Trauma Care Systems Research Articles

Twenty-four Hour Trauma Team at the University Hospital of the West Indies, Kingston, Jamaica – The Time is Now

INTRODUCTION The timely and aggressive resuscitation of seriously injured trauma patients requires rapid assessment and efficient management of the injuries. Over the past thirty years, fatalities from trauma have decreased markedly due to the increased awareness of simple trauma care principles, such as those of the American College of Physicians Advanced Trauma Life Support [ATLS] (1). However, the ATLS approach is designed so that tasks are performed in sequence, one after the other, resulting in a ‘vertical organization’. A trauma team employing a ‘horizontal organization’ has been shown to lead to significant reductions in resuscitation times (2). Trauma and injury still remain the most common causes of death under the age of 44 years worldwide and the fourth leading cause of death in the western part of the world (1, 3, 4). The Pan American Health Organization reports that trauma is among the five leading causes of hospitalization, and is estimated to represent approximately 20% of hospital admissions in Jamaica (5). In 2000, the Royal College of Surgeons in England published a report emphasizing the insufficiencies in the management of the trauma patient (6). The report recommended the organization and institution of a trauma system and most importantly “the hospital trauma team” (6). Seven years later the United Kingdom (UK) National Confidential Enquiry into Patient Outcomes and Death reported that only 20% of hospitals in the UK had established trauma teams available, and of these trauma teams, only 59.7% of patients with an injury severity score (ISS) greater than 16 had a “documented trauma team response” (4). Studies have shown that even when a trauma team works in isolation outside a designated trauma system, it is still very effective in decreasing overall patient morbidity and mortality (7–11). The main objective of any trauma care system is to “assure optimal and equitable care for all trauma victims, prevent unnecessary death and disability from trauma, contain cost and assure quality of trauma care throughout the system” (12). The establishment of a trauma team is central to the fulfillment of this objective. This team should be able to i) resuscitate and stabilize patients, ii) determine the nature and extent of injuries in order to prioritize them, and iii) prepare and transport trauma patients for definitive care, whether to an operating theatre, intensive care unit or to another hospital (13, 14). The University Hospital of the West Indies sees approximately 56 000 patients annually (15). Trauma accounts for approximately 40% of the workload in both the Accident and Emergency Unit and the surgical wards (16). Between January 2001 and December 2005, penetrating trauma accounted for almost 50% of cases seen (17). These figures are a direct reflection on the probable societal burden and cost of trauma care in Jamaica. One study showed that only approximately 15% of the total cost for each trauma patient is recovered from the patient, making the care of these patients mainly state funded (17). A more efficient trauma care delivery system will therefore lessen the burden injuries place on the health service (16). The aim of a trauma team is to provide a safe and competent evaluation of a trauma patient within the shortest possible time (2). The following is a proposal to create a functioning trauma team that intends to further decrease preventable deaths utilizing a ‘horizontal organization’ to enhance significant reductions in resuscitation times and survival.

Quality indicators used by trauma centers for performance measurement

To describe the quality indicators (QIs) that trauma centers use for quality measurement and performance improvement. Measuring and reporting quality of care is a critical step to improve the quality of care. QIs compare actual trauma care against ideal criteria and identify patients in whom care may have been suboptimal and should be further reviewed. Three hundred thirty verified trauma centers in the United States, Canada, Australia, and New Zealand had their websites reviewed and leadership surveyed regarding QI use. The indicators identified were classified according to definition specifications, phase of care, Institute of Medicine aims, and contents. Two hundred fifty-one centers responded to the survey (76%) and the majority (97%) indicated that they use QIs. We obtained 10,587 QIs from 262 centers (survey responses and website review) of which 1,102 were unique indicators. The QIs primarily assessed the safety (49%), effectiveness (32%), efficiency (27%), and timeliness (22%) of hospital processes (64%) and outcomes (24%). The majority of indicators were used by a small number of centers (551 of 1,102 unique indicators used by single centers). Our study provides the first description of the QIs used by verified trauma centers in four high-income countries with similar systems of trauma care. The majority of trauma centers measure QIs designed to examine the safety, effectiveness, efficiency, and timeliness of hospital processes and outcomes. Opportunities exist to standardize existing QIs to allow broader implementation and develop new QIs to examine patient-centered care and equality of care.

