Introduction
============

Background
----------

Worldwide, road traffic incidents (RTIs) constitute the primary cause of death due to injuries, the tenth leading cause of all deaths, and the ninth leading contributor to the global burden of disease ^[@ref-1]^. Latin America and Peru are not exceptions to these statistics ^[@ref-2],\ [@ref-3]^. Adequate management after the occurrence of a traffic incident can decrease the probability of death and disability, limit the severity caused by injury and ensure that survivors are optimally reintegrated into the community ^[@ref-4]^. In high-income countries, studies have shown that of those that die due to a RTI, 50% will die within minutes after the incident or on the way to the hospital, 15% die within the first 4 hours, and 35% die after 4 hours ^[@ref-5]^. In low- and middle-income countries (LMIC), the majority of deaths occur among victims before arriving at a health care facility (HCF), indicating that many deaths and complications could be prevented via adequate initial management and response ^[@ref-5]--\ [@ref-8]^. The experiences of developing countries with regards to evaluating the care of RTI victims are scarce and unsystematic ^[@ref-9]^. Providing quality health care services to RTI victims is also important, ensuring that they are at the center of attention of all services offered ^[@ref-10]^. Patients and users have a wide spectrum of cultures and attitudes, and both demand and hope for quality in all scientific, technical and humanistic aspects ^[@ref-11],\ [@ref-12]^.

Importance
----------

Determining the response and quality of emergency services in LMICs is important for understanding how to strengthen these services in low-resource areas. One of the first steps to approach the problem of RTIs is to rely on solid information at a national level ^[@ref-13]^, and RTIs have been considered a research priority for Peru ^[@ref-14]^.

Goals
-----

To evaluate how well the promptness of care complies with the recommendations for emergency care services during the pre-hospital and hospital periods as suggested by the US Department of Transportation (USDOT) and the National Highway Transportation Safety Administration (NHTSA) in the USA ^[@ref-15]^, and how much satisfaction the victims have with respect to the care received. Additionally, we sought to assess the association between the city and type of HCF where the victim was cared for with the quality of attention received.

Methods
=======

Study design and setting
------------------------

We conducted a cross-sectional study over a period of four weeks, August-September 2009, in the Emergency Departments of 8 HCFs in Ayacucho (South Andes), Lima (Peru's capital) and Pucallpa (rainforest region). These regions include urban areas with higher socioeconomic status and complex referral hospitals (Lima), and inner cities with a lower level of socioeconomic development (Ayacucho and Pucallpa) ^[@ref-16]^. Both public (hospitals) and private (clinics), were selected on the basis of their closeness to each city's arterial routes (highways and expressways) and the volume of RTI victims they received. The average number of potential eligible subjects receiving care at the selected facilities, for 2007--2008, ranged from 43 to 150 RTI victims per month. Based on these figures, we assumed that approximately 60 patients per site per month would be expected between August and September 2009.

Participants
------------

The study population was adult victims of RTIs seeking health care for injuries at the selected HCFs, arriving on their own or carried by others (e.g. physician, firefighter, ambulance service, police, or other road user). We did not recruit anyone that presented in an altered state of consciousness or speech, since they were not in a condition to respond to the interview; therefore we excluded critically ill patients.

The protocol was reviewed and approved by the ethical committee of Peru's Instituto Nacional de Salud and by ethics committees at the HCF if they had one. Written consent was obtained from each participant.

Data collection and processing
------------------------------

Active surveillance was used to identify all possible participants by having research interviewers present 7 AM to 1 PM and 1 PM to 7 PM, Monday to Saturday. Subjects were interviewed without interrupting their care by staff. We visited patients at home if they had been admitted or discharged during the hours or days not covered by interviewers.

We assessed whether pre-hospital care was provided by untrained personnel (other road users, police, or municipal patrol guards also called " *Serenazgo*") or by trained ones (firefighters and/or health professionals, assuming that firefighters receive first aid training). The promptness of attention was evaluated through an interviewer--administered, semi-structured questionnaire about waiting times before receiving care during the pre- and hospital periods.

