The importance of a systems approach to trauma care becomes clear when one considers the timing of death occurring secondary to traumatic injuries. The pattern of mortality takes on roughly a trimodal distribution where three peak occurrences are seen. The first peak occurs in the prehospital setting largely due to devastating head and major vascular injuries. Efforts to reduce deaths in this setting are largely societal, complex, and multidisciplinary and include such multifaceted activities as drunk driving laws; safe road construction; seat belt, helmet, and airbag laws; and violence-prevention activities such as counseling, education and outreach efforts, handgun control, and dissemination of conflict resolution skills. 45 A second peak incidence of deaths due to traumatic injuries occurs in the early minutes and hours after a patient's arrival at the hospital. Deaths in this peak are largely due to major head, chest, and abdominal injuries. Attempts to decrease deaths in this setting are largely aimed at rapid transport of patients to the most appropriate facility and prompt resuscitation and identification of injuries requiring surgical intervention. This is the most important function of a trauma system. The third peak in the trimodal distribution of deaths occurs in the intensive care unit where the sequelae of organ hypoperfusion experienced in the early postinjury period are seen. Specifically, patients who have survived the initial injury, transport, and operative resuscitation die in this setting as a result of the systemic inflammatory response syndrome and multisystem organ failure.
In recognition of the need to establish a system where injured patients are rapidly triaged to the most appropriate setting, Congress passed the Trauma Care Systems Planning and Development Act of 1990.2 This act required each state to develop a Model Trauma Care System Plan to be used as the reference document. Since this act did not carry with it specific appropriated funds, the level of implementation has varied from state to state. Ultimately, each state must determine the appropriate facility for various types of injuries, and some states have come to rely on a verification process offered by the American College of Surgeons in order to designate certain hospitals as trauma centers.6 An effective trauma system requires the teamwork of emergency medicine, trauma surgery, and trauma care subspecialists.
While each state ultimately has responsibility for designating trauma centers, some have come to rely on the guidelines of the American College of Surgeons. 7 Examples of requirements of various levels of trauma centers are listed in T§b.le 243:1. In addition to the listed essentials, a trauma center must have all the required features of lower-level trauma centers.
TABLE 243-1 Essential Characteristics of Levels I, II, and III Trauma Centers
In short, trauma centers are verified on the basis of commitment of personnel and resources needed to maintain a state of readiness to receive critically injured patients. A well-functioning trauma system ensures that not only are there appropriately designated trauma centers but also specific triage criteria to designate which patients should be transported to these centers (Table. .243-2).
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