INTRODUCTION

Every year, more than 5 million people die from injury—more than one and a half times the number of deaths from HIV, tuberculosis, and malaria combined (97)—and nearly one billion people sustain injuries that require health care (38). For every injury death, there are 20–50 nonfatal injuries that result in some form of disability, impacting quality of life, productivity, and financial security (31, 95).

Although prevention is ideal—and there are many effective and cost-effective injury prevention strategies (96)—no system will prevent all injuries, and strong evidence indicates that well-organized trauma care can save lives once injury has occurred (58, 74, 81). Estimates derived from the Global Burden of Disease data suggest that nearly 2 million lives could be saved every year if case fatality rates among seriously injured persons in low- and middle-income countries (LMICs) were similar to those achieved in high-income countries (61). Of particular relevance to resource-constrained settings, much of the evidence from high-income countries relates to organizational and administrative aspects that could be implemented with limited input of new material resources: planning of systems for trauma management (e.g., regulation to designate trauma centers, prehospital triage protocols, and transfer criteria), and verification and accreditation of trauma care services (32, 63).

However, despite the fact that nearly 90% of injuries occur in LMICs, most of the research on the impact of trauma care comes from high-income countries where systems have been implemented with few resource constraints. Assessments in LMICs have consistently identified enormous gaps in the resources needed to provide adequate care for the injured (26, 39, 104), but little context-relevant guidance exists to help policy makers and planners set priorities in LMICs, where components of trauma care systems may be implemented in distinct ways.

We aimed to systematically review the evidence, identifying reports that evaluate the impact of a trauma care system or system components in LMICs. By doing so, we have identified context-relevant reports on specific trauma system components and have characterized regional and topical research gaps to help guide future research, policy, and funding agendas.

METHODS

Search Strategy

The search strategy and study protocol were registered with PROSPERO (University of York, United Kingdom National Institute for Health Research, United Kingdom of Great Britain and Northern Ireland) on April 20, 2015 (CRD-42015019685) (80). In order to retrieve all relevant records, the initial search string (available on request) comprised only a series of general terms for injury and an LMIC filter.

For inclusion, we have used a broad definition of trauma care systems to include any component among those outlined in World Health Organization (WHO) (63, 85, 101) guidelines:

▪regulatory or legislative structure;

▪facility inspection, verification, and designation;

▪prehospital care, hospital-based care, and rehabilitation;

▪use of clinical and organizational protocols, including triage;

▪training; and

▪data collection, registries, and quality-improvement audits.

We did not include reports on specific clinical interventions that were neutral to the existence of a trauma system; for example, a comparative study of two different types of orthopedic hardware to treat fracture would not have been included, but the establishment of a new referral protocol for orthopedic care would have been. A report was considered to document impact if it described the effect of an intervention on trauma care system structure or process or on clinical or population-health outcomes among the injured. Included reports were classified by this schema, which is described in detail below.

We included reports from any country designated as low- or middle-income by the World Bank as of 2010 (105). We chose 2010 rather than more recent classifications so that we did not miss studies performed in middle-income countries that may have since become high-income countries.

Reports from military organizations were excluded if they were limited to military personnel or battlefield reports. Thus, a report on a military program delivering care exclusively within a combat zone would not be included, whereas a report on a military-run program delivering care broadly to a civilian LMIC population would.

We included reports in any language as long as there was either an abstract or full-text article available through the WHO or any of several major university libraries available to the authors. Conference abstracts were included. Review articles were not included as such, but all relevant reviews were examined for citations of reports that had not already been captured by our search. Animal studies were excluded.

Search and Data Collection

We searched the following databases: PubMed, EMBASE, CABI Global Health Database, WorldCat, Scopus, WHO Global Index Medicus, WHO IRIS, African Index Medicus, Index Medicus for the Eastern Mediterranean Region, Index Medicus for the South-East Asian Region, and Latin American and Caribbean Health Sciences literature (LILACS). The search was current as of January 28, 2016. Reference lists of included full-text reports and systematic reviews were cross-checked for relevant records.

