key: cord-0045168-qxf2l1qw authors: Choi, Jeff; Carlos, Garrison; Nassar, Aussama K.; Knowlton, Lisa M.; Spain, David A.; Gregg, David L. title: The Impact of Trauma Systems on Patient Outcomes date: 2020-06-10 journal: Curr Probl Surg DOI: 10.1016/j.cpsurg.2020.100849 sha: df0e39a6e530e1e2888e5a58242d0aeb9636f822 doc_id: 45168 cord_uid: qxf2l1qw nan Trauma is a pressing public health epidemic. In 2016 alone, trauma accounted for 29.2 million emergency department visits and 39.5 million physician office visits in the United States. 1 Trauma is the leading cause of death for those aged 46 years and younger in the United States; trauma-related mortality has increased by 23% between 2000 and 2010 across nearly all age groups. 2 In particular, the growing elderly populationsusceptible to injuries from even minor mechanisms such as ground-level fallshas seen a 56% increase in trauma-related deaths over the same decade. 2 For those who survive, regaining health and returning to work requires substantial post-acute care and rehabilitation. Accounting for medical expenditures and lost productivity, the annual burden of trauma care is approximately $670 billion in the United States. 3 Traumatic injuries also remain an important cause of morbidity and mortality globally, for both developed and developing countries. In a recent update to the Global Burden of Disease studythe most comprehensive epidemiological study to date -973 million individual healthcare encounters and 4.8 million deaths were attributable to injuries in 2013 alone. 4 The recognition of traumatic injuries as an addressable public health epidemic rather than unavoidable accidents has led to the birth and expansion of trauma systems. Trauma systems represent comprehensive infrastructures to provide optimal care for injured patients, encompassing a wide spectrum from injury prevention efforts and an integrated network of trauma centers to concerted research agendas. The United States has led the development of this systematic infrastructure to tackle the burden of trauma. In this report, we review the history of trauma systems in the United States, outline what constitutes a comprehensive trauma system, provide an overview of trauma systems in other countries, and explore the cumulative impact of trauma systems on the outcomes of patients who suffer traumatic injuries. A structured system to care for the injured arose amidst the chaos of military conflicts. The American Civil War gave birth to the medical evacuation system, which comprised of an ambulance corps and placing of surgeons near battlefields to determine who could return to battle or be transferred to field hospitals. 5 The mass casualties of World War I propagated triage through tiered echelons of increasingly capable treatment. 6 Adoption of motorized transportation for evacuation (i.e., helicopters in the Korean War) spurred more expeditious evacuation throughout subsequent conflicts. By one estimate, the average injury-to-surgery time progressively improved and mortality progressively decreased from 12 to 18 hours and 8.5% (World War I), to 6 to 12 hours and 5.8% (World War II), 2 to 4 hours and 2.4% (Korean War), and 65 minutes and 1.7% (Vietnam War), respectively. 7 While systematic care for the injured took early roots in the military, the need for a structured trauma system did not receive civilian spotlight until the publication of "Accidental Death and Disability: The Neglected Disease of Modern Society" in 1966. 8 This landmark report highlighted accidental injury as a neglected epidemic and the "leading cause of death in the first half of life's span." 8 The report underscored our country's deficient emergency medical care capacity and urged the establishment of trauma registries, hospital trauma committees, and increased funding for trauma research. 8 The same year, the federal government launched the first national effort to care for injured patients through "The National Traffic and Motor Vehicle Safety Act." 9 The mandate of vehicle standards (eg, seatbelts), improved road standards, and public education of driver safety laws (eg, laws against driving while intoxicated) led to a rapid decrease in motor vehicle fatalities by 1970, showcasing traumatic injuries to be a preventable epidemic. 10 With the national spotlight on injury, local leaders advancing trauma systems emerged. The System. This collaboration reduced trauma-related mortality by transporting critically injured patients from the field or regional hospitals via police helicopters to a dedicated trauma unit. 12 Although not as well-recognized, the first "trauma center" may have been established at the found that only 20 states had adopted trauma systems, only 5 of which were fully functional. 