Defining the bellwether procedures and processes for global trauma care: an international Delphi study

Michael F Bath¹, Joachim Amoako^{2

3}, Thomas Edmiston⁴, Amila Sanjiva Ratnayake⁵, Daphne Kabatoro^{4

6}, Dinesh Bagaria⁷, Raj Menon⁸, Jared M Wohlgemut^{9

10}, Laura Hobbs^{4

11

12}, Brandon G Smith⁴, Carlos M Nuño-Guzmán^{13

14}, Sebastian E Vélez¹⁵, Rick Brennan¹⁶, Andrew Conway Morris^{17

18}, Timothy Craig Hardcastle^{19

20}, Thomas Weiser²¹, Tom Bashford^{4

11

22}; Global Trauma Care Delphi Collaborative; Global Trauma Care Delphi

Collaborators, Affiliations

Collaborators

Global Trauma Care Delphi:
Aarne Feldheiser, Abeer Noureldin, Abhinav Gupta, Agnes S Meidert, Aitor Landaluce-Olavarria, Alberto Cucino, Alessandro Strumia, Ali Guner, Ana S Lopes, Anbin Naidoo, Andee Dzulkarnaen Zakaria, Andrea Carsetti, Andrea Gutiérrez, Andrea Sanna, Andreas Hartjes, Andres M Rubiano, Andrew G Robertson, Anis Hasnaoui, Ankur Gupta, Ankur Sharma, Annalisa Piccolo, Anusha Cherian, Apurb Sharma, Arnav Mahajan, Arthur James, Ary S de Sousa, Ashish A Bartakke, Ashraf Roshdy, Asish Kumar Panda, Asyraf Mohd Zuki, Athanasios Gargavanis, Auwal Adamu, Banu Yigit, Barbara Hallmann, Believe O Nomayo-Oriabure, Benoit Blondeau, Bhupinder Singh, Bo E Madsen, Boris V Tablov, Buh F Chu, Bulent Citgez, Carmen Lopez Soto, Charlotte Whiffin, Christina Alexopoulou, Christopher Terblanche, Conor S O'Flynn, Cornelis Slagt, Cristian Deana, Cynthia A O Akli-Nartey, Dana R Tomescu, David A Leon, David Benguria Puebla, David Wall, Devorah L Wineberg, Dhuleep Wijayatilake, Diana Adrião, Diego Pastor Marcos, Diego Visconti, Dimitrios C Papadopoulos, Dimitrios Toumpanakis, Dorothy Turitwenka, Dziwornu Kunutsor, Edward J Nevins, Elena Theophilidou, Elham Rostami, Emalee J Burrows, Emilio Rodriguez-Ruiz, Emma Muendo Loko, Emmanuel Andzie-Mensah, Emmanuel Ikwutah, Erika Noè, Esther K Haspels-Hogervorst, Eugenia Anabel Liger Borja, Evangelia Theodorou, Evangelos Kaimakamis, Fabio Guarracino, Fabio Sangalli, Francesca Mulazzani, François Dépret, Gary A Bass, Gentle Shrestha, George D Mukoro, Georgia Tsaousi, Gerard Angeles-Fite, Gerard McKnight, Gerardo M Briones, Giacomo Calini, Giacomo E Iapichino, Giuliano Bolondi, Giuseppe Pascarella, Gizem Kılıç Aydoğdu, Harald Willschke, Harri G Jones, Harrison Roocroft, Hasan K Pampal, Hatem Elkady, Helena Odenstedt Herges, Hendrik Bracht, Henry O Abiyere, Henry O Nnajiuba, Hynek Riha, Ibrahim A Saidu, Ifigenia Ravani, Indiradevi Bhagavatula, Inês C R Gomes, Inês Carolino, Ioannis Andrianopoulos, Ioannis Pantazopoulos, Ion Chesov, Isaac Chukwu, Jan A Graw, Jan Gunst, Jan Michael V Yap, Jeffrey N Wood, Jessie R Wilburn, Jihad Mallat, Joana