Maturation process and international accreditation of trauma system in a rapidly developing country.

BACKGROUND: As trauma systems mature, they are expected to improve patient care, reduce in-hospital complications and optimize outcomes. Qatar has a single trauma center, at the Hamad General Hospital, which serves as the hub for the trauma system that was verified as a level 1 trauma system by the Accreditation Canada International Distinction program in 2014. We hypothesized that this international accreditation was a major step, in the maturation process of the Qatar trauma system, that has positively impacted patient care, reduced complications and improved outcomes of trauma patients in such a rapidly developing country.
METHODS: A retrospective analysis of data was conducted for all trauma patients who were admitted between 2010 and 2018. Data were obtained from the level 1 trauma center registry at Hamad Medical Corporation. Patients were divided into Group 1- pre-accreditation (admitted from January 2010 to October 2014) and Group 2- post-accreditation (admitted from November 2014 to December 2018). Patients' characteristics and in-hospital outcomes were analyzed and compared. Data included patients' demographics; injury types, mechanism and injury severity scores, interventions, hospital stay, complications and mortality (pre-hospital and in-hospital). Time series analysis for mortality was performed using expert modeler.
RESULTS: Data from a total of 15,864 patients was collected and analyzed. Group 2 patients had more severe injuries in comparison to Group 1 (p<0.05). However, Group 2, had a lower complication rate (ventilator associated pneumonia (VAP)) and a shorter mean hospital length of stay (p<0.05). The overall mortality was 8%. In Group 2; the pre-hospital mortality was higher (52% vs. 41%, p = 0.001), while in-hospital mortality was lower (48% vs. 59%) compared to Group 1 (p = 0.001).
CONCLUSIONS: The international recognition and accreditation of the trauma center in 2014 was the key factor in the maturation of the trauma system that improved the in-hospital outcomes. Accreditation also brought other benefits including a reduction in VAP and hospital length of stay. However, further studies are required to explore the maturation process of all individual components of the trauma system including the prehospital setting.

Introduction

Traumatic injuries are one of the leading causes of death worldwide. In 2016, almost 4.9 million people lost their lives following unintentional or intentional injuries [1]. The WHO data showed that road traffic injuries (RTIs) were major contributors to fatal trauma following unintentional injuries whereas self-harm was the primary mechanism of intentional injuries [1]. For each trauma death, hundreds of people may sustain non-fatal injuries, disabilities and life-long health consequences of trauma. In addition to the morbidity and mortality burden, traumatic injuries are also associated with significant economic burden. The annual treatment cost of adult major trauma in the USA was estimated at USD 27 billion [2]. Although the ultimate goal is to prevent injuries from happening, public education, and providing high quality trauma care for patients with intentional and unintentional injuries remain crucial to prevent fatalities and reduce short- and long-term disabilities. An ideal trauma system was described by the Health Services Research Administration in 1992 as a continuing of care, emphasizing smooth management of/and transitions between recognition, stabilization, transport, treatment, rehabilitation and return of ideal functioning of the injured [3]. Evidence suggests that maturation of a trauma system improves patient care processes and reduces in-hospital complications, hospital stay, and mortality [4]. However, improvements in trauma outcomes can be attributed to changes in multiple elements of trauma care, rather than a single magic bullet and they must be tracked and documented over the years before their effects can be reported. To demonstrate what actions are needed by the managers and planners to develop a trauma system, the Trauma System Maturity Index (TSMI) was adopted by the WHO [5]. The four elements of the TSMI include prehospital trauma care, education and training, facility based trauma care, and quality assurance.

