Current status of implementation of trauma registries’ in LMICs & facilitators to implementation barriers: A literature review & consultation

Current state and common challenges and barriers of trauma registries in LMICs

Literature was assessed using the proposed research strategy. A total of 873 articles were evaluated looking for barriers and facilitators documented in LMIC trauma registry implementation between 2017-2023. For LMICs, recognizing the need for trauma registries has not been challenging, but their implementation has^2,4. This reflects on the low number of trauma registry publications and literature from the United Nations Development Index (UNDI) group of LMICs, which is only about one per cent¹². Literature suggests that multiple attempts to create and implement trauma registries have been initiated, particularly in the last decade^13-15. Figure 1 depicts the geographical distribution of the limited LMICs with documented trauma registries. Previous barriers described in the literature up until 2017 included information management and data quality, lack of human resources, lack of technology/physical resources, organization/administrative concerns, and financing funding concerns¹¹. Nonetheless, the heterogeneous distribution of LMIC throughout the world’s geographically and culturally diverse regions imposes region and country-specific challenges when implementing trauma registries^10,16-19.

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Fig. 1.

Map of all the places where LMIC trauma registries exist (2018 systematic review + additionals). Maps generated using templates from mapchart.net. LMIC, low- and middle- income country.

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Data capturing concerns included a lack of pre-hospital data, long per-patient completion time, inappropriate injury assessment tools, incomplete or inaccurate records, underreporting, no standardized form for data collection, and the use of paper-based collection requiring to be transcribed into the registry. Data quality concerns included the compromise or loss of data when transcribed into a record, excessive variables to be collected, and incomplete clinical data, making missing data common^12,20. After data collection, a rising issue in cases where the registry was successfully collected was the lack of expertise or personnel to analyze and use the data^5,21.

From an organizational standpoint, the reported challenges were in the context of data completeness when patients pass through the emergency department without being captured into the registry. Additional organizational challenges included discrepancies in injury coding, incomplete follow up data, and the unavailability of geospatial mapping in some contexts^12,22.

The lack of human resources reflects the shortage of healthcare providers that many LMICs face²³. This suggestively affected clinical care and translated to less capacity for registry maintenance and the requirement for additional personnel to sustain these registries, which often could not be paid for due to financial constraints. Overall available personnel, excessive workload, lack of training, and specialized dedicated staff were perceived as burdens that impede registries from succeeding²⁴.

Lack of technology and infrastructure included components that come on a national and facility level²³. On a national level, a lack of pre-hospital care and systems, unfavorable health policies and resource allocation, and geographical difficulties could reportedly reduce registry success^25-27. On a facility level, lack of equipment for basic clinical measurements, power loss, limited availability of electronic storage, lack of appropriate information in medical records, and unreliable and interrupted internet access, and inadequate information technology were suggestively common¹².

For funding concerns, there were a broad range of implications at various levels of implementation, and it might be the broadest category to affect registry implementation²⁸. Although initial funding might be more easily acquired, most authors reported that the end of initial research funds stalled the use of the registries, which could not be sustained with national funds, and hence remained unused. A lack of investment in trauma systems and high implementation costs regarding infrastructure, software, and personnel requirements were noted as financial burdens to implementing trauma registries¹². Hence, even if overcoming issues with initial funding, sustainability remains a major concern for most LMICs trying to maintain registries within their system. The challenges LMICs encounter during and after the implementation of trauma registries is encapsulated in Supplementary Material: Box 3, while Supplementary Material: Box 4 provides insights into Guatemala’s specific experience in their implementation.

Potential solutions and WHO’s IRTEC registry

Potential solutions for the challenges faced in implementing trauma registries in LMICs have been described¹¹. For data collection, solutions included the implementation of automated hourly backups of electronic medical records and the use of electronic trauma registry software for data collection¹¹. Solutions to overcome funding and human resource related difficulties included discussing research partnerships with HICs and simplifying data collection so the frontline physicians could complete registries. Regarding data quality, potential solutions included the standardization of variables¹¹. Additionally, the WHO proposed IRTEC, a digital tool that presents a potential solution to overcome barriers in trauma registry implementation in LMICs. Through the standardization of data collection and identification of gaps in acute illness and injury care, IRTEC may tackle data quality, organizational and administrative concerns²⁹. Figure 2 illustrates countries that have either implemented or are in the process of implementing IRTEC as of February 2023. However, like any other trauma registry, its implementation comes with challenges and potential difficulties. Supplementary Material: Box 1 summarizes the Zimbabwe case in implementing the WHO’s IRTEC registry.

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Fig. 2.

Map of countries in various phases of IRTEC implementation (map created using a template from mapchart.net). IRTEC, international registry for trauma and emergency care.

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Barriers addressed by the international registry for trauma and emergency care

IRTEC provides a standardized mechanism for collecting and analyzing quality data around trauma and emergencies. Addressing both, affordability and accessibility, the tool is maintained by WHO free of charge with no subscription fee for users. The platform is built on the open-source DHIS-2 software developed by the University of Oslo and is currently used in approximately 60 countries to collect health data³⁵. Although the provision of software and hardware through IRTEC partially mitigates the financial burden of the initial implementation, current and future research should aim to find a more long-term solution for financial constraints that allows sustainability of the registry.

