Variation in global trauma care: a survey of 187 hospitals across 51 countries

Abstract

Background: Trauma is a heterogeneous disease entity, with high rates of mortality and morbidity observed globally. While the health systems in which trauma patients are cared for worldwide have been previously assessed to varying degrees, many of the system processes that shape trauma patient outcomes remain unknown.

Methods: We conducted a survey of 187 hospitals across 51 countries, through the GOAL-Trauma collaborative network. We explored prehospital, intrahospital and rehabilitation phases of trauma care. Data were compared across Human Development Index (HDI) tertiles, with thematic analyses performed to identify similarities and variation across settings.

Findings: Hospital-based care appeared to develop preferentially out of the three phases of trauma care, with challenges from the middle HDI tertile being more analogous to the upper HDI tertile than the lower HDI tertile. A lack of emergency medical services, limited patient finances and a lack of health literacy were common causes of prehospital delay in the lower and middle HDI tertiles. Surgeons and anaesthetists working in lower and middle HDI tertiles perform approximately 3-fold and 10-fold more operations, respectively, compared with upper HDI tertile counterparts. Across all HDI tertiles, infection was reported as the most common cause of postoperative morbidity.

Interpretation: A wide range of resources and processes exist globally in trauma care. Our findings suggest that with increasing resource availability, in-hospital care of trauma patients develops preferentially over prehospital or rehabilitation services. There is a clear need to coordinate available resources across all phases of care in order to improve outcomes among trauma patients.

Keywords: Health policy; Health systems; Health systems evaluation; Injury; Surgery.

Figure 1. The most common barriers reported by respondents in accessing trauma care, numbered 1 to 5, stratified by HDI tertile. EMS, emergency medical services; HDI, Human Development Index.

Figure 2. The most common reasons reported by respondents for delays in patients arriving to hospital following their initial injury, numbered 1 to 5, stratified by HDI tertile. EMS, emergency medical serviEmergency Medical Services; HDI, Human Development Index.

Figure 3. The most common reasons reported by respondents for delays in getting patients to the operating theatre for a trauma laparotomy, numbered 1 to 5, stratified by HDI tertile. EMS, emergency medical serviEmergency Medical Services; HDI, Human Development Index.

Figure 4. The reported availability of each surgical specialty, stratified by HDI tertile. HDI, Human Development Index; O&G, Obstetrics and Gynaecology

Figure 5. Themes across trauma systems in different HDI tertiles in prehospital, in-hospital and postoperative care and rehabilitation phases of care. EMS, emergency medical serviEmergency Medical Services; HDI, Human Development Index; ICU, intensive care unit.