scholarly journals LO61: A modified Delphi study to identify trauma care modifiers for older adults

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S29-S30
Author(s):  
K. Yadav ◽  
V. Boucher ◽  
N. Le Sage ◽  
C. Malo ◽  
E. Mercier ◽  
...  
Keyword(s):  
Older Adults ◽  
Trauma Care ◽  
Delphi Study ◽  
Major Trauma ◽  
Expert Panel ◽  
Trauma Team ◽  
Trauma Centre ◽  
Trauma Patients ◽  
Median Score ◽  
Modified Delphi

Introduction: Older (age >=65 years) trauma patients suffer increased morbidity and mortality. This is due to under-triage of older trauma victims, resulting in lack of transfer to a trauma centre or failure to activate the trauma team. There are currently no Canadian guidelines for the management of older trauma patients. The objective of this study was to identify modifiers to the prehospital and emergency department (ED) phases of major trauma care for older adults based on expert consensus. Methods: We conducted a modified Delphi study to assess senior-friendly major trauma care modifiers based on national expert consensus. The panel consisted of 24 trauma care providers across Canada, including medical directors, paramedics, emergency physicians, emergency nurses, trauma surgeons and trauma administrators. Following a literature review, we developed an online Delphi survey consisting of 16 trauma care modifiers. Three online survey rounds were distributed and panelists were asked to score items on a 9-point Likert scale. The following predetermined thresholds were used: appropriate (median score 7–9, without disagreement); inappropriate (median score 1–3; without disagreement), and uncertain (any median score with disagreement). The disagreement index (DI) is a method for measuring consensus within groups. Agreement was defined a priori as a DI score <1. Results: There was a 100% response rate for all survey rounds. Three new trauma care modifiers were suggested by panelists. Of 19 trauma care modifiers, the expert panel achieved consensus agreement for 17 items. The prehospital modifier with the strongest agreement to transfer to a trauma centre was a respiratory rate <10 or >20 breaths/minute or needing ventilatory support (DI = 0.24). The ED modifier with the strongest level of agreement was obtaining a 12-lead electrocardiogram following the primary and secondary survey for all older adults (DI = 0.01). Two trauma care modifiers failed to reach consensus agreement: transporting older patients with ground level falls to a trauma centre and activating the trauma team based solely on an age >=65 years. Conclusion: Using a modified Delphi process, an expert panel agreed upon 17 trauma care modifiers for older adults in the prehospital and ED phases of care. These modifiers may improve the delivery of senior-friendly trauma care and should be considered when developing local and national trauma guidelines.

scholarly journals A Delphi study to identify prehospital and emergency department trauma care modifiers for older adults

2021 ◽  
Vol 64 (3) ◽  
pp. E339-E345
Author(s):  
Krishan Yadav ◽  
Valérie Boucher ◽  
Natalie Le Sage ◽  
Christian Malo ◽  
Éric Mercier ◽  
...  
Keyword(s):  
Older Adults ◽  
Emergency Department ◽  
Trauma Care ◽  
Delphi Study ◽  
Older Patients ◽  
Major Trauma ◽  
Trauma Centre ◽  
Expert Consensus ◽  
Consensus Methods ◽  
Modified Delphi

Background: Older patients (age ≥ 65 yr) with trauma have increased morbidity and mortality compared to younger patients; this is partly explained by undertriage of older patients with trauma, resulting in lack of transfer to a trauma centre or failure to activate the trauma team. The objective of this study was to identify modifiers to the prehospital and emergency department phases of major trauma care for older adults based on expert consensus. Methods: We conducted a modified Delphi study between May and September 2019 to identify major trauma care modifiers for older adults based on national expert consensus. The panel consisted of 24 trauma care professionals from across Canada from the prehospital and emergency department phases of care. The survey consisted of 16 trauma care modifiers. Three online survey rounds were distributed. Consensus was defined a priori as a disagreement index score less than 1. Results: There was a 100% response rate for all survey rounds. Three new trauma care modifiers were suggested by panellists. The panel achieved consensus agreement for 17 of the 19 trauma care modifiers. The prehospital modifier with the strongest agreement to transfer to a trauma centre was a respiratory rate less than 10 or greater than 20 breaths/min or need for ventilatory support. The emergency department modifier with the strongest level of agreement was obtaining 12-lead electrocardiography following the primary and secondary survey. Conclusion: Using a modified Delphi process, an expert panel agreed on 17 trauma care modifiers for older adults in the prehospital and emergency department settings. These modifiers may improve the delivery of trauma care for older adults and should be considered when developing local and national trauma guidelines.

