There was a high rate of full agreement with the suggested criteria to be used for the post hoc definition of the requirement for trauma team activation of at least 75% with 12 of the proposed criteria. These included “Glasgow coma scale < 9”, “respiratory rate < 9 or > 29/min”, “pericardiocentesis”, “advanced airway management”, “pulse oximetry (SpO2) < 90%”, “emergency surgery”, “systolic blood pressure < 90 mmHg”, “shock index > 0.9”, “cardiopulmonary resuscitation”, “deterioration of GCS ≥ 2 points before admission”,” chest tube or needle decompression” and “catecholamine administration”. They comprised nearly all of the criteria of abnormal vital signs and most of the criteria of life-saving interventions. This level of agreement was similar to the threshold of agreement of 75% and 80%, respectively, that had to be achieved in two different consensus statements for a criterion to be included [15
Looking at the level of full agreement, however, revealed some potential differences in the evaluation of some of the criteria with respect to a country’s income level. Interestingly, some of the criteria reached a lower level of full agreement in the high-income countries than in the upper-middle-income counties. The level of full agreement tended to be lower in the lower-middle- as compared to the upper-middle-income countries. The number of participants in the low-income countries was low so that the results could be highly variable. The rate of full agreement for criteria of abnormal vital signs (cerebral, respiratory, cardio-circulatory, hypothermia) as well as of advanced airway management tended to highest in the low-, upper-middle- and high-income countries in contrast to the lower-middle-income countries.
On the other hand, the level of disagreement was rather low, mostly expressed by single participants. The highest rate of disagreement (> 5%) was observed for “death within 24 h”. This leaves a number of the proposed criteria with partial agreement, i.e. a level of less than 75% of full agreement but less than 5% disagreement (“hypothermia < 35°”, “ > 2 external fixators (humerus, femur, pelvis), “abbreviated injury scale (AIS) ≥ 4”, “ICU length of stay > 24 h”, “transfusion”, “tourniquet (pre-hospital)” and “radiological therapeutic intervention”.
Although the general full agreement for the proposed criteria of post hoc trauma team requirement is very high irrespective of the country’s income level, some of the criteria may deserve some more discussion before they may reach a higher level of agreement (or are being rejected). There is no uniform pattern of different levels of agreement in the order of a country’s income. There is less full agreement for some of the criteria in high- versus upper-middle-income countries.
The survey was like a single-point vote without the possibility of discussing the different items with the other participants. Therefore, partial agreements might be “upgraded” to full agreement (or disagreed) after the exchange of arguments and rationales. This would be the normal process of achieving consensus. In the cited consensus statements, up to five voting rounds were required to achieve agreement [15
]. Having this in mind, the agreement within this single survey voting appears high and it may be concluded that the proposed criteria may be useful for most countries independent of their level of income. Nevertheless, more discussions on an international level appear to be warranted to achieve a full consensus to define a universal set of criteria that will allow for quality assessment of over- and undertriage of trauma team activation for the most severely injured patients worldwide.
The major limitation of the study is the selection bias introduced by selecting the participants based on personal knowledge and recommendation. The participants were contacted based on the recommendation of 12 different members of the study group. They may lack the possible variability of opinions compared to a random sample. Therefore, the selection of participants appears arbitrary and not representative. For example, there is a preponderance of tertiary care hospitals and the low number of hospitals included from low-income countries may bias interpretation of this proportion of the study cohort. On the other hand, our participants represent different disciplines involved in trauma care such as trauma surgeons (general surgeons), trauma surgeons (orthopedic surgeons), anesthesiologists or emergency physicians thus representing a variety of different backgrounds. Also, a high rate of responders and the personal acquaintance may offer the chance to receive valid and thoughtful answers, particularly concerning the answers about the trauma team requirement, where some thorough thought on the side of the participants is essential. Other types of selection may introduce other biases. The variation of using an “official” mailing list from worldwide active organizations would have resulted in a more representative list of countries. However, it remains arbitrary who of the physicians contacted would actually answer, which may reduce the representativeness. The less personal character of the contact with the potential participant may also confound the thoughtfulness of some of the answers. Our return rate of 75.5% compares favorably to the return rate of a study using mailing lists from international societies and networks (54%) [21
]. Including participants from one medical society (e.g. only surgeons) may also bias the results. In both approaches, it is not clear whether the answers would be representative for a whole country or would be more specific to the institution and the setting of the respondent. That this may be the case was shown by the quite differing answers from participants originating in the same country. Bearing this in mind, our results have to be interpreted with caution.
