Skip to content


Systematic Reviews

Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Strategies for successful trauma registry implementation in low- and middle-income countries—protocol for a systematic review

Systematic Reviews20187:33

Received: 25 April 2017

Accepted: 15 February 2018

Published: 21 February 2018



The benefits of trauma registries have been well described. The crucial data they provide may guide injury prevention strategies, inform resource allocation, and support advocacy and policy. This has been shown to reduce trauma-related mortality in various settings. Trauma remains a leading cause of mortality in low- and middle-income countries (LMICs). However, the implementation of trauma registries in LMICs can be challenging due to lack of funding, specialized personnel, and infrastructure. This study explores strategies for successful trauma registry implementation in LMICs.


The protocol was registered a priori (CRD42017058586). A peer-reviewed search strategy of multiple databases will be developed with a senior librarian. As per PRISMA guidelines, first screen of references based on abstract and title and subsequent full-text review will be conducted by two independent reviewers. Disagreements that cannot be resolved by discussion between reviewers shall be arbitrated by the principal investigator. Data extraction will be performed using a pre-defined data extraction sheet. Finally, bibliographies of included articles will be hand-searched. Studies of any design will be included if they describe or review development and implementation of a trauma registry in LMICs. No language or period restrictions will be applied. Summary statistics and qualitative meta-narrative analyses will be performed.


The significant burden of trauma in LMIC environments presents unique challenges and limitations. Adapted strategies for deployment and maintenance of sustainable trauma registries are needed. Our methodology will systematically identify recommendations and strategies for successful trauma registry implementation in LMICs and describe threats and barriers to this endeavor.

Systematic review registration

The protocol was registered on the PROSPERO international prospective register of systematic reviews (CRD42017058586).


TraumaTrauma registriesLow-middle-income countriesDatabaseTrauma informationAcute injury dataResource-limited setting


A trauma registry is a clinical database that captures information on large patient cohorts in order to analyze the epidemiology, study the processes, and evaluate the quality of patient care in trauma [1]. Trauma registries vary widely in their content, administration, and cost. In high-income countries (HICs), trauma registry maintenance has been reported to have an estimated direct cost of approximately USD $95 per patient in 2015 [2]. This can be explained by the large infrastructure and resource investments required to operate expansive trauma registries such as the National Trauma Data Bank (NTDB) in the USA or other national and provincial trauma registries such as the Quebec Trauma Registry or the Australian Trauma Registry [37].

The variables within different trauma registries may differ in various contexts; however, the majority include data pertaining to pre-hospital care, in-hospital interventions, injury classification, physiological response (e.g., vital signs, laboratory data), complications, and patient outcomes [1].

Trauma registries have multiple uses such as injury surveillance, clinical research, and outcomes benchmarking. Trauma data are instrumental in designing targeted quality improvement initiatives, planning resource allocation, understanding pre-hospital care and transport priorities, and tracking changes in trauma system performance over time. They have enabled the reorganization of trauma delivery into more efficient regional systems of trauma care and have played a critical role in the dramatic improvements in trauma mortality observed in many HICs [8].

Injuries cause over five million deaths per year in low- and middle-income countries (LMICs); trauma is the primary cause of mortality and morbidity in persons aged 5 to 44 years old [9, 10]. The burden of trauma mortality disproportionately affects persons living in low-income countries. For example, road traffic injuries caused 2.03% of all deaths in low-income countries in 2015, nearly double the 1.07% rate for the same year in high-income countries [11]. Therefore, development of locally relevant and sustainable trauma registries in LMICs is a public health priority. Many LMICs lack the necessary infrastructure to implement or maintain costly trauma registries similar to those operating in HICs. A scoping review of the literature published by O’Reilly and colleagues specifically investigated the distribution of trauma registry publications by continent, by country, and by United Nations Development Index (UNDI) grouping [12]. They reported that a vast majority of trauma registry publications came from HICs, while only 1% came from the lowest UNDI grouping. Nevertheless, their study documented a proliferation of trauma registries in LMICs in the last decade [12]. They found that trauma registries in LMICs typically collect fewer variables, specifically with respect to processes of care and in-hospital management. They also usually have less stringent inclusion criteria, such that all injured patients are typically entered in the registry. On the other hand, HIC trauma registries tend to collect a much larger number of variables for a more restrictive group of patients, typically those with a greater severity of injury or those requiring prolonged hospitalization [12].

