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The Golden Hour

Monday July 15, 2002
Time waits for no one and can be the most critical factor when a person 
sustains a traumatic injury.
Time waits for no one and can be the most critical factor when a person sustains a traumatic injury.
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They call it "the golden hour," 60 minutes from the moment a person sustains a traumatic injury to the time he or she receives definitive treatment. It's a brief period that can determine the course of the rest of a person's life. Trim a few minutes - even one or two - from that critical hour, and the patient's outcome can be dramatically different. A car crashes. A child falls out of a tree. A gunshot wound cripples. The minute hand starts to sweep around that 60-minute clock. It ticks away in the back of everyone's mind as the EMTs race to the scene and the ED staff gear up for the patient's arrival.
As a level one trauma center, Lutheran Medical Center in Brooklyn, NY, receives the critically injured patients in the ED. The staff has succeeded in trimming the average time a trauma patient spends in the ED to just 34 minutes. This represents a four-minute timesaving over last year. How do they do it?
Teamwork Makes It Happen
Robert Church, RN, MS, CERN, CEN, director of critical care and emergency and trauma nursing, has been overseeing the ED, MICU, SICU and PACU for more than a year. The designated trauma room is twice the size of a regular ED trauma room. Church says, "Probably one of the most important staffing decisions we made is to have a designated 'trauma nurse' who floats throughout the ED until there's a trauma case." There is no waiting for assessments and treatment to start. "We get the team there and we can get the patient on the way to the most appropriate treatment," he adds.
The trauma team consists of 15 to 17 people, depending on the level of the patient's injury. The team includes nurses, physicians, and respiratory therapists, as well as pastoral care and social services. If a a child sustains the trauma, the pediatric code team is paged.
Waiting at the Door
This team is ready for action, with diagnostic equipment that will determine how to treat the patient's injuries. "Usually when the patient arrives, he or she is greeted by 10 to 15 people waiting for the ambulance. The trauma surgeon is the person running the show, but everyone is doing a simultaneous assessment," says Church.
We have a CT scanner in the ED, so we don't waste time transporting the patient to another department. Church says, "There's also an overhead x-ray machine, so we quickly get an idea of what's going on. All these things save time - and that makes a big difference in our success."
"The patient is evaluated and if he or she needs to go to the OR, that can be done within 20 minutes or so. There's always an available OR suite and an empty bed in the ICU," says Church. When patients come into the ED, the staff quickly transfers them to the ICU where they can receive the expert monitoring that's required.
Results Count
One of the factors contributing to the success of the team at Lutheran Medical Center is NYC's large EMS system. The team brings a patient to the ED in a relatively short period of time, saving minutes. Once he or she arrives, quick action contributes to the staff's remarkable success rate.
"Last year, we saw a total of 1,566 trauma patients," reports Church. "Of those, 87% were cases of blunt trauma and 13% were cases of penetrating trauma, like gunshot wounds. For the whole year, we had 42 patients who died."
Mortality isn't the whole story - the quality of the patient's stay matters. One of the accomplishments Church is most proud of is the way pain management is handled.
"In the year 2000 it was an average of 35 minutes before we medicated them [patients] for pain, and in 2001, it was an average of 18 minutes. We've started dealing with their pain much more quickly," he says. Appropriate pain management becomes a quality issue for everyone, nursing and medical staff alike.
Stories Behind Statistics
Behind these statistics are the stories of people who are alive because they received appropriate care. Church recently met up with a patient he saw during that "golden hour" - after being struck by a car. This 47-year-old man was found on the ground with a severe head injury, complaining of head and neck pain.
The patient came in around 11 AM in February, not remembering anything that had happened to him. He went to the ICU and to the OR for a subdural hematoma evacuation. "He came back into the SICU recently for a visit and remembered people's names. He thanked everyone for what they'd done for him," Church says.
Thousands of broken bodies land in trauma units every year. When the morning alarm clock goes off, future victims have no idea that another clock will determine the course of their life later that day. That "golden hour" 60-minute clock is being beaten regularly by the trauma team's skill and commitment to excellence at Lutheran Medical Center.