FOREWORD: Function and Characteristics of a Level 1 Trauma Center in the Emergency Department

By James CarlsonHealth Humanities, Special Issue: ER Observations, 2019



In this foreword to observation articles by Barnette, Burri, Chandler, Joyner, Luterman, Piekarski, and Zheng, James Carlson goes through the history and characteristics of Level I Trauma Centers, which provide the highest quality care possible and take in the most injured patients.

Unintentional traumatic injury is the third leading cause of death in the United States behind cancer and heart disease (Murphy, Xu, Kochanek, Arias, 2018), and the leading cause of death for people under 44 (Faul et al., 2014, p. 9). Every year, thousands of people require emergency medical treatment following severe injury. According to the U.S Department of Health and Human Services’ National Hospital Ambulatory Medical Care Survey (2015), there were over 130,000 visits to American emergency departments in 2015. 57,000 (2015) of those 130,000 visits, more than 40%, resulted in admission to verified trauma centers (U.S. Department of Health and Human Services, 2015, p. 3). Each one of those 57,000 trauma center admissions represents a bone broken by a fall, an organ contusion sustained in a vehicle accident, or any of the other, virtually infinite, possible injuries a person can experience. The very worst of those cases, those involving grievous, life-threatening injuries or complicated damage requiring uncommon expertise and advanced equipment to treat, must be taken by the medical professionals who work in the specialized trauma centers that receive the highest rating possible: Level I. This rating indicates that the facility is able to provide the highest quality of care to a large number of patients and provide that care from the time of admission through to rehabilitation.

The primary objective of all trauma centers is to provide treatment of injury in order to minimize the injury’s impact on the patient’s life, however not all trauma centers are designed, equipped, or staffed to treat the same injuries (American Trauma Society, n.d.). The level designation of a trauma center sets it apart from other, similar facilities and indicates the extent to which it is prepared to treat various types and degrees of trauma, as well as the volume of patients it is prepared to treat. Trauma center designations range from Level V, the lowest, up to Level I. Level I trauma centers are extremely well-equipped, well-funded, and well-staffed. In contrast, trauma centers that are classified as Level V only have the most basic emergency medical resources at their disposal. They are meant to treat relatively minor injuries and serve primarily as short-term immediate care facilities that can evaluate and stabilize patients, and, if necessary, prepare them for transport to higher-level trauma centers. Some of these low-level facilities have minimal critical care capabilities, but they cannot provide immediate specialist treatment or adequate, long-term care (American Trauma Society, n.d.). The purpose of a Level I trauma center is to provide what most hospitals and low-level centers cannot: total care and comprehensive treatment of patients with all forms of injury and at all stages of recovery

Prior to the 1970s, a decade that saw such breakthroughs in injury prevention as the bicycle helmet, there was no official means of categorizing a trauma center based on its capabilities. This caused difficulties in ensuring that injured patients were administered the proper care. In 1976, the American College of Surgeons (ACS) released a manual titled Optimal Hospital Resources for the Injured Patient, a set of instructions that set the standard for hospital operation (American College of Surgeons, n.d.). During that time, the ACS also developed a level designation system to be applied to trauma hospitals, and in the 1980s, the ACS Level Verification Review Committee began working to review hospitals that sought to gain the status of a trauma center with a verified level designation. The ACS still reviews hospitals, granting level verifications appropriate to the facility’s resources, and many trauma centers have accepted the designation, creating a unified and organized system with fixed standards. This allows medical professionals to quickly and easily determine the best course of action for the patient with consideration of the abilities of available facilities (American College of Surgeons, n.d.).

For a designated Level I trauma center to operate in compliance with ACS standards, the facility and its staff must have access to an extremely wide variety and large quantity of specialized resources. Shifts of general surgeons and emergency physicians, as well as a compliment of nurses, must be constantly available for a trauma center to retain its Level I status, and a wide variety of specialists, including anesthesiologists, radiologists, cardiologists, maxillofacial surgeons, and many more, must be on call and readily available. Doctors and nurses must undergo ongoing education in order to stay up-to-date with medical advancements, and hospital administration must implement quality assessment programs that ensure patients receive the best care possible. Level I trauma centers also facilitate research and provide important resources for the advancement of medical science. Many of these centers are teaching hospitals that are connected to university systems (American Trauma Society, n.d.). A Level-I trauma center is also a vital component of a region’s medical system, often serving a large area that might span multiple cities and many lower-level trauma centers, providing not only 24-hour emergency and critical care, but also tertiary care, inpatient and outpatient rehabilitation, and education programs to increase public awareness of injury prevention practices (American Trauma Society, n.d.).