scholarly journals A consensus building exercise to determine research priorities for silver trauma

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Abdullah Alshibani ◽  
Jay Banerjee ◽  
Fiona Lecky ◽  
Timothy J. Coats ◽  
Rebecca Prest ◽  
...  
Keyword(s):  
Trauma Care ◽  
Research Question ◽  
Research Priorities ◽  
Trauma Centre ◽  
Future Research ◽  
Trauma Patients ◽  
List Type ◽  
Modified Delphi ◽  
Modified Delphi Technique ◽  
Research Questions

Abstract Background Emergency care research into ‘Silver Trauma’, which is simply defined as major trauma consequent upon relatively minor injury mechanisms, is facing many challenges including that at present, there is no clear prioritisation of the issues. This study aimed to determine the top research priorities to guide future research. Methods This consensus-based prioritization exercise used a three-stage modified Delphi technique. The study consisted of an idea generating (divergent) first round, a ranking evaluation in the second round, and a (convergent) consensus meeting in the third round. Results A total of 20 research questions advanced to the final round of this study. After discussing the importance and clinical significance of each research question, five research questions were prioritised by the experts; the top three research priorities were: What are older people’s preferred goals of trauma care? Beyond the Emergency Department (ED), what is the appropriate combined geriatric and trauma care? Do older adults benefit from access to trauma centres? If so, do older trauma patients have equitable access to trauma centre compared to younger adults? Conclusion The results of this study will assist clinicians, researchers, and organisations that are interested in silver trauma in guiding their future efforts and funding toward addressing the identified research priorities.

