Trauma center organization and verification for current therapy of trauma and surgical critical care

Trauma system organization

The optimal trauma care system is an inclusive network of injury care facilities that operate under the premise to get the right patient to the right hospital in the right amount of time in order to receive the right care. It is incumbent upon trauma systems to utilize a patient-centered approach to limit death and disability from injury through efforts directed toward prevention, improved access to care, and improved quality of care. Trauma system organization is highly variable contingent upon trauma center resources and the injury care needs of the population in a given geographic area. In general, trauma system resources tend to be concentrated in areas of higher patient volume and acuity. At the highest tier of the system organization is the Level I trauma center. Most Level I facilities are located within major urban environments and also function as tertiary referral centers within the inclusive trauma system. These centers foster the development of trauma system infrastructure elements including trauma leadership, professional resources, information management, performance improvement, research, graduate medical education, outreach, and advocacy. By virtue of their inherently academic disposition, Level I centers generally serve as a regional trauma system resource for injury care. In addition, due to their size and resourcing, most are capable of managing large numbers of injured patients and have immediate availability of in-house trauma surgeons and ancillary trauma service teams.

Similar to the Level I center, Level II trauma centers tend to be located in communities with higher population density. The Level II centers are held to very similar resource and care standards as the Level I facilities with the exception that the verification of Level II trauma centers is not contingent upon having a graduate medical education program, research capacity, education, or specific volume requirements. In order to highlight the trauma center resource density, it has been reported that 35% of the land mass, inclusive of nearly 90% of the population of the United States, is within 60 minutes of a Level I or Level II trauma center via ground or aeromedical evacuation system. The benefit of this concentration of resources manifest by Level I and II trauma centers has been demonstrated in the context of the association between trauma center volumes and trauma patient outcomes in which trauma center volume is directly associated with decreased average length of stay and improved patient mortality after injury. Recent epidemiological studies of trauma patients show that the risk of death is significantly lower when care is provided in a trauma center rather than in a non–trauma center, which supports continued efforts at injury care regionalization. It has also been demonstrated that more severely injured patients with an injury severity score of >15 have better mortality rates when treated at Level I trauma centers as compared with lower tier centers.

The Level III trauma centers constitute the vast majority of trauma centers and are the last level of fully functional injury care. Level III centers must have the capability for provision of 24-hour immediate coverage by emergency medicine physicians and the prompt availability of general surgeons and anesthesiologists. At Level III facilities, most injuries can be managed from resuscitation through operation and to rehabilitation. Level III facilities have the capacity to resuscitate, stabilize, and transport more severely injured patients to a higher level of definitive care.

Level IV trauma centers are not ubiquitous across the United States and are generally located in rural environments with a paucity of resuscitative and surgical resources. At the most basic level these facilities must have basic emergency department facilities in which to implement Advanced Trauma Life Support protocols and a trauma nurse(s) and physicians available upon patient arrival. The main capability for these hospitals is the recognition of injury and initial care phase. Due to their lack of acute injury care resources, many of these facilities have standing interfacility transfer agreements within the trauma system.

Trauma center organization

The development and success of a trauma center is contingent upon three basic building blocks: hospital administrative and financial support, trauma program, and medical staff support. First, the hospital and its leadership must have a firm administrative and financial commitment to the development of a trauma center including incorporating the program into the formal organizational structure at a point commensurate with other clinical care departments of equal stead. Within this organizational structure, the trauma program must have the authority and latitude to accomplish its requisite programmatic goals and objectives as defined by the optimal resources guidance. Comprehensive administrative support must include funding of the trauma program commensurate with the appropriate level of personnel, education support, and community outreach. The second foundation of trauma center development is medical staff support exhibited as thorough professional support, including specialty care services, encumbered by the care of the trauma patient.

The essential components of injury care within a trauma center include the trauma team, the trauma service, and the trauma program, which has the ultimate responsibility for the entire trauma center. The trauma team consists of the provider and ancillary support personnel that respond to emergency department trauma activations. Levels of response are guided by patient acuity and level of trauma center resources. Higher patient acuity in trauma centers with more robust resources, as in Level I and II trauma centers, encumbers a response from the general/trauma surgeon, emergency physician, anesthesia, resident trainees, trauma/emergency nursing, respiratory therapy, radiology technician, blood bank representative, security, and spiritual counsel. The team leader is the surgeon who is ultimately responsible for the patient’s disposition and care, but more importantly, all members of the team work together to effect optimal patient care according to guidelines set for by the optimal care document. The trauma service maintains the clinical responsibility for maintaining continuity of care in the multidisciplinary environment. In higher-tier trauma centers, the trauma service is often a formal clinical service or services under the guidance of trauma staff surgeons.

The trauma program within a trauma center is a multidisciplinary effort that transcends normal organizational hierarchy in order to foster inclusion and transparency, which supports injury care from prehospital care and resuscitation through rehabilitation. Integral staff elements within the trauma program are the trauma medical director, trauma surgeon staff, physician specialty staff (orthopedics, neurosurgery, emergency medicine, anesthesia, radiology), trauma program manager/trauma nurse coordinator(s), and trauma registrar(s). The key processes that distinguish a trauma center’s operations are performance improvement and multidisciplinary peer review.