Qualitative Review Protocol Targets the Bottlenecks in LMIC Prehospital Trauma Care
Trauma remains a major cause of preventable death and disability in low- and middle-income countries, where the first minutes after injury often determine whether a patient survives transport, hemorrhage, airway compromise, or delayed definitive care. This BMJ Open protocol sets out a qualitative systematic review focused on prehospital trauma systems in low- and middle-income countries, with the central aim of clarifying the barriers that weaken emergency response before patients ever reach hospital care.
The rationale is straightforward and clinically urgent. In resource-limited settings, trauma care does not fail at a single point; it often fractures across dispatch, scene response, transport, communication, staffing, equipment, and referral pathways. When those components do not function as a coordinated system, even straightforward injuries can become fatal. This review is designed to capture those failures as they are experienced in real-world practice and to organize them into themes that can inform system improvement.
One sentence captures the core problem: fragmented prehospital care can turn time-sensitive trauma into irreversible injury.
The protocol is authored by An L, Ramdane S, Kim T, Wang C, Grushka J, Deckelbaum D, Wong E, and Jastaniah A, and is indexed in Europe PMC and PubMed Central. Its publication in a methods-focused journal signals that the work is still at the planning stage rather than a completed evidence synthesis, but the clinical importance is already clear. Few areas of emergency medicine depend more heavily on system design than trauma, and few settings face greater structural constraints than LMICs.
Search Strategy, Screening Workflow, and Qualitative Coding Plan
The review will search Medline, Embase, Cochrane, EBSCO, and Web of Science, with the search extending through 31 March 2026 and scheduled for update. That broad database strategy matters because qualitative work on trauma systems is often scattered across emergency medicine, global health, surgery, nursing, and health systems journals. Limiting the search to a narrow set of sources would miss the kind of operational detail that often lives in implementation studies, contextual analyses, and mixed-methods reports.
Screening will be handled in Covidence, a platform commonly used to manage duplicate removal, title and abstract screening, and review workflow. Full-text screening will follow the same structured process. Data extraction will be performed in Microsoft Excel, while full texts will be exported into NVivo for qualitative coding. The use of NVivo indicates that the investigators are not aiming for a simple count of reported barriers; they are building a thematic map of how those barriers cluster across settings and how different systems fail in different ways.
The planned analytic approach is thematic analysis. In practical terms, that means the review will look beyond isolated obstacles and search for repeated patterns in the literature. A weak emergency number, limited ambulance coverage, poor interfacility communication, lack of trained personnel, or inadequate prehospital equipment may each appear in different studies for different reasons. Thematic analysis can place those findings into a common framework, which is often the only way to convert scattered qualitative observations into policy-relevant evidence.
Why the Prehospital Window Shapes Trauma Outcomes
Prehospital trauma care is not a decorative layer on top of emergency medicine. It is the first clinical filter through which injured patients must pass, and in many LMICs it is the only opportunity to stabilize airway, breathing, circulation, and transport before complications compound. Delays in response or referral can magnify blood loss, hypoxia, and shock long before definitive surgery or imaging becomes available. In that setting, the quality of the prehospital system can matter as much as the quality of the trauma center itself.
The protocol’s focus on barriers is particularly relevant because system weaknesses are rarely purely technical. Some arise from workforce shortages, others from geography, funding, governance, communication failures, or a lack of formalized triage pathways. A qualitative review is well suited to this problem because it can capture operational realities that are often flattened in quantitative summaries. For policy makers and clinicians, the value lies in identifying which obstacles are most persistent, which are context-specific, and which may be most amendable to intervention.
Another sentence lands with more force than a summary statistic ever could: if the ambulance never arrives, the hospital’s trauma capabilities never get a chance to matter.
What This Protocol Can and Cannot Deliver
Because this is a protocol, it does not yet provide pooled estimates, effect sizes, or ranked outcome measures. It defines the search and analysis framework rather than the final evidence base. Even so, the design already reveals what the investigators intend to prioritize: a structured synthesis of barriers in prehospital trauma care across LMICs, drawn from multiple databases and organized through qualitative coding rather than purely descriptive review.
That approach has a clear strength. Trauma system improvement in low-resource environments depends on more than importing equipment or building new facilities; it requires understanding how emergency care actually functions on the ground. A review built around themes such as access, coordination, personnel, transport, communication, and infrastructure can help distinguish broad global principles from local implementation obstacles. Those distinctions are essential when the goal is to improve survival without assuming that one model fits every setting.
The limitations are also easy to see at the protocol stage. A thematic synthesis can map recurring barriers, but it cannot by itself prove which intervention will work best in a given country or region. The usefulness of the final review will depend on the consistency and quality of the underlying qualitative literature, as well as the extent to which studies from different settings can be compared without forcing unlike systems into the same template. Even so, a carefully executed synthesis can still do important clinical work: it can name the failure points that currently keep trauma care fragmented before hospital arrival.
For emergency clinicians, trauma surgeons, global health teams, and health system planners, the central question is not abstract. It is whether a patient with severe injury can move fast enough from scene to stabilization, and from stabilization to definitive care, before preventable deterioration takes hold. This protocol is aimed at the part of the system where that chain most often breaks.