Category Archives: Trauma Center

Trauma Center

Trauma Surgeon Response To Trauma Activations

The American College of Surgeons Committee on Trauma (ACS-COT) and all trauma center designating agencies stipulate an expected response time for the trauma surgeon to the highest-level activation. Nearly universally, the expected time is 15 minutes, although a few centers have actually reduced that short time frame.

Let’s look at this a little more closely. In the US, a majority of Level I through Level III centers are verified by the ACS-COT. They are subject to Standard 5.4 in the Resources for Optimal Care of the Injured Patient, July 2025 edition. Here is how the standard reads:

5.4 For the highest level of activation, at least 80 percent of the
time, the trauma surgeon must be at the patient’s bedside
within 15 minutes (Level I or II trauma centers) or 30 minutes
(Level III trauma centers) of patient arrival.

The understanding is that the surgeon needs to be at the patient’s bedside as soon as possible to begin providing the highest level of care. Ideally, they should be present before the patient arrives to help prep the trauma team. However, prenotification is not always possible due to various factors. If a patient shows up unannounced, the surgeon is given 15 minutes to arrive at Level I-II centers and 30 minutes at Level III centers.

This all seems very straightforward. But what happens when a non-activated patient (or an intermediate-level activation patient) suddenly meets highest-level criteria during that initial evaluation? Clearly, the 15-minute (or 30-minute for Level III) rule now applies if the surgeon is not already present. But when does the clock start ticking? Is the surgeon now expected to be at bedside within that original 15- or 30-minute window? Or does the clock start when the upgraded activation is triggered?

The answer is relatively simple. The surgeon now has 15 or 30 minutes from the moment they are notified of the highest-level activation to arrive at the bedside.

Here’s an example. A young patient is involved in a motor vehicle crash and complains of abdominal pain to pre-hospital providers. He is transported to the local Level II center but does not meet any of their trauma activation criteria. The emergency physician and their helpers assess him. The FAST exam is weakly positive, and the patient’s pulse rate is 100. 30 minutes after arrival, while waiting for CT scan, he drops his systolic pressure to 60, which persists across two readings. The emergency physician recognizes immediately that this patient now meets highest-level activation criteria and calls the trauma alert.

Bottom line: The surgeon must arrive within 15 minutes from this call. If they do so, they meet the criterion, and the performance improvement program can confirm that they arrived on time. They are not expected to be there 15 minutes after the patient initially arrived because they cannot travel backward in time.  Triggering a higher-level activation should be automatic if the patient suddenly meets any of the trauma activation criteria. But the surgeon is now expected to respond as if the patient had only just arrived.

In my next post, I’ll discuss when upgrading a trauma activation is an indication of undertriage.

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Trauma Center

Trauma Service Best Practice: The Afternoon Handoff

In my previous post, I stressed using a structured process to hand off information between the overnight trauma team and the incoming day providers. There is one more very important handoff that occurs in most centers as well: the afternoon handoff. This involves the transition between the day team, who received the morning report, and the trauma professionals who relieve them in the late afternoon or early evening.

This handoff is not nearly as involved as the morning one. Hospitals are structured to be very busy during the morning and afternoon shifts, and activity then tapers off in the evening and at night. However, a smooth transition of personnel is essential to ensure seamless patient care.

Following is the list of items I think are essential for that afternoon handoff:

  1. Introductions. This may not be necessary because the afternoon team is typically smaller than the morning report team, and the players typically know each other well.
  2. Urgent issues. This is a list of critical events that need to be addressed soon or immediately. These are typically much less common in the afternoon, but may still occur.
  3. Pending transfers in. The day team should list any scheduled transfers in from outside hospitals that have not yet arrived.
  4. Existing patient lists.  The service lists should be run at this point. Any pending work or tasks not completed by the day shift should be listed so they can be seamlessly picked up by the relief team.
  5. START THE EVENING!!

Just like morning report, this handoff should be conducted at a set time and place to develop consistency. It also allows all players to adhere to any overtime or work hour restrictions.

If your center includes other items on these checklists that you find helpful, please email or leave a comment below.

Click here to read the morning report best practice post

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Trauma Center

Trauma Service Best Practice: The Morning Report

Trauma professionals are immersed in patient care for a significant portion of their workday. They accumulate and process a lot of information about many patients during that time. But at some point, they actually get to go home!