The survey questionnaire was pilot-tested beforehand. There was sufficient evidence that there was adequate comprehension of the SERVQUAL instrument and its face validity. The modified Service Quality questionnaire (SERVQUAL) ^[@ref-17],\ [@ref-18]^ had a Cronbach alpha of 0.96, indicating good internal consistency and reliability of the instrument in the target population.

Outcome measures
----------------

We defined the pre-hospital period as starting from the moment the incident occurred until the moment prior to arrival at the HCF, and hospital period as starting from arrival at the HCF onwards. Waiting times were self-reported by subjects. The quality of care during the pre-hospital period was evaluated on a 5-point Likert-type scale ranging from "Very Poor Care" to "Very Good Care". To evaluate the pre-hospital quality of care for the purpose of analysis, we combined the categories of "Very poor care" and \"Poor care\".

The Service Quality (SERVQUAL) questionnaire was used to determine customer satisfaction ^[@ref-17],\ [@ref-18]^ with the HCF service received. SERVQUAL proposes a "discrepancy model" where the difference between expectations of what should be received versus perceptions of what was actually received at the point-of-care indicates the quality of service ^[@ref-18]--\ [@ref-20]^. We used a modified SERVQUAL using 18 (out of 22) pairs of questions that have the most relevance to health care ^[@ref-19]^, and that has been frequently used to evaluate quality of health care in Peru ^[@ref-21]--\ [@ref-25]^. SERVQUAL evaluates satisfaction in five dimensions: i) tangibles: appearance of the physical facilities, equipment, staff, and communication materials; ii) reliability: delivering the service exactly as promised or as agreed; iii) responsiveness: willingness to quickly and immediately assist customers at a given opportunity; iv) assurance: courtesy and the ability to convey credibility without risks or prejudice when providing service; and v) empathy: willingness to put oneself in the place of another, to think first of the patient, and to serve according to specific characteristics and situations.

In addition to SERVQUAL, we examined other variables that demonstrate evidence of deficiencies in distinct processes of patient care, including the explanation of the diagnosis and the treatment of the victim using a structured questionnaire (see [Data File](#B1){ref-type="supplementary-material"}). Finally, we asked the participants which primary aspect of the HCF where they attended should be improved.

Data analysis
-------------

The hospital user satisfaction score for each of the five SERVQUAL dimensions was determined by taking the difference between expectations and perceptions (very satisfied \<0, moderately satisfied=0, somewhat or moderately dissatisfied \>0 and ≤2, and extremely dissatisfied \>2). The global score was calculated by taking the average scores of the 5 dimensions described above. Then, for analysis, satisfaction scores were dichotomized as satisfied (very satisfied and satisfied) and dissatisfied (somewhat or moderately dissatisfied and extremely dissatisfied).

We conducted a descriptive analysis of the frequencies and distribution of the variables and tested for statistically significant differences between groups using the Kruskal-Wallis test for outcomes with medians and *χ ^2^* tests for outcomes with frequencies. We used a multivariable logistic regression to evaluate the association between the degree of dissatisfaction with city type and facility type. For this analysis, we first developed models adjusted for age and sex (Model 1) and then adjusted for potential confounding variables defined *a priori*, such as education and employment (Model 2). Model 2 was also adjusted for the type of facility and type of city depending on the outcome of interest. We report odds ratios (OR) and 95% confidence intervals (95% CI). Statistical analysis was conducted with Stata 10 (STATA Corp, College Station, TX, USA).

Results
=======

Characteristics of study subjects
---------------------------------

Six public HCFs, one in Ayacucho, two in Pucallpa and three in Lima; and two private HCFs, both in Lima, participated in the study. A total of 1064 RTI victims sought care in the eight emergency departments during the study period ( [Figure 1](#f1){ref-type="fig"}). Of them, 644 participated in the study: response rate 82%, 46% female, mean participant age 37.3 (SD 15.7 years), age range 18--88 years.

