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Trauma quality indicators: internationally approved core factors for trauma management quality evaluation



Quality in medical care must be measured in order to be improved. Trauma management is part of health care, and by definition, it must be checked constantly. The only way to measure quality and outcomes is to systematically accrue data and analyze them.

Material and methods

A systematic revision of the literature about quality indicators in trauma associated to an international consensus conference


An internationally approved base core set of 82 trauma quality indicators was obtained: Indicators were divided into 6 fields: prevention, structure, process, outcome, post-traumatic management, and society integrational effects.


Present trauma quality indicator core set represents the result of an international effort aiming to provide a useful tool in quality evaluation and improvement. Further improvement may only be possible through international trauma registry development. This will allow for huge international data accrual permitting to evaluate results and compare outcomes.


Quality in medical care must be measured in order to be improved. Trauma management is part of health care, and by definition, it must be checked constantly. The only way to measure quality and outcomes is to systematically accrue data and analyze them. However, one of the main issues encountered in this activity is the difficulty to obtain complete and affordable dataset. Health care systems as well as trauma systems are different. They are differently organized around the world; discrepancies exist between them. The profound differences in organizational models may reflect even in outcomes. The necessity to evaluate the quality of care in a local, national, and even international scale has been progressively considered more necessary in the last decades. Quality of care is characterized as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with the current professional knowledge” [1]. Measurement and feedback of performance are integral to the concept of a system of care [2, 3]. Since the early 1970s, the evidence of several deaths due to suboptimal trauma care in the USA has led to the development of structured trauma systems [4]. With the development of organizational models, the number of preventable deaths has progressively decreased [2]. Quality improvement evaluates the performance of both individual providers and the systems in which they work [1].

Evaluation of quality of the service offered by health systems may be measured with quality indicators (QI).

QI are performance measures designed to compare actual care against ideal criteria for the purposes of quality measurement, benchmarking, and identifying potential opportunities for improvement [5].

The US national system was the first in developing a structured trauma quality indicators (TQI) list and in providing several tools in order to continuously check and improve results. At present, many different TQI sets exist. However, concomitant existing significant variations in the utilization of indicators and limited evidence to support the use of specific indicators over others do not allow for an exchange in TQI within the different systems [5]. In fact, around the world, trauma systems are at different points in the organizational progression. TQI list generally adopted in a system cannot be entirely applied in a different one. Actually, no clearly defined and internationally approved TQI sets exist. However, a core set of universally applicable TQI that may be transversally adopted by all trauma systems is needed. Subcategories of indicators may then be elaborated and tailored according to dedicated system analysis.

The aim of this paper is to present a list of internationally approved core items for trauma management quality evaluation.

Material and methods

A systematic revision of the literature about QI for evaluating trauma care was conducted. Researches were done on MEDLINE, Embase, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials from the earliest available date through May 31, 2019. To increase the sensitivity of the search, the grey literature and select journals by hand were investigated, reference lists to identify additional studies were reviewed, and experts in the field were contacted. Moreover, websites of the major surgical and critical care societies worldwide were investigated for obtaining QI (American College of Surgeons, American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Western Trauma Association, American Trauma Society, International Trauma Anesthesia, and Critical Care Society, British Trauma Society, Panamerican Trauma Society, Trauma Association of Canada, European Society for Trauma and Emergency Surgery, Australasian Trauma Society, Orthopedic Trauma Association,, the Society of Trauma Nurses). To further enlarge the research, also the main web search engines were utilized (i.e., Google, Yahoo, Bing, and Baidu) using the following search terms: trauma, quality, indicator, and injury.

All articles identifying and/or proposing 1 or more QI focusing on prehospital care, hospital care, posthospital care, or secondary injury prevention were considered.

Moreover, main world trauma centers’ TQI lists were analyzed. All the identified QI lists were then analyzed in order to summarize all retrieved indicators.

Once all the QI were summarized, an international expert panel web-based consensus survey was done to obtain a balanced QI list. Two hundred experts from all the 5 continents and from all the 6 WHO regions were asked to express their evaluation of importance (0–10 marks, where 0 was not relevant and 10 was very important) about all the proposed QI. Items with ≥ 70% of preferences to values 8 to 10 have been accepted as important and passed through the next steps. During the survey, expert panel components had the opportunity to suggest further quality indicators they consider important and not present in the proposed list.