19 The following section details components of a comprehensive trauma system that we are still striving for. The modern comprehensive trauma system optimizes cost-effective and high-quality care of the injured patient starting with injury recognition, triage to an appropriate trauma center, multidisciplinary inpatient care, and outpatient follow-up of long-term physical and psychosocial sequelae. Beyond the clinical care continuum, a trauma system also prioritizes outreach, education and advocacy, data collection through registries, research, funding, and disaster preparedness and response. Coordination of comprehensive trauma care requires strong leadership and community engagement at the trauma center, regional, state, and national levels. ( Figure 1 ). Since its inception in 1922, the American College of Surgeons Committee on Trauma (ACS COT) has been integral in leading US trauma system development. ACS COT provides trauma center verification and assessment of regional trauma systems and resources to support quality improvement. 20 Within the ACS COT, the Verification Review Committee (VRC) performs on-site review of trauma centers. 21 Notably, some states have no formal process or laws giving authority for trauma designation. Funding for trauma systems is also dependent on the state, but some trauma systems receive no state funding. 26 Interstate variability of trauma systems has resulted in suboptimal distribution of trauma centers. A 2003 report found that despite a doubling of the number of trauma centers between 1991 and 2002, the number of level I and II trauma centers per million population varied from 0.19 to 7.8 by state. 27 A recent study similarly revealed non-uniform access to trauma care in the United States, with lower injury mortality rates in states that had a clustering of trauma centers compared to states with dispersed trauma centers. 28 In 2015, the ACS COT developed the Needs Based Assessment of Trauma Systems (NBATS) tool to determine the number of trauma centers per level designation needed in a region based on injury volume, accessibility, and population characteristics. 29 The tool is applied to preexisting trauma regions of interest and incorporates community support, population, transport time, and the number of severely injured patients discharged from non-level I-III trauma center hospitals. 29 The algorithm outputs an estimate of the number of level I, II, and III trauma centers needed for the region. Application of the NBATS tool to California and Georgia state trauma systems found that urban areas had proportionally too many, and rural areas too few trauma centers. 30, 31 A similar optimization query in Florida showed that adding 2 new trauma centers did not improve the state trauma system triage performance, while a Pennsylvania study found that a rural hospital incorporation into the state system as level IV center would improve performance. 32, 33 An increasing number of states are integrating level V trauma centers within their trauma systems. NBATS is continually utilized to assess trauma center needs and direct growth within trauma regions. Although level V designation is not formally recognized by ACS COT, these hospitals are often located in rural areas and focus on high-quality patient stabilization and strong transfer protocols to more comprehensive trauma centers. For example, Washington has integrated 9 level V trauma centers as of January, 2020. 34 The optimal trauma system depends not only on a sufficient quantity of trauma centers, but also on a strategically distributed cohort based upon regional needs. ACS COT and partner organizations engage in multiple educational efforts. ATLS is a premier example. ATLS was established in 1978 by Dr. James K. Styner, an orthopedic surgeon who attributed the loss of his entire family to sub-par trauma care at a local hospital after a tragic plane crash. 35 Along with a local group of surgeons and physicians and the University of Nebraska, Dr. Styner founded systematic courses aimed at teaching advanced trauma life support skills. Since these courses were adopted by ACS COT in 1980, ATLS is now taught in more than 80 countries and has trained more than 1 million physicians. 36 Educational infrastructures allow widespread dissemination of new trauma training curricula. For example, focused assessment with sonography for trauma (FAST)a bedside ultrasonography technique to assess the presence of blood around the heart or abdominal organs after traumawas a new skill-based technology disseminated rapidly through the ATLS training curriculum. 39 After the first description of ultrasound to detect intraabdominal fluid in Europe during the 1970s, FAST was formalized as a standardized series of steps and adopted in the United States in the 1990s. 40 Today, 96% of level I trauma centers report regular use of FAST for the assessment of trauma patients. 