title: Impact of trauma system structure on injury outcomes: a systematic review protocol.
abstract: Injury represents one of the greatest public health challenges of our time with over 5 million deaths and 100 million people temporarily or permanently disabled every year worldwide. The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, the organisation of trauma care varies significantly across trauma systems and we know little about which components of trauma systems contribute to their effectiveness. The objective of the study described in this protocol is to systematically review evidence of the impact of trauma system components on clinically significant outcomes including mortality, function and disability, quality of life, and resource utilization.
  
  
  
  We will perform a systematic review of studies evaluating the association between at least one trauma system component (e.g. accreditation by a central agency, interfacility transfer agreements) and at least one injury outcome (e.g. mortality, disability, resource use). We will search MEDLINE, EMBASE, COCHRANE central, and BIOSIS/Web of Knowledge databases, thesis holdings, key injury organisation websites and conference proceedings for eligible studies. Pairs of independent reviewers will evaluate studies for eligibility and extract data from included articles. Methodological quality will be evaluated using elements of the ROBINS-I tool and the Cochrane risk of bias tool for non-randomized and randomized studies, respectively. Strength of evidence will be evaluated using the GRADE tool.
  
  
  
  We expect to advance knowledge on the components of trauma systems that contribute to their effectiveness. This may lead to recommendations on trauma system structure that will help policy-makers make informed decisions as to where resources should be focused. The review may also lead to specific recommendations for future research efforts.
  
  
  
  This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 28-06-2016. PROSPERO 2016:CRD42016041336 Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016041336 .
authors.affiliation: Department of Social and Preventative Medicine, Université Laval, Québec, QC, Canada. lynne.moore@fmed.ulaval.ca.|Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie-Urgence-Soins intensifs (Trauma-Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Center (Enfant-Jésus Hospital), 1401, 18e rue, local H-012a, Québec, G1J 1Z4, Canada. lynne.moore@fmed.ulaval.ca.
authors.forename: Lynne
authors.initials: L
authors.lastname: Moore
authors.affiliation: U Health Sciences, Baltimore, Maryland, USA.
authors.forename: Howard
authors.initials: H
authors.lastname: Champion
authors.affiliation: Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia.|School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
authors.forename: Gerard
authors.initials: G
authors.lastname: O'Reilly
authors.affiliation: Department of Surgery, Helsinki University, Helsinki, Finland.
authors.forename: Ari
authors.initials: A
authors.lastname: Leppaniemi
authors.affiliation: Emergency and Trauma Centre, The Alfred Hospital, Monash University, Melbourne, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Cameron
authors.affiliation: Trauma Service, Royal Children's Hospital, Melbourne, Australia.
authors.forename: Cameron
authors.initials: C
authors.lastname: Palmer
authors.affiliation: Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates.
authors.forename: Fikri M
authors.initials: FM
authors.lastname: Abu-Zidan
authors.affiliation: School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
authors.forename: Belinda
authors.initials: B
authors.lastname: Gabbe
authors.affiliation: Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway.
authors.forename: Christine
authors.initials: C
authors.lastname: Gaarder
authors.affiliation: Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
authors.forename: Natalie
authors.initials: N
authors.lastname: Yanchar
authors.affiliation: Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Canada.
authors.forename: Henry Thomas
authors.initials: HT
authors.lastname: Stelfox
authors.affiliation: Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California, San Diego Health System, San Diego, California, USA.
authors.forename: Raul
authors.initials: R
authors.lastname: Coimbra
authors.affiliation: Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alberta, Canada.
authors.forename: John
authors.initials: J
authors.lastname: Kortbeek
authors.affiliation: Rick Hansen Institute, Vancouver, BC, Canada.|Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Vanessa
authors.initials: V
authors.lastname: Noonan
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Amy
authors.initials: A
authors.lastname: Gunning
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Luke
authors.initials: L
authors.lastname: Leenan
authors.affiliation: Department of Emergency Medicine, University of Glasgow, Glasgow, UK.
authors.forename: Malcolm
authors.initials: M
authors.lastname: Gordon
authors.affiliation: Seth G.S. Medical College and KEM Hospital, Mumbai, India.
authors.forename: Monty
authors.initials: M
authors.lastname: Khajanchi
authors.affiliation: Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie-Urgence-Soins intensifs (Trauma-Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Center (Enfant-Jésus Hospital), 1401, 18e rue, local H-012a, Québec, G1J 1Z4, Canada.
authors.forename: Michèle
authors.initials: M
authors.lastname: Shemilt
authors.affiliation: Department of Social and Preventative Medicine, Université Laval, Québec, QC, Canada.
authors.forename: Valérie
authors.initials: V
authors.lastname: Porgo
authors.affiliation: Department of Social and Preventative Medicine, Université Laval, Québec, QC, Canada.
authors.forename: Alexis F
authors.initials: AF
authors.lastname: Turgeon
mesh_terms: D003695:Delivery of Health Care / Q000458:organization & administration*; D006295:Health Resources / Q000706:statistics & numerical data; D006801:Humans; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D012107:Research Design; D000078202:Systematic Reviews as Topic; D055512:Tertiary Prevention / Q000458:organization & administration*; D014947:Wounds and Injuries / Q000150:complications / Q000191:economics / Q000401:mortality / Q000628:therapy*
keywords: Injury outcomes; Organizational-level intervention; Trauma system