title: Trauma system development in low- and middle-income countries: a review.
abstract: BACKGROUND
  Trauma systems in resource-rich countries have decreased mortality for trauma patients through centralizing resources and standardizing treatment. Rapid industrialization and urbanization have increased the demand for formalized emergency medical services and trauma services (EMS and TS) in low- and middle-income countries (LMICs). This systematic review examines initiatives to develop EMS and TS systems in LMICs to inform the development of comprehensive prehospital care systems in resource-poor settings.
  
  
  METHODS
  EMS and TS system development publications were identified using MEDLINE, PubMed, and Scopus databases. Articles addressing subspecialty skill sets, public policy, or physicians were excluded. Two independent reviewers assessed titles, abstracts, and full texts in a hierarchical manner.
  
  
  RESULTS
  A total of 12 publications met inclusion criteria, and 10 unique LMIC EMS and TS programs were identified. Common initiatives included the integration of existing EMS and TS services and provision of standardized training and formalized certification processes for prehospital care providers, as well as the construction of a conceptual framework for system development through the public health model.
  
  
  CONCLUSIONS
  There is no single model of EMS and TS systems, and successful programs are heterogeneous across regions. Successful EMS and TS systems share common characteristics. A predevelopment needs assessment is critical in identifying existing EMS and TS resources as a foundation for further development. Implementation requires coordination of preexisting resources with cost-effective initiatives that involve local stakeholders. High-impact priority areas are identified to focus improvements. Financial stresses and mismatching of resources in LMICs are common and are more commonly encountered when implementing a high-income model EMS and TS in an LMIC. Preimplementation and postimplementation evaluations can determine the efficacy of initiatives to strengthen EMS and TS systems.
authors.affiliation: Division of Trauma and Critical Care Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, Illinois. Electronic address: tcallese@wakehealth.edu.
authors.forename: Tyler E
authors.initials: TE
authors.lastname: Callese
authors.affiliation: Center for Healthcare Studies, Northwestern Feinberg School of Medicine, Chicago, Illinois; Department of Emergency Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Richards
authors.affiliation: Galter Health Sciences Library, Northwestern Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Pamela
authors.initials: P
authors.lastname: Shaw
authors.affiliation: Division of Trauma and Critical Care Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Schuetz
authors.affiliation: Department of Emergency Medicine, State University of New York-Downstate School of Medicine, New York, New York.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Paladino
authors.affiliation: Division of Trauma and Critical Care Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Nabil
authors.initials: N
authors.lastname: Issa
authors.affiliation: Division of Trauma and Critical Care Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Mamta
authors.initials: M
authors.lastname: Swaroop
mesh_terms: D003906:Developing Countries; D004632:Emergency Medical Services / Q000458:organization & administration / Q000639:trends*; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000639:trends*; D014943:Global Health / Q000639:trends; D006801:Humans; D012959:Socioeconomic Factors; D014193:Trauma Centers / Q000458:organization & administration / Q000639:trends*
keywords: Global surgery; LMIC; Resource-poor; Systematic review; Trauma; Trauma system development