Trauma registry implementation requires a precisely defined population, adequately trained personnel, a dependable system of data collection, and the ability to analyze, report, and validate the data in a useful way [13]. Achieving these steps requires sufficient funding, which is often dependent on buy-in from stakeholders including health authorities. Financial limitations, scarcity of equipment and specialized workforce, lack of adequate health care policies and legislations, and increased trauma burden render the implementation of trauma registries very challenging in LMICs [14]. Where trauma registries do exist, they are often incomplete, subject to significant backlog, or simply cease their operations [15]. In resource-limited settings, health care dollars must be invested judiciously—consequently, trauma registries in such settings should be well-adapted to their context and must not incur prohibitive costs [8].

Improvements in health care and policy have been observed in developing countries with established trauma registries. For example, the pediatric trauma care in a large Nigerian teaching hospital was reorganized following the deployment of a simple low-cost trauma registry [16]. Another simplified trauma dataset was launched in Uganda, allowing the establishment of the Kampala Trauma Score as a triage tool in low-resource settings where high-tech measures of injury severity are not achievable [17].

No existing literature provides recommendations or guidelines for successful trauma registry implementation in a resource-limited setting. Our aim is to systematically review reports of trauma registry implementation in LMICs and to identify key parameters that contribute to success as well as factors that impede the successful implementation of a trauma registry.


The protocol was registered a priori in the PROSPERO international prospective register of systematic reviews (CRD42017058586).

A peer-reviewed search strategy was developed in collaboration with a senior hospital librarian (TL) (Additional file 1). It will be used to search the following databases for relevant studies: MEDLINE (via Ovid, 1946 to 20/Feb/2017; via PubMed, 1946 to 20/Feb/2017), Embase (via Ovid, 1947 to 20/Feb/2017), Biosis Previews (via Ovid, 1969 to 2017 week 12), Global Health (via Ovid, 1973 to 2017 week 06), Africa-Wide Information (via Ebsco), the Database of Abstracts of Reviews of Effects (via The Cochrane Library, to issue 2 of 4 April 2015), the CENTRAL Registry of Controlled Trials (via The Cochrane Library, to issue 1 of 12, January 2017), The Cochrane Methodology Register (via The Cochrane Library, to issue 3 of 4, July 2012), the NHS Economic Evaluation Database (to issue 2 of 4, April 2015), LILACS (via Bireme), ProQuest Dissertations & Theses Global (via ProQuest), Scopus (via Elsevier), and Web of Science (via ThomsonReuters). The search strategy used text words and relevant indexing to identify articles discussing trauma registries in low- or low-middle-income countries. The full MEDLINE strategy (see Additional file 1) was applied to all databases, with modifications to search terms as necessary.

Adhering to PRISMA recommendations [18], two independent reviewers (TP, ESL) will perform a first screening based on title and abstract review. Disagreements not resolved by discussion between the reviewers shall be arbitrated by the principal investigator (DP). After first screen, the remaining studies will undergo full-text review and data extraction by the same independent reviewers. Data extraction will be performed using a pre-defined data extraction sheet (Additional file 2). It includes study location, authorship, HIC partnership, funding, age of registry, scope of cases covered, number of facilities, dedicated data collectors, registry administration modality, timing of data collection, constituent variables, duration of follow-up, and presence of data quality assurance mechanisms. Furthermore, comments and citations salient to the success factors and inhibitors will be recorded. Finally, the bibliography of included articles will be hand-searched. EndNote 8 Software (Clarivate Analytics, Philadelphia, PA) will be used to upload references, eliminate duplicates, and perform screening. The selection of studies will be conducted according to the eligibility criteria outlined in Table 1.
Table 1