41, 42 Since In addition to skills-based education, organizational improvement is another educational mission of our trauma system. For example, the Disaster Management and Emergency Preparedness course targets all healthcare providers, administrators, and public health personnel who may respond to major disasters, and teaches organizational principles for responding to disasters ranging from blast injuries to chemical attacks. 49 The Other organizations focused on specific injury patterns are additional valuable academic assets within trauma systems. Organizations such as the Chest Wall Injury Society, American Spinal Injury Association, and the Brain Trauma Foundation provide the funding and medium for like-minded researchers to make discoveries that advance care for trauma patients. For example, the Chest Wall Injury Society publishes "Ribnars" that provide up-to-date evidence in managing patients with rib fractures, has completed multi-institutional studies to better inform best practices, and publishes consensus guidelines on rib fracture management for trauma centers to adopt. 51-54 The 2016 National Academies of Sciences, Engineering, and Medicine (NASEM) report, "A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury" estimated a 20% excess in mortality due to differential care among trauma centers. 55 This report underscored the need for a comprehensive national trauma system that builds on the military's knowledge of trauma patients gained during the Iraq and Afghanistan War. The report made 11 major recommendations that outlined the committee's finding for the need of national federal leadership for both the implementation and execution of a national trauma care system. 55 The report called for the White House to lead a Primary injury prevention remains a cornerstone component of the System (WISQARS), which provides fatal and nonfatal injury, violent death, and cost of injury data in the United States. 60 In a multi-pronged approach to reduce the burden of injury, the CDC has organized public awareness campaigns and funded research in the fields of traumatic brain injury, violence prevention, home and recreational safety, motor vehicle safety, and opioid overdose prevention. Funded studies have led to many impactful changes in several local communities. A study on the impact of low-cost repairs of abandoned buildings and vacant lots to prevent violence has led to nearly 10,000 abandoned buildings throughout the United States being refurbished. These improvements have shown a 39% decrease in gun assaults, 19% decrease in other assaults, and long-term reductions in gun violence around remediated abandoned buildings. 61 Another CDC-funded study to identify the suicide burden in rural Iowa revealed that 76% of violent deaths in the state were suicides. 62 The research has elevated rural suicide into public spotlight and a new federal bill that aims to provide stress management programs and public campaigns to curb rural suicides is in the works. The CDC's injury prevention mission has already met legislative success, as its effort to build a national concussion surveillance system has led to passage of the Traumatic Brain Injury Program Reauthorization Act of 2018. This bill now funds the foundational data infrastructure to support the national concussion research agenda. In conjunction with the CDC, ACS COT's subcommittee on Injury Prevention and Control is establishing itself as another centralized resource for injury prevention research and advocacy. The subcommittee has published a "Gun Safety and Your Health" brochure for the general public to prevent firearm injuries and has outlined a comprehensive approach to establish hospital-based violence intervention programs. 63 The American Heart Association has exemplified the importance of bystander response education. Bystander CPR (cardiopulmonary resuscitation) has improved outcomes and increased the chance of survival for patients suffering from cardiac arrest. 64 The potential impact of bystander intervention is significant for trauma patients, given that the vast majority of deaths occur before patients reach the hospital. For trauma patients younger than 65 years, there are 9 pre-hospital deaths for every in-hospital mortality. One estimate suggests that in 2014 alone, 30,000 of 147,000 trauma deaths may have been avoided with timely hemorrhage control. 65 Building on the military's success with tourniquets, local EMS and trauma centers continue to lead successful public educational campaigns on using tourniquets to stop bleeding. These initiatives have translated into increased on-field tourniquet usage and better outcomes upon arrival to trauma centers. 66 80 On the other hand, the cost of care at a trauma center is nearly twice the cost of care at a non-trauma center. 81 Overtriageinappropriate triage to a higher-level trauma center when a patient does not require such resourcesis not innocuous. Recent estimates suggested that a 30% overtriage rate is potentially costing trauma systems an excess of $136 million annually. 