scholarly journals Trauma 2021Perceptions of a trauma team regarding in situ simulationEpidemiology of submersion injuries in Canadian children and adolescents: 1990–2018A survey of medical and administrative directors on REBOA use in Canadian trauma centresCut to the chase: comparing cutting tools in the exposure of simulated trauma patientsPediatric major trauma. Anaesthesia education: airway, breathing, coffee and cases 2020–2021Geriatric trauma care at a level 1 trauma centre: Are we following best practice?Was the introduction of a provincially standardized consensus statement for postintubation analgesia and sedation associated with increased use of associated pharmacological therapies in New Brunswick?Are there important variations in the care of adult trauma patients with isolated, nonoperative subdural hematomas between those admitted to a neurosurgical centre and those admitted to a non-neurosurgical centre for their entire inpatient stay?Flattening the curve on the negative psychosocial impact of trauma on the family of acute care trauma survivors: a quantitative studyDoes ACLS belong in ATLS? Seeking evidence during resuscitative thoracotomyAutologous omental harvest for microvascular free flap reconstruction of a severe traumatic scalp degloving injury: a case reportDerivation and validation of actionable quality indicators targeting reductions in complications for injury admissionsASA dosing practices in the management of blunt cerebrovascular injury: a retrospective reviewA retrospective analysis of bicycle lane collisions in Vancouver, British Columbia, from 2012 to 2017Evaluating the Screening, Brief Intervention and Referral to Treatment (SBIRT) process at Vancouver General HospitalAlcohol use and trauma in Alberta after COVID-19 lockdown: overrepresentation and undertreatment are opportunities for improvementMental health and addiction diagnoses are linked to increased violent injuries and gaps in provision of resources during the COVID-19 pandemicPain management strategies after orthopedic trauma in a level 1 trauma centre: a descriptive study with a view of optimizing practicesStudy to Actively Warm Trauma Patients (STAY WARM): a feasibility pilot evaluationPrehospital trauma care in civilian and military settings including cold environments: a systematic review and knowledge gap analysisAntibiotic administration in open fractures: adherence to guidelines at a Canadian trauma centreAre we meeting massive transfusion protocol activation and blood product delivery times in trauma patients? A retrospective review from 2014 to 2018Unplanned returns to the operating room: a quality improvement initiative at a level 1 trauma centreStopping the bleed: the history and rebirth of Canadian freeze-dried plasmaThe state of the evidence for emergency medical services (EMS) care of prehospital severe traumatic brain injury: an analysis of appraised research from the Prehospital Evidence-based Practice programA mixed methods study of a paramedic falls referral program in Nova ScotiaFirst presentations of psychiatric illness at a level 1 trauma centreAlcohol and substance abuse screening in pediatric trauma patients: examining rates of screening and implementing a screen for the pediatric populationMeasuring behavioural quality and quantity of team leaders during simulated interprofessional trauma careImproving rural trauma outcomes: a structured trauma-training program for rural family physicians with enhanced surgical skills — a pilot projectTrauma treatment: evidence-based response to psychological needs after a natural disasterHow prepared are Canadian trauma centres for mass casualty incidents?The catalytic effect of multisource feedback for trauma teams: a pilot studyRetrievable inferior vena cava filter for primary prophylaxis of pulmonary embolism in at-risk trauma patients: a feasibility trialValue of data collected by the medical examiner service on the quality of alcohol and toxicology testing in fatal motor vehicle collisionsPrehospital narrow pulse pressure predicts need for resuscitative thoracotomy and emergent surgical intervention after traumaImpact of a geriatric consultation service on outcomes in older trauma patients: a retrospective pre–post studyExploring physical literacy as a condition of fall mechanism in older adultsIs the use of business intelligence software helpful in planning injury prevention campaigns?Exposure to endotracheal intubation among trauma patients in level 5 trauma centres in New Brunswick — a retrospective reviewAre early specialist consultations helpful predictors of those who require care in level 1 or 2 designated trauma centres?Neurologic outcomes after traumatic cardiac arrest: a systematic reviewClosed-loop communication in the trauma bay: identifying opportunities for team performance improvement through a video review analysisEmbolization in nonsplenic trauma: outcomes at a Canadian trauma hospitalThe matrix: grouping ICD-10-CA injury codes by body region and nature of injury for reporting purposesEvaluation of low-value clinical practices in acute trauma care: a multicentre retrospective studyTrauma 101: a virtual case-based trauma conference as an adjunct to medical educationPhysiologic considerations, indications and techniques for ECLS in trauma: experience of a level 1 trauma centreEngaging patients in the selection of trauma quality indicatorsStrategies aimed at preventing chronic opioid use in trauma and acute care surgery: a scoping reviewAugmented reality surgical telementoring for leg fasciotomyIdentification of high-risk trauma patients requiring major interventions for traumatic hemorrhage: a prospective study of clinical gestaltEvaluating best practices in trauma care of older adultsBetween paradigms: comparing patient and parent experiences of injured adolescents treated at pediatric or adult trauma centresEarly outcomes after implementation of chest trauma management protocol in Vancouver General HospitalUtility of diagnostic peritoneal lavage versus focused abdominal sonography for trauma in penetrating abdominal injuryTime to definitive surgery and survival in pediatric patients younger than 18 years with gunshot woundsThe effect of chronic obstructive lung disease on post-traumatic acute respiratory distress syndrome: predictors of morbidity and mortalityThe association between injury type and clinical outcomes in patients with traumatic renal injury after nephrectomyWhen low complication rates are a bad sign: the negative impact of introducing an electronic medical record on TQIP data completenessClinical handover from paramedic services to the trauma team: a video review analysis of the IMIST-AMBO protocol implementationGeriatric Recovery and Enhancement Alliance in Trauma (GREAT) multidisciplinary quality improvement initiative: improving process and outcome measures for geriatric trauma patientsIncreasing the safety of inadvertent iliac artery device deployment with the COBRA-OS, a novel low-profile REBOA deviceIs it better to watch before or listen while doing? A randomized trial of video-modelling versus telementoring for out-of-scope tube thoracostomy insertion performed by search and rescue medicsIndications for prehospital civilian tourniquet application by first responders: an expert consensus opinion of military physicians by the Delphi method

2021 ◽  
Vol 64 (5 Suppl 1) ◽  
pp. S37-S64
Author(s):  
Olga Bednarek ◽  
Mike O’Leary ◽  
Sean Hurley ◽  
Caleb Cummings ◽  
Ruth Bird ◽  
...  
Keyword(s):  
New Brunswick ◽  
Trauma Care ◽  
Trauma Team ◽  
Trauma Centre ◽  
Quality Improvement Initiative ◽  
Evidence Based ◽  
Trauma Patients ◽  
Trauma Outcomes ◽  
Trauma Centres ◽  
Level 1

scholarly journals Defining major trauma: a Delphi study

2021 ◽  
Vol 29 (1) ◽  
Author(s):  
Lee Thompson ◽  
Michael Hill ◽  
Fiona Lecky ◽  
Gary Shaw
Keyword(s):  
Cluster Analysis ◽  
Delphi Study ◽  
Major Trauma ◽  
Injury Severity ◽  
Expert Panel ◽  
High Energy ◽  
Trauma Centre ◽  
Delphi Process ◽  
Theory Approach ◽  
Major Trauma Centre