![Flowchart of study participation.\
\* Victims admitted to emergency services of health care facilities (HCFs) included in the study. This includes all patients cared for in the emergency department and discharged with or without previous hospitalization. \*\* Altered states of consciousness and speech directly attributable to the road traffic incident (RTI; for example, encephalocranial traumas) or not (for example, alcohol intoxication, Alzheimer's, dementia, senility, etc.) that affected the perception of the event and did not allow the respondent to answer the questionnaires.](f1000research-2-902-g0000){#f1}

Of those eligible to participate but were not interviewed, 40% were female, mean age 39.4 (SD 15.7 years), age range 18--87 years. There were no significant differences between participants and non-participants in terms of gender or age. There were no significant differences between participants by cities with respect to education or employment.

Promptness to care during the pre-hospital period
-------------------------------------------------

***Profile of first responders after the RTI event*.** According to the victims, another road user was the first responder in 72% of the cases ( [Table 1](#T1){ref-type="table"}). The median time to first response was 2 minutes (inter quartile range (IQR) 1--5) in all three cities, with no evidence of a difference in time (p=0.089). Other road users had the shortest median response time ( [Table 2](#T2){ref-type="table"}) at 2 minutes (IQR 1--3) and firefighters (in Lima only) had the longest median time at 15 minutes (IQR 10--20).

###### Descriptive statistics of participants.

                                         Lima          Pucallpa      Ayacucho      Total
  -------------------------------------- ------------- ------------- ------------- -------------
  Male                                   54            61            39            54
  Age (Mean, SD)                         38.8 (16.3)   33.3 (13.7)   36.2 (13.4)   37.3 (15.7)
  Treated in public HCF                  73            100           100           81
  **Education level**                                                              
  Any post-secondary                     33            32            27            33
  Completed secondary                    39            37            25            37
  Incomplete secondary                   12            17            7             13
  Completed primary                      8             10            14            9
  Incomplete primary                     6             4             15            6
  None                                   2             0             12            2
  **Employment status**                                                            
  Unemployed                             4             6             5             5
  Temporary                              43            56            17            43
  Permanent                              37            12            32            31
  Homemaker                              14            18            39            17
  Student                                2             8             7             4
  **First pre-hospital care provider**                                             
  None                                   8             11            24            10
  Other road user                        68            84            71            72
  Police or *Serenazgo*                  17            5             5             13
  Ambulance                              2             0             0             1
  Firefighters                           5             0             0             3
  **First hospital care provider**                                                 
  Physician                              71            7             32            53
  Nurse                                  23            30            29            25
  Medical student                        1             2             8             2
  Nurse technician                       5             61            31            20

All numbers are proportions (%) of total N for each column except where noted. *Serenazgo*: municipal patrol guards.

###### Median time (minutes) and interquartile range (IQR) to obtain initial care by provider type in each city within the pre-hospital and hospital periods.

                                Lima          Pucallpa     Ayacucho     P-value ^\*^   Total
  ----------------------------- ------------- ------------ ------------ -------------- -------------
  Firefighters                  15 (10--20)   ^†^          ^†^          ^‡^            15 (10--20)
  Other ambulance service       5 (3--30)     ^†^          ^†^          ^‡^            5 (3--30)
  Police & *serenazgo* ^\*\*^   3 (2--10)     5 (5--10)    47 (3--90)   0.1816         5 (2--10)
  Other road users              1 (1--3)      2 (1--5)     2 (1--7,5)   0.0001         2 (1--3)
  ***Hospital period***         **N=401**     **N=131**    **N=53**                    
  Physician                     5 (2--15)     4 (2--10)    2 (1--5)     0.0033         5 (2--15)
  Nurse                         5 (2--10)     5 (2--5)     10 (4--23)   0.0573         5 (2--10)
  Medical student               1 (1--1)      10 (9--30)   10 (5--15)   0.0096         5 (1--10)
  Nurse technician              2 (1--5)      5 (2--9)     5 (2--5)     0.1669         5 (2--9)

^\*^ P-value calculated with Kruskal-Wallis test.

^\*\*^ *Serenazgo*: municipal patrol guards.

^†^ No subjects were served by these providers.

^‡^ Not applicable.

N.B. The number is higher in the hospital period than the pre-hospital period as some participants could not remember details about the pre-hospital period.

