ORIGINAL ARTICLE Early Surgery in Trauma Patients Is a Key Performance Indicator of Outcome—A Case Series Analysis Dinesh Kumar Bagaria 1 & Amit Gupta 1 & Subodh Kumar 1 & Santosh Mahindrakar 1 & Ankita Sharma 1 & Biplab Mishra 1 & Narendra Choudhary 1 & Abhinav Kumar 1 & Pratyusha Priyadarshini 1 & Sushma Sagar 1 Received: 9 September 2019 /Accepted: 8 May 2020 # Association of Surgeons of India 2020 Abstract We analyzed one feasible timeline of critical surgery within the first hour of admission as a possible intervention, which could be applied in existing trauma systems in Low and middle-income countries (LMIC), and may improve trauma care outcomes. Retrospective analysis of a prospectively maintained data registry under project named TITCO (Towards Improved Trauma Care Outcome) was done at a level one trauma center in India from October 2013 to September 2015. All admitted patients who underwent critical surgery within the first hour of admission were analyzed. These patients were divided in two groups depending upon primary presentation or referred from other facility. Statistical analysis was done between these two groups to compare outcome. Sixty-one (57.6%) patients were directly admitted, whereas forty-five (42.4%) were transferred from other hospitals. The median time from injury to presentation for primary patients was 50 min with interquartile range (IQR) of 40. In referred patient median time gap between the injury to our center (not referring center) was 230 min with IQR of 350. This difference was statistically significant. Both the groups were comparable in terms of injury severity measured by ISS. Major outcome indicators in the form of median ICU and total stay, as well as mortality, were not significantly different. We propose that critical surgery within the first hour of presentation might be a useful hospital-based key performance indicator even in the existing trauma systems in LMIC to improve the outcome of injured patients. Keywords Trauma systems . Key performance indicator . Trauma care Introduction Trauma is a man-made disease of modern society. Numerous concepts and protocols have been proposed and some of them are considered the standard of care for trauma globally. One of them is the golden hour. “The golden hour” concept is prevailed among trauma caregivers worldwide and is a major force behind the development of prehospital care and transport services so that best possible care can be provided to the in- jured earliest [1]. Although the evidence is less supportive regarding the overall outcome of the application of this con- cept, the western world has robust prehospital care, transportation to appropriate facility, and structured informed transfer to higher level [2, 3]. In low and middle-income countries (LMIC) like India, the trauma system is very primitive. Due to the lack of systemic prehospital care and transportation, the dearth of competent health facilities and administrative issues, golden hour care is almost nonexistent in developing countries [4–6]. As the greatest burden of trauma-related mortality and morbidity is being taken by the developing counties [7], there is a need of the hour to develop some interventions which can be incorpo- rated in a cost-effective way in existing trauma system in these countries. One such intervention proposed is to provide adequate re- suscitation and fulfilling critical surgical needs of the injured as early as possible after reaching an appropriate trauma care facility. Studies from western countries are unable to support the contention that shorter out-of-hospital interval improves survival among injured adults [ 8 – 10 ]. The effect of prehospital delay either due to transportation or due to provid- ing informal prehospital care on outcome has not been studied yet in developing countries. * Amit Gupta amitguptaaiims@gmail.com 1 Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, Raj Nagar, New Delhi, India Indian Journal of Surgery https://doi.org/10.1007/s12262-020-02371-z