accidents in Spain by Sánchez-Mangas, et al reported that ten-minutes reduction in medical response is associated with a decrease in probability of death by one-third. ^{Reference Sánchez-Mangas, García-Ferrrer, de Juan and Martín Arroyo21}

Domain 2. Coordinated Post-Crash Response

A consistent finding of this review was recommendation of improved inter-agency coordination and communication, with a focus on the establishment of unified command in response to mass-casualty accidents. ^{Reference Hardy22–Reference Björnstig25} Sadat, et al investigated barriers and facilitators to improve response to mass-casualty traffic accidents in Iran finding that improved coordination of agencies under a unified command, resource, and response management were desirable attributes. Whilst Sadat, et al undertook a qualitative study limited to one country, Sadat’s findings are consistent with investigations in other nations. ^{Reference Sadat, Afrasiabifar and Khorasani-Zavarehg26} Some systems have pre-determined criteria for response. Lee reported disaster medical team automated dispatch to road crashes where situations/incidents where more than ten casualties have already occurred, and additional casualties are suspected, and/or confirmation of multiple traffic accidents in vehicles over ten cars. ^{Reference Lee, Lee and Kim27} Further to automated activation, Lee, et al also recommended a coordinated approach, joint operational procedures, and shared training to enhance effective scene communication in response to multi-vehicle collision in Korea. ^{Reference Lee, Lee and Kim27} Whilst structural processes exist to enable early activation and deployment of resources to significant road-crash incidents, Lee found a lack of coordinated approach existed across agencies responding to the case study investigated. ^{Reference Lee, Lee and Kim27}

Domain 3. Prehospital Post-Crash Response Treatment Systems

Understanding accident patterns can improve post-crash response training and readiness. Dong, et al identified side impact intrusion and secondary injury incidence related to patients not wearing seatbelts as key considerations for road-crash response practice in China. ^{Reference Dong28} Mengistu, et al investigated road-crash mortality in Addis Ababa, Ethiopia with a focus on the relationship between prehospital care and mortality. Key findings from this retrospective study noted that the mortality of patients who did not receive prehospital care to road-crash response was three-times more likely in the following 24-hour period. ^{Reference Mengistu, Ali and Abegaz29} Proposed timeframes of “Platinum 10 Minutes” and “Golden Hour” were not achieved in the majority of patients suffering road crash. ^{Reference Mengistu, Ali and Abegaz29} This finding is reflective of the challenge in defining injury patterns in road crash that have time dependency to hospital for improved outcomes; ^{Reference Rogers, Rittenhouse and Gross30,Reference Beck, Smith and Mercier31} in addition, further studies have noted that quality of care is also associated with survival, along with identification of time-dependent injury patterns. ⁵

Traditionally, EMS has predominantly focused on response time; however, holistic feedback from first responders in understanding barriers and challenges in post-crash response may identify opportunities for improvement. ^{Reference Brodsky32,Reference Brodsky and Hakkert33} Eftekhari, et al undertook such investigation finding that poor management of the crash scene, lack of adequate rules and regulation, poor management of time, low quality of training, poor communication and coordination, and low quality of victim management as key areas for improvement. ^{Reference Eftekhari, DehghaniTafti and Nasiriani34} These findings, whilst specific to one country, provide deeper insight into post-crash response quality improvement focus areas.

Trauma center establishment and incorporation into road-crash response practice was identified by Zarei, et al who reviewed modern concepts of system design to link key elements of response and health capacities that, when coordinated, can deliver improved outcomes. ^{Reference Mohammad, Yarandi, Rasouli and Rahimi-Movaghar35} Contemporary practice in road-crash response supports a concept of operations where decision making and health system design is informed by patient acuity, transport mode and time, and destination according to treating facility capability (ie, trauma center), an approach supported by multiple researchers investigating trauma transport practice. ^{Reference Mohammad, Yarandi, Rasouli and Rahimi-Movaghar35–Reference Bentham41}

Whilst some studies have reported an association between prehospital time and trauma survival, ^{Reference Feero, Hedges, Simmons and Irwin42} there is a lack of high-quality evidence supporting the “Golden Hour” theory and evidence showing a lack of associated outcomes in road-crash response. ^{Reference Mengistu, Ali and Abegaz29,Reference Hu, Freudenberg, Gong and Huang43–Reference Newgard, Schmicker and Hedges45} Further to this, the application of Basic Life Support (BLS) and Advanced Life Support (ALS) interventions as part of post-crash response needs to be critically reviewed. ^{Reference Jayaraman, Sethi and Wong46–Reference Meadley48} Whilst Noland has reported an association between improvements in medical care and reduced crash fatality, ^{Reference Noland49–Reference Noland and Quddus51} Al-Shaqsi reported that “existing studies reporting potential benefits of Advanced Life Support were descriptive studies with small sample sizes as opposed to testing of hypothesis and tended to be grossly confounded and biased.” ^{Reference Al-Shaqsi47} At the same time, Jayaraman, et al in their systematic review reported no evidence to suggest that ALS training for ambulance personnel improved the outcomes for injured people. ^{Reference Jayaraman, Sethi and Wong46} Likewise, Lydon, et al reported that “… it is unclear if improvements to post-crash response can deliver significant benefits.” ^{Reference Lydon, Woolley, Small, Bailey and Harrison52}