Eligibility criteria presented in PICOS format





Any age

Male and female

Not applicable


Trauma registry design and/or development or implementation

Trauma registry implementation/deployment

Description of barriers and challenges to registry development or implementation

No description of design, development, implementation, or deployment

Injury surveillance through other means than a trauma registry

Narrow focus of registry (e.g., burns, traumatic brain injury)


Not applicable

Not applicable


Registry utilization and sustainability

Registry data analysis

Comparative outcomes of pre-existing registries


Low-income country

Lower middle-income country

Middle-income country

High-income country

Summary and descriptive statistics will be reported in terms of means, standard deviations, medians, and ranges, as appropriate. As we will not be aggregating comparative or descriptive outcome data, meta-analysis is not appropriate. We will however synthesize the qualitative data in a systematic way through meta-narrative analysis, in accordance with the recommendations put forth by the Realist and Meta-Narrative Evidence Syntheses (RAMESES) project [19]. In so doing, the key qualitative findings from included studies will be presented with a specific focus on the key meta-narratives that are relevant to the successful implementation of trauma registries, and the commonalities and differences between them [20]. We suspect that qualitative data yielded from surveys, questionnaires, or interviews is likely to contribute significantly to our understanding of the challenges inherent to trauma registry implementation in low-resource settings. The PRISMA checklist is included in Additional file 3 [18]. The Methodological Index for Non-Randomized Studies (MINORS) instrument will be used to critically appraise the quantitative studies [21]. Qualitative studies, which are subject to different biases by virtue of their design and methods, serve a different purpose than quantitative studies and will not undergo risk of bias assessment. The quality of reporting for implementation of trauma registries will be assessed when applicable using a checklist from the Research Effectiveness Adoption Implementation and Maintenance (RE-AIM) Framework [22, 23].

The World Bank classification of countries by income was used to define low-income, lower middle-income, and middle-income countries [24]. This classification is based on gross national income (GNI) per capita. GNI per capita cut-offs for different income classes for the 2018 fiscal year are given in Table 2.
Table 2

Gross national income (GNI) per capita cut-off values for different income classes of the World Bank classification of economies in the fiscal year 2018

Group name

GNI per capita

Low-income economies

$0 to $1005

Lower middle-income economies

$1006 to $3955

Upper middle-income economies

$3956 to $12,235

Upper income economies

$12,236 or greater


We acknowledge several limitations to this study. Trauma registries themselves have limitations, particularly when they are hospital based, due to a selection bias introduced by virtue of the fact that many injured patients either cannot reach a hospital or do not seek medical treatment [25]. Furthermore, in institutions where baseline medical documentation is limited, it can be challenging to obtain a precise estimate of patient uptake within the registry. This can skew the interpretation of registry data by deflating the denominator [26]. Although this systematic review will adhere to PRISMA guidelines and follow strict methodological principles, it remains impossible to completely account for the limitations of the studies included within the review itself. For example, there may be significant heterogeneity in the studies as well as moderate to high risk of bias. These elements can decrease the validity of any results or conclusions of a systematic review. Furthermore, systematic reviews can be limited in their ability to identify all relevant negative or inconclusive studies due to publication bias. We attempted to overcome this by searching gray literature and conference proceedings, in addition to traditional databases of published literature.