However, many of the answers received in the survey of Miclau et al. [21
] and our study are quite comparable: There was a similar availability of designated trauma centers (33.3 vs. 27.8% in low-income countries and 68.8 vs. 71.0% in high-income countries). The availability of a formalized emergency medical service is in the same range for all levels of income in both studies, indicating that the participating countries in our survey may not substantially differ from a larger cohort of countries. In a systematic review about trauma systems around the world 32 countries have been evaluated [22
]. The authors included fewer low- and middle-income countries (N
= 9) compared to 23 countries of that type in our study. Therefore, their results with respect to tertiary care trauma centers and the availability of a trauma team may not be comparable to ours. Furthermore, 84% of the publications used in their study were older than 5 years and 50% older than 10 years, so that considerable improvements may have taken place since then in many countries.
There was a preponderance of participants from tertiary care hospitals in all country income levels. Their experience and rating may be different from physicians working in regional or local hospitals. It might be speculated that such differences could be more pronounced in countries with a lower per capita income [21
]. However, the assessment from our participants from regional or local trauma hospitals did not differ substantially from those from tertiary care hospitals, although the numbers are too small to rule out this possibility. To get a definite answer, it would require interviewing physicians from hospitals from all levels of trauma care in each country. Nevertheless, it appears reasonable to assume that the participants of our study did not answer in complete contradiction to the general rating within their respective country.
The number of participating countries in our survey amounted to around 20% of all countries within the same income level, with a clear underrepresentation of low-income countries. Therefore, the high level of agreement shown in our survey may not be true for low-income countries. Indeed, Miclau et al. [21
] have shown, that even in designated trauma centers in low-income countries, important musculoskeletal injury resources such as spine board, pelvic binder, computed tomography or post-anesthesia care unit are lacking to a much higher degree in comparison with countries with lower-middle-income or higher-income level.
Although we have gathered information about pre-hospital trauma care and facility-based trauma care, we cannot assign to our participants the WHO trauma maturity index [23
], because we are lacking information about education and training and quality assurance. We did not explicitly assess whether our participants in low- and middle-income countries fulfill the Bellwether procedures for essential surgical care like cesarean delivery, laparotomy and treatment of open fractures [24
]. Since all of them do have a general surgeon (100%), a trauma or orthopedic surgeon (100%) and a gynecologist (69%) as well as a specially equipped resuscitation area available, they could be classified as fulfilling the requirements of a high-level care.
Despite these limitations, it appears valid to assume that the proposed criteria for correct trauma team activation may be useful not only for high-income countries but at least also for lower-middle- and upper-middle-income countries. Although the requirements they pose may not be met in low-income countries and the entire territory of middle-income countries they appear to be recognized by many of the physicians practicing in these countries as well as in the high-income countries. They could be used for quality assurance in the care of severely or polytraumatized patients within trauma hospitals with benchmarks individualized by countries and dynamic over time. While there appears to be a large subset of criteria with high universal acceptance, some of the criteria with only partial agreement or even disagreement will have to be discussed in the future on a worldwide or a country-specific level to recommend which patient should or should not have received trauma team activation. A generally accepted or locally adapted criterion standard could be used to validate field triage criteria as well as to measure the performance of trauma systems in the different countries and adapt them to their specific conditions, circumstances and resources. It could further be used to compare the efficiency and capabilities of the initial care of severely injured patients worldwide.