The Hamad Trauma Center [HTC] is the only national tertiary trauma care center in Qatar; it is based in the Hamad General Hospital (HGH), the hub of the not-for-profit governmental healthcare system in the country. The evolution of the trauma system in Qatar began in late 2007 with the establishment of the trauma surgery section at HGH as a part of improving emergency care project with the University of Pittsburgh [UOP] [6]. The trauma surgery section was expanding the trauma care team to include trauma surgeons, emergency physicians, nurses, anesthetists, intensivists, clinical pharmacists, a psychologist, physiotherapists, nutritionists and other allied medical personnel. All components of the trauma system in Qatar, from the Ambulance Service to Rehabilitation, rapidly evolved over the years by achieving several important developmental milestones, including international accreditations. The journey from inception to maturation involved several advancements in multiple components of the trauma system such as pre-hospital care (ambulance services), trauma resuscitation unit at the trauma center, development of the Qatar Trauma Registry, trauma performance improvement program (TPIP), Trauma and Critical Care Fellowship Program (TCCFP), Hamad Injury Prevention Program (HIPP), post trauma follow up clinics (including psychotherapy clinic) and the Clinical Research Unit. The trauma system was accredited by the Accreditation Canada Distinction Program in the year 2014. This was achieved through the creation and implementation of specific processes and demonstration of functionality of essential elements of the trauma system that were required by the accrediting body. It was the process of attaining this accreditation, as the hub of a trauma system, which contributed to the maturation and brought several positive changes in the provision of the trauma care quality [6]. Based on this accreditation, our center was recognized as a level 1 trauma center. The present study aims to determine the effects of this maturation process on the outcomes of trauma patients in a rapidly developing country (Qatar). We hypothesized that the international accreditation is a major step in the maturation process of the national trauma system that is associated with improved patient care and outcomes (Fig 1).

Fig 1

Milestones in development and maturation of the trauma system in Qatar.

Methods

A retrospective analysis of data obtained from the Qatar trauma registry at HGH was conducted for trauma patients who were admitted to the tertiary level 1 HTC, from 01/01/2010 to 31/12/2018. All trauma patients, regardless of age, gender, type of mechanism and severity of injury were included whereas patients with incomplete relevant data were excluded. HTC is the only level 1 trauma center in Qatar that provides trauma care, free of charge, for all residents and citizens (a total of 2.7 million inhabitants).

Collected data included admission and discharge details; demographic information (age & gender); injury types (i.e., work-related) and mechanisms (i.e. motor vehicle crash (MVC), pedestrian injuries, fall from heights, fall of heavy objects, sport-related injuries and assault), body regions injured (head, chest, spine or abdomen); Glasgow Coma Score (GCS), Abbreviated Injury Scales (AIS) and Injury Severity Score (ISS); level of trauma activation (i.e., T1); blood alcohol concentration (BAC) screening; radiography; blood transfusion; activation of Massive Transfusion Protocol (MTP); use of intracranial pressure monitors (ICP); exploratory laparotomy; craniotomy or craniectomy; complications (ventilator associated pneumonia (VAP) or sepsis; length of stay (LOS) in the Emergency Department (ED), intensive care unit (ICU) and hospital; discharge to rehabilitation or home; pre-hospital and in-hospital mortality.

The total pre-hospital time (TPT) in this study was defined as the time from the Emergency Medical Service (EMS) notification to hospital arrival. The GCS is a neurological scale that provides reliable and objective evaluation of consciousness; ranging from 3 to 15. The AIS is an anatomically-based injury severity scoring system that classifies each injury by body region on a 6- point scale. The ISS assesses the combined effects of multiply injured patients and is based on the AIS [7, 8]. The ISS ranges from 1 to 75 and correlates with mortality, morbidity and other measures of severity. The level of trauma activation depends on the injury severity and priority for care. T1 or priority 1 (P1) represents critically injured patients who need immediate life-saving interventions. Massive transfusion is defined as replacement of >1 blood volume in 24 hours, or >50% of blood volume in 4 hours. MTP is activated for the critically bleeding patients who are anticipated to require massive transfusion. ED time was categorized into ≤ 4h and >4h. The cut-off 4h was chosen based on the National Hospital Ambulatory Medical Care Survey published by the CDC [9].

Trauma patients included in this study were classified into two groups, before (group 1; from 01/01/2010 to 31/10/2014) and after accreditation in 2014 (group 2; 01/11/2014 to 31/12/2018). The HTC accreditation in 2014 was a landmark achievement, which endorsed the quality and safety of the trauma care provided. HTC became the first trauma center outside Canada to obtain this recognition. The accreditation was awarded to the HTC based on its degree of compliance with the Accreditation Canada standards; achievement of performance indicator thresholds; implementation of trauma protocols, clinical practice guidelines and commitment to excellence and innovation [10].

The study groups were compared in terms of patient characteristics, TPT, prehospital mortality and in-hospital outcomes. Also, the trauma research output of the trauma system was compared based on the number and types of PubMed indexed publications in the 2 eras of the study.