Burdened by high clinical volumes, limited resources, lack of specialized workforce, and vulnerable populations, health care providers in LMICs face multiple barriers to effective and universal provision of health care [27]. Clinicians in the most resource-deprived parts of the world understand the need for quality improvement initiatives endorsed by health authorities and funded appropriately to make sustainable changes for better access to care and patient outcomes. However, these same clinicians may have few resources at their disposal to conduct high-yield research and implement impactful projects. Many efforts have been deployed to provide guidelines for optimization and prioritization of essential trauma care in LMICs [28, 29]. Similar LMIC-centered endeavors have been deployed in collaboration with HIC partners to define optimal resources for children’s surgery and define standards for research and quality improvement in resource-limited settings [30]. Given the significant burden of morbidity and mortality resulting from traumatic injury in children in LMICs, and acknowledging the importance of trauma systems that can collect, analyze, and synthesize data on injury mechanisms and outcomes, this study will investigate the successful factors for trauma registry implementation in LMICs, as well as its inhibitors.

Trauma registries vary widely in their patient inclusion criteria, in the extent of data they collect, and the funding they receive. This variability is not undesirable in-and-of itself, given the necessity for a local trauma registry to be adapted to the specific context in which it will be used. General strategies, recommendations, and precautions for successful trauma registry implementation can nevertheless be extracted from the growing published experience of trauma registry use in LMICs. To our knowledge, no study has yet reviewed and summarized the pearls and pitfalls of trauma registry implementation in LMICs. This methodology will provide trauma registry developers in LMICs with an evidence-based framework built on the experience of colleagues from around the world. This information will have the potential to improve local and international efforts to initiate and maintain trauma registries in LMICs.



High-income countries


Low- and middle-income countries



Not applicable


No external funding was received for this study.

Availability of data and materials

Data included in this protocol were obtained by publically available published articles. Aggregate extracted data will be made available from the corresponding author upon request.

Authors’ contributions

TP took part in the study design, search strategy development, and protocol preparation. ESL took part in the study design, search strategy development, and critical revision of the protocol. TL took part in the search strategy development. DP took part in the study design and critical revision of the protocol. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable for this study

Consent for publication

Not applicable for this study

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

McGill University, Montreal, Canada
McGill University Health Centre, Montreal, Canada


