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Definition/Introduction

In the United States, trauma centers are assigned levels through a designation and verification process. Designation criteria vary by state, and the process is managed by state or regional authorities rather than healthcare organizations.[1] Trauma center levels I to V reflect available resources for treating patients with traumatic injuries. A level I trauma center provides the highest level of care for severe injuries, whereas centers designated levels IV and V stabilize patients before transferring them to higher-level facilities. Designation differs between adult and pediatric trauma centers.

The American College of Surgeons (ACS) evaluates and verifies trauma centers to improve trauma care. Unlike designation, ACS verification confirms that a facility meets resource and operational standards for patients with traumatic injuries. The ACS assesses a center’s preparedness, policies, resources, and quality improvement processes, granting verification for 3 years.[2]

Issues of Concern

Trauma centers are verified as adult or pediatric facilities. Hospitals may have different designation levels for adult and pediatric populations. The ACS verifies trauma centers based on specific criteria, as explained below.

A level I trauma center is a tertiary care hospital that provides comprehensive care from initial injury through rehabilitation. The requirements for this kind of facility include the following:

• 24-hour in-hospital access to general surgeons
• Specialty availability, including anesthesia, emergency medicine, intensive care unit (ICU), neurosurgery, orthopedic surgery, radiology, ophthalmology, and geriatric care
• Surgical expertise in cardiothoracic, vascular, hand, plastic, obstetric and gynecologic, otolaryngologic, and urologic surgery
• Referral center for community hospitals that require specialized trauma care
• Public health initiatives, including injury prevention programs
• Ongoing education for all professionals involved in trauma care
• Quality monitoring and improvement efforts
• Teaching and research in trauma management
• Identification and intervention for polysubstance use
• Mental health screening for individuals with traumatic injuries
• Minimum annual patient volume, treating at least 1,200 trauma cases or 240 patients with an Injury Severity Score (ISS) over 15
• Pediatric requirement, with level I pediatric trauma centers treating at least 200 trauma patients under 15 years of age annually

A level II trauma center provides initial treatment for all trauma cases, with the ability to stabilize and transfer patients requiring more specialized care. Requirements for such facilities include the following:

• 24-hour access to general surgeons
• Specialty availability, including anesthesia, emergency medicine, ICU, neurosurgery, orthopedic surgery, radiology, ophthalmology, and geriatric care
• Surgical expertise in cardiothoracic, vascular, hand, plastic, obstetric and gynecologic, otolaryngologic, and urologic surgery
• Coordination with level I trauma centers for specialized care when needed
• Ongoing education for all professionals involved in trauma care
• Quality monitoring and performance improvement programs

A level III trauma center provides prompt assessment, management, surgery, and stabilization for patients with traumatic injuries. Key components include the following:

• 24-hour access to emergency medicine physicians
• Availability of general surgeons, anesthesia, ICU, and orthopedic surgery
• Quality monitoring and improvement programs
• Transfer agreements for patients requiring a higher level of care
• Support for outlying hospitals, providing backup care when needed
• Continuing education for all trauma care team members
• Community outreach programs focused on traumatic injury prevention

A level IV trauma center delivers Advanced Trauma Life Support (ATLS) before transferring patients to a higher level of care. Requirements for these centers include the following:

• Emergency department capable of implementing ATLS protocols
• Availability of on-call nurses and physicians upon patient arrival
• Surgical and intensive care services, when available
• Transfer agreements for patients needing advanced trauma care
• Quality monitoring and improvement initiatives
• Community outreach programs focused on traumatic injury prevention

A level V trauma center provides initial evaluation, stabilization, and transfer coordination for patients needing advanced care. Essential components include the following:

• Emergency department capable of implementing ATLS protocols
• Availability of on-call nurses and physicians upon patient arrival
• After-hours protocols if the facility is not open round-the-clock
• Surgical and intensive care services, when available
• Transfer agreements to ensure timely access to higher-level trauma care

Trauma center designation ensures that patients receive appropriate care based on the severity of their injuries and the facility’s available resources. Each level plays a distinct role within the trauma system, from initial stabilization to comprehensive treatment and rehabilitation.[3]

Clinical Significance

Research indicates that trauma management at a designated trauma center leads to better outcomes than care at a nondesignated facility.[4][5] Receiving treatment at a designated trauma center significantly reduces mortality risk following traumatic injury.[6][7][8][9] Telehealth has been proposed as a strategy to enhance trauma care access in rural areas. Peer-to-peer telehealth consultations may help prevent early trauma-related deaths and minimize unnecessary transfers for low-acuity injuries.[10]

Nursing, Allied Health, and Interprofessional Team Interventions

Approximately 80% of medical errors stem from inadequate communication, particularly in high-risk environments such as trauma facilities. Strengthening interprofessional teamwork involves enhancing communication, fostering shared responsibility, promoting collective decision-making, and ensuring a clear understanding of team member roles.[11]

Review Questions

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References

1.

American College of Surgeons Committee on Trauma. Statement on trauma center designation based upon system need.Bull Am Coll Surg.2015 Jan;100(1):51-2. [PubMed: 25626271]

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 (Baltimore).2019 Jun;98(25):e16133. [PMC free article: PMC6636922] [PubMed: 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.J Trauma Acute Care Surg.2016 Oct;81(4):735-42. [PubMed: 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.J Public Health (Oxf).2018 Dec 01;40(4):848-857. [PMC free article: PMC6306086] [PubMed: 29190373]

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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.J Am Coll Surg.2017 Aug;225(2):194-199. [PubMed: 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.N Engl J Med.2006 Jan 26;354(4):366-78. [PubMed: 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?J Am Coll Surg.2012 Sep;215(3):372-8. [PubMed: 22632909]

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. [PubMed: 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).J Am Coll Surg.2006 Feb;202(2):212-5; quiz A45. [PubMed: 16427544]

10.

Hashmi ZG, Park C., American College of Surgeons Committee on Trauma Teletrauma Spotlight Session Workgroup. Using Teletrauma to Improve Access to Trauma Care in the US: A Call for Action.J Am Coll Surg.2025 Feb 01;240(2):212-219. [PubMed: 39268968]

11.

Courtenay M, Nancarrow S, Dawson D. Interprofessional teamwork in the trauma setting: a scoping review.Hum Resour Health.2013 Nov 05;11:57. [PMC free article: PMC3826522] [PubMed: 24188523]

Disclosure:Alison Southern declares no relevant financial relationships with ineligible companies.

Disclosure:Daniel Celik declares no relevant financial relationships with ineligible companies.

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