Results of the survey were analyzed and discussed during an international event in Pisa, Italy, on September 27, 2019. Then, results of discussion were diffused for a further international round of evaluation and discussion between international panels of recognized experts in the field. Through subsequent rounds of evaluation, in a modified Delphi process, the manuscript reached the definitive version together with the definitive TQI core list.


After systematic reviews of the existing literature about TQI and the trauma center/society protocol and TQI lists, a total of 1288 indicators were obtained. After analysis and elimination of duplicate QI or integration of the similar ones into a single comprehensive indicator, 89 were proposed for international evaluation. After international round, 82 were considered to be included into the definitive list (Tables 1, 2, 3, and 4).

Table 1 Prevention and structure indicators
Table 2 Process indicators (TTA Trauma Team Activation, GCS Glasgow Coma Scale, TBI traumatic brain injury, ED emergency department, AIS Abbreviated Injury Scale, ISS Injury Severity Score, CT computed tomography, TEG tromboelastography, ROTEM rotational thromboelastometry, ICU intensive care unit, EX-LAP explorative laparotomy, SBP systolic blood pressure, OR operating room, E-FAST extended focused assessment with sonography in trauma, REBOA resuscitative endovascular balloon occlusion of the aorta, CNS central nervous system)
Table 3 Outcome, post-traumatic management, and society integrational effect indicators (VAE ventilator-associated events, TBI traumatic brain injury, ED emergency department, ICU intensive care unit, OR operating room)
Table 4 Secondary analysis of primary indicators

Average agreement was of 97% within the different experts about the different QI.

Participating centers and surgeon distribution across the different hospitals in the World Health Organization (WHO) regions are presented in Figs. 1 and 2. Answers were analyzed, and the distributions of the importance given to the different indicators have been reported in Figs. 3 and 4 showing some variation within the different the WHO regions.

Fig. 1
figure 1

Trauma center level distribution of international experts

Fig. 2
figure 2

Expert distribution according to the World Health Organization (WHO) regions

Fig. 3
figure 3

Differences in perceiving the importance of the different items for the different answers according to the WHO region

Fig. 4
figure 4

Centroid distribution of the differences in perceiving the importance of the different items for the different answers according to the WHO region

The different regions showed homogeneous differences in perceiving the importance of the different items for the different answers (Fig. 3) and for the centroid of the average of the various answers (Fig. 4).

Categories into which TQI have been divided are as follows:

  • Prevention

  • Structure

  • Process

  • Outcome

  • Post-traumatic management

  • Society integrational effects


According to the WHO definitions, quality comprises three elements: structure, process, and outcome [1].

Structure refers to stable, material characteristics (infrastructure, tools, technology) and the resources of the organizations that provide care and the financing of care (levels of funding, staffing, training, skills, payment schemes, incentives) [1].

Process is the interaction between caregivers and patients during which structural inputs from the health care system are transformed into health outcomes. The process is the actual provision of medical care to the patient [1].

Outcomes can be measured in terms of health status, deaths, or disability-adjusted life years—a measure that encompasses the morbidity and mortality of patients or groups of patients. Outcomes also include patient satisfaction or patient response to the health care system [1].

At present, however, trauma system evolution must take into consideration the necessity to relate the system to the context into which it operates. For this reason, quality evaluation must comprise some more aspects influenced by and influencing the trauma patient’s management.

Present manuscript aims to answer to the recognized necessity of an international agreement about a QI core set. Quality improvement is mainly a behavioral change, and it is impossible to change if no shared and agreed points exist. Shared and largely approved and agreed-on QI are needed to improve quality not in a competitive view but in a reciprocal improvement behavior. It is not possible to proceed with a transparent, explicit, systematic, data-driven performance measurement if there is no agreement upon indicators and measures. A very high number of existing proposed TQI have been searched, reported, and resumed. For sure, search may not have been exhaustive, despite the evaluation of multiple databases using comprehensive research strategies and imposing no language restrictions. As a counterpart, the very high number of redundant indicators clearly shows how it approximated the completeness. We can assume that very few eventual other QI may have been not considered.

