A trauma care system is an organized and coordinated effort in a defined geographic area to deliver the full spectrum of care to an injured patient, from the time of the injury through transport to an acute care facility and to rehabilitative care (Eastman et al., 1991; Mendeloff and Cayten, 1991). A trauma care system consists of three major providers—prehospital, acute care, and rehabilitation—that, when closely integrated, ensure a continuum of care. For general descriptions of prehospital, acute, and rehabilitative care, see Box 6.1. This chapter concentrates on prehospital and acute care rather than rehabilitation because the latter was the subject of two recent Institute of Medicine (IOM) reports (IOM, 1991, 1997a).

In a trauma system, the integration of prehospital, acute care, and rehabilitation providers is administered by a public agency whose cardinal roles are to provide leadership, coordinate service delivery, establish minimum standards of care, designate trauma centers (offering 24-hour specialized treatment for the most severely injured patients), and ensure system evaluation and refinement. Trauma care systems are best endowed with the following major clinical or operational components: medical direction, prevention, communication, training, triage, prehospital care, transportation, hospital care, public education, rehabilitation, and medical evaluation (ACEP, 1992; HRSA, 1992; ACS, 1993). How these components are configured, organized, and emphasized differs according to state, regional, and local circumstances, as there are many examples of trauma systems throughout the United States.

An overarching goal of a trauma care system is to match the severity of the injury to the most appropriate and cost-effective level of care in a geographic region (ACEP, 1992; HRSA, 1992; ACS, 1993). Patient matching is thought to be accomplished best by an inclusive trauma care system (i.e., one that harnesses the resources of all hospitals and trauma care providers in a community or region to meet the needs of all injured patients, the majority of whom [85–90 percent] are not severely injured; ACS [1993]). Most existing trauma systems are "exclusive" in orientation insofar as they focus mostly on the major trauma patient. Exclusive systems do not include all area hospitals, only prehospital providers and trauma centers to which the major trauma patient is triaged. Trauma centers are hospitals that are specially designed to care for the most critically injured patients. There are four levels of trauma center designation (Box 6.2), the pinnacle of which is the Level I center. Inclusive trauma care systems incorporate all hospitals and acute care facilities in a region to deliver quality care for all injured patients, regardless of severity. Inclusive trauma care systems marshal communitywide resources, broaden the number of stakeholders, enhance surveillance capacity, and seek to avert the overburdening of trauma centers with non-critically injured patients for whom expensive trauma center care is unnecessary. An inclusive philosophy of trauma care was espoused by federal legislation, the Trauma Care Systems Planning and Development Act of 1990 (P.L. 101-590),

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