***First response by trained personnel*.** With regards to trained personnel as first care providers, firefighters and ambulance services represented 4% of first responders in Lima ( [Figure 2](#f2){ref-type="fig"}) with a median response time of 10 minutes (IQR 5--20). There were no instances of trained personnel being the first responders in the other locations.

![Profile of individuals that provided initial care during the pre-hospital period, by city.\
There were a total of 644 patients. \* *Serenazgo*: municipal patrol guards.](f1000research-2-902-g0001){#f2}

***Care received after first response*.** Only 21% of the respondents who were not treated by a trained first responder received further care from a trained provider before arriving at the HCF, though 2% did not respond to the question. The median additional time-to-trained-care by a trained provider, following a first response by any non-trained care provider, was 15 minutes (IQR 10--20). There was strong evidence of a difference in time-to-trained-care (p=0.0002) between cities with Lima at 15 minutes (IQR 10--20), Pucallpa at 10 minutes (IQR 6--10), and Ayacucho at 120 minutes (IQR 20--240).

***Global care during the pre-hospital period*.** Overall, 22% of the victims reported having received some sort of care by trained responders, be it first response or afterwards (27% in Lima, 7% in Pucallpa and 18% in Ayacucho). Taking together the entire pre-hospital period, 66% never received care by a qualified responder before arriving to a HCF (75% in Lima, 92% in Pucallpa and 74% in Ayacucho, p\<0.001).

***Observed versus recommended standard pre-hospital response times*.** Taking into account the response time standards of the DOT and NHTSA for pre-hospital care, only 35% of RTI victims received care during the first 8 minutes or less. Only 10% of the victims arrived at the HCF within the response time standard of 38 minutes after the incident. Cities differed in meeting this standard: 13% in Lima, 4% in Pucallpa and 5% in Ayacucho; p\<0.002. The median time from the occurrence of the RTI until arrival at the HCF was 30 minutes (IQR 15--45). When examining this time by city we found strong evidence of a difference between cities (p=0.0001); the median time in Lima was 30 minutes (IQR 20--45), 20 minutes (IQR 10--35) in Pucallpa, and 40 minutes in Ayacucho (IQR 20--270).

Promptness to care received during the hospital period
------------------------------------------------------

***Provision of care at HCF*.** At arrival at the HCF, the type of professionals involved in the provision of care varied dramatically between cities ( [Figure 3](#f3){ref-type="fig"}). For all victims, the median time of response-to-initial-care after arriving at a facility was 5 minutes (IQR 2--10). There was no evidence of difference in this time by city (p=0.1547) or by type of HCF (p=0.3327). When disaggregated by professions, the time of response-to-initial-care was different for doctors and medical students but not for nurses and nurse technicians ( [Table 2](#T2){ref-type="table"}).

![Caregiver that provided initial care during the intra-hospital period after the incident.\
There were a total of 644 patients.](f1000research-2-902-g0002){#f3}

When a physician was not the initial caregiver, the additional median waiting time to see a physician was 10 minutes (IQR 5--20). Reported times for Lima were 7 minutes (IQR 3--20), 10 minutes (IQR 5--20) in Pucallpa and 10 minutes (IQR 10--20) in Ayacucho, though these different times were not borderline statistically significant (p=0.0505).

***Total elapsed time from the road traffic incident until intra-hospital care*.** The overall median time from the RTI until any care was received at a HCF was 33 minutes (IQR 22--65). In Lima the overall median time was 35 minutes (IQR 23--70), 25 minutes (IQR 17--42) in Pucallpa, and 52.5 minutes (IQR 27--275) in Ayacucho. Care at a HCF was received by 62% of the participants during the first "golden hour". The proportion in Lima that received care in these first 60 minutes i.e. within the "golden hour" was 60%, 77% in Pucallpa, and 44% in Ayacucho (p\<0.001).

Patient satisfaction
--------------------

***Satisfaction with care received during the pre-hospital period*.** Less than 10% of the victims reported that their first responder provided them with a poor care service. By type of first responder, 6% of the victims reported poor care by pedestrians, 7% by firefighters, 8% by the police, 8% by other ambulance services, and 9% by *serenazgo*.