Present paper demonstrated that a common set of clearly defined, evidence-based, broadly accepted trauma QIs does not exist. A large group of heterogeneous indicators are diffusely and non-homogeneously utilized. Moreover, the vision and perception of TQI across the world is widely different as clearly shown in Figs. 3 and 4. This different perception is the reflection of different cultural and organizational models, and at the same time, it results in slightly different priorities. However, present international effort aims also to balance the differences in a shared TQI in order to promote intersystem comparison and improvement.

One of the main factors emerging from the analysis is the imbalance existing between QIs evaluating prehospital, in-hospital, and posthospital management. In fact, current literature universally focused on in-hospital phase of trauma care. Very few QIs are dedicated to the analysis of the pre- and posthospital phases. This reflects the lack in organizational systems, indifferently from the WHO region and from the resources of the system. This may be due to a disconnect between the professional figures reflecting on the three phases of trauma management. The in-hospital phase is diffusely considered the most important. For this reason, organizational efforts are maximized in this part with very few resources dedicated to the others. However, it should be stressed as the pre- and posthospital phases may strongly impair the effectiveness of the in-hospital trauma management. Lastly, prevention phase is not considered nor evaluated at all.

Donabedian stratification of healthcare QIs into structure, process, and outcome evaluation is valid and diffusely accepted [6,7,8]. However, as trauma involves more than the hospital and may impact on multiple different levels of the sanitary and economical systems, its quality management evaluation should encompass more than the already defined three key-points. It must consider the system in which the “structure” is included in, and international trauma registries must consider obtaining data even regarding socio-economical setting together with the performance of the specific hospital/system.

This paper proposes a six level stratification of TQI: prevention, structure, process, outcome, post-traumatic management, and society integrational effects.

Quality measures other than mere hospital morbidity and mortality and management process are strongly needed to evaluate the real outcome dimensions referring to trauma prevention, health-related quality-of-life, psychosocial impact of the injury, etc. with the aim of providing a more refined specificity for all the different components of patient care.

All these phases reflect even direct and indirect costs that may be even very important in a national and international view. For these reasons, they should also be included into trauma system quality evaluation. Cost evaluation however should be done at a local or national level. International cost comparison may be impossible or at least useless due to vastly different organizational/legal/economical models.

Lastly, a need to improve the science behind the development, validation, and use of indicators is urgent.


Present trauma quality indicator core set represents the result of an international effort aiming to provide a useful tool in quality evaluation and improvement. Further improvement may only be possible through international trauma registry development. This will allow for huge international data accrual permitting to evaluate results and compare outcomes.

Availability of data and materials

Not applicable



Quality indicators


Trauma quality indicators


World Health Organization


Trauma Team Activation


Glasgow Coma Scale


Traumatic brain injury


Emergency department


Abbreviated Injury Scale


Injury Severity Score


Computed tomography




Rotational thromboelastometry


Intensive care unit


Explorative laparotomy


Systolic blood pressure


Operating room


Extended focused assessment with sonography in trauma


Resuscitative endovascular balloon occlusion of the aorta


Central nervous system


Ventilator-associated events


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WSES Trauma Quality Indicators Expert Panel

