The Golden Hour is elusive in rural trauma: A 10-year analysis from a Level I trauma center in Montana

BACKGROUND: The "Golden Hour" represents the critical period following traumatic injury when timely definitive care is essential for survival. Although most U.S. residents live within 60 min of a Level I or II trauma center, rural populations face greater challenges in accessing such care. This study evaluated trauma transfer patterns and outcomes in Montana and neighboring rural regions. METHODS: A 10-year retrospective review (2012-2022) was conducted at a rural Level I trauma center. Patients were excluded if they lacked a documented injury time, had an Injury Severity Score (ISS) of 75, or transfer times exceeding 48 h. The remaining 4213 trauma activations were categorized as direct scene admissions (n = 2221) or interfacility transfers (n = 1992). Multivariate logistic regression identified mortality predictors. RESULTS: Transfer patients had longer hospital (6.0 vs. 3.0 days; p < 0.0001) and ICU stays (4.6 vs. 3.7 days; p = 0.0045) and higher unadjusted mortality (5.0% vs. 3.0%; p < 0.0001). However, transfer status was not an independent predictor of mortality after adjustment. Mortality was significantly associated with ISS, age, hospital length of stay, and shock index. Mean transfer time was 7 h and mean distance was 188 miles. Most transfers (81.4%) originated from small or isolated rural towns with limited surgical coverage and greater reliance on advanced practice providers (p < 0.0001). CONCLUSIONS: Rural trauma patients experience significant delays in access to definitive care. Enhancing resources and trauma training for rural providers, particularly advanced practice providers, may mitigate outcome disparities across geographically underserved regions. Further regional studies are needed to reduce time to definitive care.