The IRTEC platform collects and analyzes variables that are specified in the WHO Dataset for Injury (DSI). Determined by a team of global stakeholders, the DSI is a set of 46 core and 28 extended variables that cover the minimum set of recommended data elements for effective monitoring of injury care. Standardized clinical trauma forms that capture these data points are available to support data collection in the emergency care unit³⁵. The centralized software allows for offline data entry and management. However, elements such as hardware availability and internet connectivity are still barriers that need to be handled by the implementation sites. The tool allows data and reports’ visualization and breakdowns across individual and aggregate facility performance in a region, and provides internal data quality control and analysis, reducing the burden of information management.

Data can be used to identify facility-level gaps and high-yield targets for targeted quality improvement interventions. The outcome variables and audit filters in IRTEC allow analysis based on the quality of care (e.g., flag deaths that should be rare or non-existent in a well-functioning emergency system), coverage (i.e., facility-based proxies to determine coverage of pre-hospital care in surrounding catchment areas), timeliness (i.e., 24h, 48h, 72h in-hospital mortality based on initial condition and injury mechanism), and system coordination (i.e., referrals to the emergency unit). Thus, the platform seeks to ensure high quality in both data collection and analysis. Supplementary Material: Box 4 summarizes the solutions IRTEC offers for addressing prevalent obstacles.

Persistent challenges

While IRTEC provides a promising way forward that addresses many of the barriers in country-specific trauma registries, the implementation poses significant challenges. Hospitals must transition from their internal documentation systems to IRTEC, which requires modifying existing patient data collection tools to match the WHO Dataset for Injury or dealing with dual documentation. Facilities hoping to use IRTEC must also designate and train personnel to collect the data and appoint individuals to oversee the transition process. Financial concerns are a challenge, as payments must be made for data collectors and internet subscriptions to sync data. Structural issues, such as unreliable internet, device compatibility, and high provider turnover rate, pose further barriers.

The transition to IRTEC will also require significant administrative efforts, including bringing in the Ministry of Health for increased adoption, providing train-the-trainer courses, and facilitating employee buy-in to a new system. Sites using manual data must navigate using a digital platform and transcribe hand-written data into a compatible digital format. On the provider end, healthcare professionals must be convinced to consistently complete their documentation in the correct format and fill out all of the mandatory variables in readable writing. Quality checks must also be conducted internally by hospital personnel. However, the local Ministry of Health may provide additional oversight through data quality checks across hospital sites and supervisory site visits for quality improvement activities and implementation concerns. Although few countries have yet reached the data-analysis phase, the goal would be for in-country research officers to host morbidity and mortality conferences to discuss and create new trauma protocols based on the results.

Beyond administrative concerns, some are hesitant to implement a standardized registry. In particular, those hospitals with more advanced data collection systems may resist adopting a standardized registry that would limit the variables they are interested in exploring, as explained by the interviewees^30,32. Supplementary Material: Box 5 summarizes the barriers yet to be overcome for successful IRTEC implementation.

Study limitations

This study had several limitations. First, this study synthesized the body of knowledge available on barriers to trauma registry implementation in LMICs, but it did not quantify elements that may be beneficial to account for specific implementation challenges at a local and national level in each LMIC. This may slightly underestimate the prevalence of independent trauma registries in LMICs.

An updated systematic review may be beneficial for further understanding of these elements. Second, the literature review failed to capture non-English articles, as well as papers published in local journals. This may have prevented the capture of additional insights that have made trauma registries fail in the past, and more specifically target these barriers to ensure better registry implementation. Additionally, the small sample size of expert consultants (only two) as well as the context diversity, limits the generalizability of our findings. Contacting trauma registry implementers from LMICs that are not in collaboration with the WHO was especially challenging, as this UNDI group of countries is represented only by one per cent of authorship on trauma registry publications, as evidenced by the results of our literature review. We, however, attempted to include an example of an independent registry implementation by including Guatemala in this work. This limitation emphasizes the importance of our proposed intervention of establishing a robust network of trauma registry implementers, that can capture LMIC implementers and listen to their experience. Such an initiative would broaden the pool of information by including more countries that have implemented their trauma registry.

Finally, our focus on WHO’s IRTEC as the primary solution for the barriers faced by LMICs might limit our insight in learning about additional resources that can help tackle these barriers. Further research is needed on the efficacy of IRTEC to mitigate implementation barriers, as well as on other potential facilitators that are not captured in IRTEC.

Proposed interventions

Some of the proposed interventions to address the current challenges include establishing a robust network of trauma registry implementers to guide future efforts and elicit potential champions for IRTEC registry implementation. This network could systematically review the knowledge on trauma registry implementation in LMICs by updating prior published reviews and creating a contact list. Furthermore, it is important to establish best practices for IRTEC implementation based on existing efforts. As of 2023, thirteen countries are in the process of implementing IRTEC, with five actively collecting data²⁹. An additional four countries have implemented IRTEC in the past but have since stopped data collection²⁹. Information on context-specific motives for data collection cease are yet to be identified. These sites in various stages of IRTEC implementation can provide valuable information on facilitators and barriers to adopting IRTEC as a national trauma registry across contexts. Lastly, it is important to understand the feasibility of IRTEC implementation across a diverse range of settings. It would be important to assess clinicians’ and administrators’ perspectives on the acceptability, appropriateness, and feasibility of IRTEC at their site, including the ability to integrate WHO standardized clinical data entry forms into the workflow.