82 Overtriage can overcrowd trauma centers and adversely impact patient care; in fact, a review of mass casualties from terrorist bombings showed a direct correlation between overtriage rates and the mortality rates of critically injured patients. 83 ACS COT considers an undertriage rate of <5% and an overtriage rate of <35% to be acceptable targets for trauma systems. 84 Appropriate triage per ACS COT guidelines has been projected to save $568 million per year. 85 Unfortunately, both over-and undertriage remain prevalent. A study of trauma patients in California revealed an average 35% undertriage rate, especially among patients with older age, increasing co-comorbidities, or fall as a mechanism of injury. 86, 87 Undertriage was also associated with increased mortality. 86, 87 Although EMS providers are expected to follow triage protocols, a prospective cohort study found that EMS provider judgment was the most common triage mechanism used. 88 This has been partly attributed to poor validity of the ACS COT triage decision scheme for pediatric and elderly patients. 88, 89 Compliance with prehospital triage protocols vary widely across EMS systems around the world, ranging from 21% to 94%. 90 However, studies have shown that nearly all such protocols fail to accurately identify severely injured patients, risking undertriage. 90, 91 Systemwide efforts to optimize prehospital triage continue, ranging from refining trauma team activation models within trauma centers to reducing EMS helicopter overutilization. 92 Locally, some EMS providers are now proactively conducting epidemiologic studies to anticipate and adapt to evolving local trauma needs. 93 Rural patients face geographic and resource barriers to timely high-quality trauma care. Approximately 15.9% of the US population lives more than an hour away from a level I or II trauma center . . 92 Rural trauma patients have increased likelihood of undertriage and decreased likelihood of transportation to a level I or II trauma center. 94 Inappropriate undertriage to a nondesignated trauma center has been associated with a 30% increase in mortality within the first 48 hours. 95 Prehospital care is especially important for rural communities, as transport times can exceed 2 hours and total pre-hospital times can exceed 4 hours. 96 Although all EMS systems must have a physician in charge of overseeing the care provided by their prehospital providers, in rural areas with a shortage of physicians, EMS units may function without appropriate oversight. Amidst these resource barriers, rural patients are at higher risk of suffering injuries. They are more likely to be at higher risk for workplace injury (i.e., involved in jobs that require operating machinery) and two thirds of all fatal motor vehicle accidents in the United States occur in rural areas. 97 The rural paramedic paradox (rural areas farthest from appropriate hospitals have the greatest EMS needs yet have the most trouble maintaining EMS services) is an unfortunate reality. 96 The regionalized trauma network (RTN) was first defined by The Department of Health and Human Resources as "a pre-planned, comprehensive, and coordinated statewide and local injury response network that includes all facilities with the capability to care for the injured. It is the system's inclusiveness, or range of pre-planned trauma center and non-trauma center resource allocation, that offers the public a cost-effective plan for injury treatment". 98 In short, RTN is a single entity comprised of acute care hospitals within a region working to reduce the burden of traumatic disease. To avoid ineffective distribution of resources and ensure sufficient experience in managing trauma patients within a RTN, the ACS COT currently recommends level I trauma centers admit at least 1200 trauma patients or 240 severely injured patients per year. 99 A RTN may be an inclusive or exclusive system. An inclusive system (wherein many hospitals partake in trauma patient care to the extent of their capabilities and available resources) is generally favored over exclusive trauma systems (wherein trauma patient care is limited to several highly specialized tertiary and quaternary centers). In Ohio, inclusive RTN establishment was associated with lower patient mortality and increased utilization of non-level I trauma centers. 100 The same Ohio RTN establishment was also associated with decreased mortality for specific subgroups of injured patients, such as those who required trauma laparotomies or suffered traumatic brain injuries. 101, 102 Similar findings were replicated in other US regions, such as in a Pennsylvania study (where incorporating smaller level IV trauma centers led to decreased mortality rates and better coordination among regional hospitals) and a study evaluating 24 different state trauma systems (severely injured patients had greater survival within inclusive trauma systems). 