A trauma center is a hospital equipped to provide comprehensive emergency medical services to patients suffering traumatic injuries. Trauma centers grew into existence out of the realization that traumatic injury is a disease process unto itself requiring specialized and experienced multidisciplinary treatment and specialized resources.
According to the CDC, injuries are the leading cause of death for children and adults ages 1–44.[1]
The leading causes of trauma are motor vehicle accidents, falls, and assaults.
In the United States, a hospital can receive Trauma Center verification by meeting specific criteria established by the American College of Surgeons (ACS) and passing a site review by the Verification Review Committee.[2] Official designation as a Trauma Center is determined by individual state law provisions. Trauma centers vary in their specific capabilities and are identified by "Level" designation: Level-I (Level-1) being the highest, to Level-III (Level-3) being the lowest (some states have five designated levels, in which case Level-V (Level-5) is the lowest).
Higher levels of trauma centers will have trauma surgeons available, including those trained in such specialties as Neurosurgery and Orthopedic surgery[3] as well as highly sophisticated medical diagnostic equipment. Lower levels of trauma centers may only be able to provide initial care and stabilization of a traumatic injury and arrange for transfer of the victim to a higher level of trauma care.
The operation of a trauma center is extremely expensive. Some areas are under-served by trauma centers because of this expense (for example, Harborview Medical Center in Seattle is the only Level I trauma center to serve the entirety of Washington, Idaho, Montana, and Alaska).[4] As there is no way to schedule the need for emergency services, patient traffic at trauma centers can vary widely. A variety of different methods have been developed for dealing with this.
A trauma center will often have a helipad for receiving patients that have been airlifted to the hospital. In many cases, persons injured in remote areas and transported to a distant trauma center by helicopter can receive faster and better medical care than if they had been transported by ground ambulance to a closer hospital that does not have a designated trauma center. The trauma level certification can directly affect the patient's outcome and determine if the patient needs to be transferred to a higher level trauma center.
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The concept of a trauma center was developed at the University of Maryland, Baltimore, in the 1960s and 1970s by heart surgeon and shock researcher R Adams Cowley, who founded what became the Shock Trauma Center in Baltimore, Maryland, in 1961.[5] Cook County Hospital in Chicago, Illinois claims to be the first trauma center (opened in 1966) in the United States.[6] Dr. David R Boyd interned at Cook County Hospital from 1963-1964 before being drafted into the United States Army. Upon his release from the Army, Dr. Boyd became the first shock-trauma fellow at the Shock Trauma Center from 1967-1968. Dr. Boyd returned to Cook County Hospital, where he went on to serve as resident director of the Cook County Trauma Unit.[7]
In the United States, trauma centers are ranked by the American College of Surgeons (ACS), from Level I (comprehensive service) to Level III (limited-care). The different levels 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. Level I and Level II designations are also given adult and or pediatric designations.[8] Additionally, some states have their own trauma-center rankings separate from the ACS. These levels may range from Level I to Level IV. Some hospitals are less-formally designated Level V.
The ACS does not officially designate hospitals as trauma centers. Numerous U.S. hospitals that are not verified by ACS claim Trauma Center designation. Most states have legislation which determines the process for designation of Trauma Centers within their state. The ACS describes that responsibility as "a geopolitical process by which empowered entities, government or otherwise, are authorized to designate." The ACS's self-appointed mission is limited to confirming and reporting on any given hospital's ability to comply with the ACS standard of care known as Resources for Optimal Care of the Injured Patient.[9]
The Trauma Information Exchange Program (TIEP) is a program of the American Trauma Society in collaboration with the Johns Hopkins Center for Injury Research and Policy and is funded by the Centers for Disease Control and Prevention. TIEP maintains an inventory of trauma centers in the U.S., collects data and develops information related to the causes, treatment and outcomes of injury, and facilitates the exchange of information among trauma care institutions, care providers, researchers, payers and policy makers.
Note: A trauma center is a hospital that is designated by a state or local authority or is verified by the American College of Surgeons.[10]
A Level I Trauma Center provides the highest level of surgical care to trauma patients. Being treated at a Level I Trauma Center increases a seriously injured patient’s chances of survival by an estimated 20 to 25 percent.[11] It has a full range of specialists and equipment available 24 hours a day[12] and admits a minimum required annual volume of severely injured patients. A Level I trauma center is required to have a certain number of surgeons, emergency physicians and anesthesiologists on duty 24 hours a day at the hospital, an education program, and preventive and outreach programs. Key elements include 24-hour in-house coverage by general surgeons and prompt availability of care in varying specialties—such as orthopedic surgery, neurosurgery, plastic surgery (plastic surgeons often take calls for hand injuries), anesthesiology, emergency medicine, radiology, internal medicine, oral and maxillofacial surgery (trained to treat injuries of the facial skin, muscles, bones), and critical care—which are needed to adequately respond and care for various forms of trauma that a patient may suffer. Additionally, a Level I center has a program of research, is a leader in trauma education and injury prevention, and is a referral resource for communities in nearby regions.[13]
A Level II trauma center works in collaboration with a Level I center. It provides comprehensive trauma care and supplements the clinical expertise of a Level I institution. It provides 24-hour availability of all essential specialties, personnel, and equipment. Minimum volume requirements may depend on local conditions. These institutions are not required to have an ongoing program of research or a surgical residency program.
A Level III trauma center does not have the full availability of specialists, but does have resources for emergency resuscitation, surgery, and intensive care of most trauma patients. A Level III center has transfer agreements with Level I or Level II trauma centers that provide back-up resources for the care of exceptionally severe injuries, Example: Rural or Community hospitals.[13]
A Level IV trauma center exists in some states where the resources do not exist for a Level III trauma center. It provides initial evaluation, stabilization, diagnostic capabilities, and transfer to a higher level of care. It may also provide surgery and critical-care services, as defined in the scope of services for trauma care. A trauma-trained nurse is immediately available, and physicians are available upon the patient's arrival to the Emergency Department. Transfer agreements exist with other trauma centers of higher levels, for use when conditions warrant a transfer.[13][14]
Provides initial evaluation, stabilization, diagnostic capabilities, and transfer to a higher level of care. May provide surgical and critical-care services, as defined in the service's scope of trauma-care services. A trauma-trained nurse is immediately available, and physicians are available upon patient arrival in the Emergency Department. If not open 24 hours daily, the facility must have an after-hours trauma-response protocol.
A facility can be designated an adult Trauma Center, a pediatric Trauma Center, or an adult & pediatric Trauma Center. If a hospital provides trauma care to both adult and pediatric patients, the Level designation may not be the same for each group. For example, a Level 1 adult Trauma Center may also be a Level 2 pediatric Trauma Center. This is because pediatric trauma surgery is a specialty unto itself. Adult trauma surgeons are not generally specialized in providing surgical trauma care to children, and vice versa, and the difference in practice is significant.
There is one Trauma Center in the country which is designated at a Level above a Level 1 Trauma Center. The R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center is the only hospital in the world dedicated to trauma care alone. It is a free-standing, self contained, trauma hospital which accepts only patients with traumatic injuries, or patients in need of hyperbaric medicine such as smoke inhalation or carbon monoxide poisoned patients, or those with Necrotizing fasciitis (gangrene, also known as the 'flesh eating bacteria'). Shock Trauma, as it is known, carries the designation of Primary Adult Resource Center in the state of Maryland and provides a level of care above that found even in Level 1 Trauma Centers. It is also the state Neurotrauma (brain and spinal cord injury) center.
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