We imported the retrieved records from each database into EndNote [Thomson Reuters, United States of America (USA)] and removed duplicates. At least two reviewers (I.H. Drewett, S. Salerno, H. Sawe, B. Stewart) screened the titles and abstracts; a senior reviewer (T. Reynolds) resolved classification conflicts. Similarly, two reviewers (S. Salerno, B. Stewart) assessed full-text reports and extracted data, and a senior reviewer (T. Reynolds) resolved classification conflicts. We used Google Forms (Google Inc., USA) to extract the data, which included first author; publication year; title; structured brief summary of report; intervention evaluated; type of impact; and direction of demonstrated impact (i.e., positive, neutral, negative). We classified the impact type as affecting

▪Structure—resulting in sustained change in the physical or human resources needed to provide trauma care (e.g., increased availability of materials after a change in supply chain management or increased capacity sustained over time after an educational intervention) or sustained improvement in trauma care administration;

▪Process—influencing aspects of care delivery, such as time intervals to trauma care (e.g., time from injury to first provider, or from injury to intervention), appropriate use of vital interventions (e.g., airway maneuvers for patients with obstructed airways, chest tube placement for pneumothorax), or protocol compliance; and/or

▪Clinical or population-health outcome—influencing individual patient outcomes (e.g., death, disability, quality of life) or other population-health outcomes (e.g., condition-specific mortality).

We did not include descriptive reports on educational initiatives unless they reported changes in capacity that were sustained over time (classified as a structural impact on human resource capacity) or reported an impact on process or outcomes. Thus, we did not include descriptive reports on educational initiatives when the only outcome reported was end-of-training exam performance.

Data Analysis

We classified the included reports by year of publication, country/countries of origin, type of intervention, and category of impact. A brief summary is provided for each report. We also tagged reports with broad cross-cutting categories of potential use to LMIC trauma care system stakeholders: (a) prehospital care, (b) lay providers, (c) pediatric care, and (d) cost-effectiveness analysis or costing. These categories were not mutually exclusive. Given the limited literature on this topic, we did not filter the reports on the basis of quality or risk of bias, and we decided a priori not to perform pooled analyses of results in light of the broad inclusion strategy and the expected marked heterogeneity.

RESULTS

We retrieved 4,284 records from the systematic search of all databases and identified an additional 11 records by reviewing the citations of systematic reviews. After removing 224 duplicates, 2,625 irrelevant titles, and 1,260 abstracts that did not meet the inclusion criteria, we reviewed 186 full-text reports. Among these 186 reports, an additional 115 failed to meet the inclusion criteria; in total, we included 71 reports from 32 LMICs (Figure 1). One compendium of trauma care system case studies met inclusion criteria and was counted as a single publication, though its components are discussed separately in the relevant discussion sections. The number of reports published per year generally increased after 1993, and the majority (63%) were published after 2006 (Figure 2). Table 1 shows the characteristics of included reports.

Table 1

Characteristics of included reports

Training, development of prehospital systems, and overall system organization initiatives were the interventions most commonly reported, followed by initiatives to implement clinical protocols and improve the availability of specialty care (e.g., orthopedic or neurosurgical care). Table 2 shows a summary of all included articles, interventions assessed, and outcomes.

Table 2

Brief summary of included reports

Training

Twenty-five reports from 18 countries described the impact of training programs. Many of these demonstrated sustained structural impacts: For example, a two-year training program designed around the WHO Guidelines for Essential Trauma Care and implemented across government hospitals in Botswana resulted in sustained changes in availability of physical and human resources (40). Many of these reports also demonstrated improvements to process measures: An educational symposium in South Africa led to increased compliance with universal barrier precautions at a tertiary hospital trauma unit (20). Other reports assessed the impact of training on mortality and morbidity: At a Médecins Sans Frontières–run first-level referral hospital in Masisi, Democratic Republic of the Congo, training nonspecialists to perform toileting of open fractures and external fixation decreased amputation rates among open fractures from 100% to 21% over 7 years (18). A surgical skills training program for nondoctors in Cambodia showed substantial reductions in postoperative infection rates and trauma mortality (93).

Prehospital Systems

Fifteen reports from 11 countries assessed the impact of establishing or organizing prehospital systems, ranging from lay-provider-based systems, to city- or country-wide formal prehospital systems, to aeromedical transport systems. These reports described improvements in structure, process, and health outcomes, even with severe resource limitations. For example, a new community-based prehospital system in rural Uganda reported sustained staff retention and functional ambulances over six months (30), while a prehospital care system using paramedics and laypersons in rural Iraq found increased use and acceptance of the system by the local population over time (103), as well as a significant reduction in mortality and improvement in severity scores after the intervention (71).

