Wartime trauma surge volume and its impact on surgical care delivery and patient outcomes: A nationwide study.

Abstract

An effective medical response to multiple-casualty incidents is critical for trauma systems worldwide. These events-which strain, but do not exceed, trauma center capacity-are increasingly common in civilian settings as a result of natural disasters, terrorism, and armed conflicts. This study evaluates the impact of combat casualty load on the time to urgent surgical intervention and on clinical outcomes during the Israel-Hamas war in southern Israel. This retrospective cohort study analyzed data from the Israel National Trauma Registry and included combatants who were hospitalized between October 27, 2023, and October 31, 2024, at 7 civilian Level I trauma center in Israel. Patients were stratified by arrival time and casualty volume per hour. The primary outcome was transfer to urgent surgery within 60 minutes of arrival. Secondary outcomes included in-hospital mortality and time to surgery. A total of 1,388 patients were included. The median age was 23 years (interquartile range, 21.0-28.0), and 99% were male. Most patients (93%) were evacuated by helicopter; 78% sustained penetrating injuries. Hemodynamic compromise was observed in 8% of cases. No significant differences were found in the proportion of urgent surgical interventions performed within 60 minutes or in in-hospital mortality across the different arrival clusters. Multivariable logistic regression revealed that only severe or critical injury (adjusted odds ratio, 4.62; 95% confidence interval, 1.56-17.17, P = .01, and adjusted odds ratio, 10.08; 95% confidence interval, 3.52-36.72, P < .001, respectively) and arrival during the morning shift (adjusted odds ratio, 2.83, 95% confidence interval, 1.27-6.71, P = .01) were independently associated with expedited surgical care. Clustered arrival of multiple combat casualties-ranging from 1 to 6 per hour-to civilian Level I trauma centers was not associated with delays in surgical care, increased mortality, or higher admission rates to the intensive care unit. However, night admissions were associated with longer times to operative care. These findings provide valuable insights for optimizing hospital and prehospital emergency response strategies during multiple casualty events.