15 .103 RTN's impact may come to fruition rapidly; one study reported that reduced mortality was seen within 2 years of establishing a RTN. 104 Foreseeing that RTNs may help close the gap in rural trauma care, ACS COT has recommended incorporating existing rural hospitals within trauma systems as level III or IV trauma centers. Trauma regionalization allows closer working relationships among regional hospitals and their urban counterparts. Closer working relationships may entail more formalized transfer protocols and increased availability of consultation; in Hawaii, providing resources for rural hospitals to grow into level III trauma centers decreased the need to transfer rural trauma patients to remote higher level centers without adversely affecting patients outcomes. 105 However, the risk for secondary over-triage (during patient transfer) that may occur with closer regional partnerships should be remembered. A retrospective cohort study in Ohio found that a significant number of patients transferred from level III to level I or II trauma centers were discharged without requiring more intensive care within 48 hours. 106 A recent multicenter study including 93 centers participating in TQIP showed that both major complication rates and risk-adjusted mortality improved after implementing TQIP. 114 The state of Michigan has leveraged its existing relationship between its trauma centers and a private healthcare payer (Blue Cross Blue Shield) and built the Michigan Trauma Quality Improvement on top of TQIP. Under this initiative, the private healthcare payer has further incentivized quality improvement by instituting a pay-for-participation rather than pay-for-performance model for trauma centers. 115 In addition to participating in the NTDB and TQIP, level I, II, and III trauma centers must institute hospital-run Performance Improvement and Patient Safety committees (PIPS). PIPS committees include the trauma program manager, a EMS representative, and physician representatives from surgery, emergency medicine, and radiology. The multi-disciplinary team meets regularly to track performance, conduct peer case reviews, monitor compliance, and correct any hospital-specific problems of deficiencies. PIPS committees have reported various quality improvement successes, such as significantly decreasing ionizing radiation exposure for pediatric patients or reducing mortality through a multi-faceted trauma program overhaul. 116, 117 Long Term Outcomes The impact of injury lasts well beyond hospitalization. Injured patients often face longterm social dysfunction, post-traumatic stress disorder, and chronic pain. [118] [119] [120] Patients with low resilience, low educational levels, and low household incomes are especially at risk of poor longterm outcomes after injury. 121, 122 Identifying long-term sequelae for specific injuries is important because early intervention opportunities for high-risk groups may exist. Both TQIP and NTDB capture comprehensive hospitalization characteristics, but not long-term outcomes. Long-term outcomes of trauma patients are difficult to monitor due to variable trauma system utilization and poor follow-up. 123 Injured patients do not always present to well-structured RTNs, patients injured outside their immediate communities are less likely to follow up at their admitting trauma center, and arranging follow-up with a local hospital may be difficult. Most importantly, a national effort to track long-term trauma outcomes is lacking; post-hospitalization data collection is left to the discretion of individual trauma registries. 124 Minimizing readmissions is an important long-term outcome goal. Up to 50% of trauma readmissions and post-discharge emergency departments visits are not captured when patients present to hospitals different from their index trauma admission hospitals. 125 Patients most commonly re-present with superficial infectious complications and complications related to firearm injuries. 126 Although insurance status is less likely to affect trauma care provided during index hospitalization, insurance status significantly impacts trauma readmissions. Those who are poorly insured are less likely to follow up after trauma admissions, whereas Medicare patients are more likely to be healthcare super-utilizers after trauma discharge. 127, 125 With an added layer of complexity, up to 19% of trauma patients may undergo a change in insurance status (gaining or losing coverage) after discharge-discharge planning for trauma patients has an evolving barrier . 