Osório, Joanna Shepherd, Joaquín C Joaco, Johannes Ehler, John R Prowle, John V Taylor, Jonathon D Taylor, José M Alonso-Íñigo, Juan A Llompart-Pou, Juan C Lopez-Delgado, Kalavathy Swarna, Kamal Jayasuriya, Kate Hancorn, Kellie Bateman, Khuram Maqbool, Kirubel Geletu, Koen M E M Reyntjens, Kristina E Fuest, K W Karen Tsang, Larissa Dsilva, Lars-Olav Harnisch, Laura Borgstedt, Laura Galarza, Leandro B Carvalho, Lene Russell, Leonid A Lichman, Liam D Quinn, Lilav Hasan, Lodovico Sartarelli, Lok Ka Cheung, Lovenish Bains, Luca Carenzo, Luigi Vetrugno, Mabel Banson, Mafalda Mourisco, Mahan Sadjadi, Mansoor N Bangash, Marc L C Yang, Marcel J H Aries, Marcella C A Müller, Maria Bringas, Martin Helan, Martin W Dünser, Mate Berczi, Matt McKenna, Matthew Woods, Melanie Premstaller, Mercedes Pilkington, Mervyn Mer, Michael El-Boghdady, Michal Kalina, Michal Kawka, Michelle S Chew, Miguel Garcia-Marin, Miguel Prista Monteiro, Mirza Aun Muhammad Baig, Mo Al-Haddad, Mohamed Almurtada Abdelwahab, Mohamed Sheikh Hassan, Nan Wang Mohan Gurjar, Nebiyou S Bayleyegn, Nebojsa Brezic, Neeraj Kumar, Neeru Sahni, Nele M Baert, Nelson Ahadi Isaya, Nichole Starr, Nicolò Marchesini, Nik Ahmad Shaiffudin, Nikolaos Koronakis, Nils I Corson, Niraj Tyagi, Oles Yehorov, Oliver Smith, Olivier Santos, Otavio Ranzani, Otavio T Ranzani, Paër-Sélim Abback, Patrick Biston, Patrick Meybohm, Patrizio Petrone, Pedro M G Gomes, Pedro Povoa, Peter M Spieth, Petra O P Wahjoepramono, Philip I Bastone, Philipp Venetz, Pierre Mora, Pierre Pasquier, Prashant Nasa, Priya Baby, Puvanendiran Shanmugam, Qing Yuan Goh, Rajib Hasan, Rakesh Garg, Ram Jeevan, Randeep S Jawa, Reesha Joshi, René R Schmutz, Richard A Crawford, Robert K Parker, Roberta M L Roepke, Robin Manidas, Ronald R Barbosa, Ryan Breslin, Sagarika Panda, Salvatore Lucio Cutuli, Samir Samal, Samira Akbas, Sebastian Schnaubelt, Sebastien Gaujoux, Sergey E Katorkin, Sergio M Navarro, Sergio Marcos Contreras, Shah M Rahman, Sharon Einav, Shilpi Karmakar, Simant K Jha, Slavica Kvolik, Somnath Bose, Sotiria Koutsouki, Stavros Gourgiotis, Stefan P Wirtz, Stephanie Giaquinto, Stephanie Mifsud, Sunder Balasubramaniam, Susan Yoong, Tariq H Khan, Tchokam Lionelle, Teresa C Guimarães, Thangaraj Munusamy, Theodoros Aslanidis, Thierry Bège, Thomas Botrel, Thomas Clavier, Tina Tomić Mahečić, Tomasz Jodlowski, Tomasz Torlinski, Vasileios Kaldis, Vincenzo Russotto, Wael Hassan, Waleed Bin Ghaffar Waleed, Wellingson Paiva, Xavier Chapalain, Xavier-Jean Taverna, Yashoda Khadka, Yoshiro Hayashi, Yoshiro Kobe, Yunushan F Aydoğdu, Yuti Sheth, Yuzaidi Mohamad, Zainub Jooma, Zeliha A Ozdemirkan, Zeljka Gavranovic, Zhongheng Zhang, Zudin A Puthucheary

