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Survival rates differ among level 1 trauma centers
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CHICAGO—Trauma centers designated as level I may have significantly different results when treating patients with similar injuries, according to a report in the February issue of Archives of Surgery, one of the JAMA/Archives journals.

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"Decades of concerted efforts by trauma professionals and patient advocacy groups have led to the development of trauma centers in most states," the authors write as background information in the article. "A critical component of these systems is the use of explicit criteria for the availability of personnel, equipment and services through the process of trauma center verification by the American College of Surgeons (ACS)." These criteria are based on structures and processes deemed essential for providing the best care.

Shahid Shafi, M.D., M.P.H., and colleagues at the University of Texas Southwestern Medical School, Dallas, analyzed data from 211,479 patients admitted to 47 level I trauma centers between 1999 and 2003. The patients were divided into three groups based on the severity of their injuries, assessed by a number of measures such as blood pressure and the presence or absence of shock. The average percentage of patients who survived was calculated for all trauma centers; survival rates from individual centers were then compared to this average.

The average survival rate was 99 percent for patients with mild injuries, 75 percent for those with moderate injuries and 35 percent for those with severe injuries. "For mild injuries, survival at five centers (11 percent) was significantly worse than that at their counterpart centers," the authors write. "With increasing injury severity, the percentages of outcome disparities increased (15 percent of centers for moderate injuries and 21 percent of centers for severe injuries) and persisted in subgroups of patients with head injuries, patients sustaining penetrating injuries and older (more than 55 years) individuals."

"These variations in outcomes may represent a substantial quality chasm in the delivery of trauma care," they continue. It is possible that the verification process may not specify all resources needed to provide optimal care, the authors note. For example, one previous study showed that the presence of a trauma and surgical critical care fellowship program improved outcomes at level I trauma centers, though it is not a criterion required for verification.

In addition, having all the necessary resources does not ensure they will be deployed adequately. "If confirmed, our preliminary data suggest that the logical next step for the trauma community is to move beyond focusing on personnel and processes and to start focusing on the outcomes achieved by the use of those resources," the authors conclude.
(Arch Surg. 2008;143[2]:115-119. Available to the media pre-embargo at

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at} .

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