As data were retrieved anonymously with no direct contact with patients, it was not possible to involve patients or the public in the design or conduct of our research. This observational retrospective study received an expedited review and was approved by the Institutional Review Board (HMC IRB# MRC-01-20-103) of Hamad medical corporation, Qatar.

Statistical analysis

The statistical data analysis was performed using the SPSS 21.0 Statistical Analysis program (SPSS Inc., Chicago, IL). Categorical data were presented as numbers and proportions. Continuous data were reported as mean with the standard deviations (SD) for normally distributed data and as median [interquartile rage (IQR)] for not normally distributed data. While comparing two groups, differences in categorical data were assessed using the Chi-square tests and the significance of statistical differences were attributed to a two tailed p value of <0.05. The continuous data between two groups were compared using Student’s T test for normally distributed data and non-parametric tests for the comparison of not normally distributed data. The two study periods were further compared based on the injury severity (ISS and GCS) and ED length of stay. Time series analysis (forecasting) for outcome was performed using expert modeler for total, prehospital and in-hospital mortality.

Results

A total of 15,864 patients were admitted during the study period, of which 8316 (52%) and 7548 (48%) were admitted during the pre and post—accreditation period, respectively (). The mean age of the study cohort was 31 years and the majority (90%) were males. The most common mechanism of injury was MVC (33%) followed by falls (29%). Nearly 30% of injuries reported were work-related injuries. Although the male predominance remained unchanged, the mean age was found slightly higher in group 2. There was no statistically significant difference in the mechanism of injuries in both study groups. However, there was a slight increase in work-related injuries observed in group 2.

The median TPT was 55 minutes; this was 6 min longer in group 2 when compared to group 1 (59 vs.53 minutes, p = 0.001). Overall, the BAC was tested in 55% of all patients; and there was a significant increase in the screening rate in group 2 (67% vs. 44%, p = 0.001). The median ED stay time was higher in group 2 (405 vs. 322 minutes).

During the study period, computed tomography (CT) of the head, abdomen, chest and spine were performed in 66%, 64%, 56% and 34% of patients respectively. Head injury was reported in 31% of patients. Utilization of CT increased significantly in group 2 (CT head, chest, abdomen and spine). The ISS was significantly higher in group 2 in which over 40% had mean ISS of greater than12. The GCS at the scene and upon hospital arrival were lower in group 2 (p<0.05). In addition, the proportion of T1 activation was higher in group 2 (22% vs. 14%, p = 0.001). shows the pattern of in-hospital fatality per cases and ISS by year. The ISS trend was in parallel with the mortality trend across the years. shows the breakdown of ISS, GCS and ED stay. Patients with mild injury (ISS 0–9 and GCS 14–15) were more prevalent in the pre-accreditation period whereas moderate or severe injuries were more likely encountered in the post-accreditation period. In the 1st group, one third of cases stayed 4h or less in the ED in comparison to one quarter of the cases from the 2nd group.

Interventions like blood transfusion; MTP activation; craniotomy or craniectomy and ICP monitor use were higher in group 2 (p<0.05). Exploratory laparotomies were comparable across the groups. Despite the significant increase in diagnostic and treatment interventions including blood transfusions in group 2 suggesting a higher proportion of severely injured patients, complications were less in group 2 (i.e., VAP) or comparable (i.e., sepsis). ICU LOS was comparable, with shorter hospital LOS in group 2 (4 vs. 5 days, p = 0.001). Discharge to rehabilitation services was higher in group 2 than group 1 (7% vs. 4%, p = 0.001).

The overall mortality was 8% in the study cohort. It was significantly higher in group 2 when compared to group 1 (9% vs. 7%, p = 0.001) mostly due to higher pre-hospital mortality in this group (52% vs. 41%, p = 0.001). The in-hospital mortality was significantly lower in group 2 (48% vs. 59%, p = 0.001). There were no significant differences in the number of days in hospital before death across the study groups. Fig 2 shows time series analysis for outcome (mortality). For the total mortality, there was relative increasing trend with cyclical variation (stationary R-squared 0.74, p = 0.09), in-hospital mortality showed a decreasing trend after the year of 2014 (Stationary R-squared 0.76, p = 0.09) and prehospital mortality showed increasing trend (stationary R-squared 0.73, R square 0.29, p = 0.73 and 0 outliers).

Fig 2

Time series analysis for outcome.