What happens to all that knowledge from their workday? It must be shared to provide good continuity of care. So ideally, it is passed on to the team coming in to relieve them.

Many trauma centers have adopted some form of “morning report” to share knowledge from the outgoing night team with the incoming day team. In my experience, many of these meetings are relatively unstructured. They work, but they could be more effective/efficient.

A “best practice” for the morning report is to systematize it so it always includes all the key items needed for the shift transition. The best way to accomplish this is with a checklist. Pilots use these to make sure they don’t forget key tasks, such as lowering the landing gear at the right time. The same thing applies to the trauma morning report.

Here is a list of what I consider to be the key items to include in your morning report:

  1. Introductions. This is a quick round of self-introductions, with names and roles. In many trauma centers where the team is small and everyone knows each other, this step may be unnecessary. However, larger centers with large teams or frequent rotations on and off the service will definitely benefit from this step.
  2. Urgent issues. This is a list of critical events that need to be addressed soon or immediately. This could be a patient who just started crashing. Some members of the incoming team may need to leave to deal with these situations.
  3. Pending transfers in. The night team should describe any transfers they have accepted, with a summary of the patients and their known needs upon arrival.
  4. Patient phone calls. If any patient calls (i.e., from previously discharged patients) were relayed to the overnight team by the call center, these should be detailed so the a member of the day team (MD or RN as appropriate) can follow up as needed.
  5. New patient summaries. All new admissions should be presented briefly, including mechanism of injury, pertinent exam finding, workup completed, diagnoses, further studies needed, and the proposed treatment plan.
  6. Existing patient lists. Service lists should be run, and any patients that have needs that must be taken care of before rounds should be noted. Examples include a serial abdominal exam or a wound check if a possible infection is suspected.
  7. Discharge list. Hopefully, discharge planning has been ongoing during each patient’s stay. All patient discharges planned for the day should be noted so they can be examined early by a team member to ensure they are on track for leaving the hospital early in the day.
  8. Team assignments. This depends on the size of the service and the number of teams. Some personnel may be assigned to a specific service. Some may be directed to go to the OR, the ICU, or cover the clinic.
  9. START THE DAY!!

Ideally, morning report should occur at the same time every day of the week, every day of the year. Most tend to start between 6 and 8 am. If emergencies occur and morning report is interrupted, key personnel should tend to the acute problem and any remaining members continue with morning report. As soon as the emergency has ended, the incoming team members should reassemble to complete the checklist. In some situations, it may be more convenient to continue this at rounds. But be sure to cover all key items as early as possible.

Click here to read the afternoon handoff best practice post

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Trauma Center

Secondary Overtriage: Level III vs Nontrauma centers

Secondary overtriage is defined as a trauma patient transfer to a higher-level trauma center where the patient ultimately does not require any major intervention. Frequently, these patients are discharged directly from the receiving hospital’s ED or soon thereafter. The downside of secondary overtriage is that it may unnecessarily use considerable resources at the tertiary center.  This creates a clear drain on the receiving center and contributes to the congestion issues that have been prevalent since the COVID-19 pandemic.

A recent paper examined the impact of trauma center designation for the referring center on patterns of secondary overtriage. Specifically, it examined whether the referring hospital was a designated level three state trauma center or a non-level three center. It was written by the HCA Health Care Center for Trauma and Acute Care Surgery Research in Nashville. The paper focused on resource consumption at the upstream Level I trauma center, including hospital length of stay, intensive care unit length of stay, and average ventilator days.

Here are the factoids:

  • A total of 2,309 inter-facility transfers to a single level one center were analyzed.
  • Transfers from 20 referring non-tertiary facilities over two years were reviewed. Only centers that referred more than 30 patients per year were included (see my comments below). All were part of the same regional trauma system.
  • Five of the referring centers were Level III trauma centers (4 ACS verified in the receiving Level I center’s hospital system, and one center designated by the State of Tennessee).
  • The other 15 were non-Level III centers (Level IV or non-trauma centers).
  • Secondary over triage was formally defined as patients who had no major surgical intervention under anesthesia and 1) were either discharged home directly from the ED within two days or 2) were admitted and discharged alive from the hospital without transfer to hospice within two days.
  • Secondary overtriage occurred in 24% of transfers from a Level III versus 28% of non-Level III transfers. This is statistically significant and indicates that transfer from a non-Level III center is associated with a 31% higher likelihood of secondary overtriage.
  • Mortality rates were similar between the groups,  but transfers from non-Level III centers had shorter hospital, ICU, and ventilator days, which suggested they were lower acuity transfers.

