Re-examination of a Battlefield Trauma Golden Hour Policy.

Background: Most combat casualties who die, do so in the prehospital setting. Efforts directed toward alleviating prehospital combat trauma death, known as killed in action (KIA) mortality, have the greatest opportunity for eliminating preventable death. Methods: 4,542 military casualties injured in Afghanistan from September 11, 2001 to March 31, 2014 were included in this retrospective analysis to evaluate proposed explanations for observed KIA reduction following a mandate by Secretary of Defense Robert M. Gates that transport of injured service members occur within 60 minutes. Using inverse probability weighting to account for selection bias, data were analyzed using multivariable logistic regression and simulation analysis to estimate the effects of 1) gradual improvement, 2) damage control resuscitation, 3) harm from inadequate resources, 4) change in wound pattern, and 5) transport time on KIA mortality. Results: The effect of gradual improvement measured as a time trend was not significant (AOR=0.99; 95%CI 0.94-1.03; p=0.58). For casualties with military injury severity score >= 25, the odds of KIA mortality were 83% lower for casualties who needed and received prehospital blood transfusion (AOR=0.17; 95%CI 0.06-0.51; p=0.002); 33% lower for casualties receiving initial treatment by forward surgical teams (AOR=0.67; 95%CI 0.58-0.78; p

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