Discussion

The present study describes the effect of implementing the required processes and protocols in order to attain the international recognition and accreditation of the national trauma system in a rapidly developing country. The process of care at the trauma center observed significant changes over the years as evidenced by an increase in the utilization of the diagnostic procedures and treatment/interventions in the post-accreditation period, i.e. after 2014. Furthermore, there were significant declines in the critical complication rates of VAP and total hospital LOS post-accreditation. Despite the higher prehospital mortality after 2014, which can be attributed partly to the increase in the whole country population as well as severity of injuries, there was a significant decrease in the in-hospital mortality. Also, there was an improvement in the compliance for sentinel processes for traumatic brain injury (i.e. ICP monitor) and bleeding patients (MTP activation).

The elements of the national trauma system of Qatar rapidly evolved with the targeted creation of the essential elements of trauma system and center, i.e. Education, Research, Quality Improvement, Registry and Injury Prevention, and ACS Orange Book use. This process, which happened over few years, was guided by the requirements set by Accreditation Canada International and the Committee on Trauma, American College of Surgeons and each was based on the acquisition of material, manpower and financial resources that were combined to fulfill each of these requirements. This process culminated in the achievement of several important developmental milestones, such as the creation of the ACGME-based Trauma and Critical Care Fellowship, increased number of publications from the Trauma Research Unit, establishing the Qatar national trauma registry, and the international accreditations of the trauma center, the laboratory department (CAP) and the ambulance service (JCI).

Provision of trauma care at accredited centers by a dedicated professional team substantially improves the quality of care and outcomes of trauma patients. Peitzman et al., demonstrated that maturation of trauma center was associated with improved survival, fewer complications, and a shorter length of stay among trauma patients [4]. The study included a total of 15,303 trauma patients admitted between 1987 and 1995 in a level 1 trauma center in Pennsylvania of the United States (US). This center was accredited as a level I trauma center by the state in 1987–1988. In this period, dedicated trauma operating room and trauma ICU were established. In addition, dedicated trauma surgeons and full-time emergency physicians were appointed, and the trauma registry was upgraded [4]. The study duration (9 years) and number of patients included in the US study were similar to our study, and the key findings were also comparable in the post-accreditation period.

Harmsen et al., also demonstrated improved trauma care in the Netherlands by reporting significant decline in mortality over the years in a level 1 trauma center [11]. This study included severely injured patients (ISS>15) and the trauma scores across the study groups (2004–2005 vs. 2014) were comparable. However, the number of trauma surgical interventions and the number of blood products transfused were less in the more recent cohort when compared to the earlier cohort. The study concluded that the observed survival was better than the predicted survival in the recent cohort [11]. Our study included all trauma patients regardless of the severity of injuries. Patients admitted in the post-accreditation period had a higher proportion of severe injury, i.e., patients with ISS>12 were greater in the post-accreditation period compared to the pre-accreditation period (42% vs. 37%). Some of the core performance indicators determined by the Accreditation Canada included trauma patients with ISS >12; ED LOS, hospital LOS and trauma mortality [10]. In addition, higher ISS, higher proportion of head injury patients, lower GCS and higher proportion of T1 activations reported in group 2 suggest that these patients had severer injuries and required more surgical interventions and blood transfusions which contrasts to the Harmsen et al., study. In addition to the survival benefits and shorter hospital LOS, Lansink et al., demonstrated shorter ICU LOS associated with trauma center maturation when adjusted for age, ISS, and survival [12].

Barquist et al., demonstrated a significant reduction in mortality rate associated with trauma system maturation. This was partly attributed to positive changes in field triage and early transportation of patients to trauma centers [13]. Takahashi et al. demonstrated that an increase in the rate of transfer of patients to a higher-level medical institution might result in decreased mortality rate [14]. In our study, the median TPT increased in group 2, probably due to the injury characteristics of the victims, i.e. more severe injuries including head injury, and therefore on-scene management might be longer.

