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

Introduction 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 Results 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. Conclusion 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.

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, Trauma.org, 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.

Results
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).
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 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

Discussion
According to the WHO definitions, quality comprises three elements: structure, process, and outcome [1].   6. Morbidity and mortality rates in frail patients (i.e., elderly or transplanted) Fig. 1 Trauma center level distribution of international experts 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.

Conclusion
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.