BOX 6.2 Levels of Trauma Centers

Trauma centers are acute care facilities that are specially designed to care for the most critically injured patients. There are four types—or levels—of trauma centers, the qualifying criteria for which were established by the American College of Surgeons (ACS, 1993):

  • Level I—A facility that meets criteria for a Level I trauma center has the highest degree of sophistication in treating the most severely injured patients. A Level I trauma center is a regional tertiary care facility required to have immediate availability of specialized surgeons, anesthesiologists, physician specialists, nurses, and resuscitation equipment. It also is required to conduct certain types of prevention and research activities.

  • Level II—A facility that meets a Level II trauma center designation satisfies virtually all of the same clinical and facilities requirements as the Level I center, but is not required to conduct research and certain types of prevention activities. Most cities and suburban areas have Level I and/or II centers.

  • Level III—A facility that meets a Level III trauma center designation is required to have emergency services and the availability of general surgeons, but it is not required to meet the extensive clinical and facilities criteria of a Level I or Level II center. A Level III center typically serves a rural area that does not have a Level I or Level II center.

  • Level IV—A facility that meets a Level IV trauma center designation can be either a hospital or a clinic in a remote area where more sophisticated care is unavailable. It is new classification added by the ACS in 1993 to accommodate patients in the most rural areas by linking them to higher levels of care. The key role of a Level IV center is to resuscitate and stabilize patients and arrange for their transfer to the closest, most appropriate level of trauma center.

The plight of rural areas has been a major factor propelling an inclusive philosophy of trauma care systems (Shackford, 1995). Rural emergency medical services have lagged behind their urban counterparts for a host of reasons, including greater transport times, insufficient volume of patients to maintain the skills of providers, and too sparse a population density to sustain local public financing (OTA, 1989; HRSA, 1990). In comparison with urban areas, rural areas experience higher mortality rates for motor vehicle crashes (Baker et al., 1987; Mueller et al., 1988; Flowe et al., 1995) and a higher proportion of deaths at the scene (Rogers et al., 1997b). To incorporate rural acute care facilities into an integrated system of care, the American College of Surgeons (ACS) created a new level of trauma center (Level IV) in 1993 and specified the organizational and clinical criteria needed for a facility to meet this level (Box 6.2). The facility may be a clinic or hospital, with or without a physician available. The purpose of

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