***Satisfaction with care received during the intra-hospital period*.** The response rate to this survey component was 99%. In all cities and public HCFs we found a high proportion, around 75% or more, of victims that were dissatisfied. This was observed in each of the specific domains as well as in the global aggregate ( [Table 3](#T3){ref-type="table"}). The highest proportions of satisfaction were at private HCFs, but only in the domains of tangibles, assurance, and empathy ( [Table 3](#T3){ref-type="table"}).

###### Proportion of dissatisfaction, score for each of the domains, both individual and global scores, listed in the modified Service Quality questionnaire by city and health care facility type.

  ----------------------------------------------------------------------------------------------------
                   Lima\    Pucallpa\   Ayacucho\   P-value ^\*^   Public\   Private\   P-value ^\*^
                   n=442\   n=139\      n=59\                      n=518\    n=122\     
                   %        %           %                          %         %          
  ---------------- -------- ----------- ----------- -------------- --------- ---------- --------------
  Global           89       96          100         0.002          95        78         \<0.001

  Tangibles        73       88          95          \<0.001        84        53         \<0.001

  Reliability      84       85          98          0.013          89        70         \<0.001

  Responsiveness   83       76          90          0.048          86        67         \<0.001

  Assurance        77       77          92          0.035          83        59         \<0.001

  Empathy          76       78          92          92             83        56         \<0.001
  ----------------------------------------------------------------------------------------------------

^\*^ P-value calculated with χ ^2^ for trend.

In an adjusted multivariable analysis ( [Table 4](#T4){ref-type="table"}) there were no evidence of an association between city and satisfaction, except in the domain of responsiveness. Compared to Lima, provincial HCFs showed more satisfaction in responsiveness (OR 0.32, 95% CI 0.15--0.68). Initially, the chances of lower satisfaction, in both global and specific domains, was 3 to 4-fold higher in the provinces compared to Lima, but these estimations became attenuated in the fully adjusted model ( [Table 4](#T4){ref-type="table"}).

###### Association of dissatisfaction, global and by domain, with city.

  Lima (reference) vs. Provinces ^\*^   Model 1 ^\*\*^   Model 2 ^¶^           
  ------------------------------------- ---------------- -------------- ------ --------------
  Global                                3.90             (1.64--9.32)   1.41   (0.42--4.70)
  Tangibles                             3.46             (2.06--5.83)   1.57   (0.72--3.39)
  Reliability                           1.52             (0.91--2.54)   0.89   (0.39--2.08)
  Responsiveness                        0.79             (0.51--1.22)   0.32   (0.15--0.68)
  Assurance                             1.29             (0.84--1.97)   0.63   (0.32--1.25)
  Empathy                               1.43             (0.93--2.21)   0.55   (0.27--1.12)

^\*^ Provinces: Ayacucho y Pucallpa.

^\*\*^ Model 1 adjusted for age and sex.

^¶^ Model 2 adjusted for age, sex, education, employment, type of establishment, caregiver that provided care in the facility, time from the event to facility, and explanation of diagnosis to the patient.

There was strong evidence of an association between dissatisfaction and the type of HCF, which was observed in all domains of care provision. Compared to private services, participants who received care at public HCFs were 4 to 7 times more likely to report dissatisfaction. These estimates became stronger in fully adjusted models, and the magnitude of the odds estimates nearly doubled in the domains of responsiveness and empathy ( [Table 5](#T5){ref-type="table"}).

###### Association of dissatisfaction, global and by domain, with type of health care facility.

  Private (reference) vs. Public HCF   Model 1 ^\*^   Model 2 ^¶^           
  ------------------------------------ -------------- -------------- ------ ---------------
  Global                               5.01           (2.82--8.90)   5.05   (1.88--13.54)
  Tangibles                            4.82           (3.14--7.41)   4.97   (2.41--10.23)
  Reliability                          3.39           (2.10--5.47)   3.93   (1.75--8.84)
  Responsiveness                       2.99           (1.90--4.70)   5.12   (2.34--11.22)
  Assurance                            3.38           (2.20--5.20)   3.81   (1.87--7.77)
  Empathy                              3.92           (2.55--6.01)   6.56   (3.17--13.61)

^\*^ Model 1 adjusted for age and sex.