Affiliations

¹ International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK mb2583@cam.ac.uk.
² University of Ghana Medical School, Accra, Ghana.
³ Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana.
⁴ International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK.
⁵ Department of Surgery, Army Hospital, Colombo, Sri Lanka.
⁶ Department of Anaesthesia, Kampala Hospital, Kampala, Uganda.
⁷ Department of Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India.
⁸ Department of Surgery, National University Hospital, Singapore.
⁹ Department of General Surgery, Royal Alexandra Hospital, Paisley, UK.
¹⁰ Centre for Trauma Sciences, Queen Mary University of London, London, UK.
¹¹ NIHR Global Health Research Group on Acquired Brain and Spine Injury, University of Cambridge, Cambridge, UK.
¹² Department of Anaesthesia, East & North Hertfordshire NHS Trust, Stevanage, UK.
¹³ Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.
¹⁴ Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico.
¹⁵ Hospital de Urgencias de Córdoba, Córdoba, Argentina.
¹⁶ Global Health Consultant, -, Sydney, New South Wales, Australia.
¹⁷ JVF Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
¹⁸ Perioperative, Acute, Critical Care and Emergency Medicine Section, Department of Medicine, University of Cambridge, Cambridge, UK.
¹⁹ Department of Surgical Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal College of Health Sciences, Durban, South Africa.
²⁰ Trauma and Burns Unit, Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal Department of Health, Durban, South Africa.
²¹ Department of Surgery, Stanford University, Stanford, California, USA.
²² Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.

PMID: 41720581
DOI: 10.1136/bmjgh-2025-020909

Defining the bellwether procedures and processes for global trauma care: an international Delphi study

Michael F Bath et al. BMJ Glob Health. 2026.

. 2026 Feb 20;11(2):e020909.

doi: 10.1136/bmjgh-2025-020909.