The efforts of both the TPIP and HIPP programs may have accounted for the higher rate of compliance to BAC screening (in 2014), MTP activation (started in 2010), trauma activation and field triage criteria. The joint efforts and the development of local standards and protocols such as TBI management in partnership of trauma and neurosurgery may explain the observed increase in ICP monitoring and craniotomy according to the Trauma Brain Foundation guidelines. In parallel, higher compliance with ICU bundles of care such as the ventilator bundle, hand washing and antimicrobial stewardship may account for the lower VAP and complications rates and shorter LOS. Moreover, increased cooperation within the trauma with other disciplines such as rehabilitation resulted in facilitated transfer and higher patient acceptance rates by rehabilitation programs despite the rapid growth in the Qatar population and relatively less beds in these programs. The population growth and stress on the existing hospital beds may account for the increase in the time spent in the ED observed after 2014.

Qatar provides pre-hospital ambulance emergency services (ground and helicopter) to all residents, free of charge, which is integrated with the primary, secondary and tertiary hospital services across the country. The “trauma by-pass protocol” field triage criteria allows for transfer of patients directly from the scene to HTC. The helicopter EMS system in Qatar, is accredited by the European Aeromedical Institute and evolved from a single-patient MD902 helicopter a few years ago operated only daylight hours, to two Augusta-Westland 139 helicopters operating on 24-hour basis [15]. Ambulances are staffed by Critical Care Paramedics (CCP) and Ambulance Paramedics (AP). The CCP program (n = 9) was established in 2008 to provide additional clinical skills and expertise for the management of critically ill patients during transfer. These interventions include diagnostic and therapeutic emergency cardiac procedures, surgical airway techniques, needle thoracentesis, rapid sequence intubation and administration of a comprehensive critical care medication formulary (e.g. tranexamic acid). The addition of the mentioned procedures may explain in part the observed trivial increase in the TPT.

Also, there are many changes in the prehospital notification system that underwent significant improvement from Hamad Communication Center, to the recent addition of state-of-the-art National Communication Command Center. Another addition to consider beside the step up approach system that the EMS (ambulance use: Emergency Medical Technicians (alpha unit), CCP (Charlie unit), the navigation tools after 2014 (i.e.: GPS system that allows the ground ambulance to reach the target location faster) and the country wide distribution of ambulances to allow timely response to the scence. Also, Disaster Planning and program was added in the Trauma System, such as the establishment and creation of the Mass Trauma Incident (MTI) protocol.

Education is one of the components of the trauma system which is closely linked to the performance improvements activities, recording and analyzing quality indicators that are international benchmarking feasible such as NTSD, TQIP program, CAP, Ambulance services, JCI, and Leapforg [16]. A TCCFP was started in 2011. This program utilized an ACGME-based curriculum that focused on augmenting the critical care skills and knowledge of all physicians who were part of the HTC staff, regardless of their primary medical specialty. It was later expanded as a requirement for all physicians who joined the staff. The TCCFP, has provided education and training to our physicians covering trauma and critical care services, which have been associated with enhanced clinical outcomes as described by Pronovost et al., and others [17, 18]. The Advanced Trauma Life Support course, for both physicians and nurses, is also a required course for all current HTC staff and all must maintain their certification in such standard courses, resulting in a consistent conduct and language of trauma care at the HTC.

Clinical research remains as a key component of a matured trauma system to disseminate experience and contribute to global evidence-based patient care. Although research in emergency settings is challenging due to the time-critical nature of interventions, there was a rapid improvement in trauma research output at HTC as evident by the increasing number of research grants and publications. The trauma research unit was established in mid-2011. Trauma and vascular surgery publications in PubMed indexed journals went from 24 manuscripts before 2014 to 115 by the end of 2018. Raeeszadeh et al., identified Qatar as one of the leading countries in producing peer-reviewed publications in trauma surgery in MEDLINE; where Qatar was the third highest in 2017 [19].

Injury prevention education and outreach program by the HIPP largely contributed to improving public health and safety. Since its establishment, the HIPP obtained various research funds to support injury prevention education and surveillance programs. Road safety programs are fundamental; the HIPP proposed to comply with the global five-pillar matrix plan which includes road safety management, safer roads, safer vehicles, safer road users, and post-crash response. It is believed that trauma mortality associated with RTIs can be reduced by half [6]. However, the increase in population and number of motor vehicles registered in Qatar over the years resulted in elevated risk for RTIs [20, 21]. The number of road motor vehicles per 1,000 inhabitants was 450 in 2010 and increased by 28% in the following 8 years to reach 575 per 1,000 inhabitants in 2018 [20].

