American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Revised Statement on Trauma Center Designation Based upon System Need and the Economic Drivers Impacting Trauma Systems

The following statement was developed by the American College of Surgeons (ACS) Committee on Trauma’s (COT) Trauma Systems Evaluation and Planning Committee and was approved by the Board of Regents at its October 2014 meeting. The addendum addressing specific issues related to the economic drivers impacting trauma systems was added in June 2021 with the approval of the Board of Regents during its meeting in Chicago, IL.


Regional trauma system implementation has been shown to improve mortality and reduce complications. The number, level, and location of trauma centers are critical elements of trauma system function and disaster response. The importance of controlling the allocation of trauma centers, as well as the need for a process to designate trauma centers based upon regional population need, has been recognized as an essential component of trauma system design since the 1980s. As there is no national trauma system legislation or infrastructure, state and local governments have established these systems of care with significant variability in structure, process, resources, and authority. As a result, in most states the number and distribution of trauma centers is not matched to the needs of the population, with ongoing inadequate access to care in rural areas, while some urban and suburban areas have a plethora of trauma centers that raises costs and dilutes the patient volumes, particularly at Level I trauma centers.

Adequate trauma center volume is important for clinical proficiency, innovation and research, leadership development, education, and expertise. The COT has encouraged government officials responsible for trauma center designation to develop metrics to determine the need for additional trauma care prior to adding or upgrading new trauma centers in a region.

Nonetheless, few trauma systems are able to operationalize these concepts, especially when faced with real or potential challenges that stem from powerful health care institutions or providers. Without both a strong mandate and clear statutory authority that is backed by a transparent and fair process, lead agencies for many trauma systems have been unable to make potentially controversial decisions and, in some cases, have abdicated their responsibility for trauma center designation. When this situation occurs, trauma center designation becomes driven by the needs and ambitions of individual health care organizations or hospital groups rather than the needs of injured patients within the region. When changing economic fortunes determine the desirability of trauma center designation, hospitals may opt in or out of the system based upon their own perceived gains without consideration of the needs of the populations served. The result is a situation in which the resources available for the care of injured patients change with the economic tide.

Recent changes in health care economics have made trauma center designation generally more desirable, and certain areas have developed a perceived oversupply of high-level trauma centers with potentially adverse effects on cost and efficiency of patient care. History has shown that changes in health care economics can also make trauma center designation less desirable and, as a result, some trauma centers drop high-level designation despite demonstrated population need—a scenario that played out frequently in the 1990s. Both outcomes are detrimental to the long-term stability of a regional trauma system and to the population it serves.

The issue is not simply that the proliferation of new trauma centers is without merit—quite the contrary. It is far more common for regions to lack access to trauma care because no high-level designated trauma centers are located nearby, a need that can best be filled by encouraging the development of new trauma centers in the appropriate locations. The problem arises when a lead agency passively allows health care organizations and hospital groups to establish new trauma centers in areas that yield an economic advantage, while ignoring areas of true need. Such uncontrolled growth of trauma centers—some of which may lack long-term commitment—has the potential to undermine the quality of trauma care within a region, creating areas of oversupply and adverse competition while ignoring underserved areas entirely.

In order to best serve the needs of injured patients through optimization of regional trauma system function, the ACS Committee on Trauma supports the following guidelines:

  • The designation of trauma centers is the responsibility of the governmental lead agency with oversight of the regional trauma system. The lead agency must have a strong mandate, clear statutory authority, and the political will to execute this responsibility.
  • The lead agency should be guided by the local needs of the region(s) for which it provides oversight. As such, it is the responsibility of physicians, nurses, prehospital health care providers, and their respective organizations to advocate for the interests of the patients and citizens they serve throughout the entire region. The collective interests of these citizens and patients supersede the interests of the providers and their respective organizations.
  • Trauma center designation should be guided by the regional trauma plan based upon the needs of the population being served, rather than the needs of individual health care organizations or hospital groups. It is the professional obligation of the surgeons, physicians, nurses, emergency medical services (EMS) providers, and public health professionals to work together to ensure that patients’ needs come first.
  • Trauma system needs should be assessed using measures of trauma system access, quality of patient care, population mortality rates, and trauma system efficiency. Possible measures to be considered include the following:
    • Number of Level I and Level II centers per 1,000,000 population
    • Percentage of population within 60 minutes of a Level I/Level II center
    • EMS transport times
    • Percentage of severely injured patients seen at a trauma center
    • Trauma-related mortality
    • Frequency and nature of interhospital transfers
    • Percentage of time trauma hospitals are on diversion status
  • Allocation of trauma centers should be reassessed on a regular schedule based on an updated assessment of trauma system needs.
  • The applicability of specific metrics and benchmarks for trauma care resources, as well as the resources available to meet these needs, will vary from region to region; the details of the needs assessment methodology and regional trauma center designation criteria should be derived through a broad-based, locally driven consensus process that is balanced, fair, and equitable.
  • An international group of recognized experts, stakeholders, and policymakers should be convened to discuss and plan for optimal future regional trauma system development.

Addendum on managing the economic drivers impacting trauma systems

The current health care environment in some regions of the U.S. has established economic advantages to becoming a Level I or II trauma center, which may shift the focus away from what is best for the patient or population served to what is best for the hospital or hospital system. As a result, the goal of achieving trauma center designation based on population need continues to be a challenge and the growth of hospital networks and network-driven insurance coverage can impact patient triage based on insurance requirements rather than patient need.

To address these issues, the ACS COT Executive Committee makes the following additional recommendations:

  • In evaluating applications for new or higher-level trauma centers, the state or regional authority should conduct a detailed analysis of access to care and model the impact of the new center on the volumes of existing trauma centers. Geospatial modeling based on EMS transport times and interfacility transfer patterns can be a useful tool in this assessment.
  • State and regional authorities should develop objective metrics to determine the need for additional trauma centers in their region.
  • Trauma activation fees are important in supporting continuous readiness of trauma centers to care for all severely injured patients. These fees should be based on the actual readiness costs and not driven by excessive pricing.
  • Trauma team activations that trigger such activation fees should be confined to those patients at greatest risk of needing immediate intervention.
  • The trauma center performance improvement program should regularly review trauma team activations that trigger activation fees to ensure the appropriate triage is maintained and based on medical criteria. It is expected this review process addresses both under-triage and over-triage.
  • Trauma patient triage and transfer decisions should be based on the needs of the patient and not be affected by the patient’s insurance status.
  • Insurance companies should not be allowed to refuse payment for trauma services or to direct transfer of trauma patients to lower-level trauma centers or nontrauma center hospitals based on network status.
  • States that offer trauma funding to support their trauma system should ensure that these funds are equitably distributed to support uncompensated trauma care for vulnerable populations in addition to general readiness costs.