Zygimantas Kuliesius1, Luigi Conti2, Agron Dogjani3, Jae Gil Lee4, Heitor Consani5, Domenico Russello6, Marina Bortul7, Teresa Gimenez Maurel8, Hossein Samadi Kaf9, Harissou Adamou10, Vasilescu Alin11, Umberto Robustelli12, Norio Sato13, Charalampos Seretis14, Martha Quiodettis15, Carlos Augusto Gomes16, Victor Kong17, Andee Dzulkarnaen Zakaria18, Ali Guner19, Mahir Gachabayov20, Sharfuddin Chowdhury21, Francesco Pata22, Alberto Garcia23, Miran Rems24, Koray Das25, J.G. Riedel26, Konstantinos Lasithiotakis27, Ruslan Sydorchuk28, Larysa Sydorchuk29, Eftychios Lostoridis30, Alexander Buia31, Michael McFarlane32, Renzo Ciani33, Virginia María Durán Muñoz-Cruzado34, Dario Tartaglia35, Orestis Ioannidis36, Måns Muhrbeck37, Martin Reicher26, Francesco Roscio38, Marco Ceresoli39, Dimitrios Tsiftsis40, Alfie Kavalakat41, Tadeja Pintar42, George Georgiou43, Gabriele Ricci44, Rajashekar Mohan45, Sten Saar46, Isidoro Di Carlo6, Arda Isik47, Ali Yasen Yasen Mohamed Ahmed48, Ricardo Alessandro Teixeira Gonsaga49, Fabrizio Sammartano50, Luis Tallon-Aguilar34, Tomohisa Shoko51, Jeremy Hsu52, Yoshiro Kobe53, Christian Galatioto35 Luigi Romeo54, Mauro Podda55, Andrea Mingoli56, Rafael Castro Delgado57, Gerald Ekwen58, Vanlander Aude59, Carles Olona60, Paolo Boati61, Stefano Magnone62, Massimo Capaldi44, Miklosh Bala63, Edoardo Picetti64, Ionut Negoi65, Kenneth Y. Y. Kok66, Asri Che Jusoh67, Bruno Amato68, Gabriela Elisa Nita69, Andrew de Beaux70, Zaza Demetrashvili71, R. Justin Davies72, Jae Il Kim73, André Pereira74, Luca Fattori39, Ciro Paolillo75, Wagih Ghannam76, Fernando Machado Rodriguez77, Luca Berardi78, Maria Gioffrè Florio79, Matthias Hecker80, Vincent Dubuisson81, Donal B. O’Connor82, Nicola De'Angelis83, Ivan Dobrić84, Damien Massalou85, Per Örtenwall86, Emmanouil Pikoulis87, Bakarne Ugarte-Sierra88, W.P. Zuidema89, Aristotelis Kechagias90, Sanjay Marwah91, Andrey Litvin92, Ioannis Nikolopoulos93, Antonio Pesce94, Selman Uranues95, Davide Luppi96, Sascha Flohe97, Aleix Martínez-Pérez98, Manuel Lorenzo99, Luigi Branca Vergano100, Mario Manca101, Paolo Malacarne102, Hayato Kurihara103, Sandy Widder104, Marsia Pucciarelli35, Fabio Monzani105, Pietro Brambillasca106, Davide Corbella106, Ferdinando Agresta107, Lynne Moore108, Luis Antonio Buonomo109, Amos O. Adeleye110, Dennis Kim111, Massimiliano Veroux94, Timothy Craig Hardcastle112, Salomone Di Saverio72, Alfonso Recordare113, Ines Rubio-Perez114, Sergey Shlyapnikov115, Razrim Rahim116, Gustavo Miguel Machain Vega117, Kessel Boris118, Robert Sawyer119, Oussama Baraket120, Kjetil Soreide121, Clemens Weber122, Chen-June Seak123, Simon Herman124, Emiliano Gamberini125, Silvia Costa126, Gualtiero Mazzocconi127, Edgard Lozada128, Dimitrios Manatakis129, Varut Lohsiriwat130, Adamu Ahmed131, Bahaa Elbery132, Guido Alberto Massimo Tiberio133, Massimo Santini134, Luca Mellace135, Cathrine Harstad Enoksen136, Piotr Major137, Dario Parini138, Mario Improta139, Paola Fugazzola139, Silvia Pini102, Gaetano Liberti140, Costanza Martino125, Lorenzo Cobianchi141, Gabriele Canzi142, Enrico Cicuttin141, Jakub Kenig143, Mauro Zago144, Sandro Giannessi145, Michelangelo Scaglione146, Eugenio Orsitto147, Roberto Cioni148, Lorenzo Ghiadoni105, Francesco Menichetti149, Vanni Agnoletti125, Gabriele Sganga150, Paolo Prosperi151, Franco Roviello152, Paolo De Paolis153, Giovanni Gordini154, Francesco Forfori155, Paolo Ruscelli156, Francesco Gabrielli39, Adolfo Puglisi35, Andrea Bertolucci35, Santino Marchi157, Massimo Bellini157, Sergio Casagli158, Belinda De Simone159, Fabio Carmassi146, Stefano Marchetti146, Marco Accorsini146, Camilla Cremonini35, Federica Morelli35.