Due to the operational expense of large hospitals, limitations of medical resources and equipment, and a finite number of medical specialists, a large region may have only a single Level-I trauma center. Since population density is highest and resources are most available in urban areas, most large trauma centers are located in or near cities, where the number of injuries per square mile is highest and the infrastructure is most able to handle the center’s logistical needs. According to Hsia and Shen (2011), This creates a problem with access to trauma care for those living far away from large urban centers, as well as people who live in cities without a verified Level I trauma center. Those in disadvantaged communities, impoverished persons, and the uninsured also have restricted access to trauma centers. People who live in rural areas are particularly affected by limited access to high-level trauma care. In the case of an injury severe enough to require the specialized emergency care of a Level I trauma center, the extra minutes required for an ambulance to reach a remote location and transport the injury victim to a care facility, or a moment of hesitation due to the possible financial repercussions of contacting emergency services, might cost the patient his or her life or diminish the patient’s ability to recover (2011). Additionally, those living farther from a trauma center are less able to take advantage of specialist care, outpatient rehabilitation services, and public education programs offered by their region’s Level I trauma center. Compounding the problem of reduced access for certain groups is the fact that many trauma centers across the US have closed in recent decades. In 1990, there were 1125 trauma centers in the United States (2011). By 2005, 339 of those trauma centers had closed, and between 2001 and 2007, 69 million individuals, nearly a quarter of the United States population, faced an increase in travel time from home to the nearest trauma center, with 16 million facing an increase of 30 minutes or more (Hsia & Shen, 2011, p. 1-6). Additionally, Hsia and Shen found that hospitals, including those designated as trauma centers, are less likely to remain open if they are near disadvantaged communities, meaning that closures disproportionately affect individuals who are already vulnerable (2011, p.1). The closure of a single Level-I trauma center also has major effects on nearby medical facilities. From 1999 to 2009, following the closure of the Martin Luther King Jr. Hospital in Los Angeles, California, admissions to other Los Angeles trauma centers increased significantly to redistribute the closed hospital’s patient load, a total of 37,131 patients. Those patients were mainly from disadvantaged, impoverished communities with a high percentage of uninsured. In one Los Angeles trauma facility, admissions of uninsured patients increased to 44.6% from 12.9% (Hsia & Shen, 2011). Improving access to trauma centers is a main objective of the Healthy People 2020 initiative, which was launched by the United States Department of Health and Human Services in 2010 as part of a decades-long, ongoing effort to improve the health of all US citizens (Healthy People 2020, 2015). This goal has been partially accomplished by opening new facilities to replace those that have closed. From 2012 to 2016, 117 Level I and Level II trauma centers opened in the US, and funding for trauma centers has increased, somewhat relieving the pressure on older and less well-equipped facilities (Johnson, 2015).

The Department of Health and Human Services has taken measures to fix the broad issues in the medical system, but Level I trauma centers themselves must work continually to improve internal conditions for both care providers and patients. As the foremost in emergency medicine, as well as critical and long-term care, Level I trauma centers face unique challenges. They are also, however, subject to some of the more common problems associated with emergency services, only on a larger scale. Emergency rooms have been described as “interrupt-driven” working environments (Brixey et al., 2008, p. 1). The ever-changing demands of an emergency department rarely allows the doctors and nurses to maintain a smooth workflow or perform a task from start to finish, although the interrupted tasks are usually completed after the interruption has been resolved. It is accepted by US government agencies and organizations devoted to patient safety that interruptions increase the risk of error. Mitigating the impact of interruptions in a facility dedicated to responding to life-threatening emergencies, however, is a difficult and complicated task. In recent decades, technological advancement has further complicated that task. In 2008, for instance, it was found that pagers and cellphones, which had been accepted as a means to increase emergency room effectiveness, also created a source of interruptions (Brixey et al., 2008).

Brixey et al.’s study emphasizes the impact of a small amount of time wasted by an interruption and demonstrates the importance of time and personnel management to the operation of a Level I trauma center. Severe injuries require the doctors and nurses of a trauma center emergency department to be diligent and prepared to respond as quickly as possible in order to spare the injury victim as much suffering as possible. Finding and implementing new methods of working in a trauma center emergency department is necessary to reduce patient waiting time and improve treatment outcomes. Open fractures are a relatively common injury in Level I trauma center emergency departments, and their treatment can be complicated, often requiring multiple specialists (Johnson, Goodman, Haag, and Hayda, 2017). These kinds of fractures have a high likelihood of causing long-term complications, and that likelihood increases with the period of time that passes before the patient is administered antibiotics. Johnson et al. (2017) found that a new, multidisciplinary approach to the treatment of open fractures resulted in a significantly reduced time between admission and administration of antibiotics compared to the previous method of treatment. This research, conducted in a Level-I trauma center, proves that there is room for improvement, and could provide a model for the treatment of open fractures as well as other time-sensitive injuries (Johnson et al., 2017).

The advancement of medical science has uniquely benefited Level-I trauma centers by decreasing the mortality rates of critically injured patients. Due to the severity of the injuries they treat and their ability to provide long-term care, Level I trauma centers typically have high patient mortality compared to other hospitals. Between 2003 and 2009, implementation of new standard operating procedures caused a decrease in 28-day mortality, from 22% to 11% (Cuschieri, Ozrazgat-Baslanti, Wang, Ghita, Loftus, Stortz, . . . Brakenridge, 2017, p. 2). This higher rate of patient survival, however, has resulted in an increased rate of patients entering a state of chronic critical illness which involves extended or repeated need of intensive care and prolonged organ dysfunction. Chronic critical illness usually results in very poor outcomes after discharge, and a decreased quality of life (Cushieri et al., 2017).

Level-I trauma centers stand at the forefront of medical science. They represent the frontier, the cutting edge of research and practice, as well as a stronghold for the thousands who find themselves suddenly desperate. They treat the very worst of injuries with the very best minds and the very best technology, and they are constantly improving to ensure that they are best able to treat those who depend on the services they provide. In being the best and doing the most to provide comprehensive treatment, Level I trauma centers are unique, and so the challenges faced by the doctors and nurses who keep them running are also unique. Our trauma system, however, is subject to the issues that permeate the society it keeps safe. A Level I trauma center functions best when the people it serves are able to make use of its services and aware of how it is serving them. In the following articles, Burri, Barnette, Joyner, Chandler, Luterman, Piekarski, and Zheng explore the characteristics of a Level I trauma center and the function it performs in the medical system.



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James Carlson