Two reports specifically addressed the impact of establishing or reorganizing dispatch systems to improve access to care. In Monterrey, Mexico, an increase from 2 to 4 ambulance dispatch stations decreased mean response time by 40%; coupled with training, these prehospital care improvements cost only US$77,600 per year (16% of the annual system budget) (13). A new dispatch algorithm implemented in Tehran, Iran (Islamic Republic of), improved utilization of existing resources and resulted in a 16% decrease in unnecessary trauma responses (7).

Overall System Organization

An additional 15 reports in 12 countries addressed overall system organization, including incorporation of standardized guidelines for trauma care systems (e.g., WHO Guidelines for Essential Trauma Care) and mechanisms for designation of trauma centers. The reports ranged from a modeling study to estimate the overall global impact of integrated trauma care systems—which suggested that nearly two million lives could be saved annually if global survival rates from severe injury mirrored those in high-income countries (61)—to a spatial analysis of access to trauma care in Haiti and Namibia (92).

Other reports examined the impact of using WHO guidelines for assessment and planning of trauma services (52): In Viet Nam, trainings targeted to deficiencies that were identified through a WHO-based assessment led to sustained structural improvements (87). Two reports specifically assessed the impact of designating trauma centers (23, 91), including one that demonstrated differential outcomes at designated pediatric trauma care centers: In Moscow, Russia, children who suffered a road traffic injury and were cared for by prehospital providers with pediatric-specific training and were taken to pediatric trauma centers were significantly less likely to die than were children who were cared for by the general trauma care system (91).

Clinical Protocols

Six reports in four countries assessed the impact of introducing clinical protocols on mortality and a range of other clinical outcomes. The protocols ranged from using a locally adapted South African Triage Score in Botswana to reduce over- and undertriage rates (68) to implementing standardized protocols for resuscitation and brain injury management at a level 1 trauma center in Colombia (53, 54). Other reports had multipronged interventions: For example, a tertiary hospital in Shanghai, China, performed a three-pronged intervention that included (a) making specialist surgeons part of the initial bedside management of the severely injured; (b) promoting an interdisciplinary approach to patient care; and (c) performing resuscitation, evaluation, and testing in parallel. This intervention bundle resulted in a decrease in severity-adjusted mortality rate, in emergency department length of stay, and in time from admission to operation (57).

Specialty Care Availability

Five reports from seven countries examined the impact of increased availability of specialist care on a range of outcomes. For example, establishing a rapid response team for thoracic injuries in a tertiary hospital in Thailand reduced mortality (28), while the implementation of a telemedicine specialist program between the USA and two Armenian and Russian Federation medical centers immediately after disaster situations improved the accuracy of diagnoses and treatment plans (46).

Disaster Preparedness and Response

Only three reports examined the impact of disaster response and preparedness, two of which were based on modeling estimates. A report from China found that a facility's surge capacity was important in determining mortality and disability outcomes among earthquake victims with serious head injuries (106). A comparative modeling study of three countries that had suffered earthquakes (Armenia, Japan, USA) found that differences in disaster preparedness and response were closely correlated with injury mortality and morbidity (19), and a global modeling study suggested that the availability of a pediatric trauma care center could decrease time to care and save lives during a disaster (17).

Establishing a Quality-Improvement Program

Only two reports directly assessed the impact of establishing a quality-improvement program. A tertiary hospital in Karachi, Pakistan, showed improved mortality after implementing several trauma quality-improvement initiatives: morbidity and mortality meetings, a trauma quality-improvement committee, and a trauma registry with regular audits (41). The program was also paired with training and system organization improvements. In a tertiary hospital in Khon Kaen, Thailand, a trauma quality-improvement program included participatory action research, peer review, and an audit of a newly created trauma registry to identify problems with trauma care delivery, root causes of the problems, and potential solutions. Outcomes monitored over a subsequent six-year period showed a decrease in delayed diagnoses, incorrect diagnoses, medical errors, and mortality rates (62).

Rehabilitation

Only two reports from a single WHO compendium of “success stories” (62) described the impact of rehabilitation interventions. A small multidisciplinary rehabilitation team at a trauma center in Brazil began providing early rehabilitation on the trauma wards to improve mobility, teach self-care and use of adaptive devices, and coordinate patient follow-up with outpatient rehabilitation. Resulting improvements included decreased falls among the elderly, improved access to prostheses for amputees, and a substantial decrease in the rate of complications from spinal cord injury.

