Published 7/1/2015
Douglas W. Lundy, MD; Philip R. Wolinsky, MD; Chris Cribari, MD

Demystifying Trauma Center Levels

Just as sports medicine physicians tend to distinguish themselves by the notoriety of the athletic team that they cover, trauma surgeons tend to do the same by the level of trauma center that they cover. However, what a center is required to have to achieve a specific level and how the process actually occurs tends to be a mystery to many.

For nearly 30 years, the American College of Surgeons (ACS) has verified trauma center designations, although the ACS’ involvement with trauma care goes back much earlier. The ACS Committee on Trauma (COT) can trace its roots to 1922, when, as the Committee on Fractures, it sought to establish principles and guidelines that would improve the poor treatment provided to fracture patients.

Orthopaedic surgeons continue to be actively involved in the ACS COT, which has a separate subcommittee of AAOS fellows who are interested in trauma systems and their development. The ACS COT meets twice a year and conducts various educational courses, including Advanced Trauma Life Support (ATLS), Rural Trauma Team Development, Advanced Trauma Operative Management, and Advanced Surgical Skills for Exposure in Trauma. The ACS COTpublication, Resources for the Optimal Care of the Injured Patient, includes the standards that hospitals must meet to be verified by the ACS as a trauma center.

Verification differs from designation. Designation is a legal process implemented by the state or county with statutory authority. Trauma centers are usually designated by the department of health or department of emergency medical services (EMS) in the individual state or county. Most of these agencies have adopted the ACS standards to one degree or another. Some states simply require trauma centers to be ACS verified; others adopt the ACS standards and then verify and designate the centers themselves.

Trauma centers are verified and designated from Level I (the highest) to Level IV (the lowest). Within a trauma system, local authorities often designate one trauma center as the lead facility and a resource facility for others within the region. The lead facility may be a Level I, II, or III center.

Orthopaedic surgeons who provide trauma services at an ACS-verified trauma center must be either board-certified or board-eligible by the American Board of Orthopaedic Surgery, the American Osteopathic Association, or the Royal College of Physicians and Surgeons of Canada. An alternate pathway is available for individuals who completed their training outside the United States or Canada and are not board-certified by one of these organizations.

All orthopaedic surgeons providing trauma services must complete 48 hours of trauma-related continuing medical education every 3 years. At Level I and II centers, participating orthopaedic surgeons are encouraged to demonstrate a commitment to trauma by completing a formal trauma fellowship and participating in combat-related trauma (through military service). They are also encouraged to also participate as an instructor in ATLS. These aspirations clearly demonstrate the importance of committed orthopaedic surgeons to a well-coordinated trauma service.

Level I centers
A trauma system’s Level I trauma centers are usually the most capable hospitals to provide comprehensive definitive care for the critically injured patient. These are tertiary care facilities that have established methods to efficiently accept transfers of critically ill patients. They are often university-affiliated teaching facilities. One feature of Level I facilities is their responsibility for leadership in education, research, and system planning.

To maintain this level of proficiency and ensure adequate case loads for resident education, Level I centers are required to admit at least 1,200 trauma patients annually or have 240 patients with an Injury Severity Score (ISS) greater than 15.

ISS is a complex scoring system that correlates closely to the morbidity and mortality of injured patients. The ISS is calculated from the assessment of the patient’s injuries according to the Abbreviated Injury Scale (AIS) and is the sum of the squares of the highest AIS in the three most severely injured body regions.

Each Level I director of orthopaedic trauma must have completed an Orthopaedic Trauma Association (OTA)–approved fellowship in orthopaedic trauma. Qualified attending trauma surgeons are required to be at the patient’s bedside within 15 minutes of the patient’s arrival and usually stay in the hospital 24 hours a day when on call. Even so, a backup mechanism should be in place in case the attending is busy. An orthopaedic surgical resident (PGY-4 or PGY-5) may provide trauma resuscitation while the attending orthopaedist is providing patient care.

Level II centers
Level II trauma centers are not necessarily a step down in the quality of trauma care that can be provided to injured patients. According to Resources for the Optimal Care of the Injured Patient, “The Level II trauma center is a hospital that also is expected to provide initial definitive trauma care, regardless of the severity of injury. Level I and Level II trauma centers are expected to be clinically equivalent except for complex, specialized injuries such as replantation.” Clinical outcomes, as well as care, should be equivalent at both Level I and II trauma centers.)