Level-I Trauma Center Effects on Return-to-Work Outcomes

Injury is the leading cause of death for persons aged 1-44 years in the United States. Injuries have a substantial economic cost. For that reason, regional systems of trauma care in which the more acutely injured patients are transported to Level-I (L-I) trauma centers (TCs) has been widely advocated. However, the cost of TC care is high, raising questions about the value of such an approach. To study L-I TC effectiveness and study return-to-work (RTW) outcomes. Using data from National Study on the Costs and Outcomes of Trauma, the authors address the issue of selection bias by comparing naive estimates to matching techniques, as well as to nonlinear instrumental variable models (2SRI) and bivariate probit estimators. Individuals ages 18-64 who were mainly working before traumatic injury. Patients selected for the study were treated at 69 hospitals located in 12 states in the United States. N = 1790. Treatment is binary indicator on whether treated at L-I TC. Outcome is binary indicator on whether returned to work within 3 months after injury. Covariates include: demographics, pre-injury characteristics (job, health and insurance status), injury descriptors, other income sources, etc. Across all models that control for unobserved factors, the authors find that L-I TC treatment is positively associated with RTW within 3 months after injury. The estimated average marginal effect of treatment on the probability of RTW ranges from 23 to 38 percentage points. Benefits of L-I TC care extend beyond mortality and morbidity.

Training in Trauma Care

In a dubious distinction for the country, the World Health Organization has revealed in its first ever Global Status Report on Road Safety that more people die in road accidents in India than anywhere else in the world, including the more populous China. (Dipak Kumar Dash, TNN, Aug 17, 2009, 04.10 am IST. New Delhi) About 250 people die in road accidents in India everyday (‘Strategy on road safety must’ TOI on 7th March, 2009) and the total number of deaths every year due to road accidents has now passed the 135,000 mark, according to the latest report of National Crime Records Bureau or NCRB. Besides road traffic accidents we have our share of victims of terrorist activities, accidents at work places, natural and man-made disasters, etc. Out of these about 78% are men in age group of 20–44 years, causing significant impact on productivity. (Joshipura MK, Shah HS, Patel PR, Divatia PA. Trauma care systems in India—An overview. Indian J Crit Care Med 2004;8:93-7) No credible data is available to ascertain the outcome of trauma victims; it is generally perceived that outcomes in patients with single system injury (e.g. musculoskeletal trauma) have improved. Unfortunately, the same cannot be said for polytrauma. There is a high mortality rate amongst those with multisystem injuries, which can be attributed to the primitive state of trauma-care systems, lack of prehospital care and inadequate critical care. It is established that the mortality in serious (ISS > 16) injuries is six times worse in a developing country such as India compared to a developed country. (Mock CN, Jurkovich GJ, nii-Amon-Kotei D, Arreola-Risa C, Maier RV. Trauma mortality patterns in three nations at different economic levels: Implications for global trauma system development. J Trauma 1998;44:804-14.) For any improvement in this area, it is essential to establish trauma system in the country and have health care professionals trained to provide efficient care to trauma victims at every step—pre-hospital, in-hospital and rehabilitation. Establishment of trauma system would fall within the purview of central and state government authorities. But professional bodies such as The Association of Surgeons of India can play pivotal role in training of health care professionals. Unfortunately such efforts have remained restricted to a few pockets in our country.

Multidisciplinary trauma team care in Kandahar, Afghanistan: Current injury patterns and care practices

Multidisciplinary trauma care systems have been shown to improve patient outcomes. Medical care in support of the global war on terror has provided opportunities to refine these systems. We report on the multidisciplinary trauma care system at the Role III Hospital at Kandahar Airfield, Afghanistan.We reviewed the Joint Trauma System Registry, Kandahar database from 1 October 2009 to 31 December 2010 and extracted data regarding patient demographics, clinical variables and outcomes. We also queried the operating room records from 1 January 2009 to 31 December 2010.In the study period of 1 October 2009 to 31 December 2010, 2599 patients presented to the trauma bay, with the most common source of injury being from Improvised Explosive Device (IED) blasts (915), followed by gunshot wounds (GSW) (327). Importantly, 19 patients with triple amputations as a result of injuries from IEDs were seen. 127 patients were massively transfused. The in-hospital mortality was 4.45%.From 1 January 2010 to 31 December 2010, 4106.24 operating room hours were logged to complete 1914 patient cases. The mean number of procedures per case in 2009 was 1.27, compared to 3.11 in 2010.Multinational, multidisciplinary care is required for the large number of severely injured patients seen at Kandahar Airfield. Multidisciplinary trauma care in Kandahar is effective and can be readily employed in combat hospitals in Afghanistan and serve as a model for civilian centres.

