Last Updated on October 29, 2023
A trauma center is a hospital equipped to provide comprehensive emergency medical services to patients suffering from traumatic injuries. Trauma centers were established as the medical establishment realized that traumatic injuries often require complex and multi-disciplinary treatment, including surgery in order to give the victim the best possible chance for survival and recovery.
Trauma centers vary in their specific capabilities and are identified by “Level” designation: ( Level-I being the highest and Level-IV being the lowest).
Higher levels of trauma centers will have trauma surgeons available. Lower levels of trauma centers may only be able to provide initial care and stabilization of a traumatic injury and arrange for the transfer of the victim to a higher level of trauma care.
The American College of Surgeons Committee on Trauma classifies trauma centers as follows:
Level I Trauma Center
An in-house trauma team is available 24 hours a day. The facility can provide full resuscitation and definitive surgical care for all injured patients. Level I trauma centers are typically located in population-dense regions.
In addition to providing the highest level of clinical care, these centers have a commitment to training, research, and community outreach.
Level II Trauma Center
The level of clinical care available is very similar to that available at a Level I trauma center. An in-house trauma surgeon is not required but must be immediately available. Level II centers usually provide trauma care in regions where the population is less dense (e.g., suburban, rural).
Level III Trauma Center
These centers are often the initial contact for injured patients in rural areas. An in-house general surgeon is not required but must be available in a timely manner. In addition, higher-level subspecialists (e.g., neurosurgeons) are not required. Formalized transfer agreements with Level I/II trauma centers are central to providing optimum patient care in this environment.
Level IV Trauma Center
Physicians skilled in trauma management at the advanced trauma life support (ATLS)-level are available to begin resuscitation and evaluation of injured patients. Surgical resources may be limited and are not mandatory.
Level IV trauma centers are designed to stabilize injured patients in remote areas and most patients will require transfer.
Different Levels of Trauma Centers – Criteria for Designation
Outlined below are common criteria for Trauma Centers. 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).
Level I
Level I Trauma Center is a comprehensive regional resource. It is a tertiary care facility in which all types of trauma cases can be treated. A Level I Trauma Center is capable of providing total care for every aspect of injury – from prevention through rehabilitation.
Elements of Level I Trauma Centers Include:
- 24-hour in-house coverage by general surgeons, and prompt availability of care in specialties such as orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine, plastic surgery, oral and maxillofacial, pediatric and critical care.
- Referral resource for communities in nearby regions.
- Provides leadership in prevention, public education to surrounding communities.
- Provides continuing education of the trauma team members.
- Incorporates a comprehensive quality assessment program.
- Operates an organized teaching and research effort to help direct new innovations in trauma care.
- Program for substance abuse screening and patient intervention.
- Meets minimum requirement for annual volume of severely injured patients.
Level II
A Level II Trauma Center is able to initiate definitive care for all injured patients.
Elements of Level II Trauma Centers Include:
- 24-hour immediate coverage by general surgeons, as well as coverage by the specialties of orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, and critical care.
- Tertiary care needs such as cardiac surgery, hemodialysis, and microvascular surgery may be referred to a Level I Trauma Center.
- Provides trauma prevention and continuing education programs for staff.
- Incorporates a comprehensive quality assessment program.
Level III
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 backup care for rural and community hospitals.
- Offers continued education of nursing and allied health personnel or the trauma team.
- Involved with prevention efforts and must have an active outreach program for its referring communities.
Level IV
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. Trauma nurse(s) and physicians are 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.
Level V
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
- 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 , II or III Trauma Centers.
Trauma Team and Level of Responses
A pre-established response to injured patients is essential for the organized care of injured patients. This should be the protocol in spite of type of institutions.
In trauma centers, trauma teams consisting of attending physicians, residents, nurses, and ancillary personnel routinely respond.
In nondesignated hospitals, an established procedure should facilitate the evaluation and resuscitation process.
Levels of response have been established to mobilize personnel efficiently and effectively.
After the initial evaluation by emergency physician, a call for response is given whose level depends on the trauma patient and physician assessment.
Following response levels are known
Full Response or Level I Response
A level designed for patients who are physiologically unstable or who present with life- or limb-threatening injuries. It requires higher-level personnel (e.g., anesthesiologist, trauma surgeon, etc).
Level Two Response
This level is intended for patients with normal prehospital physiology, but with potentially serious injury based on the mechanism of injury.
In some institutions, emergency physicians are the primary physicians for this level of response.
Level III Response or Trauma Consult
These patients have typically sustained a low-energy mechanism of injury and present with normal physiologic parameters.
Their evaluation is usually completed by the emergency physician with no formalized team mobilization required.
After the initial workup is complete, a referral is made to the trauma surgeon or the appropriate surgical subspecialist for further evaluation.
Trauma Resuscitation Area
A dedicated space for trauma resuscitation is recommended in the trauma centers where a substantial load of trauma is dealt with on daily basis. The size of the area largely depends on the volume and acuity of trauma managed.
The trauma resuscitation area should be adjacent but physically separate from the general casualty. Maintaining separate access and a dedicated area facilitates security and minimizes disruption to the main casualty while allowing the trauma team to focus on trauma resuscitation and care.
Naturally, the access to any non-essential personnel should be limited. A convenient access to the radiology suite, operating room, and intensive care unit is ideal. If loads are higher, access to plain radiography and computed tomography should be located within the trauma resuscitation area.
Sufficient room lighting and an overhead operating room light for each trauma stretcher are must. Monitoring equipment, suction, and gases should be mounted above the patient on fixed columns or movable overhead booms. The ceiling mounts should be higher than the height of tallest members.
The space must be capable of accommodating the full trauma team, necessary equipment without causing any discomfort to the care personnel.
It should allow for the performance of the following emergency procedures
- Endotracheal intubation
- Cricothyroidotomy/surgical airway
- Insertion of central venous catheters
- Thoracostomy
- Placement of urinary catheters
- Resuscitative thoracotomy
- Diagnostic peritoneal lavage
- Splinting of fractures