Authors

Collaborators

Global Trauma Care Delphi:
Aarne Feldheiser, Abeer Noureldin, Abhinav Gupta, Agnes S Meidert, Aitor Landaluce-Olavarria, Alberto Cucino, Alessandro Strumia, Ali Guner, Ana S Lopes, Anbin Naidoo, Andee Dzulkarnaen Zakaria, Andrea Carsetti, Andrea Gutiérrez, Andrea Sanna, Andreas Hartjes, Andres M Rubiano, Andrew G Robertson, Anis Hasnaoui, Ankur Gupta, Ankur Sharma, Annalisa Piccolo, Anusha Cherian, Apurb Sharma, Arnav Mahajan, Arthur James, Ary S de Sousa, Ashish A Bartakke, Ashraf Roshdy, Asish Kumar Panda, Asyraf Mohd Zuki, Athanasios Gargavanis, Auwal Adamu, Banu Yigit, Barbara Hallmann, Believe O Nomayo-Oriabure, Benoit Blondeau, Bhupinder Singh, Bo E Madsen, Boris V Tablov, Buh F Chu, Bulent Citgez, Carmen Lopez Soto, Charlotte Whiffin, Christina Alexopoulou, Christopher Terblanche, Conor S O'Flynn, Cornelis Slagt, Cristian Deana, Cynthia A O Akli-Nartey, Dana R Tomescu, David A Leon, David Benguria Puebla, David Wall, Devorah L Wineberg, Dhuleep Wijayatilake, Diana Adrião, Diego Pastor Marcos, Diego Visconti, Dimitrios C Papadopoulos, Dimitrios Toumpanakis, Dorothy Turitwenka, Dziwornu Kunutsor, Edward J Nevins, Elena Theophilidou, Elham Rostami, Emalee J Burrows, Emilio Rodriguez-Ruiz, Emma Muendo Loko, Emmanuel Andzie-Mensah, Emmanuel Ikwutah, Erika Noè, Esther K Haspels-Hogervorst, Eugenia Anabel Liger Borja, Evangelia Theodorou, Evangelos Kaimakamis, Fabio Guarracino, Fabio Sangalli, Francesca Mulazzani, François Dépret, Gary A Bass, Gentle Shrestha, George D Mukoro, Georgia Tsaousi, Gerard Angeles-Fite, Gerard McKnight, Gerardo M Briones, Giacomo Calini, Giacomo E Iapichino, Giuliano Bolondi, Giuseppe Pascarella, Gizem Kılıç Aydoğdu, Harald Willschke, Harri G Jones, Harrison Roocroft, Hasan K Pampal, Hatem Elkady, Helena Odenstedt Herges, Hendrik Bracht, Henry O Abiyere, Henry O Nnajiuba, Hynek Riha, Ibrahim A Saidu, Ifigenia Ravani, Indiradevi Bhagavatula, Inês C R Gomes, Inês Carolino, Ioannis Andrianopoulos, Ioannis Pantazopoulos, Ion Chesov, Isaac Chukwu, Jan A Graw, Jan Gunst, Jan Michael V Yap, Jeffrey N Wood, Jessie R Wilburn, Jihad Mallat, Joana Osório, Joanna Shepherd, Joaquín C Joaco, Johannes Ehler, John R Prowle, John V Taylor, Jonathon D Taylor, José M Alonso-Íñigo, Juan A Llompart-Pou, Juan C Lopez-Delgado, Kalavathy Swarna, Kamal Jayasuriya, Kate Hancorn, Kellie Bateman, Khuram Maqbool, Kirubel Geletu, Koen M E M Reyntjens, Kristina E Fuest, K W Karen Tsang, Larissa Dsilva, Lars-Olav Harnisch, Laura Borgstedt, Laura Galarza, Leandro B Carvalho, Lene Russell, Leonid A Lichman, Liam D Quinn, Lilav Hasan, Lodovico Sartarelli, Lok Ka Cheung, Lovenish Bains, Luca Carenzo, Luigi Vetrugno, Mabel Banson, Mafalda Mourisco, Mahan Sadjadi, Mansoor N Bangash, Marc L C Yang, Marcel J H Aries, Marcella C A Müller, Maria Bringas, Martin Helan, Martin W Dünser, Mate Berczi, Matt McKenna, Matthew Woods, Melanie Premstaller, Mercedes Pilkington, Mervyn Mer, Michael El-Boghdady, Michal Kalina, Michal Kawka, Michelle S Chew, Miguel Garcia-Marin, Miguel Prista Monteiro, Mirza Aun Muhammad Baig, Mo Al-Haddad, Mohamed Almurtada Abdelwahab, Mohamed Sheikh Hassan, Nan Wang Mohan Gurjar, Nebiyou S Bayleyegn, Nebojsa Brezic, Neeraj Kumar, Neeru Sahni, Nele M Baert, Nelson Ahadi Isaya, Nichole Starr, Nicolò Marchesini, Nik Ahmad Shaiffudin, Nikolaos Koronakis, Nils I Corson, Niraj Tyagi, Oles Yehorov, Oliver Smith, Olivier Santos, Otavio Ranzani, Otavio T Ranzani, Paër-Sélim Abback, Patrick Biston, Patrick Meybohm, Patrizio Petrone, Pedro M G Gomes, Pedro Povoa, Peter M Spieth, Petra O P Wahjoepramono, Philip I Bastone, Philipp Venetz, Pierre Mora, Pierre Pasquier, Prashant Nasa, Priya Baby, Puvanendiran Shanmugam, Qing Yuan Goh, Rajib Hasan, Rakesh Garg, Ram Jeevan, Randeep S Jawa, Reesha Joshi, René R Schmutz, Richard A Crawford, Robert K Parker, Roberta M L Roepke, Robin Manidas, Ronald R Barbosa, Ryan Breslin, Sagarika Panda, Salvatore Lucio Cutuli, Samir Samal, Samira Akbas, Sebastian Schnaubelt, Sebastien Gaujoux, Sergey E Katorkin, Sergio M Navarro, Sergio Marcos Contreras, Shah M Rahman, Sharon Einav, Shilpi Karmakar, Simant K Jha, Slavica Kvolik, Somnath Bose, Sotiria Koutsouki, Stavros Gourgiotis, Stefan P Wirtz, Stephanie Giaquinto, Stephanie Mifsud, Sunder Balasubramaniam, Susan Yoong, Tariq H Khan, Tchokam Lionelle, Teresa C Guimarães, Thangaraj Munusamy, Theodoros Aslanidis, Thierry Bège, Thomas Botrel, Thomas Clavier, Tina Tomić Mahečić, Tomasz Jodlowski, Tomasz Torlinski, Vasileios Kaldis, Vincenzo Russotto, Wael Hassan, Waleed Bin Ghaffar Waleed, Wellingson Paiva, Xavier Chapalain, Xavier-Jean Taverna, Yashoda Khadka, Yoshiro Hayashi, Yoshiro Kobe, Yunushan F Aydoğdu, Yuti Sheth, Yuzaidi Mohamad, Zainub Jooma, Zeliha A Ozdemirkan, Zeljka Gavranovic, Zhongheng Zhang, Zudin A Puthucheary

