National assessment of trauma care system capacity in Ecuador: Evaluating institutional resources and practitioner KAPS domains

We evaluated Ecuador's trauma care system capacity by analyzing the discrepancy between hospital infrastructure and the individual dimensions of the Knowledge, Attitudes, Practices, and Safety (KAPS) framework among medical specialists. A nationwide, multicomponent cross-sectional study was conducted (2025-2026), comprising a complete structural audit of 49 eligible public hospitals (Levels II and III) and a KAPS survey of 215 trauma-facing specialists representing 36 institutions (73.5% institutional participation rate). Spatial workflow efficiency was assessed via Emergency Department-to-Computed Tomography (ED-CT) transit distances. Independent multivariable Poisson regression models evaluated each KAPS dimension separately, reporting adjusted Incidence Rate Ratios (IRR)accounting for institutional clustering and professional seniority. The institutional audit revealed significant operational constraints: 51.0% of hospitals lacked 24/7 radiological coverage, and 16.3% experienced CT scanner downtime. Spatial ED-to-CT distances were significantly greater in Level III tertiary centers, reaching up to 300 meters (p = 0.006). Among specialists (N = 215 across 36 hospitals), ecological associations with provincial trauma volume yielded wide confidence intervals spanning the null value across domains (Knowledge: rho = 0.113, 95% CI: -0.39-0.61; Reported Practice: rho = -0.160, 95% CI: -0.66-0.34), reflecting low statistical precision from macro-level aggregation. Dimension-specific multivariable models revealed marked inter-specialty divergence: Emergency Physicians exhibited lower Knowledge (aIRR = 0.61; 95% CI: 0.50-0.74), but higher rate ratios in Reported Practices (aIRR = 1.48; 95% CI: 1.34-1.65), Attitudes (aIRR = 1.12; 95% CI: 1.09-1.16), and Safety (aIRR = 1.18; 95% CI: 1.12-1.25) relative to General Surgery. Ecuador's trauma network exhibits a measurable discrepancy between nominal infrastructure and operational availability. System capacity is constrained by physical architectural barriers and a divergence between practitioners' subjective perceptions and objective decision-making skills. Strategic priorities must include a unified National Trauma Registry, integrated teleradiology, and continuous scenario-based training.