Pre-hospital care delays in trauma-related mass casualty incidents: a comparative international survey of high-income and low- and middle-income country perspectives.

backgroundMass casualty incidents (MCIs) place substantial demands on pre-hospital systems. Extended pre-hospital times are associated with adverse patient outcomes. The factors perceived as contributing to these delays are poorly characterized across different resource settings. This study aimed to identify and compare pre-hospital care providers' perceptions of factors associated with pre-hospital delays during trauma-related mass casualty incidents across high-income and low- and middle-income countries.

methodsA cross-sectional online survey was conducted between May and August 2024. Pre-hospital care providers with experience of at least one trauma-related mass casualty incident were recruited globally via professional associations, alumni networks, and social media. The survey comprised expert-reviewed Likert-scale items and open-ended questions. Participants were stratified by national income level using World Bank classifications. Quantitative data were analyzed using the Mann-Whitney U test and chi-squared or Fisher's exact tests. Open-text responses were analyzed using thematic analysis following the framework of Braun and Clarke.

resultsOf 225 eligible responses from 54 countries, 158 (70.2%) were from high-income countries and 67 (29.8%) from low- and middle-income countries. Poor communication and geographical challenges were the most frequently cited delay factors, with agreement rates of 84% and 80%, respectively. Agreement that equipment inadequacy contributed to delays was reported by 75% of respondents from low- and middle-income countries compared with 46% of respondents from high-income countries. Thematic analysis identified eight qualitative delay themes: communication and coordination issues, resource limitations, infrastructure and scene access challenges, hospital capacity and preparedness, administrative and policy issues, training and preparedness gaps, security and safety barriers, and responder emotional burden and stress. Administrative and policy barriers were reported exclusively by participants from high-income countries. Responder emotional burden and stress emerged solely from qualitative responses and lacked corresponding quantitative items. Regular training and prior mass casualty experience were widely endorsed as optimizing factors, with agreement rates of 95% and 90%, respectively.

conclusionsClinician-perceived delay factors showed similar patterns across settings, particularly communication failures, while differing in emphasis by resource context. Communication improvement, integrated into routine MCI training and operational planning, may represent a modifiable area for reducing perceived pre-hospital delays.