^¶^ Model 2 adjusted for age, sex, education, employment, city, caregiver that provided care in the facility, time from the event to facility, and explanation of diagnosis to the patient.

Explanation of diagnosis and treatment of the patient
-----------------------------------------------------

Nearly 20% of participants reported that their diagnosis was not explained to them: 12% in Lima, 37% in Pucallpa, and 26% in Ayacucho (p\<0.001). The person explaining the diagnosis was usually a physician (95%). For the rest of the RTI victims, it was a nurse (3%) or medical student (2%). A lower proportion of subjects (16%) reported a lack of explanation about the treatment or procedures indicated. In Lima, 12% reported their treatment was not explained, 24% in Pucallpa, and 31% in Ayacucho (p\<0.001).

Areas for improvement according to patient's perception
-------------------------------------------------------

The response rate to this question was 90%. The majority, 58% of RTI victims, reported that promptness of care was the top ranking HCF's aspect that should improve. This was followed by conduct or behavior towards patients, and then by improvements in equipment and tools ( [Table 6](#T6){ref-type="table"}). Most of the aspects highlighted for improvement were similar between public and private HFCs. While only a small difference (6% vs. 0%) the provision of more administrative and medical information ranked worse in private facilities compared to public ones.

###### Aspects that should be improved in health care facilities (HCFs) according to patients, by city and type of establishment.

                                                                      City   Type of HCF                        
  ------------------------------------------------------------------- ------ ------------- ------ ------ ------ ------
  Promptness of care                                                  63.1   46.4          55.9   57.6   58.6   58.4
  Conduct towards patients                                            10.8   24.6          23.7   15.3   15.3   15.3
  Equipment & tools                                                   7.7    23.2          1.7    3.5    11.9   10.7
  Layout of facilities                                                9.5    0.7           0      5.9    6.6    6.5
  Knowledge of health care personnel                                  4.3    5.1           17.0   4.6    6.0    5.9
  Provision of more administrative and medical information            1.5    0             0      5.9    0.2    1.0
  More personnel                                                      1.0    0             0      1.2    0.6    0.7
  Lack of medications at HCF's pharmacy                               0.5    0             1.7    0      0.6    0.5
  Less administrative processes                                       0.5    0             0      2.4    0      0.3
  Cleanliness of premises or equipment                                0.5    0             0      1.2    0.2    0.3
  Decreasing cost of care                                             0.3    0             0      1.2    0      0.2
  Coordination or orderliness among personnel for provision of care   0.3    0             0      1.2    0      0.2

Emergency response times, response provider and patient satisfaction data for individuals in three Peruvian health care facilities.File 1: Service quality questionnaire and promptness of health care formulary (Spanish) used to collect data from patients involved in road traffic incidents in three different Peruvian cities between August -- September 2009. File 2: Service quality questionnaire and promptness of health care data collected from patients involved in road traffic incidents in three different Peruvian cities between August -- September 2009. City: 0 'Lima' 1 'Pucallpa' 2 'Ayacucho'; type of health care facility (HCF): 0 \'Private\' 1 \'Public\'.Click here for additional data file.

Discussion
==========

By taking advantage of active surveillance at HCFs that had a high volume of RTIs in three Peruvian cities, this study demonstrated notable deficiencies in the promptness and quality of care in the management of RTI victims. These include untrained first responders, a lengthy elapsed time until receiving attention by qualified caregivers, and above all, a marked dissatisfaction with the care received. Strong evidence of dissatisfaction was observed in public HCFs as compared with private institutions but not by geographical location, with the exception of responsiveness. Participants from Lima, the largest city in the country, were more likely to show dissatisfaction in terms of responsiveness as compared with other settings.