128 Nevertheless, studies have already identified many readmission risk factors including older age and frailty, discharge to skilled nursing or extended care facilities, history of falls, alcohol abuse, discharge against medical advice, firearm injuries requiring surgery, and interpersonal stressors. 126, 129, 130, 131 Protective factors include access to home health services, early cognitive behavior therapy for acute stress disorder, and early multi-disciplinary patient and family teaching. 132, 133 Trauma centers must undertake early identification of readmission risk factors and discharge planning to mitigate readmissions. Widespread post-discharge data collection is needed to understand the true physiologic and psychologic burden of injury, better identify opportunities to improve long-term outcomes, and track the impact of intervention efforts. Of note, what constitutes a successful recovery after trauma requires further study. A recent study suggested that those who maintain or regain a cohesive sense of self and those highly engaged in their recovery process have positive assessments. 134 Disasters ( These simulations showed that cities with more concentrated trauma centers would have lower total and out-of-hospital mortality rates, and found that longer wait and transport times needed to transport patients to trauma centers predictably increased mortality and resource consumption. 136 Alarmingly, not all trauma systems had the capacity to provide adequate care. The need to lay out well-defined disaster plans, regularly practice their enhancement, and the readiness for postdisaster analysis all remain pressing needs of US trauma systems today. The burden of injury is global. According to the World Health Organization (WHO), more than 5 million deaths annually are attributed to traumatic injuries; more than 90% of these deaths occur in mid-to-low income countries. 138 The WHO Trauma System Maturity Index classifies various national trauma systems into 4 categories based on the level of maturity and resources from level I (least mature) to level IV (most mature). 139 The index is evaluated on the domains of prehospital trauma care, facility based trauma care, education and training, and quality assurance. As expected, many high-income countries report mature trauma systems and lower trauma-related mortality compared to mid-to-low income countries. 140 In an effort reduce this disparity, the WHO has released a how-to guide for national quality improvement in trauma care through its "Guidelines for Trauma Quality Improvement Programmes." 139 Many mid-tolow income countries have referred to these guidelines to conduct need assessments and inform policy development. However, only a minority of these countries have implemented these guidelines. 141 Even high income countries have yet to establish truly comprehensive trauma systems. For example, many lack nationally implemented trauma registries. 140 Despite these shortcomings, the global burden of trauma as measured by disability adjusted life years (DALY) a summative index that includes premature mortality and non-fatal outcomes measured as years lived with disabilityis improving. Global DALY rates for injuries have decreased by 31%, and the rate of decline in DALY rates has been significant for all major injuries between 1990 and 2013. 142 Middle-to-low income countries often lack organized prehospital trauma systems at a national scale. Field-to-hospital transport is often undertaken in non-EMS specialized vehicles by individuals who lack certified training. 143 150 High-income countries do have system-wide variability in pre-hospital management strategies. 150 For instance, whereas the US pre-hospital model prioritizes rapid patient transport to trauma centers through a "scoop and run" approach, France's pre-hospital model more heavily emphasizes in-field triage and assessment by physicians. 151 Japan and Hong Kong's EMS systems are entirely run by paramedics, whereas many European countries have ambulances staffed by paramedics and specially trained physicians. [152] [153] [154] [155] Similar to the United States, geography attributes to regional differences within national prehospital systems, with lower level of life support available in rural regions and less densely populated regions reliant on EMS support by helicopter. 140 The impact of an integrated trauma system on improved trauma patient outcomes is clear. One estimate suggests that if global survival rates for severe injuries mirror those in high-income countries, up to 2 million lives could be saved annually. 156 166 This association between adherence to formal trauma system guidelines and improved survival after injury has been replicated in other countries such as Hong Kong and Australia. 167, 168 Other Components Trauma registries rarely exist in mid-to-low income countries due to the lack of digital resources to maintain a costly registry. 