Cross-Cutting Areas

We also categorized reports into broad topical areas of potential interest for particular trauma care system stakeholders: Among the included reports, 32 addressed some aspect of the prehospital setting, 16 addressed lay providers, 15 extrapolated existing data to model the impact of trauma care interventions on LMICs, 13 evaluated cost-effectiveness or costing, and only 1 was specific to pediatric patients.

DISCUSSION

Our review returned 71 reports from 32 countries (Figure 3), which describe potentially useful interventions to strengthen care for the injured in LMICs. These 32 countries, however, represent only one-quarter of LMICs globally, which suggests a substantial research gap that spans all regions. Just over half of reports came from only eight countries: Iraq, Mexico, Ghana, Iran (Islamic Republic of), Cambodia, China, Haiti, and South Africa. Included reports describe a broad range of interventions, with types of impact relatively evenly distributed across trauma care structures, processes, and outcomes (see Figure 4).

Training

Included reports covered several trauma care training programs oriented to limited-resource settings and aimed at prehospital care providers, nurses, clinical officers, general practitioners, and specialists. These programs generally addressed conditions similar to those covered by the American College of Surgeons’ Prehospital Trauma Life Support and Advanced Trauma Life Support, while providing alternatives to costly proprietary course materials and providing more context-relevant management protocols that do not assume the availability of advanced diagnostic and therapeutic resources (56, 79).

Reports on these programs described positive impacts on structural, process, and outcome measures (15, 34, 62, 66), including reduced trauma-related mortality and morbidity in a number of settings as well as sustained improvements in clinical care capacity in other settings. The clinical effectiveness and cost-effectiveness of the reported programs suggest that dedicated trauma care training should be integrated into initial and ongoing certification pathways for prehospital and hospital-based trauma care providers and that this may require alternatives to proprietary international courses.

Of note, multiple initiatives specifically addressed training to extend the scope of practice for providers (task shifting or task sharing) as a means of expanding access to timely emergency care for injury. In Cambodia, for example, nondoctor health care providers were trained to provide essential trauma surgical care at rural first-level referral hospitals (93), and the Médecins Sans Frontières–run program in Democratic Republic of the Congo greatly improved outcomes by training nonspecialists to deliver specialized orthopedic services such as toileting of open fractures and external fixation (18).

These reports suggest that task sharing may be an important mechanism for expanding the availability of services and improving quality and that training initiatives should be aligned with the frontline reality that emergency care for injury is delivered by a range of providers.

Prehospital Systems

Prehospital systems are essential to ensure timely access to emergency care, especially for severely injured patients. In some countries, as many as 80% of injury deaths occur prior to patients’ arrival at a health care facility (61); thus, World Health Assembly resolution 68.15 on surgical and anesthesia care explicitly addresses the “primary level” of the health system, and the time-dependent targets of the Lancet Commission on Global Surgery, for example (8, 78), will never be met without prehospital systems and basic emergency care at lower levels of the health system. A recent review and meta-analysis estimated that prehospital systems can reduce injured patients’ risk of death by 25% (44), and estimates for special situations, such as in combat zones, are even higher (47).

Unlike hospital-based trauma care services, which have long existed in some form in most systems and are usually expanded incrementally, many countries still lack formal prehospital services altogether, allowing investigators the possibility to study the initial establishment of the system itself. Multiple reports support the idea that the essential functions of a prehospital system can be achieved in many ways, depending on the context and available resources (96). While some reports address the impact of establishing formal professional prehospital systems (9, 59, 82), several reports describe innovative lay provider initiatives that led to improved mortality and other positive impacts. For example, a motorcycle-based prehospital transport system for snakebite victims in Nepal and the establishment of layperson prehospital care systems in Cambodia, Iraq, and South Africa illustrate the potential for prehospital care to be effective, even with resource-limited implementation (48, 49, 86, 90).

In particular, dispatch protocols emerge as a critical mechanism for strengthening prehospital care delivery. Included studies suggest that dispatch algorithms allow better alignment between existing prehospital resources and the clinical needs of injured patients, lowering costs and improving efficiency and outcomes (7, 13).