Regionalization strategy of the emergency medical service system

A regionalization strategy is a model for improving the performance of the emergency medical service (EMS) system. The regionalization strategy has goals to provide appropriate, timely, effective, and efficient EMS in a region. However, the current EMS regionalization model in Korea is insufficient to achieve these goals due to a shortage of resources in rural regions, crowded emergency departments in metropolitan regions, and non-customized and mismatched levels of emergency departments. Recently, the concept of the regionalization model has been changed from a general regionalized model to a specialty care regionalization one. For example, the trauma care system, cardiac arrest care system, stroke care system, and ST elevation myocardial infarction care system are modern regionalization strategies to improve the performance of EMS. This is a new method of customizing and matching between region-based needs and the supply of EMS. If we can implement this strategy, we can expect improved performance of regional EMS systems.

Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma

Trauma care in the general population has largely become protocol-driven, with an emphasis on fast and efficient treatment, good team communication at all levels of care including prehospital care, initial resuscitation, intensive care, and rehabilitation. Most available literature on trauma care has focused on adults, allowing the potential to apply concepts from adult care to pediatric care. But there remain issues that will always be specific to pediatric patients that may not translate from adults. Several new devices such as intraosseous (IO) needle systems and techniques such as ultrasonography to cannulate central and peripheral veins have become available for integration into our pre-existing trauma care system for children. This review will focus specifically on the latest techniques and evidence available for establishing intravenous access, rational approaches to fluid resuscitation, and blood product transfusion in the pediatric trauma patient.

Systematic review of multidisciplinary rehabilitation in patients with multiple trauma

Multiple trauma is a cause of significant disability in adults of working age. Despite the implementation of trauma systems for improved coordination and organization of care, rehabilitation services are not yet routinely considered integral to trauma care processes. MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, Physiotherapy Evidence Database, Latin American and Caribbean Literature on Health Sciences and Cochrane Library databases were searched up to May 2011 for randomized clinical trials, as well as observational studies, reporting outcomes of injured patients following multidisciplinary rehabilitation that addressed functional restoration and societal reintegration based on the International Classification of Functioning, Disability and Health. No randomized and/or controlled clinical trials were identified. Fifteen observational studies involving 2386 participants with injuries were included. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach assessed methodological quality as 'poor' in all studies, with selection and observer bias. Although patients with low functional scores showed improvement after rehabilitation, they were unable to resume their pretrauma level of activity. Their functional ability was significantly associated with motor independence on admission and early acute rehabilitation, which contributed to a shorter hospital stay. Injury location, age, co-morbidity and education predicted long-term functional consequences. Trauma care systems were associated with reduced mortality. The gaps in evidence include: rehabilitation settings, components, intensity, duration and types of therapy, and long-term outcomes for survivors of multiple trauma. Rehabilitation is an expensive resource and the evidence to support its justification is needed urgently. The issues in study design and research methodology in rehabilitation are challenging. Opportunities to prioritize trauma rehabilitation, disability management and social reintegration of multiple injury survivors are discussed.

Papel da Radiologia Intervencionista no atendimento ao paciente politraumatizado

O trauma é causa importante de morte e afastamento do trabalho. A Radiologia Intervencionista por meio de técnicas minimamente invasivas pode ser útil para politraumatizados estáveis com lesões vasculares ou de órgãos sólidos. Apesar de exigir treinamento, máquinas e materiais adequados, pode proporcionar melhores resultados. Lesões intra-abdominais devem ser suspeitadas no trauma pélvico e/ou torácico com instabilidade. Hematomas, equimoses ou petéquias devem ser correlacionadas ao trajeto vascular e órgãos. O lavado peritoneal, tomografia, ressonância magnética e FAST (focused assesment with sonography for trauma) podem ser utilizados. Angiografias não são ideais para traumas abdominais agudos por não excluirem lesões associadas, mas, no território periférico são úteis para planejamento. Apesar da necessidade cirúrgica para casos graves, condutas conservadoras podem determinar melhor evolução em muitos casos. Nas lesões vasculares abdominais e orgãos maciços, angioplastia com ou sem stent pode ser utilizada nas lesões intimais e transmurais, e embolização nos sangramentos ativos. Lesões hepáticas podem ser conduzidas conservadoramente, por meio da embolização percutânea ou cirurgicamente. A embolização esplênica e renal deve ser considerada para pacientes selecionados. Na região cervical, são alternativa para lesões carotídeas de difícil acesso, acima do ângulo da mandíbula e petrosas. Por sua vez, stents revestidos ou endopróteses expandiram as indicações terapêuticas na aorta abdominal e torácica. Pequenas lesões das extremidades, assintomáticas e não oclusivas, podem ser tratadas conservadoramente. Lesões de membros e pélvicas necessitam estabilização óssea para controle. A indicação para embolização baseia-se na condição hemodinâmica e presença de sangramento. Maiores evidências comparando estas técnicas à cirurgia, ainda são necessárias