169 Trauma Course-Belgium). The modern US trauma system has evolved over the course of a century. From surgeons near battlefields who decided who could and could not return to the heat of war, an intricate trauma system that spans the entire continuum of clinical care, research, education, advocacy, and disaster preparedness has emerged. Trauma systems across the globe have proven their ability to improve patient outcomes. Despite the successful impact (Table 1) , unmet needs and opportunities exist for trauma systems in the United States ( Table 2) . The work has yet to be completed. Despite recognition of the burden of trauma and our system's critical role in improving patient outcomes, trauma remains severely underfunded; in 2016, trauma accounted for only 2.9% of the National Institutes of Health's extramural budget. 171 Accomplishing the mission Zero Preventable Deaths After Injury will require funding to match the scope of the continued injury epidemic and a ceaseless march to a truly comprehensive trauma system. 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Trauma Surg Acute Care Open Trauma system: the backbone of disaster preparedness A Geographic Simulation Model for the Treatment of Trauma Patients in Disasters How to Set Up a Regional Medical Operations Center to Manage the COVID-19 Pandemic American College of Surgeons Disabilityadjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study World Health Organization, International Society of Surgery, International Association of Trauma Surgery and Intensive Care Trauma systems around the world: A systematic overview Uptake of the World Health Organization's trauma care guidelines: a systematic review Quantifying the burden of disease: the technical basis for disability-adjusted life years Emergency medical services in Zimbabwe Improvements in prehospital trauma care in an African country with no formal emergency medical services Trauma care systems in Thailand Prehospital trauma care reduces mortality. Ten-year results from a time-cohort and trauma audit study in Iraq Emergency Response in Resource-poor Settings: A Review of a Newly-implemented EMS System in Rural Uganda Low-cost improvements in prehospital trauma care in a Latin American city Impact of Trauma Dispatch Algorithm Software on the Rate of Missions of Do trauma systems work? A comparison of major trauma outcomes between Aberdeen Royal Infirmary and Massachusetts General Hospital Development of trauma systems and effect on outcomes after injury Emergency medical service systems in Japan: past, present, and future. Resuscitation Prehospital care in Hong Kong Trauma systems and early management of severe injuries in Scandinavia: review of the current state Trauma care systems in Belgium An estimate of the number of lives that could be saved through improvements in trauma care globally Trauma care systems in Saudi Arabia: an agenda for action Trauma care in India: current scenario A standardized trauma care protocol decreased in-hospital mortality of patients with severe traumatic brain injury at a teaching hospital in a middle-income country First aid strategy for severe traumatic patients in hospital Effects of rapid response trauma team in thoracic injuries in northern trauma center level I Finnish Trauma Audit 2004: current state of trauma management in Finnish hospitals Implementation of a trauma system in Norway: a national survey Trauma care systems in France Restructuring an evolving Irish trauma system: What can we learn from Europe and Australia? Surgeon Mortality in Canadian Trauma Systems: A Multicenter Cohort Study The effect of an organized trauma system on mortality in major trauma involving serious head injury: a comparison of the United kingdom and victoria, australia Trauma care systems: a comparison of trauma care in Classifying, measuring and improving the quality of data in trauma registries: A review of the literature The Impact of Trauma Care Systems in Low-and Middle-Income Countries. Annual Review of Public Health The Toll of Death and Disability From Traumatic Injury in the United States-The "Neglected Disease" of Modern Society, Still Neglected After 50 Years Her research interests are in addressing barriers in access to care and reducing disparities among vulnerable surgical populations He earned his MD from Wayne State University, completed general surgery residency at Robert Wood Johnson University Hospital, and fellowship training at University of Louisville. He is the current President of the American Association for the Surgery of Trauma and a Council Member of the American Board of Surgery. His research focus is in assessment of clinical care, systems of care, and assessment of stress response and posttraumatic stress disorder after trauma The Neil and Claudia Doerhoff Fund supports scholarly activities of Dr. Choi. We would like to thank Dr. Beatrice Sun for assistance with initial literature searches.