Definition/Introduction
In the United States, trauma centers are identified through a designation process and a verification process. The criteria for the designation of a trauma center varies from state to state, and the designation process itself is the responsibility of state or regional authorities and not healthcare organizations.[1] The trauma center level (Level I- Level V) refers to the resources available to care for a trauma patient. A Level I trauma center can provide the highest level of care for a patient presenting after a traumatic injury. A Level IV or V trauma center will stabilize an injured patient and arrange for transfer to a higher level of care. This designation is unique for adult and pediatric facilities.
Trauma centers are evaluated and verified by the American College of Surgeons (ACS) to improve trauma care. The ACS provides verification of trauma centers, not a designation. Itverifies that the facility has the resources available for the traumapatient. The ACS will evaluate a facility's preparedness, resources, policies, and qualityimprovement process. Verification by the ACSis valid for three years.[2]
Issues of Concern
Trauma centers are verified as an adult or pediatric trauma centers. It is not uncommon for hospitals to have designations for different levels for adult and pediatric populations. The criteria for trauma centers verified by the ACS are as follows.[3]
A Level I Trauma Center is a tertiary care hospital that offersa comprehensive approach to the trauma patient from injury through rehabilitation. Key components include:
24-hour in-hospital access to general surgeons
Availability of anesthesia, emergency medicine, neurosurgery, orthopedic surgery, radiology, plastic surgery, and maxillofacial surgery
Referral center for community hospitals
Public health education including the prevention of traumatic injuries
Continuing education for all team members involved in trauma care
Quality assessment and improvement programs
Teaching and research in trauma management
Polysubstance abuse identification and intervention
Evaluates and treats a minimum number of trauma patientsannually
A Level II Trauma Center initiates the treatment ofall trauma patients. Key components include:
24-hour access to general surgeons
Availability of anesthesiology, radiology, emergency medicine, neurosurgery, and orthopedic surgery
Sub-specialized care may be necessary to transfer to a Level I Trauma Center
Continuing education for all team members involved in trauma care
Quality assessment and improvement programs
A Level III Trauma Center provides prompt assessment, management, surgery, and stabilization for trauma patients. Key components include:
24-hour access toemergency medicine physicians
Availability of general surgeons
Quality assessment and improvement programs
Agreements to transfer patients requiring a higher level of care
Backup care for outlying hospitals
Continuing education for all team membersinvolved in trauma care
Outreach education program for prevention of traumatic injuries
A Level IV Trauma Center can provide Advanced Trauma Life Support (ATLS) to trauma patients before transfer to a higher level of care.Key components include:
Emergency department able to implement ATLS protocols
Nurses and physicians available whentrauma patients arrive
Surgery and intensivecare, when available
Agreements to transfer patients requiring a higher level of care
Quality assessment and improvement programs
Outreacheducation program for prevention of traumatic injuries
A Level V Trauma Center can provideevaluation, initial management, and preparation before transfer to a higher level of trauma care. Key components include:
Emergency department able to implement ATLS protocols
Nurses and physicians available when trauma patients arrive
After hours protocols if the facility closes
Surgery and intensive care, whenavailable
Agreements to transfer patients requiring a higher level of care
Clinical Significance
Research has shown that trauma management given at a designated trauma center is superior compared to trauma management at a facility that is not designated as a trauma center.[4][5]Mortalityrisk from traumaissignificantly lower if patients receive care at a designated trauma center.[6][7][8][9]
Nursing, Allied Health, and Interprofessional Team Interventions
Approximately 80% of errors in medicine are a result of inadequatecommunication. High-risk environments includetrauma facilities. Interprofessional teamwork and development should focus on communication, shared responsibility, collective decision-making, and understanding the roles of team members.[10]
References
- 1.
American College of Surgeons Committee on Trauma. Statement on trauma center designation based upon system need. Bull Am Coll Surg. 2015 Jan;100(1):51-2. [PubMed: 25626271]
- 2.
Elkbuli A, Dowd B, Flores R, Boneva D, McKenney M. The impact of level of the American College of Surgeons Committee on Trauma verification and state designation status on trauma center outcomes. Medicine (Baltimore). 2019 Jun;98(25):e16133. [PMC free article: PMC6636922] [PubMed: 31232965]
- 3.
Shafi S, Barnes S, Ahn C, Hemilla MR, Cryer HG, Nathens A, Neal M, Fildes J. Characteristics of ACS-verified Level I and Level II trauma centers: A study linking trauma center verification review data and the National Trauma Data Bank of the American College of Surgeons Committee on Trauma. J Trauma Acute Care Surg. 2016 Oct;81(4):735-42. [PubMed: 27257710]
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Dodson BK, Braswell M, David AP, Young JS, Riccio LM, Kim Y, Calland JF. Adult and elderly population access to trauma centers: an ecological analysis evaluating the relationship between injury-related mortality and geographic proximity in the United States in 2010. J Public Health (Oxf). 2018 Dec 01;40(4):848-857. [PMC free article: PMC6306086] [PubMed: 29190373]
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Grossman MD, Yelon JA, Szydiak L. Effect of American College of Surgeons Trauma Center Designation on Outcomes: Measurable Benefit at the Extremes of Age and Injury. J Am Coll Surg. 2017 Aug;225(2):194-199. [PubMed: 28599966]
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MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, Salkever DS, Scharfstein DO. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006 Jan 26;354(4):366-78. [PubMed: 16436768]
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Glance LG, Osler TM, Mukamel DB, Dick AW. Impact of trauma center designation on outcomes: is there a difference between Level I and Level II trauma centers? J Am Coll Surg. 2012 Sep;215(3):372-8. [PubMed: 22632909]
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Schubert FD, Gabbe LJ, Bjurlin MA, Renson A. Differences in trauma mortality between ACS-verified and state-designated trauma centers in the US. Injury. 2019 Jan;50(1):186-191. [PubMed: 30266293]
- 9.
Demetriades D, Martin M, Salim A, Rhee P, Brown C, Doucet J, Chan L. Relationship between American College of Surgeons trauma center designation and mortality in patients with severe trauma (injury severity score > 15). J Am Coll Surg. 2006 Feb;202(2):212-5; quiz A45. [PubMed: 16427544]
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Courtenay M, Nancarrow S, Dawson D. Interprofessional teamwork in the trauma setting: a scoping review. Hum Resour Health. 2013 Nov 05;11:57. [PMC free article: PMC3826522] [PubMed: 24188523]