The Canadian Forces trauma care system

According to the Trauma Association of Canada, a trauma system is a preplanned, organized and coordinated injury-control effort in a defined geographic area. An effective trauma system engages in comprehensive injury surveillance and prevention programs; delivers trauma care from the time of injury to recovery; engages in research, training and performance improvement; and establishes linkages with an all-hazards emergency preparedness program. To support Canada's combat mission in Afghanistan, the Canadian Forces (CF) developed a comprehensive trauma system based around its trauma hospital--the Role 3 Multinational Medical Unit (R3MMU) at Kandahar Airfield. This article reviews the essential components of a modern trauma system, outlines the evidence that trauma systems improve care to injury victims and describes how the current CF trauma system was developed.

Needle Decompression for Tension Pneumothorax in Tactical Combat Casualty Care: Do Catheters Placed in the Midaxillary Line Kink More Often Than Those in the Midclavicular Line?

Tactical Combat Casualty Care (TCCC) is a system of prehospital trauma care designed for the combat environment. Needle decompression (ND) is a critical TCCC intervention, because previous data suggest that up to 33% of all preventable deaths on the battlefield result from tension pneumothoraces. There has recently been increased interest in performing ND at the fifth intercostal space in the midaxillary line to prevent complications associated with landmarking second intercostal space in the midclavicular line site. We developed a model to assess whether catheters placed in the midaxillary line for decompressing tension pneumothoraces are more prone to kinking than those placed in the midclavicular line because of adducted arms during military transport. To simulate ND, we secured segments of porcine chest walls over volunteer soldiers' chests and placed 14-gauge, 1.5-inch angiocatheters through the porcine wall segments which were affixed to either the midaxillary or midclavicular location on the volunteers. We then assessed for occlusion and kinking by flow of normal saline (NS) through the angiocatheter in situ. The angiocatheter was then transduced using standard arterial line manometry, and the opening pressures required to initiate flow through the catheters were measured. The opening pressures were then converted to mm Hg. We also assessed for catheter occlusion after the physical manipulation of the patient, by simulated patient transport. We observed that there was a significant pressure difference required to achieve free flow through the in situ angiocatheter between the fifth intercostal space midaxillary line versus the second intercostal space midclavicular line site (13.1 ± 3.6 mm Hg vs. 7.9 ± 1.8 mm Hg). This study suggests that the 14-gauge, 1.5-inch angiocatheter used for ND in the midaxillary line may partially and temporarily occlude in patients who will be transported on military stretchers. The pressure of 12.8 mm Hg has been documented in animal models as the pressure at which hemodynamic instability develops. This may contribute to the reaccumulation of tension pneumothoraces and ultimate patient deterioration in military transport.

Type et épidémiologie des blessures de guerre, à propos de deux conflits actuels : Irak et Afghanistan

Since March 2003, military operations in Iraq “Operation Iraqi Freedom” (OIF) and in Afghanistan “Operation Enduring Freedom” (OEF), have made many wounded and killed in action (KIA). This article proposes to highlight the specific epidemiology of combat casualties, met in these both non-conventional and asymmetric conflicts. Personal protective equipments, Kevlar helmet and body armor, proved their efficiency in changing features of war injuries. Health Force Services organized trauma care system in different levels, with three main objectives: immediate basic medical care in battalion aid station, forward surgery and early aeromedical evacuation. The Joint Theater Trauma Registry (JTTR), a war injury registry, provides medical data, analyzed from the combat theater to the military hospital in United States. This analysis concluded that during modern conflicts, most injuries are caused by explosive devices; injuries are more severe and interestingly more specifically the head region and extremities than the trunk. Hemorrhage is the first cause of death, leading to the concept of avoidable death. Specific databases focused on mechanisms and severity of injuries, diagnostic and treatment difficulties, outcomes can guide research programs to improve war injuries prevention and treatment.

