Patients from all backgrounds and of all ages can unexpectedly find themselves needing care for trauma injuries. However, during the first half of life, more people die from injuries—such as traffic accidents, gunshot wounds, falls, or burns—than any other cause.
Traumatic injuries cause 59 percent of all deaths for people from birth to age 44 in the U.S. This statistic clearly shows the critical importance of trauma care systems and prevention programs to address this leading source of preventable mortality among younger populations.
The 20th-century wars showed the medical community the life-saving importance of hemorrhage control, resuscitation, and rapid transport to definitive care, now essential capacities in trauma centers. Over the years, the American trauma system has garnered lessons from experience and groundbreaking reports and evolved to function as five distinct trauma center levels.
A 1976 American College of Surgeons (ACS) publication—Optimal Hospital Resources for Care of the Seriously Injured—provided criteria for categorizing hospitals based on the level of trauma care they could provide. This publication established the guidelines for trauma center standards and verification and is regularly updated as Resources for Optimal Care of the Seriously Injured Patient. Ongoing research at trauma centers continues to improve the system.
What Are Trauma Centers?
Trauma centers are the heart of a trauma system, providing comprehensive, multidisciplinary care for injured patients, as well as training, research, and collaboration in preparation for disaster scenarios. Based on the available professional and technological resources, there are different trauma center levels (I-V) in relation to their scope of care; level I is the most comprehensive.
According to the American Trauma Society:
“The primary goal of a trauma system is to have the right patient get the right care at the right time. Within a geographic area, a trauma system encompasses pre-hospital notification and treatment, acute hospital care, and access to rehabilitation services when needed.”
What is the difference between an ICU and a trauma unit?
Trauma units specifically care for patients with severe injuries, while ICUs treat a broader range of critical conditions.
Is the trauma center the same as the emergency room?
Trauma centers focus on critical injuries, while emergency rooms treat a wider variety of medical conditions at varying levels of severity.
What Each Level of A Trauma Center Means
From the most advanced comprehensive level I centers, to the vital rural level IV and V facilities, each level of trauma center or trauma unit plays a critical role in the trauma system, sparing no effort to ensure injured patients receive the right care in time.
Level 1 (Level I) Trauma Center
A level I trauma center is a comprehensive regional resource that serves large cities and is equipped to provide the most complete and complex level of care for trauma patients. Treatment at a level I trauma center can cut back on mortality by 25 percent in comparison to a non-trauma center. The specific characteristics of a level I are as follows:
Number of patients: A minimum of 1,200 trauma patients yearly or 240 patients with an Injury Severity Score (ISS) of over 15.
Services and Specialties:
- Surgically directed critical care service with 24-hour pre and post-anesthesia services
- 24-hour laboratory services and radiology
- An operating room available within 15 minutes
- An adequate blood supply
- ICU team coverage
- Support services
- Substance abuse screening and patient intervention
Specialists:
- 24/7 in-house attention by general surgeons
- Prompt availability of care including a full spectrum of surgical specialists in areas such as neurosurgery, orthopedic, cardiothoracic, maxillofacial, cardiothoracic, and plastic surgery, as well as anesthesiologists, emergency physicians, and advanced practitioners, radiologists, specialists in internal medicine, oral and, respiratory therapy, pediatric and critical care
- Orthopaedic care supervised by an individual who has completed a fellowship in orthopaedic traumatology approved by the Orthopaedic Trauma Association
- Cardiothoracic surgeons available 24 hours a day, and cardiopulmonary bypass equipment
Training provided by the trauma center:
A level I trauma center exercises leadership in both injury care and prevention, with several programs including the following:
- Community outreach education on prevention
- Continuing education for trauma team members
- Emergency medicine and surgical specialty residency programs
- Rotations for senior residents
- Acute care surgery fellowships
Most level I trauma centers are university-based teaching hospitals.
Research:
An ongoing trauma research program with at least 20 peer-reviewed articles published in specified journals or 10 peer-reviewed articles and four trauma-related scholarly activities
Evaluation
A quality assessment program, that is not only responsible for assessing the care provided within its trauma program but also for supporting the assessment of care across the regional trauma system.
This trauma center ideally serves as an extensive resource for all organizations dealing with injured patients in the area. At level I, lead centers play an important role in developing local trauma systems, preparing for regional disasters, and advancing trauma care through research.
At level I trauma centers, patients with very severe injuries have a 15-22 percent lower risk of mortality compared to level II facilities after adjusting for injury severity and other factors. For less severely injured patients, mortality risks are similar between level I and level II.
Level 2 (Level II) Trauma Center
According to the ACS, “The standards for the provision of clinical care to injured patients for level I and level II trauma centers are identical.” The difference between a level I facility and a level II, has more to do with research, training, resources, and the number of patients.
Differences Between Level I and Level II
- Unlike level I trauma centers, level II trauma centers are not expected to provide outreach training, conduct research, or produce publications. Although they may take on additional responsibilities related to education, system leadership, and disaster planning, this is not required for verification.
- A level II may outsource procedures with a higher degree of complexity.
- Tertiary care requirements such as cardiac surgery, hemodialysis, or microvascular surgery may be transferred to a level I trauma center.
- Level II trauma centers may have fewer technology resources and skilled personnel to provide life-saving care to critically injured patients.
- They are also not as well equipped to handle mass casualty incidents.
- The minimum number of trauma patients per year varies depending on the location and local conditions.
Surgeons and Specialists on Duty for Level II
- Although the surgeons and specialists are not required to be present 24/7, they are on call.
- Attending surgeons must be involved in major decisions, present for resuscitations and procedures, and actively participate in critical care for seriously injured patients.