McDermott, et al investigated 243 road crash cases in Victoria, Australia from 1997-1998 that were reviewed by multi-disciplinary medical, forensic, and prehospital expert panels to evaluate prehospital treatment during road trauma. ^{Reference McDermott, Cooper, Hogan, Cordner and Tremayne53} It found that 77% of patients had prehospital errors or inadequacies, of which 67% contributed to death; however, technique errors and diagnostic delays were infrequent. A single death was considered preventable, with another two being potentially preventable. Key points from the study included:

• 21% of all fatalities required extrication, with a greater percentage requiring extrication in regional areas.

• 48 technique errors were identified, of which 33 contributed to death. Most frequent errors were failed intubation and failed intravenous access.

• 10 of the 18 diagnosis errors contributed to death. This included tension pneumothorax (1); hypovolemic shock (2); misplaced endotracheal tube (1); fractured ribs/bilateral flail chest and respiratory failure (2); severe hypoxia treated with morphine, not O2 (1); fractured pelvis (1); and under-estimation of severity of injury (2). And,

• Load-and-Go protocols should be implemented for patients not trapped, which allows for most prehospital interventions to be commenced/completed enroute. ^{Reference McDermott, Cooper, Hogan, Cordner and Tremayne53}

The study concluded that since the review of 1998 data, the high prevalence of prehospital deficiencies had been addressed by a Ministerial Task Force on Trauma and Emergency Services. However, the study did not provide information, discussion, or further analysis to explain or support this conclusion. It should also be noted that while McDermott, et al technically met the inclusion criteria of this current SLR as it was published in 2005, the cases it reviewed were from the late 1990s, well before the Decade of Action for Road Safety.

In this study, three specific research questions were explored:

1. 1. What is the evidence to support post-crash response practices?

2. 2. How can identified trends support improved patient outcomes? And

3. 3. Did the Decade of Action for Road Safety improve prehospital road-trauma response? If not, why not?

With respect to the first question, 89 studies met the inclusion criteria for the study of 17,052 potential studies initially identified from four major databases. Whilst there was limited commonality between included studies, this shows compelling evidence to inform contemporary post-crash response practices.

With respect to the second question, again, there were limited trends to support improved patient outcomes. Interestingly, there was no evidence to support the time-honored concepts of the “Platinum 10 Minutes” and the “Golden Hour,” with the limited evidence located appearing to question the validity of these concepts. ^{Reference Rogers, Rittenhouse and Gross30,Reference Hu, Freudenberg, Gong and Huang43} The single study that focused on scene management suggests that good rescue and treatment practices may be more important than whether a patient reaches a trauma center within a defined or arbitrary time frame. ^{Reference Dong28} Further to this, the evidence suggests that BLS may be a more appropriate intervention when responding to road-crash trauma than ALS practices. ^{Reference Jayaraman, Sethi and Wong46–Reference Meadley48} Indeed, the findings of Ma and Lee, et al may indicate time from crash to patient treatment on scene may be a more important factor than time to a trauma center. ^{Reference Ma, Zhang and Yan18,Reference Lee, Abdel-Aty, Cai and Wang20} Ultimately, these findings suggest, albeit in a limited way, that there is little contemporary evidence to support post-crash response practices beyond those completed more than a decade ago by McDermott, et al. ^{Reference McDermott, Cooper, Hogan, Cordner and Tremayne53} Further, these findings suggest that prehospital services should re-examine current practices and consider whether the funding and time invested in ALS training, on-going certification, and associated equipment would be better spent on additional prehospital ambulances and resources that would ultimately reduce the time to accessing/reaching dedicated trauma centers.

With respect to the third question, no evidence was found in the literature that the Decade of Road Safety Action has had an impact on improved patient outcomes or reduced road fatalities. A review of published statistics tells a similar story; in Australia, road-traffic deaths have remained relatively unchanged over the last decade, with a slight decrease in fatality rates of 5.1% to 4.6%, while in the United States, road-crash fatality rates have increased with a rate 2.3-times higher than the average of other high-income countries. ^{54,Reference Worley55} During the Decade of Action on Road Safety in the period from 2013-2016, there was no reduction in road-traffic deaths in any of the low-income countries reviewed by the WHO. ^{4,Reference Tavakkoli, Torkashvand-Khah and Fink56} Similar trends were reported by WHO for countries within Southeast Asia from 2007-2015. ⁵⁷ Even with the limited improvements in prehospital care, the ever-increasing number of people relying on motor-vehicle transport, coupled with poor driving behaviors, unsafe vehicles, and sub-standard road conditions, has resulted in increased rates of road trauma globally. ^{1,Reference Worley55} Part of the problem may be associated with the inability of governments and organizations to consider a systems approach to road-traffic safety as opposed to examining individual interventions. Indeed, Tavakkoli, et al suggest this may be a significant cause in the Decade of Action on Road Safety ultimately being ineffective. ^{Reference Tavakkoli, Torkashvand-Khah and Fink56}