The implications of these findings are important for improving emergency services in these locations. Considering that other road users were usually the first responders and that the victims often had to wait until they arrived at a HCF to receive their first care from trained personnel, it is likely that most victims are not receiving adequate care in the pre-hospital period and so not meeting standards suggested by the USDOT and the NHTSA in the USA ^[@ref-15]^. Ideally, the response time should be 8 minutes or less in at least 90% of all care. In our study, the median time from an RTI event to any form of care received at a HCF was 33 minutes. Indeed, 66% never received care by a qualified responder before arriving to a HCF. A previous study by the Assisted Emergency Transport System of ESSALUD in Lima, Peru by Lira *et al.* ^[@ref-26]^ looked at the times from ambulance departure to arrival to an RTI event. They found that only 7/258 events (2.7%) met the target response time (defined as within 8 minutes in at least 90% of events).

The differences between the aforementioned international standards and those we observed could be due to incompletely developed service networks and assistance models in our study setting. In Peru these are comprised of a fragmented rendering of services and a disjointed reference and counter-reference system ^[@ref-27]^. It is important to note that in Peru pre-hospital care is limited to the care and transport of patients to a HCF, thus the adequate conditions of opportunity (i.e. early treatment, ideally as close to the RTI as possible), quality, and appropriateness (i.e. the best possible care for a given scenario) are limited and not necessarily guaranteed.

Though the reasons for the delayed responses were not an objective of this study, the findings were distinct enough in each context, i.e. city or type of HCF, that more research should be dedicated to understanding response time delays in the different locations and facility types. In relation to the notable delay observed in Ayacucho, one might speculate that the type of incidents and victims differ substantially than those in other cities. For example, these incidents could have occurred outside the city and/or could be related to highway incidents, which is suggested by the statistics from the police (Policía Nacional del Perú) ^[@ref-28]^ and another study by our Program ^[@ref-3]^. The factors associated with a variation in the quality of care of patients that suffered from a RTI were diverse and also intimately related to the problems faced by health care systems. These factors are variable and depend on the context of where care is offered-from any immediate care given after an incident, continuing through the specialized care during the hospital period, and also the rehabilitation of the victims.

The SERVQUAL instrument used in this study sheds light on remarkable statistics of global dissatisfaction, close to 90% in all cities and all types of HCFs. Thus, these findings increase our understanding of the most salient aspects of dissatisfaction with trauma care in Peru. One method to improve the quality of hospital care that has demonstrated cost-effectiveness is the implementation of improvement programs for trauma and emergency services laid out in the Guidelines for Essential Trauma Care, published by the WHO ^[@ref-4]^. Their application to our health system has been insufficient at present ^[@ref-29]^.

Strengths and limitations
-------------------------

One of the strengths of the study was the active surveillance strategy we enacted. First, the coverage of the study (n=644) exceeded the volume of victims expected; as described in the methods approximately 60 patients per site per month were expected, 480 in all sites. Our active surveillance strategy yielded 34% more events than anticipated and unveils ongoing underreporting in traditional registries ^[@ref-30]^. Second, the response rate obtained (82%) indicates that the methodology used was acceptable for fulfilling the objectives of the study. This strategy, therefore, constitutes a high-quality tool that could be replicated to evaluate RTIs, for the measurement of quality in other areas and as a tool linked to a continual evaluation process with the objective of improving the quality of services. Additionally, being able to carry out an active monitoring of victims of RTI that sought care at HCFs enabled us to obtain information that truly occurred to the said victims during the period of interest.

Some limitations deserve consideration. The HCFs included in the study were restricted to larger institutions, specifically those with a high volume of RTI victims. Yet, knowledge generated by this study might inform other areas of Peru and other countries in the region with regards to gaps in management and quality of care in trauma services. Another limitation of this study is that all recorded times were self-reported by the injured or his/her family with a tendency to round the numbers. This could vary according to the seriousness of the injuries of the victim, and one could argue that there are alternative mechanisms of measurement of time that might avoid the potential biases of self-reporting. For example, a better way to estimate times in promptness of care is to use the exact date and time that an emergency call was registered and the moment that the ambulance leaves the scene. Given, however, that the majority, 66%, of those affected did not receive care from a qualified caregiver until arriving at a HCF, self-reporting was the most valid strategy to obtain the information of interest.

