Assessment Finds Gaps In Access To Nation’s Trauma Centers

Improving Distribution of Trauma Centers Important for Homeland Security

Despite improvements in the availability of trauma care in the United States, many communities still do not have access to specialized trauma care, according to an inventory of trauma services developed by the American Trauma Society (ATS), in collaboration with the Johns Hopkins Bloomberg School of Public Health. The researchers said changes in the number, distribution, and configuration of trauma centers are necessary to provide optimal care for injuries. The study, which appears in the March 26, 2003, edition of the Journal of the American Medical Association (JAMA), is particularly important with today’s emphasis on hospital preparedness and homeland security.

“The good news is that the number of trauma centers in the country has increased over the last decade. The bad news is that many communities still do not have access to adequate trauma care, especially in rural parts of the country,” said lead author Ellen MacKenzie, PhD, professor of health policy and management and director of the School of Public Health’s Center for Injury Research and Policy.

To complete the trauma center inventory, the ATS conducted interviews with trauma program directors from the nation’s hospitals to access the level of services each provided. The inventory included all facilities designated as trauma centers by either a state or local authority or verified by the American College of Surgeons Committee on Trauma (ACS/COT). Trauma centers that only cared for children were not included in the survey.

Trauma centers are classified by the services they provide. In most states, this classification is based on criteria developed by the ACS/COT. Level I and II centers provide the most comprehensive trauma care, which includes the immediate availability of trauma surgeons, anesthesiologists, and other specialized care. Level III centers provide emergency services and stabilization of patients for transfer to higher-level facilities. Level IV centers, which typically service remote areas, only provide advanced life support before transfer to other centers. The level V care designation is not formally recognized by the ACS/COT, but is used by some states.

The study found that the number of trauma centers in the U.S. more than doubled between 1991 and 2002, from 471 to 1,154. The number of states that designated or certified trauma centers also increased from 22 to 35 during the same period. Fifteen states do not have formal trauma systems to designate or verify which hospitals will provide trauma services. Every state has at least one trauma center and every state, with the exception of one, has at least one level I or level II trauma center. States vary, however, in how they go about classifying hospitals. Some states, such as Texas and Oklahoma, classify every hospital with a 24-hour emergency department at some level of trauma care. Other states, like New York and Pennsylvania, designate a more limited number of level I and level II centers only.

The study also found that 90 percent of the level I and II centers were located in metropolitan areas. The number of level I and II trauma centers in relation to the population varied greatly from state to state, ranging from 1 center per 100,000 people to 1 per 6 million people. While too few trauma centers could lead to inadequate care, the researchers noted that too many centers can also lead to costly duplication of services. In addition, low patient volumes could affect patient care since physicians perfect their skills by treating patients.

“The results of this survey suggest that aggressive steps must be taken to improve the day-to-day care of the injured and bolster the infrastructure needed to adequately respond to mass casualties and disasters when they occur,” said Harry Teter Jr., LLB, executive director of the American Trauma Society.

The inventory of centers will be maintained and used to establish ongoing communications among centers as part of the Society’s Trauma Information Exchange Program (TIEP). The TIEP is being funded by the National Centers for Disease Control and Prevention through their Center of Injury Prevention and Control.

“National Inventory of Hospital Trauma Centers” was written by Ellen J. MacKenzie, PhD, David B. Hoyt, MD, John C. Sacra, MD, Gregory J. Jurkovich, MD, Anthony R. Carlini, MS, Sandra D. Teitelbaum, MLS, and Harry Teter Jr., LLB.

The study was funded by the Centers for Disease Control and Prevention, Center for Injury Prevention and Control.

Photographs of Ellen MacKenzie are available upon request.