Limitations

The retrospective design of the present study constitutes a significant limitation, particularly on time-related variables. Nearly 28% of TPT data were missing, while other missing data on age, gender, mechanism of injury, ED stay, ISS and GCS were low ranging between 3 and 4%. The study also lacked more detailed pre-hospital time data that could be used to analyze the maturation of pre-hospital care within the trauma system. It is a single center experience; however, there is no other center in our region has awarded this accreditation yet. Although time series analysis showed the trend of mortality, the forecasting analysis showed wide prediction intervals.

Conclusions

The Qatar Trauma system witnessed a rapid evolution following accreditation of its sole Trauma Center. In-hospital mortality significantly dropped after the Accreditation compared to the previous era while prehospital mortality increased. Accreditation also brought other benefits including a reduction in complications such as VAP and hospital length of stay. The findings corroborate the hypothesis that international accreditation represents an important element in the maturation of the Trauma System. Further studies with prospective design are required to explore the maturation process of all components of the trauma system.

28 Sep 2020

PONE-D-20-26293

Maturation Process and International Accreditation of Trauma System in a Rapidly Developing Country

PLOS ONE

Dear Dr. El-Menyar,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Nov 12 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Zsolt J. Balogh, MD, PhD, FRACS

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript.

3. Thank you for including in your ethics statement:

"This observational retrospective 315 study received an expedited review and was

316 approved by the Institutional Review Board (HMC IRB# MRC-01-20-103).".

i) Please amend your current ethics statement to include the full name of the ethics committee/institutional review board(s) that approved your specific study.

ii) Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”).

For additional information about PLOS ONE ethical requirements for human subjects research, please refer to http://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research

Additional Editor Comments (if provided):

Dear Authors,

Our reviewers have major concerns about your methodology and found your paper rather marginal.

Please attempt to address their questions and concerns in an itemised fashion to potentially reconsider it for review.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thankyou for the opportunity to review the article “Maturation Process and International Accreditation of Trauma System in a Rapidly Developing Country”.

I commend the authors on being leaders in improving trauma care in Qatar.

To determine if the positive results are because of the improved trauma system, there needs to be;

1. Specific detail about the trauma system and the changes introduced

2. A time series analysis of outcomes. It is not possible to do a pre/post analysis based on accreditation, because many of the changes were made leading up to accreditation – so the conclusions are not valid.

You have the data to do this, and it is possible. I suggest this is conducted and the manuscript revised and resubmitted.

I also have some minor comments around the abstract

The background in the abstract is a hypothesis, there needs to be a little bit of introduction / need for the paper provided – for example, some detail about the changes that were introduced as part of the trauma system

Methods: what type of analyses were performed?

In the conclusion you have introduced new results.

Reviewer #2: Thank you for your submission which sought to determine the effects of trauma system maturation to Level 1 trauma care on the outcomes of trauma patients in a rapidly developing country (Qatar).

Abstract: Appropriate representation of the manuscript.

Introduction: Provides thorough information as to the reason for the study.

Patients and methods:

Please add appropriate reference to AIS coding section.

It is difficult to see the split of injury severity within the data. The provision of ISS grouping i.e. <12, 12-15, >15 or similar would provide better understanding of the nuances of care for injured groups and also assist in the understanding of access to time critical intervention. An example of data that requires greater understanding is the ED LOS times. 405 mins is significant for those with ISS >15, but not so with those <15.

Results: Appropriately described.

Discussion: See comments

Comments:

The paragraph on education either needs to be related to the study data of removed as it does not currently add value to the discussion.

This is an important body of work and I would like to commend you on your commitment to improving the care provided to injured people and their families. Development and maturation of systems of care are never easy, particularly in developing countries.

Whilst I am enthusiastic about the results here, I do feel that further breakdown and analysis of data is required (as suggested above). I look forward to future developments.

Thank you for your paper.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

7 Oct 2020

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript.

3. Thank you for including in your ethics statement:

"This observational retrospective 315 study received an expedited review and was

316 approved by the Institutional Review Board (HMC IRB# MRC-01-20-103).".

i) Please amend your current ethics statement to include the full name of the ethics committee/institutional review board(s) that approved your specific study.

ii) Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”).

For additional information about PLOS ONE ethical requirements for human subjects research, please refer to http://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research

Reply: done

Comments to the Author

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review the article “Maturation Process and International Accreditation of Trauma System in a Rapidly Developing Country”.

I commend the authors on being leaders in improving trauma care in Qatar.

