Systemic Inefficiency versus Geographic Proximity: Decoupling Distance from Prehospital Delay in Urban Interhospital Trauma Transfers, Guayaquil-Ecuador.
The Journal of surgical research · 2026-07-03 · Observational study
Abstract
INTRODUCTION: The "golden hour" concept remains debated in low- and middle-income countries with fragmented systems. This study evaluated the synergistic association of prehospital delay and injury severity on outcomes, specifically analyzing referral system inefficiencies. METHODS: A retrospective study of 339 trauma patients was conducted in Guayaquil, Ecuador. Multivariable Poisson regression models with robust variance and restricted cubic splines were developed specifically for the n= 274 cohort (≤240 min) to identify independent predictors of complications and mortality, focusing on the time × New Injury Severity Score interaction. Urban distance analysis (n = 84) was performed to isolate geographic from systemic factors. RESULTS: Penetrating injuries predominated (80%, out of 273 penetrating cases, firearms n = 218). Prehospital delay independently predicted complications (P = 0.042), with a risk ratio of 1.55 (95% confidence interval: 1.01-2.38). A lethal synergistic interaction was identified between time and severity (P = 0.003); while delays were tolerated in moderate trauma, mortality escalated exponentially for critical patients (New Injury Severity Score 55) after the first hour. Kaplan-Meier analysis confirmed a survival disadvantage after the "golden hour" (P = 0.024). Crucially, for urban transfers, transport distance did not differ significantly between early and delayed groups (P = 0.226), indicating that systemic referral inefficiencies (door-in-door-out delays), rather than geography, drive prehospital exhaustion. CONCLUSIONS: Prehospital delay and injury severity exhibit a lethal synergistic interaction. The "golden hour" is frequently exhausted by referral chain inefficiencies regardless of physical proximity. Transitioning to a direct primary transport model ("scoop and run") is associated with mitigated physiological debt and potentially improves survival in critical penetrating trauma.
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Tags
Interfacility & critical care transport · Low- and middle-income settings · Mortality & survival · Time intervals · Urban
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