Abstract Introduction Retrospective trauma scores are often used to categorise trauma, however, they have little utility in the prehospital or hyper-acute setting and do not define major trauma to non-specialists. This study employed a Delphi process in order to gauge degrees of consensus/disagreement amongst expert panel members to define major trauma. Method A two round modified Delphi technique was used to explore subject-expert consensus and identify variables to define major trauma through systematically collating questionnaire responses. After initial descriptive analysis of variables, Kruskal-Wallis tests were used to determine statistically significant differences (p < 0.05) in response to the Delphi statements between professional groups. A hierarchical cluster analysis was undertaken to identify patterns of similarity/difference of response. A grounded theory approach to qualitative analysis of data allowed for potentially multiple iterations of the Delphi process to be influenced by identified themes. Results Of 55 expert panel members invited to participate, round 1 had 43 participants (Doctor n = 20, Paramedic n = 20, Nurse n = 5, other n = 2). No consistent patterns of opinion emerged with regards to professional group. Cluster analysis identified three patterns of similar responses and coded as trauma minimisers, the middle ground and the risk averse. Round 2 had 35 respondents with minimum change in opinion between rounds. Consensus of > 70% was achieved on many variables which included the identification of life/limb threatening injuries, deranged physiology, need for intensive care interventions and that extremes of age need special consideration. It was also acknowledged that retrospective injury severity scoring has a role to play but is not the only method of defining major trauma. Various factors had a majority of agreement/disagreement but did not meet the pre-set criteria of 70% agreement. These included the topics of burns, spinal immobilisation and whether a major trauma centre is the only place where major trauma can be managed. Conclusion Based upon the output of this Delphi study, major trauma may be defined as: “Significant injury or injuries that have potential to be life-threatening or life-changing sustained from either high energy mechanisms or low energy mechanisms in those rendered vulnerable by extremes of age”.

scholarly journals Defining major trauma: A Delphi study.

2020 ◽  
Author(s):  
Lee Thompson ◽  
Michael Hill ◽  
Fiona Lecky ◽  
Gary Shaw
Keyword(s):  
Cluster Analysis ◽  
Delphi Study ◽  
Major Trauma ◽  
Injury Severity ◽  
Expert Panel ◽  
High Energy ◽  
Trauma Centre ◽  
Delphi Process ◽  
Theory Approach ◽  
Major Trauma Centre

Abstract Introduction: Retrospective trauma scores are often used to categorise trauma, however, they have little utility in the prehospital or hyper-acute setting and do not define major trauma to non-specialists. This study employed a Delphi process in order to gauge degrees of consensus/disagreement amongst expert panel members to define major trauma.Method: A two round modified Delphi technique was used to explore subject-expert consensus and identify variables to define major trauma through systematically collating questionnaire responses.After initial descriptive analysis of variables, Kruskal-Wallis tests were used to determine statistically significant differences (p <0.05) in response to the Delphi statements between professional groups. A hierarchical cluster analysis was undertaken to identify patterns of similarity/difference of response.A grounded theory approach to qualitative analysis of data allowed for potentially multiple iterations of the Delphi process to be influenced by identified themes.Results: Of 55 expert panel members invited to participate, round 1 had 43 participants (Doctor n=20, Paramedic n=20, Nurse n=5, other n=2). No consistent patterns of opinion emerged with regards to professional group. Cluster analysis identified three patterns of similar responses and coded as trauma minimisers, the middle ground and the risk averse. Round 2 had 35 respondents with minimum change in opinion between rounds.Consensus of >70% was achieved on many variables which included the identification of life/limb threatening injuries, deranged physiology, need for intensive care interventions and that extremes of age need special consideration. It was also acknowledged that retrospective injury severity scoring has a role to play but is not the only method of defining major trauma. Various factors had a majority of agreement/disagreement but did not meet the pre-set criteria of 70% agreement. These included the topics of surgical intervention, use of Tranexamic Acid, burns, spinal immobilisation and whether a major trauma centre is the only place where major trauma can be managed.Conclusion: Based upon the output of this Delphi study, major trauma may be defined as: “Significant injury or injuries that have potential to be life-threatening or life-changing sustained from either high energy mechanisms or low energy mechanisms in those rendered vulnerable by extremes of age”.