  1. Moore L, Clark DE. The value of trauma registries. Injury. 2008;39(6):686–95.View ArticlePubMedGoogle Scholar
  2. Cameron PA, Finch CF, Gabbe BJ, Collins LJ, Smith KL, McNeil JJ. Developing Australia’s first statewide trauma registry: what are the lessons? ANZ J Surg. 2004;74(6):424–8.View ArticlePubMedGoogle Scholar
  3. Pape HC, Grotz M, Schwermann T, Ruchholtz S, et al. The development of a model to calculate the cost of care for the severely injured: an initiative of the Trauma Register of the DGU. Unfallchirurg. 2003;106(4):348–57.View ArticlePubMedGoogle Scholar
  4. Schwermann T, Grotz M, Blanke M, Ruchholtz S, Lefering R, Schulenburg JM, Krettek C, Pape HC. Evaluation of costs incurred for patients with multiple trauma particularly from the perspective of the hospital. Unfallchirurg. 2004;107(7):563–74.View ArticlePubMedGoogle Scholar
  5. Victorian State Trauma Outcomes Registry (VSTORM). URL: [Accessed on 2 Aug 2017].
  6. Trauma Audit and Research Network. URL: [Accessed on 2 Aug 2017].
  7. American College of Surgeons. National Trauma Data Bank. URL: [Accessed on 2 Aug 2017].
  8. Nwomeh BC, Lowell W, Kable R, Haley K, Ameh EA. History and development of trauma registry: lessons from developed to developing countries. World J Emerg Surg. 2006;31:1–32.Google Scholar
  9. Gosselin R. Injuries: the neglected burden in developing countries. Bull World Health Organ. 2009;87(4):246.View ArticlePubMedPubMed CentralGoogle Scholar
  10. Mock C, Abatanga F, Goosen J, Joshipura M, Juillard C. Strengthening the care of injured children globally. Bull World Health Organ. 2009;87(5):382–9.View ArticlePubMedPubMed CentralGoogle Scholar
  11. Global Burden of Disease Data Visualizations. Institute for Health Metrics and Evaluation. URL: [Accessed on 2 Aug 2017].
  12. O’Reilly GM, Cameron PA, Joshipura M. Global trauma registry mapping: a scoping review. Injury. 2012;43:1148–53.View ArticlePubMedGoogle Scholar
  13. Porgo TV, Moore L, Tardif PA. Evidence of data quality in trauma registries: a systematic review. J Trauma Acute Care Surg. 2016;80(4):648–58.View ArticlePubMedGoogle Scholar
  14. Ankomah J, Stewart BT, Oppong-Nketia V, et al. Strategic assessment of the availability of pediatric trauma care equipment, technology and supplies in Ghana. J Pediatr Surg. 2015;50(11):1922–7.View ArticlePubMedPubMed CentralGoogle Scholar
  15. Mehmood A, Razzak JA. Trauma registry—needs and challenges in developing countries. J Pak Med Assoc. 2009;59(12):807–8.PubMedGoogle Scholar
  16. Cassidy LD, Olaomi O, Ertl A, Ameh EA. Collaborative development and results of a Nigerian trauma registry. J Registry Manag. 2016;43(1):23–8.PubMedGoogle Scholar
  17. Kobusingye OC, Lett RR. Hospital-based trauma registries in Uganda. J Trauma. 2000;48(3):498–502.View ArticlePubMedGoogle Scholar
  18. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analysis: the PRISMA statement. Ann Int Med. 2009;151(4):264–9.View ArticlePubMedGoogle Scholar
  19. Greenhalgh T, Wong G, Westhorp G, Pawson R. Protocol—realist and meta-narrative evidence synthesis: evolving standards (RAMESES). BMC Med Res Methodol. 2011;11:115.View ArticlePubMedPubMed CentralGoogle Scholar
  20. Wong G, Greenhalgh T, Westhorp G, Buckingham J, Pawson R. RAMESES publication standards: meta-narrative reviews. BMC Med. 2013;11:20.View ArticlePubMedPubMed CentralGoogle Scholar
  21. Slim K, Nini E, Forestier D, Kwiatkowsky F, Panis Y, Chipponi J. Methodological index for non-randomized studies (MINORS): development and validation of a new instrument. ANZ J Surg. 2003;73:712–6.View ArticlePubMedGoogle Scholar
  22. RE-AIM criteria for conducting literature reviews. Available from [Accessed on 08 Jan 2018].
  23. Michie S, Fixsen D, Grimshaw JM, Eccles MP. Specifying and reporting complex behavior change interventions: the need for a scientific method. Implement Sci. 2009;4:40.View ArticlePubMedPubMed CentralGoogle Scholar
  24. The World Bank Classification of Country by Income. URL: World Bank classification of countries by income [Accessed 2 Aug 2017].Google Scholar
  25. Mefire AC, Mballa GA, et al. Hospital-based injury data from level III institution in Cameroon: retrospective analysis of the present registration system. Injury. 2013;44(1):139–43.View ArticleGoogle Scholar
  26. St-Louis E, Roizblatt D, Deckelbaum DL, et al. Identifying pediatric trauma data gaps at a large urban trauma referral centre in Santiago, Chile. Pan Am J Trauma. 2017; In PrintGoogle Scholar
  27. Grimes GE, Bowman KG, Dodgion CM, Lavy CB. Systematic review of barriers to surgical care in low-income and middle-income countries. World J Surg. 2011;35(5):941–50.View ArticlePubMedGoogle Scholar
  28. Mock C, Joshipura M, Goosen J, Maier R. Overview of the essential trauma care project. World J Surg. 2006;30(6):919–29.View ArticlePubMedGoogle Scholar
  29. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Surgery. 2015;158(1):3–6.View ArticlePubMedGoogle Scholar
  30. Goodman L, St-Louis E, Yousef Y, et al. The global initiative for children’s surgery: optimal resources for improving care. Eur J Pediatr Surg. 2017; In PrintGoogle Scholar


© The Author(s). 2018


By submitting a comment you agree to abide by our Terms and Community Guidelines. If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.