1 Republican Vilnius University Hospital, Vilnius, Lithuania

2 Department of Surgery, G. Da Saliceto Hospital, Piacenza, Italy

3 Department of General Surgery and Trauma, University Hospital of Trauma, Tirana, Albania

4 Yonsei University College of Medicine, Seoul, Korea

5 Emergency section, Santa Casa, Piracicaba, Brazil

6 Department of Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, Cannizzaro Hospital, University of Catania, Catania, Italy

7 Surgical Department, University of Trieste, Trieste, Italy

8 General and Digestive Surgery, Miguel Servet University Hospital, Zaragoza, Spain

9 Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran

10 Faculty of Health Sciences, University of Zinder, Zinder National Hospital, Zinder, Niger

11 First Surgical Clinic, St. Spiridon Hospital, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania

12 AORN Antonio Cardarelli, Napoli, Italy

13 Dept. of Emergency and Critical Care Medicine, Ehime University Hospital, Toon, Japan

14 George Eliot Hospital NHS Trust, Warwickshire, UK

15 General Surgery dept., Hospital Santo Tomas, Panama City, Panama

16 Hospital Universitário Terezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora - Suprema, Juiz de Fora, Brazil

17 Department of Surgery, University of KwaZulu Natal, Durban, South Africa

18 Department of Surgery, School of Medical Sciences, University Sains Malaysia, Kelantan, Malaysia

19 Karadeniz Technical University, Dept. of General Surgery, Trabzon, Turkey

20 Vladimir City Emergency Hospital, Vladimir, Russia

21 Trauma Center, King Saud Medical City, Riyadh, Saudi Arabia

22 Department of Surgery, Nicola Giannettasio Hospital, Corigliano-Rossano, Italy

23 Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia

24 Department of Abdominal and General Surgery, General Hospital Jesenice, Jesenice, Slovenia

25 Adana City Education and Research Hospital, Adana, Turkey

26 Dept. of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany

27 Department of General Surgery, University Hospital of Heraklion, Crete, Greece

28 General Surgery Department, Bukovinian State Medical University, Chernivtsi, Ukraine

29 Family Medicine and Primary Care Department, Bukovinian State Medical University, Chernivtsi, Ukraine

30 1st Department of Surgery, Kavala General Hospital, Kavala, Greece

31 Department of General, Visceral and Thoracic Surgery, Asklepios Klinik Langen, Langen, Germany

32 Department of Surgery, Radiology, Anaesthetics and Intensive Care, University of the West Indies, Mona, Jamaica

33 Aurelia Hospital, Roma, Italy

34 General and Digestive Surgery Department, Virgen del Rocío University Hospital, Seville, Spain

35 General Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy,

36 4th Surgical Department, Medical School, Aristotle University of Thessaloniki, General Hospital “G. Papanikolaou”, Thessaloniki, Greece