- Residents in year four or five of a postgraduate program or attending emergency physicians can begin resuscitation while awaiting the trauma surgeon. Still, they cannot substitute for the surgeon.
- The on-call trauma surgeon must be dedicated to that single trauma center while on duty.
- A published backup call schedule for trauma surgery must be ready and on hand.
- The trauma director must have the responsibility and authority to determine each general surgeon’s ability to participate on the trauma panel based on an annual review.
- The surgeon must be present in the emergency department on patient arrival, with adequate notification from the field.
- The surgeon’s presence must be in compliance at least 80 percent of the time.
Similar to level I, level II also provides trauma prevention and continuing education programs for staff, incorporates comprehensive quality assessment, and participates in regional disaster management plans and exercises.
Level 3 (Level III) Trauma Center
Level III centers have agreements with level I or II trauma facilities as a backup for severely injured patients in cases such as multiple trauma.
Key Differences between Level II and Level III Trauma Centers:
Staffing and Resources
- Level II centers require 24/7 on-call coverage by in-hospital general trauma surgeons, specialists, and anesthesiologists, while level III facilities do not require in-hospital trauma surgeons or surgical specialists.
- A general/trauma surgeon and anesthesia and operating room personnel must be available within 30 minutes of being called.
- The surgeon’s presence must be in compliance at least 80 percent of the time.
Services
- Level III facilities focus more on resuscitation, initial stabilization, prompt assessment, and the transfer of complex cases to higher-level centers.
- Fall-related injuries and fractures are often treated at this level.
Level III facilities fill an important role in the broader trauma system by providing initial care, and deciding which patients require transfer to centers with greater capabilities.
Level 4 (Level IV) Trauma Center
Level IV centers are generally located in underserved or sparsely populated areas.
Key Differences with Level III
- Level IV does not have trauma surgeons or surgical specialists. These centers have 24/7 emergency services with a physician or a mid-level provider such as physician assistants (PAs), nurse practitioners (NPs), or advanced practice registered nurses (APRNs) on-site or on-call. A well-organized resuscitation team is important.
- A trauma nurse is immediately available.
- This level provides 24-hour emergency services, nursing care, and advanced trauma life support (ATLS) prior to transferring to a higher-level trauma center.
Level IV centers develop and periodically review collaborative treatment and transfer guidelines with input from higher-level trauma facilities in the region.
Level 5 (Level V)
A level V trauma center provides services similar to level IV, generally in remote rural areas, that may be available only on a part-time basis, such as a ski area clinic that is seasonal and open only during daylight hours. To provide optimal care, level IV and V facilities need to have institutional support, a dedicated and well-trained trauma team, appropriate equipment, and a structured performance improvement process.
Differences Between Level IV and Level V Trauma Centers
- At a level V center, a trauma-trained nurse is immediately available, and physicians are available when the patient arrives in the emergency room.
- These centers may not be open 24/7, but they have an after-hours response service.
This level provides care for the least complex cases and has the least infrastructure and professional resources. As part of the trauma system, it often provides the first emergency attention before transferring patients to level I-III facilities.
Emergency nurse practitioners (ENPs) are in high demand in trauma centers as well as in emergency departments, urgent care facilities, and critical access hospitals. They also earn the third highest salary in the nursing profession.
Adult vs Pediatric Trauma Centers
In 2020, there were 157 pediatric trauma centers (PTCs) in the U.S. (82 level I, 64 level II, 11 level III). Differences between adult and pediatric facilities at each level include the following:
Level I PTCs
- Volume of patients: Pediatric level I centers must admit at least 200 injured children under age 15 annually, whereas adult level I facilities must have a yearly volume of at least 1,200 trauma patients.
- Resources: A PTC level I requires a pediatric trauma service directed by a pediatric surgeon, pediatric specialists in various disciplines, and a separate pediatric ER and ICU.
Level II PTCs
- Volume of patients: Pediatric level II centers must attend at least 100 injured children annually, whereas the minimum number of patients in adult level II facilities varies.
- Resources: Pediatric level II facilities must meet the same resource requirements as adult trauma centers but with the corresponding pediatric specialties.
Level III PTCs
- Level III adult and pediatric trauma centers have similar capabilities focused on initial stabilization and transfer to higher-level facilities when needed.
In summary, the key differences are the pediatric-specific staffing, equipment, and volume requirements at levels I and II.
Designation vs Verification of Trauma Centers
State or regional authorities designate trauma centers and the ACS verifies that the facility has the resources available for the trauma patient, evaluating a facility's preparedness, resources, policies, and quality improvement process. The ACS delineates 108 specific criteria for verification, including the volume of trauma patients, continuous availability of specialty staff, and provider-to-patient ratios for every trauma center.
How are trauma centers designated? Authorities and administrators consider the characteristics of an area's patient population when determining the construction of new trauma facilities.
Are You Interested in Working in a Trauma Center?
Registered nurses (RNs) with trauma or emergency certifications can find jobs in trauma centers. The Board of Certification for Emergency Nursing (BCEN) and the Emergency Nurse Association (ENA) offer trauma specialty certifications such as Certified Emergency Nurse (CEN), Certified Pediatric Emergency Nurse (CPEN), Trauma Certified Registered Nurse (TCRN), Geriatric Emergency Nursing Education (GENE), or Emergency Severity Index. Find out more about this specialization in Nursa’s ER Nurse Specialty Guide.
As a whole, the trauma system is critical for reducing preventable deaths and disabilities, especially among younger populations, where injuries are the leading cause of mortality. To learn more, explore specialties like acute care or disaster response that support this life-saving work. In addition to trauma centers, you may be interested in investigating other types of facilities, such as rehabilitation facilities, hospitals, or home healthcare, where many nurses find worthwhile jobs.
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