Substance Use and Facial Injury

The use of alcohol and illicit drugs is a common theme in patients presenting with traumatic injury to trauma centers. In addition to associated patient care issues, these common precipitants of clinician contact and costly hospitalizations present a particular fiscal challenge to our trauma care systems and compromise their ability to provide conventional medical services. Estimates compiled by the Institute of Medicine’s Committee on Injury Prevention and Control indicate that the costs of injury are higher than those of any other health problem, and are roughly equal to the costs associated with heart disease (second most costly) and cancer (third most costly) combined. Similar injury trends are increasingly manifest in children and adolescents; between 2002 and 2004, more than 13 million emergency department isits in the United States involved adolescents 10 to 19 years of age, with injury onstituting 42% of these visits. Given that alcohol and substance use are common antecedent risk factors for traumatic injury, a significant portion of facial injuries should be considered as preventable. The focus of this article is to: (1) detail the connection between substance use and orofacial injuries among adults and adolescents, (2) discuss the sequelae of substance-use–related orofacial injuries (ie, complications and reinjury), and (3) discuss the need for collaborative care across disciplines.

Hospital Preparedness for Radiation Emergencies and Medical Management of Multiple Combined Radiation Injury Victims

Radiological accidents and disasters can have a huge and lasting impact on public health. Hospitals should be prepared to respond to potential radiation emergencies as determined by risk assessments based on local and regional radioactive hazards, threats and vulnerabilities. Approach to hospital management of multiple combined radiation injury victims require attention to casualty triage, decontamination and prevention of secondary contamination, healthcare personnel radiation safety, trauma care system, medical staff knowledge of radiation related injuries and availability of pharmaco-therapeutic options. Considering surge science, preparedness strategies are described according to the key components of the “3 S” system.

Trauma care system in Iran

Objective The high burden of injuries in Iran necessitates the establishment of a comprehensive trauma care system. The purpose of this paper is to describe the current status of trauma system regarding the components and function. Methods The current status of trauma system in all components of a trauma system was described through expert panels and semi-structured interviews with trauma specialists and policy makers. Results Currently, various organizations are involved in prevention, management and rehabilitation of injuries, but an integrative system approach to trauma is rather deficient. There has been ongoing progress in areas of public education through media, traffic regulation reinforcement, hospital care and prehospital services. Meanwhile, there are gaps regarding financing, legislations and education of high risk groups. The issues on education and training standards of the front line medical team and continuing education and evaluation are yet to be addressed. Trauma registry has been piloted in some provinces, but as it needs the well-developed infrastructure (regarding staff, maintenance, financial resources), it is not yet established in our system of trauma care. Conclusions It seems that one of the problems with trauma care in Iran is lack of coordination among trauma system organizations. Although the clinical management of trauma patients has improved in our country in the recent decade, decreasing the burden of injuries necessitates an organized approach to prevention and management of trauma in the context of a trauma system.

(A175) Traffic Injury Severity Prediction by Algorithm of Automatic Crash Notification System

IntroductionSince 2009 automatic crash notification system(ACNS) using event data recorder(EDR) and mobile communication have been developed for early detection of traffic accident and prediction of physical injury of victims for increase of survival rate via early medical treatment. For adequate prediction of injury, authors developed the guideline and algorithm from parameters related to accident and medical situation. Methods: Expert survey was done about the adequate parameters related to accident and medical situation. Medical record of traffic accident admission was analyzed in a trauma center of a university hospital in Seoul, Korea. Additionally epidemiology of traffic accident death in a region was done. Afterwards data of medical record was linked to data of traffic accident insurance companies.ResultsThe important parameters for prediction of physical injury of victims were as follows: Intercept, deltav, belt, age, intrus, sex, multiple, roll, ejection, narrow, height, weight, steering defect, track loc.ConclusionsPrediction of physical injury severity of victims on traffic accident spot and immediate transfer of related information to adequate medical institution by automatic mobile communication can help the traffic accident victims and upgrade the trauma care system of traffic accident.

