Distance and delay define rural trauma care timelines

Billings Clinic investigators tracked trauma patients arriving directly from the scene versus patients transferred between facilities and found much longer times to reach the tertiary center for transfers, while adjusted mortality aligned with Injury Severity Score, age, hospital length of stay, and shock index rather than transfer status.

The “Golden Hour” refers to a critical period after traumatic injury when timely definitive care is essential for survival. Rural communities face structural barriers to reaching Level I or Level II trauma centers within 60 minutes, even as most U.S. residents live within that window.

Greater distance to tertiary care, staffing shortages, higher uninsured rates, and higher poverty can slow transfers from critical access hospitals. Lower population density, harsh winters, and inconsistent prehospital care infrastructure add constraints in parts of the Northwest and Midwest.

Testing transfers across wide distances

In the study, “The Golden Hour is elusive in rural trauma: A 10-year analysis from a Level I trauma center in Montana,” published in the American Journal of Emergency Medicine, researchers conducted a retrospective review to evaluate trauma transfer patterns and outcomes across Montana and neighboring rural regions.

Trauma registry records covered Jan. 1, 2012 through Dec. 31, 2022 at a rural Level I trauma center in the Northwestern United States. Among 8,418 trauma registry entries, 4,265 had a documented injury time.

Demographic variables included age, sex, Injury Severity Score, shock index, vital signs, and comorbidities drawn from patient charts and trauma flowsheets. Transfer distance calculations used road distance to account for uncrossable geographic features.

Longer journeys to trauma centers

Transfer patients showed greater injury severity than patients transported directly from the scene. Mean Injury Severity Score measured 14.5 among transfers and 8.3 among direct admissions. Hospital stays lasted longer for transferred patients at 6.0 days compared with 3.0 days for direct admissions. Intensive care unit stays also lasted longer, at 4.6 days versus 3.7 days.

Unadjusted mortality measured 5.0% among transferred patients and 3.0% among patients arriving directly from the scene.

Arrival time at the trauma center differed sharply between groups. Patients transported directly from the scene reached the trauma center in about 2 hours, while transferred patients arrived in about 7 hours.

The distance from the injury site to the trauma center also differed substantially. Direct admissions traveled 18.1 miles on average, while transfers traveled over 188 miles on average.

What predicted survival

Multivariate logistic regression linked mortality to Injury Severity Score, age, hospital length of stay, and shock index. Age showed an odds ratio of 0.95. Injury Severity Score showed an odds ratio of 0.91.

Patients with an Injury Severity Score below 15 showed higher odds of survival than those with an Injury Severity Score at or above 15, with odds ratio 3.13. Shock index also showed association with survival with odds ratio 0.53.

Transfer status did not show association with mortality in the adjusted model. Distance from injury to the trauma center and injury time to arrival at the trauma center also did not show association with mortality.

Care teams in remote facilities

Most transferred patients came from small or isolated rural towns. Rural-Urban Commuting Area classifications showed 81.4% of transfers originated from these communities.

Urban hospitals were far more likely to have surgical coverage available. On-call trauma surgeons were present at 93.2% of urban centers compared with 12.6% of isolated rural centers. General surgeons were present at 93.5% of urban facilities compared with 29.8% of isolated rural facilities.

Advanced practice providers were present at nearly all facilities across the region. Presence reached 99.7% in urban centers and 89.3% in isolated rural centers.

Isolated small rural facilities showed far lower access to surgeons than larger rural hospitals, with surgeon presence at 31.6% in isolated rural centers compared with 79.8% in small rural facilities and 94.7% in large rural facilities.

© 2026 Science X Network