The authors concluded that there is value in the trauma designation requirements and process, which may allow those centers to retain patients who might otherwise be unnecessarily transferred to a higher-level center.

Bottom line: This is an important and well-written paper that addresses the significant issue of secondary overtriage, which occurs frequently every day across this country. It had enough statistical power to identify differences between transfers from trauma and non-trauma centers. 

It does have a few weaknesses, however. As always, a single-center retrospective study raises a few flags, but the statistical power remains significant here. The authors excluded non-trauma centers that referred fewer than 30 patients per year. This could bias the sample toward hospitals that have active referral relationships. I can’t predict the actual impact on their data. Finally, there is no realistic way to capture the actual reason for transfer using registry data. This factor is really unknown in most papers on trauma transfers and hints at the very complex reasons that centers decide to transfer. 

Every state has a verification or designation process for trauma centers. The system exists. The individual hospitals typically decide whether to participate. This paper suggests that all hospitals should participate in a system to the best of their capabilities, so they can optimize patient care and relieve as much strain on the overall system as possible. The next step in research on this topic is to focus on the individual patient impact (and their families) of these potentially unnecessary transfers. 

Reference: Secondary overtriage: impact of trauma center designation and trauma system integration. Trauma Surg Acute Care Open. 2026 Feb 23;11(1):e002027. doi: 10.1136/tsaco-2025-002027. PMID: 41743404; PMCID: PMC12931552.

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Mechanism, Trauma Center

Trauma Activation For Strangulation: Yes or No?

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Trauma activation criteria generally fall into four broad categories: physiology, anatomy, mechanism of injury, and cofactors. Of these, the first two are the best predictors of patients who require assessment by the full trauma team. Many trauma centers employ mechanistic criteria, often to their chagrin. They typically end up with frequent team activations, and the patient usually ends up having only trivial injuries.

However, there are some mechanisms that just seem like they demand additional attention. Death of another occupant in the vehicle. Fall from a significant height. But what about a patient who has been strangled?

Unfortunately, the published literature gives us little guidance. This usually means that trauma centers will then just do what seems to “make sense.” And unfortunately, this frequently results in significant overtriage, with many patients going home from the emergency department.

Since there is little to no research to show us the way, I’d like to share my thoughts:

  • As a guiding principle, the trauma team should be activated when the patient will derive significant benefit from it. The primary benefit the team provides is speed. The team approach results in a quicker diagnosis based on physical examination and FAST. It enables patients to undergo diagnostic imaging more quickly, if appropriate. And gets them to the OR more quickly when it’s not appropriate to proceed to CT.
  • Activating for a strangulation mechanism alone is probably a waste of time.
  • Look at the patient’s physiology first. Are the vital signs normal? What is the GCS? If either is abnormal, activate.
  • Then check out the anatomy. If the patient has any voice changes or has obvious discoloration from bruising, crepitus, or subcutaneous emphysema, call the team. They may suffer a deteriorating airway at any moment.

If physiologic and anatomic findings don’t trigger activation, then standard evaluation is warranted. Here are some things to think about:

  • A complete physical exam is mandatory. This not only includes the neck, but the rest of the body. Strangulation is a common injury from domestic violence, and other injuries are frequently present.
  • If there are any marks on the neck, CT evaluation is required. This includes soft tissue, CT angiography, and cervical spine evaluation. All three can be done with a single contrast-enhanced scan. The incidence of spine injury is extremely low with strangulation, but the spine images are part of the set anyway.
  • CT of the chest is never indicated. There is no possibility of aortic injury with this mechanism, and all the other stuff will show up on the chest x-ray, if significant enough for treatment.
  • Even if there are no abnormalities, your patient may need admission while social services arranges a safe place for their discharge. Don’t forget the social and forensic aspects of this injury. Law enforcement may need photographic evidence or statements from the patient so this event can’t happen again.

Next post: Trauma Activation for Hanging: Yes or No?

Reference: Strangulation forensic examination: best practice for health care providers. Adv Emerg Nurs J 35(4):314-327, 2013.

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