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Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review
  1. Isabelle Feldhaus1,
  2. Melissa Carvalho2,
  3. Ghazel Waiz3,
  4. Joel Igu4,
  5. Zachary Matthay3,
  6. Rochelle Dicker2,
  7. Catherine Juillard2
  1. 1Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
  2. 2Department of Surgery, University of California Los Angeles, Los Angeles, California, USA
  3. 3Department of Surgery, Center for Global Surgical Studies, University of California San Francisco, San Francisco, California, USA
  4. 4Johns Hopkins University Carey Business School, Baltimore, Maryland, USA
  1. Correspondence to Dr Rochelle Dicker, Department of Surgery, University of California, Los Angeles, CA 90095, USA; RDicker{at}


Background About 5.8 million people die each year as a result of injuries, and nearly 90% of these deaths occur in low and middle-income countries (LMIC). Trauma scoring is a cornerstone of trauma quality improvement (QI) efforts, and is key to organizing and evaluating trauma services. The objective of this review was to assess the appropriateness, feasibility, and QI applicability of traditional trauma scoring systems in LMIC settings.

Materials and methods This systematic review searched PubMed, Scopus, CINAHL, and trauma-focused journals for articles describing the use of a standardized trauma scoring system to characterize holistic health status. Studies conducted in high-income countries (HIC) or describing scores for isolated anatomic locations were excluded. Data reporting a score’s capacity to discriminate mortality, feasibility of implementation, or use for QI were extracted and synthesized.

Results Of the 896 articles screened, 336 were included. Over half of studies (56%) reported Glasgow Coma Scale, followed by Injury Severity Score (ISS; 51%), Abbreviated Injury Scale (AIS; 24%), Revised Trauma Score (RTS; 19%), Trauma and Injury Severity Score (TRISS; 14%), and Kampala Trauma Score (7%). While ISS was overwhelmingly predictive of mortality, 12 articles reported limited feasibility of ISS and/or AIS. RTS consistently underestimated injury severity. Over a third of articles (37%) reporting TRISS assessmentsobserved mortality that was greater than that predicted by TRISS. Several articles cited limited human resources as the key challenge to feasibility.

Conclusions The findings of this review reveal that implementing systems designed for HICs may not be relevant to the burden and resources available in LMICs. Adaptations or alternative scoring systems may be more effective.

PROSPERO registration number CRD42017064600.

  • quality improvement
  • risk adjustment
  • wounds and injuries

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  • Contributors CJ and RD conceived the study objectives and oversaw overall study design and implementation. IF and GW designed the search strategy and data acquisition procedures. IF, GW, JI, ZM, and MC implemented the screening of articles for eligibility for review as well as extracted data from relevant articles. IF with support from MC interpreted and synthesized the data as well as drafted the article. All authors reviewed and approved the final article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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