Prehospital care system improvements must always take local resource availability, disease burden, and geography into account. It is worth noting that the capital and operating costs in all the included reports were well beneath the WHO-CHOICE (Choosing Interventions that are Cost Effective) threshold values for cost-effectiveness by region and were similar to costs of other recommended health interventions (e.g., bed nets for malaria prevention, antiretroviral therapy for HIV, aspirin and β-blocker for ischemic heart disease) (98).

Overall System Organization

Effective system organization ensures that injured patients receive timely care that is matched to their clinical needs, even when doing so requires bypassing lower levels of the health system. Five of the 15 reports in this section were modeling studies that extrapolate existing data to LMIC contexts, and they suggest that improvements in system organization could have a dramatic impact. While these models are based on a number of assumptions (about the capacity of trauma care systems in LMICs to approach outcomes seen in high-income countries), they are supported by the included studies that tested actual interventions in LMIC contexts.

The included reports demonstrate that improvements to system organization and planning can be feasible and sustainable, even in environments with very limited resources. In addition, one study from Ghana (excluded from our review because it did not specify an intervention) documented sustained improvements in the availability of critical trauma care resources at district and regional hospitals after broad changes in trauma care system governance and organization (88).

The benefits of improved coordination between trauma system components are well documented in high-income countries, and our review suggests that similar improvements in limited-resource settings may result in equally significant benefits. Indeed, these interventions may be even more valuable in contexts where maximizing the effectiveness of limited resources is critical.

Clinical Protocols

Clinical protocols provide guidance for a systematic approach to injury, improving early recognition of clinical needs and ensuring appropriate management. Included reports describing implementation of protocols for triage, assessment, management, and care coordination demonstrated improvements in care process and outcomes (53, 54, 68). These interventions may have particular importance in limited-resource settings where clinical volume is high and junior providers must often practice with limited supervision (63).

Specialist Availability

Trauma care is a multidisciplinary enterprise, and input from a range of specialty services (such as radiology, orthopedics and neurosurgery) is critical to providing a comprehensive response to injury. Several organizational aspects of a trauma system can affect the timeliness and availability of advanced specialty services. Included reports suggest that access can be improved by a range of low-cost (team organization, communication protocols) and higher-cost interventions (creation of new health care facilities).

Disaster Response and Preparedness

Preparing the everyday emergency care system to respond to extraordinary events ensures uninterrupted delivery of services in the face of increased demand. Not only do underprepared systems fail to deliver adequate and timely care during disasters, but they may also collapse in the face of system stressors, leading to additional secondary mortality and morbidity beyond that caused by the disaster itself. The few included reports on this topic suggest that the availability of specialized services can mitigate the impact of disasters but that there must be mechanisms in place to ensure that services can be rapidly disseminated where they are needed.

Trauma Quality-Improvement Programs

Although only two included reports specifically described the establishment of formal quality-improvement programs (41, 62), both demonstrated notable improvements in mortality and other positive impacts. Quality-improvement programs are integral to successful trauma care systems (101), are low-cost, and can be performed in nearly any setting where trauma care is provided.

Lay Providers

Incorporating lay providers into trauma care systems has been both clinically effective and cost-effective in multiple and disparate LMIC settings (25, 31). A notable number of included reports from our review (16 reports, mostly among those addressing training or prehospital initiatives) described the systematic use of lay providers to deliver emergency care services. Lay provider programs in Ghana, South Africa, and Uganda demonstrated long-term skill retention and utilization (50, 67, 90). Programs in rural Cambodia (49), Iraq (48), and Nepal (86) demonstrated improved mortality and were highly cost-effective.

Cost

Thirteen reports examined the cost or cost-effectiveness of the interventions assessed. Among the most cost-effective interventions are those that expand basic emergency care training to a range of lay and nondoctor providers (12), those that expand the scope of practice of nonspecialist providers (18), and those that target better organization of existing resources. Cost-based analysis will be critical to priority setting where resource limitations necessitate choices.

Evidence Gaps

Among the trauma system components identified in WHO guidelines, our review returned very few reports in the areas of rehabilitation and legislation and governance. In addition, only one report evaluated pediatric-specific trauma care mechanisms.

Disability after injury is 20–50 times more common than death; much of the resultant morbidity can be alleviated by early and appropriate rehabilitation services that increase functioning, prevent secondary complications (e.g., pressure sores, contractures), and promote independence (55). Rehabilitation is critical to maximizing the effectiveness of emergency and surgical care services for injury and should be an area of priority inquiry and planning.