The Effect of an Organized Trauma System on Mortality in Major Trauma Involving Serious Head Injury

To compare outcomes following major trauma involving serious head injury managed in an inclusive trauma system (Victoria, Australia) and a setting where rationalization of trauma services is absent (England/Wales).The introduction of regionalized trauma systems has the potential to reduce preventable deaths, but their uptake has been slow around the world. Improved understanding of the benefits and limitations of different systems of trauma care requires comparison across systems.Mortality outcomes following major trauma involving serious head injury managed in the 2 settings were compared using multivariate logistic regression. Data pertaining to the period July 2001 to June 2006 (inclusive) were extracted from the Trauma Audit and Research Network (TARN) in the United Kingdom and the Victorian State Trauma Registry (VSTR) in Australia.A total of 4064 (VSTR) and 6024 (TARN) cases were provided for analysis. The odds of death for TARN cases were significantly higher than those for VSTR cases [odds ratio = 2.15, 95% confidence interval = 1.95-2.37]. After adjusting for age, gender, cause of injury, head injury severity, Glasgow Coma Scale score, and Injury Severity Score, TARN cases remained at elevated odds of death (3.22; 95% confidence interval = 2.84-3.65) compared with VSTR cases.Management of the severely injured patient with an associated head injury in England and Wales, where an organized trauma system is absent, was associated with increased risk-adjusted mortality compared with management of these patients in the inclusive trauma system of Victoria, Australia. This study provides further evidence to support efforts to implement such systems.

Inefficiencies in a Rural Trauma System: The Burden of Repeat Imaging in Interfacility Transfers

Within regionalized systems of trauma care, injured patients initially evaluated at local hospitals (LHs) are often transferred to trauma centers (TCs) for a higher level of care. To determine the need for transfer, LHs obtain imaging studies such as computed tomography (CT) scans. Many TCs then repeat these scans with the burden of extra cost, increased radiation to the patient, and the potential complications of contrast administration. This article evaluated the frequency of repeated CT scans at TCs and the most common reasons for repeating the studies.

Current state and future perspectives of trauma care system in mainland China

Objective To investigate the current state of trauma care in mainland China, and to propose possible future suggestions for the development of the trauma care system in mainland China. Method An extensive Medline/PubMed search on the topic of trauma care or trauma care system was conducted. Publications in Chinese that could best describe the state of trauma care in China were also included. In addition, two meetings were held by Group for Trauma Emergency Care and Multiple Injuries, Trauma Society of Chinese Medical Association to discuss the development and perspectives of trauma care system in mainland China. Important conclusions from the two meetings were included in this publication. Results Trauma has become an increasing public health problem in mainland China in association with the rapid growth of the economy over the past 30 years. Although great progress has been made in regards to the care of the injured, there is still no government agency dedicated to deal with trauma-related issues, or a national trauma care system operating on the Chinese mainland. Various trauma prevention measures have been taken, but with little effect. Funds contributed to trauma-related research has increased in recent years and promoted rapid development in this field, but further improvement in research is needed. However, many groups such as the Trauma Society of the Chinese Medical Association have continued to explore mechanisms for the treatment of trauma patients and have developed various types of regional trauma care systems, resulting in improved trauma care and a better outcome for the injured. Conclusions Although great progress has been made in trauma care in mainland China, there are many failings. To improve trauma care in China, the establishment of a sophisticated trauma system and various enhancements on trauma prevention are urgently required.

Barriers and facilitators to provide effective pre-hospital trauma care for road traffic injury victims in Iran: a grounded theory approach

BackgroundRoad traffic injuries are a major global public health problem. Improvements in pre-hospital trauma care can help minimize mortality and morbidity from road traffic injuries (RTIs) worldwide, particularly in low- and middle-income countries (LMICs) with a high rate of RTIs such as Iran. The current study aimed to explore pre-hospital trauma care process for RTI victims in Iran and to identify potential areas for improvements based on the experience and perception of pre-hospital trauma care professionals.MethodsA qualitative study design using a grounded theory approach was selected. The data, collected via in-depth interviews with 15 pre-hospital trauma care professionals, were analyzed using the constant comparative method.ResultsSeven categories emerged to describe the factors that hinder or facilitate an effective pre-hospital trauma care process: (1) administration and organization, (2) staff qualifications and competences, (3) availability and distribution of resources, (4) communication and transportation, (5) involved organizations, (6) laypeople and (7) infrastructure. The core category that emerged from the other categories was defined as "interaction and common understanding". Moreover, a conceptual model was developed based on the categories.ConclusionsImproving the interaction within the current pre-hospital trauma care system and building a common understanding of the role of the Emergency Medical Services (EMS) emerged as key issues in the development of an effective pre-hospital trauma care process.