Level Headed: Choosing a Trauma Center

Your local hospital just got their Level III trauma center designation and verification. As a medic in the area, do you take all of your trauma patients to this new trauma center? This is a constant dilemma amongst EMS providers. The answer is usually not black and white, so it takes some serious critical thinking on the part of the medic on scene to appropriately make that decision. Let’s consider a scenario: 49 y/o/m involved in a head-on MVC. The patient is alert and orientated, but has an open femur fracture and bruising on the abdomen and chest consistent with “seat belt sign”. Extrication time was approximately 30 minutes. What do you do? Do you transport the patient to the Level III trauma center that is 10 minutes away, do you drive them to the Level I trauma center that is 50 minutes away, or do you call the nearest helicopter to the scene to expedite transport to the Level I trauma center? It can be a difficult decision, because it directly impacts your patient’s morbidities and overall mortality.

Starting out in EMS, I must admit that I was unaware what the different trauma centers had to offer. I was under the assumption that if they were a trauma center, they can handle any trauma no matter what their designation might be. Knowing what I know now, I can safely say that this is not the case. Trauma center designation varies from state to state, and it is regulated by state and local processes. The American College of Surgeons (ACS) verifies trauma centers through a 3 year voluntary process. The ACS does not designate, but it verifies the resources needed to meet minimum guidelines. “These include commitment, readiness, resources, policies, patient care, and performance improvement.” The ACS verifies 5 different levels of trauma centers. Listed below are some common criteria the ACS have listed on the American Trauma Society website for Level I through Level III:

Level I

Level I trauma center is a comprehensive regional resource that is a tertiary care facility central to the trauma system. 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 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.

Most of us know that Level I trauma centers provide the highest level of services and resources for trauma care. As you can see, the criteria moves down from there.  Is there a decision-making tool that can assist medics in determining which patients need to go to a certain level of trauma center in their system?  Yes! The Centers for Disease Control (CDC) collaborated with the ACS and developed guidelines for which trauma patients should be taken to a Level I center or the highest level trauma center available in their area.  Below are the guidelines that were developed and updated in 2011. The CDC also has an app available on iTunes that guides you down the triage tree.

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Believe it or not, some EMS crews in my local area do not have a choice in the matter. There are several county EMS agencies here that are not allowed to call for a helicopter or bypass the local Level III trauma center. All minor AND major traumas have to go to the Level III center in their county, or they will be reprimanded. This is usually based on the assumption that Level III centers are not that much different when compared to Level I’s and II’s. As you can see, this is far from the truth. Deciding which level trauma center to transport to can directly affect your patient’s outcome. Study after study demonstrates improved mortality rates for trauma patients taken to Level I centers as opposed to Level II’s and III’s. Norwood, Cook, and Berne concluded that mortality rates decreased from 51% to 31% for major torso vascular injuries when taken to a Level I instead of a Level II. Dubs et al. looked at 16,037 severe isolated head trauma patients taken to a Level I versus a Level II. They found that patients taken to a Level II had a higher mortality rate of 13.9% compared to 9.6% of patients taken to a Level I. Demetriades et al. looked at 130,154 trauma patients from 256 trauma centers and concluded that severely injured patients had “considerably better outcomes” when treated at a Level I center compared to a Level II. The evidence continues to show that patients treated at a Level I trauma center have considerably fewer complications, higher survivability, and better functioning outcomes when compared to the other levels.

Our main goal for any severely injured trauma patient is to get them to the highest level of definitive care in the shortest amount of time; whether by ground or by air. As a medic on the street, you must take all of this into consideration when deciding where and how to transport your trauma patients.


American Trauma Society. (n.d).  Trauma Centers Levels Explained. Retrieved from http://www.amtrauma.org/?page=traumalevels

Demetriades, D., Martin, M., Salim, A., Rhee, P., Brown, C., Doucet, J., & Chan, L. (2006, June). Relationship Between American College of Surgeons Trauma Center Designation and Mortality in Patients with Severe Trauma (Injury Severity Score > 15). Journal of the American College of Surgeons, 202, 212-215, https://doi.org/10.1016/j.jamcollsurg.2005.09.027

Dubose, J. J., Browder, T., Inaba, K,. Teixeira, P.G., Chan, L.S., & Demetriades, D. (2008, December). Effect of trauma center designation on outcome in patients with severe traumatic brain injury. Archives of Surgery,143, 1213-1217. doi: 10.1001/archsurg.143.12.1213

Guyette, F. X., & Cone, D. C. (2016, October 16). Prehospital and Air Medical Care. Retrieved from https://aneskey.com/prehospital-and-air-medical-care/

Norwood, S., Cook, A.D., & Berne, J.D., (2011, January). Level I verification is associated with a decreased mortality rate after major torso vascular injuries. The American Surgeon, 77(1), 32-37.

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