Undertriage of the elderly major trauma patient continues in major trauma centre care: a retrospective cohort review

2020 ◽  
pp. emermed-2019-208541
Author(s):  
Antonia C Hoyle ◽  
Leela C Biant ◽  
Mike Young
Keyword(s):  
Older Patients ◽  
Major Trauma ◽  
Trauma Team ◽  
Trauma Centre ◽  
Trauma Patients ◽  
Severely Injured ◽  
Severely Injured Patients ◽  
Major Trauma Centre ◽  
Trauma Triage ◽  
Injured Patients

BackgroundMajor trauma (Injury Severity Score (ISS) ≥16) in older people is increasing, but concerns persist that major trauma is not always recognised in older patients on triage. This study compared undertriage of older and younger adult major trauma patients in the major trauma centre (MTC) setting to investigate this concern.MethodsA retrospective review of Trauma Audit and Research Network data was conducted for three MTCs in the UK for 3 months in 2014. Age, ISS, injury mechanism and injured areas were examined for all severely injured patients (ISS ≥16) and appropriate major trauma triage rates measured via the surrogate markers of trauma team activation and the presence of a consultant first attender, as per standards for major trauma care set by National Confidential Enquiry into Patient Outcomes and Deaths, Royal College of Surgeons of England and the British Orthopaedic Association. Trends in older (age ≥65) and younger (ages 18–64) adult major trauma presentation, triage and reception were reviewed.ResultsOf 153 severely injured patients, 46 were aged ≥65. Older patients were significantly less likely to receive the attention of a consultant first attender or trauma team. Similar trends were also seen on subgroup analysis by mechanism of injury or number of injured body areas. Older major trauma patients exhibit a higher mortality, despite a lower median ISS (older patient ISS=20 (IQR 16–25), younger patient ISS=25 (IQR 18–29)).ConclusionOlder major trauma patients are at greater risk of undertriage, even in the MTC environment. Existing hospital trauma triage practices should be further investigated to explain and reduce undertriage of elderly trauma patients.

Performance improvement challenges for managing abdominal trauma at a New Major Trauma Centre

2014 ◽  
Vol 96 (10) ◽  
pp. e1-e4
Author(s):  
P Macgoey ◽  
C Lamb ◽  
NR Tai ◽  
BA Cotton ◽  
AJ Brooks
Keyword(s):  
Trauma Care ◽  
Major Trauma ◽  
Trauma Centre ◽  
Trauma Patients ◽  
England And Wales ◽  
Improved Outcomes ◽  
Major Trauma Centre ◽  
The Us ◽  
Trauma Networks ◽  
Injured Patients

A number of reports spanning more than two decades have highlighted significant deficiencies in UK trauma care. 1–4 data suggest that seriously injured patients in england and wales endure in-hospital mortality rates that are 20% higher than their counterparts in the us. 5 more than 30 years ago, improved outcomes for major trauma patients were demonstrated by provision of an organised system of trauma care that included the resources of a trauma centre. 6 Trauma care throughout england and wales has recently been reorganised into regional trauma networks. 7

scholarly journals Falls downstairs: The impact on a UK major trauma centre

Trauma ◽  
2021 ◽  
pp. 146040862110029
Author(s):  
Joshua Callon ◽  
Daniel Thomas ◽  
Simon J Mercer
Keyword(s):  
Older Patients ◽  
Major Trauma ◽  
Average Length ◽  
Trauma Team ◽  
Trauma Centre ◽  
Trauma Patients ◽  
Mechanism Of Injury ◽  
Younger Patients ◽  
Major Trauma Centre ◽  
The Impact