Conclusion
==========

In conclusion, our study revealed important limitations of the health system that need to be strengthened if the objective of limiting death and disability of RTI victims is to be fulfilled. This was demonstrated by the low quality of care provided in terms of satisfaction with hospital care, especially outside Lima and in public facilities. Because of this, improving the capacity of care of RTI victims in the pre-hospital period with knowledge of first aid, particularly by other road users; reducing the wait time for care, particularly by trained caregivers; and improving the quality of hospital care are indispensable.

The *Programa de Investigación en Accidentes de Tránsito* (PIAT) Working Group was hosted by Salud Sin Límites Perú in Lima, Peru. Principal Investigators: J Jaime Miranda, Luis Huicho; Coordinator: Ada Paca-Palao; Research Assistants: Luis López, Diego Luna, Edmundo Rosales; Associate Investigator: Pablo Best; PIAT Members: Miriam Egúsquiza, Camila Gianella, Claudia Lema, Esperanza Ludeña.

We extend our thanks to all those involved with PIAT, the coordinators and field workers in each of the offices and all the participants in the study. We also thank all those from various phases that offered support: Eduardo Bedriñana (Salud Sin Límites Perú, Ayacucho, Peru), Lucie Ecker (Instituto de Investigación Nutricional, Lima, Peru), Fernando Llanos (Universidad Peruana Cayetano Heredia, Lima, Peru), Willy Lescano (US Naval Medical Research Center Detachment, Lima, Peru), David Moore (London School of Hygiene and Tropical Medicine, London, UK), Jorge Rey de Castro (Universidad Peruana Cayetano Heredia, Lima, Peru), Ian Roberts (London School of Hygiene and Tropical Medicine, London, UK), Paul Valdivia (Universidad Peruana Cayetano Heredia, Lima, Peru), Walter Valdivia (Ministerio de Economía y Finanzas, Lima, Peru).

Referee response for version 1

Morimura

Naoto

1

Referee

Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, Japan

**Competing interests:**No competing interests were disclosed.

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Version 1

This report is very important for assessing and recognizing the present status of trauma systems in the region.

I believe an analysis of mortality however, for example an investigation of preventable trauma death by trauma scoring, will give this article greater support. In addition to the evaluation of access time to the hospital and patient's satisfaction of this study, further study based on the outcome can enable the quality of the trauma management.

I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Referee response for version 1

Michalsen

Andrej

1

Referee

Department of Anaesthesiology and Critical Care Medicine, Tettnang Hospital, Tettnang, Germany

**Competing interests:**No competing interests were disclosed.

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2013

Version 1

The article describes the promptness and quality of care as perceived by approximately 640 road traffic incident victims at 8 healthcare facilities in Peru within 4 weeks. Both the promptness and the quality leave room for improvement because the average response time is far longer than internationally recommended and the quality of in-hospital services is considered low by those patients who took part in the surveillance. The abstract provides a reasonable summary of the article, except perhaps where promptness is rated as \' *adequate overall*\'; a better description here might be \"adequate under the given circumstances\".

The strength of the research is the clear methodology, which is comprehensively explained and followed. Without reliable data there will not be a sound basis for policy makers to decide on the allocation of scarce resources. Perhaps, the study period could have been longer than just four weeks to increase the validity of the results. Also, the goals for improving promptness of care lean especially towards U.S. standards without explaining their (alleged) superiority over standards in other parts of the world.

The conclusions of the study appear balanced and justified. A replication of the study at more sites in Peru and beyond would be helpful to make policy makers aware of the importance of improvements in healthcare for injury victims as injury is one of the leading causes of morbidity and mortality worldwide.

I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

[^1]: JJM and LH obtained funding for the study. JJM, ERM and LH designed the study. JJM, ERM, DAQ and LH participated in the literature search. ERM reviewed and pilot tested the instruments. JJM, ERM, APP, LL, DL and LH carried out the research. JJM, ERM and LL analyzed the data. JJM, ERM and DAQ prepared the first draft of the manuscript. DAQ, CG, PP and PB provided critical input during the preparation of the manuscript. All authors were involved in the revision of the draft manuscript and have agreed to the final content.

[^2]: **Competing interests:**No competing interests were disclosed.