37 Department of Surgery, and Department of Clinical and Experimental Medicine, Linköping University, Norrköping, Sweden

38 Division of General Surgery, ASST Valle Olona, Busto Arsizio, Italy

39 General Surgery Department, Milano-Bicocca University Hospital, Monza, Italy

40 Emergency Department, Nikaia General Hospital, Piraeus, Greece

41 Department of surgery, Jubilee Mission Medical College, Thrissur, India

42 Department of Surgery, UMC Ljubljana, Ljubljana, Slovenia

43 Surgical Department, Xanthi General Hospital, Xanthi, Greece

44 General and Emergency Surgery, San Camillo-Forlanini Hospital, Roma, Italy

45 Department of Surgery, K.S. Hegde Medical Academy, Mangalore, India

46 North Estonia Medical Centre, Tallinn, Estonia

47 General Surgery Department, Erzincan University, Erzincan, Turkey

48 General Surgery, Khartoum Teaching Hospital, Sudan

49 Surgery Trauma, Hospital Padre Albino, Catanduva, Brazil

50 Trauma Team and General Surgery, ASST Niguarda, Milano, Italy

51 Emergency and Critical Care Medicine, Tokyo Women's Medical University Medical Center East, Tokyo, Japan

52 Trauma, Westmead Hospital, Westmead, Australia

53 Dept. of Surgery, Chiba Emergency Medical Center, Chiba, Japan

54 Emergency Surgery Unit, Arcispedale Sant'Anna, Ferrara, Italy

55 Department of Emergency Surgery, Cagliari University Hospital, Cagliari, Italy

56 Surgery Dept., Policlinico Umberto I, Roma, Italy

57 SAMU-Asturias, Oviedo University, Oviedo, Spain

58 Surgery, JJ Dossen Memorial Hospital, Harper, Liberia

59 University Hospital Ghent, Ghent, Belgium

60 General and Digestive Surgery Dept., Joan XXIII University Hospital, Tarragona, Spain

61 ASST Santi Paolo e Carlo, Milano, Italy

62 General Surgery Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy

63 Hadassah Hebrew University Medical Center, Jerusalem, Israel

64 Anesthesia and Intensive Care Dept., Parma University Hospital, Parma, Italy

65 General Surgery, Emergency Hospital of Bucharest, Bucharest, Romania

66 PAPRSB Institute of Health Sciences, University Brunei Darussalam, Bandar Seri Begawan, Brunei

67 General Surgery, Kuala Krai Hospital, Kuala Krai, Malaysia

68 Dpt. of Clinical Medicine and Surgery, AU Policlinico Federico II, Napoli, Italy

69 General Surgery, Sant'Anna Hospital, Castelnovo ne' Monti, Italy

70 Royal Infirmary of Edinburgh, Edinburgh, UK

71 Department of Surgery, Tbilisi State Medical University, Kipshidze Central University Hospital, Tbilisi, Georgia

72 Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Cambridge, UK

73 Dept. of Surgery, Inje University Ilsan Paik Hospital, Goyang, South Korea

74 Department of Surgery, Centro Hospitalar e Universitário do São João, Porto, Portugal

75 Emergency Department, ASST Spedali Civili di Brescia, Brescia, Italy

76 General Surgery Department, Mansoura University Hospital, Mansoura, Egypt

77 Departamento de Emergencia, Hospital de Clínicas, Montevideo, Uruguay

78 Trauma Center ed Emergenza Chirurgica, San Martino Polyclinic Hospital, Genova, Italy

79 DEA Emergenze, AOU Policlinico G. Martino, Messina, Italy

80 Department of Respiratory and Critical Care Medicine, University Hospital Giessen, Giessen, Germany

81 Bordeaux University Hospital, Bordeaux, France

82 Tallaght University Hospital, Dublin, Ireland

83 Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, Paris, France

84 Clinical Hospital Centre Zagreb, Surgical Clinic, Zagreb, Croatia

85 Acute Care Surgery, Centre Hospitalier Universitaire de Nice, Nice, France

86 Dept. of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden

87 3rd Department of Surgery, Attiko Hospital, Athens, Greece

88 Department of General Surgery, Galdakao-Usansolo Hospital, Bizkaia, Spain

89 Trauma surgery, Amsterdam UMC, Amsterdam, The Netherlands

90 Department of Surgery, Kanta-Häme Central Hospital, Hämeenlinna, Finland

91 Department of Surgery, Pt. B.D., PGIMS, Rohtak, India

92 Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia

93 Lewisham and Greenwich NHS Trust, London, UK

94 Department of Medical and Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University Hospital of Catania, Catania, Italy

95 Department of Surgery, Medical University of Graz, Graz, Austria

96 General and Emergency Surgery, IRCCS Reggio Emilia, Reggio Emilia, Italy

97 Städt. Klinikum Solingen, Solingen, Germany

98 Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain

99 Surgery Methodist Hospital, Dallas, Texas, USA

100 Orthopedic Department, Bufalini Hospital, Cesena, Italy

101 Versilia Hospital, Lido di Camaiore, Italy

102 Anesthesia and Intensive Care Unit PS, Pisa University Hospital, Pisa, Italy

103 Emergency Surgery and Trauma Unit, Humanitas Research Hospital, Rozzano, Italy

104 Department of Surgery, University of Alberta, Edmonton, Canada

105 Dept. Clinical and Experimental Medicine, Pisa University Hospital, Pisa, Italy

106 Department of Anesthesia, Hospital Papa Giovanni XXIII, Bergamo, Italy

107 General Surgery Dept., Civil Hospital, Adria, Italy

108 Universite Laval, Quebec, Canada

109 Hospital “Dr. Alberto Balestrini” La Matanza, Buenos Aires, Argentina

110 Department of Surgery, College of Medicine, University of Ibadan, and Department of Neurological Surgery, University College Hospital, UCH, Ibadan, Nigeria