Open Access funding provided by Projekt DEAL. The WORLD-Trauma TAcTIC Study Group: Khaled Tolba Younes Abdelmotaleb, MD. Department of Anesthesia and Intensive Care, Faculty of Medicine, Aswan University, Aswan 81528, Egypt; George Abi Saad, MD, Trauma Services and Surgical Critical Care, American University of Beirut, Riad El-Solh 1107 2020, PO Box 11–0236, Beirut, Lebanon; Markus Baacke, Krankenhaus der Barmherzigen Brüder, Nordallee 1, 54292 Trier, Germany; Nehat Baftiu MD, PhD, University Clinical Centre of Kosovo, QKUK, 10000 Pristine, Republic of Kosovo; Christos Bartsokas, MD, PhD, Hippokration General Hospital of Athens, Vas.Sofias 114 ave. Region of Attica, Athens, 11527, South Africa; Lars Becker, Dr., University Hospital Essen, Hufelandstraße 55, 45147 Essen, Germany; Marco Luigi Maria Berlusconi, Dr., Responsabile di Unità Operativa Traumatologia II, Istituto Clinico Humanitas, Via Alessandro Manzoni, 56, 20089 Rozzano MI, Italy; Artem Bespalenko, Dr., Traumatology Department, Military Medical Clinical Centre of Occupational Pathology of Personnel, Odynadtsyata Linia 1, 08200 Irpin, Ukraine; Dan Bieler, Dr., Bundeswehrkrankenhaus, Rübenacher Straße 170, 56072 Koblenz, Germany; Martin Brand, MD, Department of Surgery, University of Pretoria, Bridge E, Level 7; Surgery, Steve Biko Academic Hospital, Cnr Steve Biko Road & Malan Street; Prinshof, 349-Jr, Pretoria 0002, South Africa; Edilson Carvalho de Sousa Júnior, Dr., Departamento de Clínica Geral—Cirurgia II, Universidade Federal do Piauí, Hospital São Marco, R. Olávo Bilac, 2300, Teresina, Brazil; Narain Chotirosniramit, Prof. Dr. Bangkok Hospital Chiang Mai, Mueang Chiang Mai, Thailand; Yuhsuan Chung, MD, Show Chwan Memorial Hospital, No. 542, Sec 1, Zhongshan Rd., 50008 Changhua Changhua City, Taiwan; Lesley Crichton, Dr., Department of Anaesthesia, University Teaching Hospital, Lusaka, Private Bag RW1X Ridgeway, Nationalist Road, Zambia; Peter De Paepe, MD, PhD, Department of Emergency Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; Agron Dogjani, MD, PhD, University Hospital of Trauma, Str. Lord Bajron No 40, PC 1026, Tirana, Albania; Dietrich Doll, MD, PhD, Sankt Marienhospital, Marienstr. 6–8, D-49377 Vechta, Germany and Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Jubilee Road Parktown, Johannesburg, 2196, South Africa; Ayene Gebremicheal Molla, Aksum University College of Health Science and Comprehensive Specialized Hospital, Aksum City, Tigray, Ethiopia; Timothy C. Hardcastle, MMed, FCS(SA), PhD, Inkosi Albert Luthuli Central Hospital, 800 Vusi Mzimela Rd, 4058 Mayville and University of Kwa Zulu Natal, Congella, South Africa; Kastriot Haxhirexha, Dr., MD, PhD—Clinical Hospital Tetove, 29 Noemvri NN, 4200 Tetove, Republic of the North Macedonia; Kajal Jain, MD, Department of Anesthesia & Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India; Kai Oliver Jensen, Dr., Klinik für Traumatologie, UniversitätsSpital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland; Andrey Korolev, Dr., European Clinic of Sports Traumatology and Orthopaedics, Orlovsky pereulok 7, Moscow, Russia, 129110; Li Zhanfei, Dr., Tongji Trauma Center, Tongji Hospital, Huazhong University of Science and Technology, 1095 Jie Fang Da Dao, 430030 Wuhan, Hubei Province, P.R. China; Jerry K. T. Lim, Dr., Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, 2 Simei Street 3, Singapore 529889, Singapore; Fredrik Linder, Prof. Dr., Department of Surgical Sciences, Section of Radiology, Uppsala University, Uppsala, Sweden; Nurhayati Lubis, MBBS, Bartshealth NHS Trust, Whipps Cross Hospital, London E11 1NR, Great Britain; Nina Magnitskaya, Dr., European Clinic of Sports Traumatology and Orthopaedics, Orlovsky pereulok 7, Moscow, Russia, 129110; Damian MacDonald, MD FRCPC FACEP EBCEM, Assistant Professor, Department of Emergency Medicine, University of Ottawa, Canada; Martin Mauser, MD Dr., Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa; Gerrit Matthes, Dr., Klinikum Ernst von Bergmann, Charlottenstr. 