Affiliations

¹ International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK mb2583@cam.ac.uk.
² University of Ghana Medical School, Accra, Ghana.
³ Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana.
⁴ International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK.
⁵ Department of Surgery, Army Hospital, Colombo, Sri Lanka.
⁶ Department of Anaesthesia, Kampala Hospital, Kampala, Uganda.
⁷ Department of Surgery, All India Institute of Medical Sciences, New Delhi, Delhi, India.
⁸ Department of Surgery, National University Hospital, Singapore.
⁹ Department of General Surgery, Royal Alexandra Hospital, Paisley, UK.
¹⁰ Centre for Trauma Sciences, Queen Mary University of London, London, UK.
¹¹ NIHR Global Health Research Group on Acquired Brain and Spine Injury, University of Cambridge, Cambridge, UK.
¹² Department of Anaesthesia, East & North Hertfordshire NHS Trust, Stevanage, UK.
¹³ Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.
¹⁴ Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico.
¹⁵ Hospital de Urgencias de Córdoba, Córdoba, Argentina.
¹⁶ Global Health Consultant, -, Sydney, New South Wales, Australia.
¹⁷ JVF Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
¹⁸ Perioperative, Acute, Critical Care and Emergency Medicine Section, Department of Medicine, University of Cambridge, Cambridge, UK.
¹⁹ Department of Surgical Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal College of Health Sciences, Durban, South Africa.
²⁰ Trauma and Burns Unit, Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal Department of Health, Durban, South Africa.
²¹ Department of Surgery, Stanford University, Stanford, California, USA.
²² Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.

PMID: 41720581
DOI: 10.1136/bmjgh-2025-020909

Abstract

Background: The complexity of delivering trauma care makes the assessment of its provision challenging. The identification of bellwether procedures has previously been successful in the evaluation of global surgical care; however, any equivalent in assessing trauma care is currently lacking. Through a Delphi process, we aimed to produce the bellwether procedures and processes for global trauma care.

Methods: A global Delphi process was undertaken with healthcare professionals and academics involved in trauma care from across the world. A list of potential procedures and processes was identified through literature review and expert opinion, along with subsequent additional options suggested by respondents. Three successive rounds were completed, with respondents rating the importance of each procedure or process to be undertaken at any hospital that cares for trauma patients using a five-point Likert scale.

Results: A total of 411 respondents from 78 countries completed the initial round of the Delphi process, with minimal attrition observed across rounds. Following three successive rounds of the Delphi and functional aggregation, nine bellwethers of global trauma care were determined, subdivided into three functional categories: 'Resuscitation & Stabilisation'-(1) Advanced Airway Management, (2) Short-term C-spine Immobilisation, (3) Long Bone Immobilisation; 'Diagnosis & Monitoring'-(4) Blood Gas Analysis, (5) Focused Assessment with Sonography in Trauma (FAST) Scanning, (6) Continuous Access to CT Imaging; 'Optimisation & Intervention'-(7) Blood Transfusion, (8) Tube Thoracostomy, (9) Laparotomy and Splenectomy.

Conclusion: The Global Trauma Care Delphi study has produced nine metrics that provide pragmatic indicators for the overall assessment of trauma care capabilities at any healthcare setting worldwide. These bellwethers of global trauma care can enable hospitals, local managers and health ministries to identify institutions or regions that may require more in-depth assessment, allowing standards in the management of traumatic injuries to improve.

Keywords: Delivery of Health Care; Health policy; Health systems evaluation; Traumatology.

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Conflict of interest statement

Competing interests: ACM sits on the scientific advisory board of Cambridge Infection Diagnostics and has received speaking fees from Thermo-Fisher, Biomerieux, Fischer and Paykel and Boston Scientific. All other authors have no competing interest to declare.

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Defining the bellwether procedures and processes for global trauma care: an international Delphi study

Collaborators

Affiliations

Defining the bellwether procedures and processes for global trauma care: an international Delphi study

Authors

Collaborators

Affiliations

Abstract

Conflict of interest statement

MeSH terms