World Journal of Surgery

, Volume 42, Issue 5, pp 1327–1339 | Cite as

Impact of Trauma System Structure on Injury Outcomes: A Systematic Review and Meta-Analysis

  • Lynne MooreEmail author
  • Howard Champion
  • Pier-Alexandre Tardif
  • Brice-Lionel Kuimi
  • Gerard O’Reilly
  • Ari Leppaniemi
  • Peter Cameron
  • Cameron S. Palmer
  • Fikri M. Abu-Zidan
  • Belinda Gabbe
  • Christine Gaarder
  • Natalie Yanchar
  • Henry Thomas Stelfox
  • Raul Coimbra
  • John Kortbeek
  • Vanessa K. Noonan
  • Amy Gunning
  • Malcolm Gordon
  • Monty Khajanchi
  • Teegwendé V. Porgo
  • Alexis F. Turgeon
  • Luke Leenen
  • On behalf of the International Injury Care Improvement Initiative
Scientific Review



The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes.


We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria.


We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65–0.80]) and helicopter transport (OR = 0.70 [0.55–0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4–7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44–1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [−0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68–0.85]). Quality of evidence was low or very low for mortality and healthcare utilization.


This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.



The authors would like to thank Michèle Shemilt for her assistance with the search strategy.


This research is funded by the Fonds de Recherche du Québec—Santé (research career award, LM) and the Canadian Institutes of Health Research (Foundation Grant #353374 [LM], Canada Research Chair in Critical Care Neurology and Trauma [AFT]).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

268_2017_4292_MOESM1_ESM.docx (12 kb)
Online resource 1 MEDLINE research strategy via PubMed (DOCX 12 kb)
268_2017_4292_MOESM2_ESM.docx (86 kb)
Online resource 2 Description of included studies (DOCX 85 kb)
268_2017_4292_MOESM3_ESM.pdf (90 kb)
Online resource 3 Methodological quality of studies using the Risk of Bias In Non-randomized Studies—of Interventions (ROBINS-I) assessment tool (PDF 90 kb)
268_2017_4292_MOESM4_ESM.tif (18 kb)
Online resource 4 Funnel plots of odds ratio (OR, left) and mean differences (MD, right). Legend for online resource 4: The Y axis shows the standard errors (SE) of log OR (left) and MD (right) (TIFF 18 kb)
268_2017_4292_MOESM5_ESM.pdf (181 kb)
Online resource 5 Associations between trauma system components and clinically significant outcomes measured on a multiplicative (HR, OR, RR) or additive (DP, MD) scale from studies not included in meta-analyses and for which data were available to calculate summary measures. Legend for online resource 5: CI: confidence interval; benchmarking: a = complications, b = mechanical ventilation (days), c = hospital length of stay, d = intensive care unit length of stay, e = survival; DP: difference of proportions; HR: hazard ratio; interf. trans. prot.: interfacility transfer protocols; IRR: incidence rate ratio; MD: mean difference; OR: odds ratio; Pre-hos. maj.traum.def: pre-hospital major trauma definition; RR: relative risks; TC: trauma center. Measures in black are on a multiplicative scale (null value = 1), whereas measures in gray are on the additive scale (null value = 0) (PDF 180 kb)
268_2017_4292_MOESM6_ESM.tif (69 kb)
Online resource 6 Sensitivity analysis restricted to studies of high methodological quality (TIFF 69 kb)


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Copyright information

© Société Internationale de Chirurgie 2017

Authors and Affiliations

  • Lynne Moore
    • 1
    • 2
    Email author
  • Howard Champion
    • 3
  • Pier-Alexandre Tardif
    • 1
    • 2
  • Brice-Lionel Kuimi
    • 2
  • Gerard O’Reilly
    • 4
    • 8
  • Ari Leppaniemi
    • 5
  • Peter Cameron
    • 4
    • 8
  • Cameron S. Palmer
    • 6
  • Fikri M. Abu-Zidan
    • 7
  • Belinda Gabbe
    • 8
  • Christine Gaarder
    • 9
  • Natalie Yanchar
    • 10
  • Henry Thomas Stelfox
    • 11
  • Raul Coimbra
    • 12
  • John Kortbeek
    • 13
  • Vanessa K. Noonan
    • 14
  • Amy Gunning
    • 15
  • Malcolm Gordon
    • 16
  • Monty Khajanchi
    • 17
  • Teegwendé V. Porgo
    • 1
    • 2
  • Alexis F. Turgeon
    • 1
    • 2
  • Luke Leenen
    • 15
  • On behalf of the International Injury Care Improvement Initiative
  1. 1.Department of Anesthesiology and Critical Care Medicine, Division of Critical Care MedicineUniversité LavalQuébecCanada
  2. 2.Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie – Urgence - Soins intensifs (Trauma – Emergency – Critical Care Medicine)CHU de Québec – Université Laval Research Center (Enfant-Jésus Hospital)QuébecCanada
  3. 3.Department of SurgeryUniversity of the Health SciencesAnnapolisUSA
  4. 4.Emergency and Trauma CentreThe Alfred HospitalMelbourneAustralia
  5. 5.Abdominal CenterHelsinki University hospitalHelsinkiFinland
  6. 6.Trauma ServiceRoyal Children’s HospitalMelbourneAustralia
  7. 7.Department of Surgery, College of Medicine and Health SciencesUnited Arab Emirates UniversityAl-AinUnited Arab Emirates
  8. 8.School of Public Health and Preventive MedicineMonash UniversityMelbourneAustralia
  9. 9.Department of TraumatologyOslo University Hospital UllevalOsloNorway
  10. 10.Department of SurgeryDalhousie UniversityHalifaxCanada
  11. 11.Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public HealthUniversity of CalgaryCalgaryCanada
  12. 12.Division of Trauma, Surgical Critical Care, Burns, and Acute Care SurgeryUniversity of California, San Diego Health SystemSan DiegoUSA
  13. 13.Department of Surgery, Division of General Surgery and Division of Critical CareUniversity of CalgaryCalgaryCanada
  14. 14.Rick Hansen InstituteVancouverCanada
  15. 15.Department of SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
  16. 16.Department of Emergency MedicineUniversity of GlasgowGlasgowUK
  17. 17.Seth G.S. Medical College and KEM HospitalMumbaiIndia

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