72, 14467, Potsdam, Germany and Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society; Kimani Mbugua, MD, Moi Teaching and Referral Hospital, Nandi road, 30100 Eldoret, Kenya; Sergey Mlyavykh, Dr., Trauma and Orthopedics Institute, Privolzhsky Research Medical University, 18, Verhne-Voljskaya naberejnaya, Nizhniy Novgorod, Russia, 603155; Barbaro Monzon, Dr. MD, Head Clinical Department of General Surgery, Pietersburg Hospital Polokwane 0700, South Africa, Department of Surgery, School of Medicine; Faculty of Health Sciences, University of Limpopo, South Africa; Munkhsaikhan Togtmol, Prof. Dr., General Director of National trauma and Orthopedic Research Center of Mongolia, Ulaanbaatar, Mongolia; Khreshi Mustafa, Dr. Al-Zakat Hospital, Tulkarm, Palestine; Michael Mwandri, MD PhD, University of Kwazulu Natal, South Africa, Trauma system research Adjunct physician, Meru district government hospital, P O Box 135, Duluti, Arusha, Tanzania; Pradeep Navsaria, MD, Trauma Center, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Private Bag X4, Main Road, Observatory 7937, South Africa; Stefan Nijs, Prof. Dr., Medical Head of the Traumatology Department, University Hospital Leuven, Belgium; Francisco Olmedo, Dr., HELIOS Klinikum Pforzheim, Abteilung für Unfallchirurgie und Orthopädie, Kanzlerstr. 5–7, 75175 Pforzheim, Germany; Maria C. Ortega Gonzalez, Dr., Specialist Anaesthesiologist, Director of Trauma Anaesthesia Netcare Milpark Hospital, South Africa; Jesús Palacios Fantilli, Dr, Médico de Planta Hospital de Trauma, Avenida General Santos esquina Teodoro Mongelos, Asunción, Paraguay; Marinis Pirpiris, MD, Active Orthopaedic Centre, Epworth Hospital, Epworth Centre, Level 7 Suite 5 32 Erin Street, Richmond, Victoria 3121, Australia; Francois Pitance, Dr., Traumacenter Coordinator, CHR Liège, Boulevard XII eme de ligne, 4000 Liège, Belgium; Eoghan Pomeroy, Dr., Department of Trauma and Orthopaedics, University Hospital Waterford, Dunmore Road, County Waterford, Ireland.; M. A. Sadakah, MD, Orthopedic Surgery and Traumatology, Tanta University Hospital, Egypt,Present address: Langbürgnerstraße 7c, 81549 München, Germany; Tapas Kumar Sahoo, MD, Institute of Critical Care, Medanta Abdur Razzaque Ansari Memorial Weaver's Hospital, Ranchi, India; Iurie Saratila, MPH, University Center for Simulation in Medical Training, Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova, bd. Stefan cel Mare si Sfant 165, Chisinau, Moldava; Sandro Scarpelini, Dr., Faculdade de Medicina de Ribeirão Preto da Universidade de Sao Paulo, Rua Bernardino de Campos 1000, Higienopolis 14015130, Ribeirão Preto, Brazil; Uwe Schweigkofler, Dr., BG Unfallklinik Frankfurt am Main gGmbH, Friedberger Landstraße 430, 60389 Frankfurt, Germany; Edvin Selmani, MD., Orthopedic and Trauma, University Trauma Hospital, Qyteti i nxenesve, pranë Birra Tirana, Kutia postare 8174, Tirana, Albania; Tim Søderlund, Dr., Trauma unit, Töölö Hospital, Department of Orthopaedics and Traumatology, Helsinki University Hospital, Topeliuksenkatu 5, P.O.Box 266, FI-00029, Helsinki, Finland; Michael Stein MD, FACS, Director of Trauma, Department of Surgery, Rabin Medical Center—Beilinson Hospital, Petach-Tikva, 49100, Israel; Buland Thapa, MD, Nepal Orthopedic Association, Siddhi Charan Road 260/19 Swoyambhu- 15, Kathmandu, Nepal; Heiko Trentzsch, Dr., Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, Ludwig-Maximilians-Universität, Schillerstr. 53, 80336 München, Germany and Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society; Teodora Sorana Truta, MD, Emergency Department, Mures Emergency County Hospital, Gheorghe Marinescu street 50, 540136 Targu-Mures, Romania; Selman Uranues, MD Dr., Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria; Christian Waydhas, Dr., Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany and Medical Faculty of the University Duisburg-Essen, University Hospital, Hufelandstr. 55, 45147 Essen, Germany; Christoph G. Wölfl, Dr., Marienhausklinikum Hetzelstift Neustadt an der Weinstraße, Stiftstraße 10, 67434 Neustadt/Weinstraße, Germany; Sandar Thein Yi, MD, Department of Anaesthesia, University of Medicine, 30th Street, Between 73rd and 774th Streets Chanayetharsan Township, Mandalay, Myanmar.; Ihor Yovenko, MD, Intensive Care Unit, Medical House Odrex, Raskidaylovskaya St., Odessa 65110, Ukraine; Pablo Zapattini, Dr., Mariano Roque Alonso, Asuncion, Paraguay