The impact of level of the American College of Surgeons Committee on Trauma verification and state designation status on trauma center outcomes

Abstract

The American College of Surgeons (ACS) Committee on Trauma (COT) verification and State designation of trauma centers (TCs) into Level 1 or 2 establishes a distinction based on resources, trauma volume, and educational commitment. The ACS COT and individual states each verify TCs to differentiate performance levels. We aim to determine the relationship between ACS and State Level 1 versus 2, and injury-adjusted, all-cause mortality in a national sampling.TCs were identified by review of the National Sample Program (NSP) from the National Trauma Data Bank (NTDB)-the largest validated trauma database in the nation-of the year 2013. TCs were categorized by ACS or State Level 1 or 2 status, all others were excluded. Adjusted mortality was determined using observed/expected mortality (O/E) ratios, derived by trauma and injury severity score (TRISS) methodology. Chi-squared and t test analyses were used for categorical variables, with a statistical significance defined as P-value <.05.Of the 94 TCs in the NSP, 67 had ACS and 80 had State designations. There were 38 ACS Level 1 TCs and 29 ACS Level 2. For State designations, there were 45 as State Level 1 and 35 State Level 2. ACS Level 1 TCs had a similar O/E compared with ACS Level 2 verified centers (0.73 vs 0.75, chi-square, P = .36). Level 1 TCs designated by their state, had a similar O/E compared with State Level 2 centers (0.70 vs 0.74, chi-square, P = .08).Both ACS and State Level 1 and 2 trauma centers performed similarly on injury adjusted, all-cause mortality.

Figure 1

A: TCV distribution among ACS and State Level 1 TCs shows the volume histogram for Level 1 centers. This displays the frequency distribution of trauma center volume in ACS and State Level 1 trauma centers. The majority of Level 1 trauma centers have an annual volume around 2000 to 3000 patients. The TCV follows a normal distribution with a skewness of 0.511 (SE = 0.393) and a kurtosis of –0.493 (SE = 0.768). B: TCV distribution among ACS and State Level 2 TCs shows the volume histogram for Level 2 centers. This displays the frequency distribution of trauma center volume in ACS and State Level 2 trauma centers. The majority of Level 2 trauma centers have an annual volume around 1000 to 1500 patients. The TCV follows a normal distribution with a skewness of 0.699 (SE = 0.448) and a kurtosis of 0.037 (SE = 0.872). ACS = American College of Surgeons, SE = standard error, TCs = trauma centers, TCV = trauma center volume.

Figure 2

A: ISS distribution among ACS and State Level 1 TCs shows the injury severity score histogram for Level 1 centers. This displays the frequency distribution of injury severity scores in ACS and State Level 1 trauma centers. The majority of Level 1 trauma centers treat patients with an injury severity score between 0 and 20. The ISS were positively skewed with a skewness of 2.203 (SE = 0.008) and a kurtosis of 7.915 (SE = 0.017). B: ISS distribution among ACS and State Level 2 TCs shows the injury severity score histogram for Level 2 centers. This displays the frequency distribution of injury severity scores in ACS and State Level 2 trauma centers. The majority of Level 2 trauma centers treat patients with an injury severity score between 0 and 20. The ISS were positively skewed with a skewness of 2.232 (SE = 0.013) and a kurtosis of 9.326 (SE = 0.026). C: ISS distribution in the NTDB 2013 shows the percent of each injury severity score category in the NTDB for 2013. This displays the frequency distribution of ISS for all trauma centers reported to the NTDB for 2013. The overall ISS is positively skewed. ACS = American College of Surgeons, ISS = injury severity score, SE = standard error, TCs = trauma centers, TCV = trauma center volume.