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Background: We sought to determine the achievement of key performance indicators (KPIs) of initial trauma care at district (first-level) and regional (second-level) hospitals in Ghana and to assess the effectiveness of a standardized trauma intake form (TIF) to improve care., Methods: A stepped-wedge cluster randomized trial was performed with direct observations of trauma management before and after introducing the TIF at emergency units of eight hospitals for 17.5 months. Differences in KPIs were assessed using multivariable logistic regression and generalized linear mixed regression., Results: Management of 4077 patients was observed; 30% at regional and 70% at district hospitals. Eight of 20 KPIs were performed significantly more often at regional hospitals. TIF improved care at both levels. Fourteen KPIs improved significantly at district and eight KPIs improved significantly at regional hospitals. After TIF, regional hospitals still performed better with 18 KPIs being performed significantly more often than district hospitals. After TIF, all KPIs were performed in >90% of patients at regional hospitals. Examples of KPIs for which regional performed better than district hospitals after TIF included: assessment for oxygen saturation (83% vs. 98%) and evaluation for intra-abdominal bleeding (82% vs. 99%, all p < 0.001). Mortality decreased among seriously injured patients (injury severity score ≥9) at both district (15% before vs. 8% after, p = 0.04) and regional (23% vs. 7%, p = 0.004) hospitals., Conclusions: TIF improved care and lowered mortality at both hospital levels, but KPIs remained lower at district hospitals. Further measures are needed to improve initial trauma care at this level., Clinical Trials Registration: Clinicaltrials.gov (NCT04547192)., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)