111 Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA

112 Department of Trauma ICU, IALCH, University of KwaZulu-Natal, Durban, South Africa

113 General and Emergency Surgery Department, Angel Hospital, Venezia, Italy

114 General Surgery Department, Hospital Universitario La Paz, Madrid, Spain

115 Surgical Infections Department, Emergency Care Institute n.a. Djanelidze, Saint Petersburg, Russia

116 Department of Surgery, Port Dickson Hospital, Negeri Sembilan, Malaysia

117 Universidad Nacional de Asuncion, Facultad de Ciencias Medicas, Hospital de Clinicas, San Lorenzo, Paraguay

118 Surgical Division, Hillel Yaffe Medical Center, Hadera, Israel

119 Western Michigan University, Kalamazoo, Michigan, USA

120 General Surgery, Hospital Habib Bouguefa de Bizerte, Bizerte, Tunisia

121 Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway

122 Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway

123 Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan

124 Department of Traumatology, UMC Ljubljana, Ljubljana, Slovenia

125 Anesthesia and Intensive Care Unit, Bufalini Hospital, Cesena, Italy

126 Surgery, CHVNG/E, EPE, Vila Nova de Gaia, Portugal

127 Surgery, Sandro Pertini Hospital, Roma, Italy

128 Departament of Surgery, Hospital Regional de Alta Especialidad del Bajío, León, México

129 Department of Surgery, Athens Naval and Veterans Hospital, Athens, Greece;

130 Faculty of Medicine, Department of Surgery, Siriraj Hospital, Mahidol University, Bangkok, Thailand

131 Surgery, Ahmadu Bello University Teaching Hospital Zaria, Zaria, Nigeria

132 General Surgery, Al-Hussein University Hospital, Cario, Egypt

133 Surgical Clinic, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy

134 Emergency Medicine Department, Pisa University Hospital, Pisa, Italy

135 San Carlo Borromeo Hospital, Milano, Italy

136 Orthopaedic Department, Stavanger University Hospital, Stavanger, Norway

137 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland

138 General Surgery, Santa Maria della Misericordia Hospital, Rovigo, Italy

139 General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy

140 Neurosurgery, Pisa University Hospital, Pisa, Italy

141 University of Pavia, Department of General Surgery, IRCCS San Matteo, Pavia, Italy

142 Maxillofacial Surgery Unit, Emergency Department, ASST Niguarda, Milano, Italy

143 Department of General, Oncologic and Geriatric Surgery, Jagiellonian University Medical College, Kraków, Poland

144 Department of General Surgery, General Surgery Unit, Lecco Hospital, Lecco, Italy

145 General Surgery, San Jacopo Hospital, Pistoia, Italy

146 Orthopaedic Department, Pisa University Hospital, Pisa, Italy

147 Radiology Unit, Emergency Department, Pisa University Hospital, Pisa, Italy

148 Division of Interventional Radiology, Pisa University Hospital, Pisa, Italy

149 Infectious Diseases Clinic, Pisa University Hospital, Pisa, Italy

150 Department of Emergency Surgery, "A. Gemelli Hospital", Catholic University of Rome, Roma, Italy

151 Emergency Surgery Unit, Careggi University Hospital, Firenze, Italy

152 Unit of Surgical Oncology, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy

153 General Surgery Dept., Gradenigo Hospital, Torino, Italy

154 Anesthesia and Critical Care, Ospedale Maggiore, Bologna, Italy

155 ICU Dept., Pisa University Hospital, Pisa, Italy

156 Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Torrette, Italy

157 Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, Pisa University Hospital, Pisa, Italy

158 Neuro ICU dept. Pisa University Hospital, Pisa, Italy

159 Département de Chirurgie Viscérale, Centre Hospitalier Poissy/Saint Germain en Laye, Poissy, France



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FC, YK, EM, RM, RC, CO, RI, AWK, WB, MS, AH, LA, AL, VR, IC, FV, MC, ACM, BS, AP, OC, FAZ, MM, MMi, MC, VK, MS, GPF, YO, GLB, and FCa contributed to the manuscript conception and draft, critically revised the manuscript, and contributed important scientific knowledge giving the final approval.

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Correspondence to Federico Coccolini.

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Coccolini, F., Kluger, Y., Moore, E.E. et al. Trauma quality indicators: internationally approved core factors for trauma management quality evaluation. World J Emerg Surg 16, 6 (2021).

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