Background to The Golden Hour Project
In 2017, The Institute of Pre-Hospital Care at London's Air Ambulance received generous funding from The James Tudor Foundation to launch one of the most important projects it has ever undertaken. What was then known as The Causes of Death in Trauma (CODIT) Knowledge Innovation Project was a world first and developed to transform current knowledge and understanding of why patients die from traumatic injury. This project was renamed The Golden Hour Project in 2018 to highlight the term often used in trauma to suggest that an injured patient has 60 minutes from time of injury to receive definitive care, after which morbidity and mortality significantly increase.
Major trauma is a global epidemic, causing nearly 6 million deaths per year around the world. In the UK, it is the leading cause of death for people under the age of 45 and is estimated to cause nearly £4 billion per year in lost economic output. Pre-hospital care is a critical means of combating this epidemic, as recognized by the World Health Organization and the UK’s National Audit Office. Pre-hospital care encompasses all the activities required to get a patient safely to hospital, from service dispatch and rapid transport, to medical trauma care at the scene. This trauma care ranges from basic interventions like CPR, to advanced interventions like a thoracotomy or REBOA.
The main aim of the multifaceted Golden Hour Project was to support The Institute of Pre-Hospital Care in helping the clinical pre-hospital world understand more fully the causes of death in injured patients. The project vision was to bring about an improvement in clinical practice resulting from a greater understanding of the causes of death from traumatic injury through education, innovation and research. The project mission was to collaborate widely to bring about this improvement. The rationale for The Institute of Pre-Hospital Care at London's Air Ambulance undertaking such a project was highlighted by the need to transform our understanding of why patients die, and how their cause of death is determined. Future innovations in trauma and pre-hospital care will be dependent on a detailed analysis of why those patients we wish to save succumb to their injuries.
Thus far, current thought suggests clinicians could potentially transform the service they provide to injured patients if they could correlate autopsy findings with the clinical experience, and then make educated and informed judgments around the relative impact of injury on the potential for survival. However, there are currently many challenges for clinicians wishing to use autopsy reports that have been prepared for the coroner to make clinical improvements. This is because a coroner will justifiably have a different set of objectives from those of attending clinicians when trying to understand what has happened to a patient.
Increasingly, with advances in diagnostic procedures, the value of the autopsy has been challenged over the years. Even so, studies from across the world have revealed the true value of autopsies by highlighting rates of discrepancies between clinical and post-mortem diagnoses, and their use as an educational tool for the medical profession. If it was accepted that having access to an autopsy report might transform the care we can provide to future patients, it is important to recognize that there have been considerable questions over the quality of these reports, even when examined from the coroners’ point of view.
Over the years, studies into the quality of the autopsy report have produced some alarming findings:
- A study in 2005 found that at least a third of all death certificates are likely to be incorrect.
- A report on adult deaths in 1990 showed that in only 39% of autopsies a clinico-pathological correlation was provided to explain the death.
A landmark study examining the quality of coroners' autopsies in the UK was published in 2006. Understanding the findings of this NCEPOD (National Confidential Enquiry into Patient Outcome and Death) report is crucial if we are to improve our quality of understanding of why our patients die from their injuries. They key findings of this report demonstrate:
- A lack of national criteria and standards for investigating reported deaths.
- Poor communication and collaboration between pathology and coronial services.
- Below standard clinical performance of the post-mortem examination and inaccurate determination of the cause of death.
- Poor communication and working between clinical and pathology teams.
A major challenge facing London’s Air Ambulance was that doctors were rarely privy to information on the causes of death in their patients. This was due to complex arrangements with coroners, pathologists and, in a relative paucity of resources, in patient follow-up. Essentially, this meant that the doctor, who flew to a patient in a helicopter, delivered life-saving and cutting-edge interventions on scene and attempted to save a life, would not be able to discover the cause of death in his or her patient. As a result, we could only innovate for new treatments speculatively, and based on poor quality data and information. There were examples of gold standard practices in this area from across the world that we could emulate and improve upon.
If London’s Air Ambulance is to set a new bar as a world leader in the delivery of pre-hospital care for patients, it needs to dramatically improve its work on the causes of death from critical injury. This project would involve working strategically with coroners, pathologists and the police service to produce a set of gold standards, Royal College Guidance and national best practice documents relevant to this subject area.
Therefore, there was an urgent need for The Golden Hour Project to help shape The Institute of Pre-Hospital Care's innovation and education agenda for the next decade and its ongoing strategy of challenging traditional dogma as well as setting new standards in the management of sick and injured patients in the pre-hospital phase of care. For example, we recently redefined through peer review publications, unprecedented material on the mechanisms of death following head injury. This is known as Impact Brain Apnoea. Clinicians from across the world are now considering treatments for head injured patients in a totally different way from those mechanisms previously thought to be responsible. This means that we can prevent patients from dying in the future.