To determine if the positive results are because of the improved trauma system, there needs to be;

1. Specific detail about the trauma system and the changes introduced

Reply: thanks, detailed trauma system changes were given in the introduction and discussion in addition to figure 1. See line 81-101 and 216-226

2. A time series analysis of outcomes. It is not possible to do a pre/post analysis based on accreditation, because many of the changes were made leading up to accreditation – so the conclusions are not valid.

You have the data to do this, and it is possible. I suggest this is conducted and the manuscript revised and resubmitted.

Reply: time series analysis done and shown in figure 2

I also have some minor comments around the abstract

The background in the abstract is a hypothesis, there needs to be a little bit of introduction / need for the paper provided – for example, some detail about the changes that were introduced as part of the trauma system

Reply: done in line 30-33

Methods: what type of analyses were performed?

Reply: analyses methods added

In the conclusion you have introduced new results.

Reply: conclusion revised.

Reviewer #2: Thank you for your submission which sought to determine the effects of trauma system maturation to Level 1 trauma care on the outcomes of trauma patients in a rapidly developing country (Qatar).

Abstract: Appropriate representation of the manuscript.

Introduction: Provides thorough information as to the reason for the study.

Patients and methods:

Please add appropriate reference to AIS coding section.

Reply: done , ref 7 and 8 added

It is difficult to see the split of injury severity within the data. The provision of ISS grouping i.e. <12, 12-15, >15 or similar would provide better understanding of the nuances of care for injured groups and also assist in the understanding of access to time critical intervention. An example of data that requires greater understanding is the ED LOS times. 405 mins is significant for those with ISS >15, but not so with those <15.

Reply: new table (3) added with the breakdown of injury severity , GCS and ED time

Results: Appropriately described.

Discussion: See comments

Comments:

The paragraph on education either needs to be related to the study data of removed as it does not currently add value to the discussion

Reply: education paragraph revised.

This is an important body of work and I would like to commend you on your commitment to improving the care provided to injured people and their families. Development and maturation of systems of care are never easy, particularly in developing countries.

Whilst I am enthusiastic about the results here, I do feel that further breakdown and analysis of data is required (as suggested above). I look forward to future developments.

Reply: further analyses done and shown in table 3 and figure 2

Submitted filename: reply to comments.docx

Click here for additional data file.

25 Nov 2020

Maturation Process and International Accreditation of Trauma System in a Rapidly Developing Country

PONE-D-20-26293R1

Dear Dr. El-Menyar,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Zsolt J. Balogh, MD, PhD, FRACS

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thankyou for addressing my comments. I have no further comments

........................................................

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

2 Dec 2020

PONE-D-20-26293R1

Maturation Process and International Accreditation of Trauma System in a Rapidly Developing Country

Dear Dr. El-Menyar:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Zsolt J. Balogh

Academic Editor

PLOS ONE

Table 1

Comparative analysis of the pre-and post-accreditation periods.

