Trauma center levels across the United States are identified in two fashions – A designation process and a verification process.
A study showed lower mortality rates, higher GCS scores at discharge, and higher rates of favorable outcomes in trauma centers than in non-trauma centers. The regional trauma medical system seems to have a positive impact in treating patients with severe TBI 1)
The different levels (ie. Level I, II, III, IV or V) refer to the kinds of resources available in a trauma center and the number of patients admitted yearly. These are categories that define national standards for trauma care in hospitals. Categorization is unique to both Adult and Pediatric facilities.
Trauma Center designation is a process outlined and developed at a state or local level. The state or local municipality identifies unique criteria in which to categorize Trauma Centers. These categories may vary from state to state and are typically outlined through legislative or regulatory authority.
Trauma Center Verification is an evaluation process done by the American College of Surgeons (ACS) to evaluate and improve trauma care. The ACS does not designate trauma centers; instead, it verifies the presence of the resources listed in Resources for Optimal Care of the Injured Patient. These include commitment, readiness, resources, policies, patient care, and performance improvement.
This is a voluntary process by the Trauma Center being verified and lasts for a 3-year period.
As mentioned above, Trauma categories vary from state to state. Outlined below are common criteria for Trauma Centers verified by the ACS and also designated by states and municipalities. Facilities are designated/verified as Adult and/or Pediatric Trauma Centers. It is not uncommon for facilities to have different designations for each group (ie. a Trauma Center may be a Level I Adult facility and also a Level II Pediatric Facility).
A Level III Trauma Center has demonstrated an ability to provide prompt assessment, resuscitation, surgery, intensive care and stabilization of injured patients and emergency operations.
Elements of Level III Trauma Centers Include:
24-hour immediate coverage by emergency medicine physicians and the prompt availability of general surgeons and anesthesiologists. Incorporates a comprehensive quality assessment program Has developed transfer agreements for patients requiring more comprehensive care at a Level I or Level II Trauma Center. Provides back-up care for rural and community hospitals. Offers continued education of the nursing and allied health personnel or the trauma team. Involved with prevention efforts and must have an active outreach program for its referring communities.
A Level IV Trauma Center has demonstrated an ability to provide advanced trauma life support (ATLS) prior to transfer of patients to a higher level trauma center. It provides evaluation, stabilization, and diagnostic capabilities for injured patients.
Elements of Level IV Trauma Centers Include:
Basic emergency department facilities to implement ATLS protocols and 24-hour laboratory coverage. Available trauma nurse(s) and physicians available upon patient arrival. May provide surgery and critical-care services if available. Has developed transfer agreements for patients requiring more comprehensive care at a Level I or Level II Trauma Center. Incorporates a comprehensive quality assessment program Involved with prevention efforts and must have an active outreach program for its referring communities.
A Level V Trauma Center provides initial evaluation, stabilization and diagnostic capabilities and prepares patients for transfer to higher levels of care.
Elements of Level V Trauma Centers Include:
Basic emergency department facilities to implement ATLS protocols Available trauma nurse(s) and physicians available upon patient arrival. After-hours activation protocols if facility is not open 24-hours a day. May provide surgery and critical-care services if available. Has developed transfer agreements for patients requiring more comprehensive care at a Level I though III Trauma Centers.
Kim et al., enrolled 322 patients with severe trauma and TBI from January 2015 to December 2016. Clinical factors, indexes, and outcomes were compared before and after trauma center establishment (September 2015). The outcome was the Glasgow outcome scale classification at 3 months post-trauma.
Of the 322 patients, 120 (37.3%) and 202 (62.7%) were admitted before and after trauma center establishment, respectively. The two groups were significantly different in age (p=0.038), the trauma location within the city (p=0.010), the proportion of intensive care unit admissions (p=0.001), and the emergency room stay time (p<0.001). Mortality occurred in 37 patients (11.5%). Although the preventable death rate decreased from before to after center establishment (23.1% vs. 12.5%), the difference was not significant. None of the clinical factors, indexes, or outcomes were different from before to after center establishment for patients with severe TBI (Glasgow coma scale score ≤8). However, the proportion of inter-hospital transfers increased and the time to emergency room arrival was longer in both the entire cohort and patients with severe TBI after versus before trauma center establishment.
They confirmed that for patients with severe trauma and TBI, establishing a trauma center increased the proportion of ICU admissions and decreased the emergency room stay time and preventable death rate. However, management strategies for handling the high proportion of inter-hospital transfers and long times to emergency room arrival will be necessary 2).