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EMS, Trauma Center Designation

Author: Alison P. Southern Editor: Daniel H. Celik Updated: 7/17/2023 9:10:01 PM

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. It verifies that the facility has the resources available for the trauma patient. The ACS will evaluate a facility's preparedness, resources, policies, and quality improvement process. Verification by the ACS is valid for three years.[2]

Issues of Concern

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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 offers a 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 patients annually

A Level II Trauma Center initiates the treatment of all 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 to emergency 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 members involved 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 when trauma patients arrive
  • Surgery and intensive care, when available
  • Agreements to transfer patients requiring a higher level of care 
  • Quality assessment and improvement programs
  • Outreach education program for prevention of traumatic injuries 

A Level V Trauma Center can provide evaluation, 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, when available
  • 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] Mortality risk from trauma is significantly 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 inadequate communication. High-risk environments include trauma 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. Bulletin of the American College of Surgeons. 2015 Jan:100(1):51-2     [PubMed PMID: 25626271]

Level 1 (high-level) evidence

[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. 2019 Jun:98(25):e16133. doi: 10.1097/MD.0000000000016133. Epub     [PubMed PMID: 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. The journal of trauma and acute care surgery. 2016 Oct:81(4):735-42. doi: 10.1097/TA.0000000000001136. Epub     [PubMed PMID: 27257710]

[4]

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. Journal of public health (Oxford, England). 2018 Dec 1:40(4):848-857. doi: 10.1093/pubmed/fdx156. Epub     [PubMed PMID: 29190373]

Level 2 (mid-level) evidence

[5]

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. Journal of the American College of Surgeons. 2017 Aug:225(2):194-199. doi: 10.1016/j.jamcollsurg.2017.04.034. Epub 2017 Jun 9     [PubMed PMID: 28599966]

[6]

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. The New England journal of medicine. 2006 Jan 26:354(4):366-78     [PubMed PMID: 16436768]

[7]

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? Journal of the American College of Surgeons. 2012 Sep:215(3):372-8. doi: 10.1016/j.jamcollsurg.2012.03.018. Epub 2012 May 24     [PubMed PMID: 22632909]

Level 2 (mid-level) evidence

[8]

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. doi: 10.1016/j.injury.2018.09.038. Epub 2018 Sep 21     [PubMed PMID: 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). Journal of the American College of Surgeons. 2006 Feb:202(2):212-5; quiz A45     [PubMed PMID: 16427544]

[10]

Courtenay M, Nancarrow S, Dawson D. Interprofessional teamwork in the trauma setting: a scoping review. Human resources for health. 2013 Nov 5:11():57. doi: 10.1186/1478-4491-11-57. Epub 2013 Nov 5     [PubMed PMID: 24188523]

Level 2 (mid-level) evidence