Variables	Overall	Pre-accreditation	Post-accreditation	P-value
	(N = 15,864)	(n = 8316, 52.4%)	(n = 7548, 47.6%)
Age	30.4±16.5	29.9±16.4	30.8±16.5	0.002
Males	14278 (90.0)	7465 (89.8)	6813 (90.3)	0.29
Mechanism of injury (n = 15,848)
• Motor vehicle crash	5238 (33.1)	2683 (32.3)	2555 (33.9)	0.09
• Fall	4589 (28.9)	2444 (29.4)	2145 (28.4)
• Pedestrian	2042 (12.9)	1061 (12.8)	981(13.0)
• Fall of heavy objects	960 (6.1)	532 (6.4)	428 (5.7)
• Other	3019 (19.0)	1582 (19.1)	1437 (19.0)
Work related injuries	4759 (30.0)	2432 (29.2)	2327 (30.8)	0.03
Prehospital time	55 IQR (37–72)	53 IQR (37–68)	59 IQR (39–75)	0.001
Referrals
• From outside country	206 (1.3)	170 (2.0)	36 (0.5)	0.001
• Within Qatar	2102 (13.2)	984 (11.8)	1118 (14.8)
BAC screening	8732 (55.0)	3648 (43.9)	5084 (67.4)	0.001
Alcohol positives (n = 8732)	1027 (11.8)	482 (13.2)	545 (10.7)	0.001
Head Injury	4879 (30.8)	2471 (29.7)	2408 (31.9)	0.001
Head CT	10445 (65.8)	4944 (59.5)	5501 (72.9)	0.001
Chest CT	8819 (55.6)	3564 (42.9)	5255 (69.6)	0.001
Abdominal CT	10145 (63.9)	4702 (56.5)	5443 (72.1)	0.001
CT-spine	10152 (64.0)	4540 (54.6)	5612 (74.4)	0.001
ISS	10 IQR (5–17)	9 (5–15)	10 (5–17)	0.001
ISS>12 (%)	6049 (39.5)	2937 (37.1)	3112 (42.2)	0.001
Trauma level1(T1) activation	2807 (17.7)	1157 (13.9)	1650 (21.9)	0.001
Blood transfusion	2660 (16.8)	1236 (14.9)	1424 (18.9)	0.001
MTP activation	588 (3.7)	247 (3.0)	341 (4.5)	0.001
ICP monitor	362 (2.3)	147 (1.8)	215 (2.8)	0.001
Exploratory Laparotomy	819 (5.2)	433 (5.2)	386 (5.1)	0.79
Craniotomy/Craniectomy	463 (2.9)	221 (2.7)	242 (3.2)	0.04
VAP	656 (4.1)	406 (4.9)	249 (3.2)	0.001
Sepsis	195 (1.2)	102 (1.2)	93 (1.2)	0.97
ICU stay	4 IQR (2–11)	4 IQR (2–11)	4 IQR (2–10)	0.65
Hospital LOS	5 IQR (2–12)	5 IQR (2–13)	4 IQR (2–11)	0.001
ED stay time (min)	356 IQR (200–598)	322 IQR (180–525)	405 IQR (225–690)	0.001
Discharge to rehabilitation	844 (5.4)	350 (4.3)	494 (6.6)	0.001
Total mortality	1280 (8.1)	608 (7.3)	672 (8.9)	0.001
• Prehospital mortality	603 (47.1)	251 (41.3)	352 (52.4)
• In-hospital mortality	677 (52.9)	357 (58.7)	320 (47.6)
Time of in-hospital death
• <48 hrs. in-hospital	349 (52.6)	193 (55.3)	156 (49.7)	0.22
• >48 hrs. to 7 days	183 (27.6)	95 (27.2)	88 (25.2)
• >1 week	131 (19.8)	61 (17.5)	70 (20.1)

Data expressed as count (percentage) or mean ± standard deviation or median with interquartile range (IQR) whenever appropriate; BAC: Blood Alcohol Concentration; CT: computed tomography; ISS; Injury Severity Score; GCS: Glasgow Coma Score; AIS: Abbreviated Injury Scale; MTP: Massive Transfusion Protocol; ICP: Intracranial pressure monitor; VAP: Ventilator Associated Pneumonia; ICU; Intensive Care Unit; ED: Emergency Department: LOS: Length of Stay

Table 2

Injury severity and mortality per year.

Year	Hospitalization (n)	In-hospital mortality	In-hospital mortality per 100 admissions	Median ISS	ISS Interquartile range
					25%	75%
2010	1382	66	4.8	9	5	17
2011	1697	55	3.2	9	5	14
2012	1736	67	3.9	9	5	14
2013	1716	76	4.4	10	5	17
2014	1604	107	6.7	10	5	17
2015	1672	99	5.9	10	5	17
2016	1757	79	4.5	10	5	17
2017	1695	56	3.3	10	5	17
2018	1719	72	4.2	10	5	17

Injury severity Score (ISS)

Table 3

Pre and post accreditation based on injury severity and emergency (ED) length of stay.

	Pre-accreditation	Post-accreditation	P-value
Injury severity score (ISS)			0.001
0–9	3395 (51.5)	3125 (44.0)
10–15	1494 (22.7	1795 (25.3)
16–24	979 (14.9)	1217 (17.1)
>25	720 (10.9)	962 (13.6)
Glasgow coma scale (GCS)			0.001
</ = 3	766 (11.6)	1020 (14.4)
4–13	306 (4.6)	472 (6.7)
14–15	5556 (83.8)	5597 (79.0)
ED length of stay			0.001
≤ 4 hr	2389 (36.2)	1834 (26.3)
> 4hr	4202 (63.8)	5133 (73.7)