Introduction Major trauma centres are increasingly managing a significant injury burden in older patients, with falling downstairs being a prevalent mechanism of injury. Literature evaluating the impact of falls on stairs upon UK trauma networks is limited. Gaining a greater understanding of this may allow for more effective planning of services and improvements in training and education. This study evaluates the impact of falls downstairs on a UK major trauma centre. Methods A single centre retrospective service evaluation of local major trauma data over a 3-year period from 01/01/2017 to 31/12/2019. Included were patients who activated a trauma call whose mechanism of injury recorded at the time of admission was a fall downstairs. We excluded patients less than 16 years of age. Results There were 4480 major trauma patients who presented in the study period and of these, 860 (19.2%) sustained injuries following a fall downstairs. The most common age group presenting was 70–79 years; younger patients (<60 years) made up 43.3% with the majority (56.7%) being older. All but one patient were managed by a consultant-led trauma team, 6.4% of patients were admitted to critical care and 1% received an urgent operation. The overall mortality rate was 8.5%. Older patients made up 85% of those who died and had nearly four times longer average length of stay than younger patients (9.69 v 2.49 days). Conclusion Falls downstairs place a significant burden on the major trauma centre. There is a stark contrast in the use of hospital resources and outcomes between older and younger patients.

scholarly journals Simplified treatment algorithm for the management of trauma-induced hemorrhage without viscoelastic testing

2021 ◽  
Vol 6 (1) ◽  
pp. e000779
Author(s):  
Sebastian Casu
Keyword(s):  
Major Trauma ◽  
Point Of Care ◽  
Treatment Algorithm ◽  
Standard Of Care ◽  
Trauma Team ◽  
Trauma Patients ◽  
Treatment Protocols ◽  
Treatment Algorithms ◽  
Number Of Treatment ◽  
Uncontrolled Bleeding

Uncontrolled bleeding after major trauma remains a significant cause of death, with up to a third of trauma patients presenting with signs of coagulopathy at hospital admission. Rapid correction of coagulopathy is therefore vital to improve mortality rates and patient outcomes in this population. Early and repeated monitoring of coagulation parameters followed by clear protocols to correct hemostasis is the recommended standard of care for bleeding trauma patients. However, although a number of treatment algorithms are available, these are frequently complex and can rely on the use of viscoelastic testing, which is not available in all treatment centers. We therefore set out to develop a concise and pragmatic algorithm to guide treatment of bleeding trauma patients without the use of point-of-care viscoelastic testing. The algorithm we present here is based on published guidelines and research, includes recommendations regarding treatment and dosing, and is simple and clear enough for even an inexperienced physician to follow. In this way, we have demonstrated that treatment protocols can be developed and adapted to the resources available, to offer clear and relevant guidance to the entire trauma team.

scholarly journals Effectiveness of trauma care systems at different stages of development in reducing mortality: a systematic review and meta-analysis protocol

BMJ Open ◽  
2021 ◽  
Vol 11 (6) ◽  
pp. e047439
Author(s):  
Rayan Jafnan Alharbi ◽  
Virginia Lewis ◽  
Sumina Shrestha ◽  
Charne Miller
Keyword(s):  
Systematic Review ◽  
Trauma Care ◽  
Data Extraction ◽  
Meta Analysis ◽  
Trauma System ◽  
Secondary Data ◽  
Trauma Centre ◽  
Trauma Patients ◽  
Trauma Systems ◽  
Stages Of Development

IntroductionThe introduction of trauma systems that began in the 1970s resulted in improved trauma care and a decreased rate of morbidity and mortality of trauma patients. Worldwide, little is known about the effectiveness of trauma care system at different stages of development, from establishing a trauma centre, to implementing a trauma system and as trauma systems mature. The objective of this study is to extract and analyse data from research that evaluates mortality rates according to different stages of trauma system development globally.Methods and analysisThe proposed review will comply with the checklist of the ‘Preferred reporting items for systematic review and meta-analysis’. In this review, only peer-reviewed articles written in English, human-related studies and published between January 2000 and December 2020 will be included. Articles will be retrieved from MEDLINE, EMBASE and CINAHL. Additional articles will be identified from other sources such as references of included articles and author lists. Two independent authors will assess the eligibility of studies as well as critically appraise and assess the methodological quality of all included studies using the Cochrane Risk of Bias for Non-randomised Studies of Interventions tool. Two independent authors will extract the data to minimise errors and bias during the process of data extraction using an extraction tool developed by the authors. For analysis calculation, effect sizes will be expressed as risk ratios or ORs for dichotomous data or weighted (or standardised) mean differences and 95% CIs for continuous data in this systematic review.Ethics and disseminationThis systematic review will use secondary data only, therefore, research ethics approval is not required. The results from this study will be submitted to a peer-review journal for publication and we will present our findings at national and international conferences.PROSPERO registration numberCRD42019142842.

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