The criteria and the volume of patients transferred from a Level II center to a Level I center varies. In areas that cannot support the requirements of a Level I center, the Level II center serves as the trauma resource facility for the region.

The standards for clinical care of injured patients are the same for both Level I and Level II centers. Level II facilities located in population-dense areas near a Level I center provide supplemental high-level trauma services and work with the nearby Level I facility to maximize the care of injured patients. Level II centers in rural settings must serve as the highest level of care provision for injured patients. As with Level I centers, the attending trauma surgeon at a Level II center is expected to respond to the injured patient no more than 15 minutes after the patient’s arrival.

In all Level II centers, the director of orthopaedic trauma must be “highly experienced and committed to the orthopaedic care of injured patients”; a fellowship in orthopaedic trauma is desirable.

Level III centers
Level III centers provide trauma resuscitation for injured patients in areas that do not have immediate access to higher level centers. These centers are staffed by appropriately trained emergency department physicians and general surgeons who can rapidly assess and stabilize injured patients. An orthopaedic surgeon must always be available on call at Level III trauma centers.

Level III centers must have predefined categories of injuries that will require transfer and have transfer protocols in place that enable them to move severely injured patients to a higher level of care. Patients with lesser injuries may receive definitive treatment at Level III centers.

Attending trauma surgeons are expected to provide continuous coverage at the facility and to respond within 30 minutes of the patient’s arrival. However, surgeons do not have to stay in the hospital and can respond from home or the office.

Level IV centers
The Level IV center is a vital resource for resuscitation of injured patients in locales that cannot support a higher level facility. They are nearly always located in rural areas that lack the population density and surgical manpower and support that would enable the facility to qualify as a Level III center. The Level IV trauma center must be continually staffed by a well-trained physician or midlevel provider who is capable of performing ATLS resuscitation. These facilities do not provide definitive care and must always have transfer arrangements with higher level hospitals so that patients can be moved after being stabilized.

Orthopaedic surgeons who care for trauma patients require effective systems and protocols to be in place to effectively perform their role. The orthopaedic surgery requirements defined by the ACS COT and outlined in chapter 9 of Resources for the Optimal Care of the Injured Patient provide a basic foundation to enable orthopaedic trauma surgeons to best utilize their skills and talents. Regardless of the level of the trauma center, orthopaedic trauma surgeons perform a vital role on the trauma team.

Douglas W. Lundy, MD, MBA, and Philip R. Wolinsky, MD, are orthopaedic trauma surgeons. Chris Cribari, MD, is a general surgeon and one of the editors of the ACS Resources for Optimal Care of the Injured Patient 2014.

Common Recommendations for Level I and Level II Trauma Centers
Level I and Level II trauma centers must meet similar requirements in terms of orthopaedic surgery. According to the ACS, “Patients who have multiple fractures, fractures associated with multiple injuries, complex fractures (including pelvic, acetabular, intra-articular, and spinal column fractures), and high-grade soft-tissue injuries are appropriate candidates for musculoskeletal trauma care in a Level I or II trauma center.”

Although many orthopaedic trauma procedures may be performed on a semi-elective basis, orthopaedic surgeons must have access to the operating room (OR) for both urgent and emergent cases. During verification visits by the ACS, the facility’s leadership must demonstrate their commitment to enable rapid access to the OR by orthopaedic surgeons. Any delays in care are reviewed under the trauma performance improvement and patient safety process (PIPS) required of all verified trauma centers.

Level I and II centers must have an orthopaedic liaison to the trauma committee/director. The liaison’s duties include the following:

  • Develop a list of qualifications required of orthopaedic surgeons to participate in trauma call at the center and ensure that all participating surgeons meet those criteria.
  • Cooperate with the nursing administration to support the nursing needs of orthopaedic trauma patients.
  • Develop orthopaedic treatment protocols.
  • Ensure orthopaedic participation in the trauma program’s PIPS process by attending more than 50 percent of the meetings.
  • Organize the orthopaedic trauma call schedule.
  • Coordinate inter-service communication and efficient management of patients with musculoskeletal injury.


  1. Rotundo MF, Cribari C, Smith RS (eds): Resources for Optimal Care of the Injured Patient 2014, American College of Surgeons, 2014.