The only explicit example of a governance intervention identified in our search was the creation of the Trauma Secretariat in Sri Lanka, which was included in the WHO compendium of success stories (62). Through a series of assessments using WHO tools and consultative meetings with local technical experts, the Trauma Secretariat oversaw development of an action plan to build a comprehensive trauma system countrywide. The Secretariat catalyzed and coordinated expansion of a prehospital system; creation of a National Injury Sentinel Surveillance System; nationwide rollout of trauma care training; development of guidelines, protocols, and a system for trauma center designation; and creation of the Ministry of Disaster Management. While the Trauma Secretariat was partially supported both financially and technically by international organizations, most of the work was done using local resources, expertise, and time, much of it volunteered.

Reports on these kinds of interventions are poorly represented in the scholarly literature in general, and their absence in this review should not be taken as an indication that they are not important. In addition to those mentioned above, critical legislative and governance interventions to improve care for the injured may include

▪Establishing a lead government agency to coordinate emergency care (not limited to disaster response),

▪Explicitly incorporating emergency care into the national health plan,

▪Establishing national legislation ensuring access to emergency care without regard to ability to pay,

▪Establishing dedicated certification pathways for prehospital providers, and

▪Establishing a toll-free, universal access number for emergency care.

Injury is a leading cause of death among the young everywhere in the world and the top global killer of adolescents (100). Findings from high-income countries suggest that dedicated systems of care for injured children can avert deaths and disability (72, 76). In LMICs, pediatric-specific trauma care resources and expertise are more often deficient than those for general trauma care (2, 11, 75); planning and organizing care for injured children should be a priority area for research and system development, given the large burden of pediatric injury in LMICs.

LIMITATIONS

Our study has several limitations. Although we built the search strategy to be as inclusive as possible by using broad search terms (e.g., “wounds and injuries”) and queried a range of the largest global databases, it remains a search of published, and primarily scholarly, literature. This limits our ability to capture interventions such as legislation and regulation that are less likely to be the subject of scholarly studies. In addition, some reports may have been missed without specific search terms for each trauma care system component, though it is unlikely that such reports would not have at least included the broader terms “trauma” or “injury.” We did not search gray literature (e.g., theses, dissertations, government documents, working papers) but did include conference proceedings.

The included reports almost certainly reflect some degree of publication bias. Ninety-two percent of reports described positive outcomes and 8% described neutral outcomes; no report described negative outcomes. Although the generally positive outcomes may be a true reflection of the impact of trauma care system components, the lack of negative outcome reports suggests some publication bias. Many of the included studies were based on reported data, which may limit validity, and we did not exclude studies with small sample sizes, which may limit the generalizability of the trends discussed. Finally, a number of the studies were based on models, and this review did not attempt to evaluate the assumptions underlying the models.

Our search was intentionally limited to LMICs and to studies that demonstrated impact, as this was the focus of our inquiry. Therefore, our results should not be interpreted as a comprehensive survey of the evidence base for trauma care systems, nor as a comprehensive description of the current state of trauma care in LMICs, but as a summary of the current evidence for LMIC implementation with documented impact. Lessons from high-income countries regarding trauma system development, maturation, and specific system components are certainly also useful for LMICs and should be considered when planning research priorities. Despite these limitations, the findings allow for reasonable conclusions about the potential impact of trauma care systems and system components in LMICs, provide context-relevant guidance for LMIC planners, and help identify topical gaps that necessitate specific study and funding.

CONCLUSION

This review has identified and described reports that evaluated the impact of trauma care systems and system components in LMICs. Although we identified 71 reports, the majority of LMICs had no reports at all. Reports that described the results of trauma care training, prehospital system establishment, overall system organization, and improvements to the availability of specialty care were more common than reports on other system components. These findings suggest several priority areas for research, program development, and funding. Specifically, there are a number of low-cost, high-value-added organizational interventions that involve only minimal input of new material resources. Quality-improvement, costing, rehabilitation, and legislation and governance are particularly neglected areas. We hope the results of this review will help guide more efficient and effective trauma care system development, as well as research and funding agendas.

disclosure statement

The authors are not aware of any affiliations, memberships, funding, or financial holdings that might be perceived as affecting the objectivity of this review. The authors alone are responsible for the views expressed in this article and do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.