Key takeaways
CHICAGO (August 27, 2025) — One third of severely injured trauma patients in the United States are first treated at hospitals designated as Level III or non-trauma centers, and less than half of those patients get transferred out to a Level I trauma center where they can receive more comprehensive trauma care, according to a study published in the Journal of the American College of Surgeons (JACS) .
“This study provides an updated assessment of our national trauma system. There is wide variation in access to trauma care across our country. We need to develop state systems that are inclusive of all hospitals so that every person, regardless of where they are, gets optimal care and is treated at the right place for their injuries,” said study co-author Marta L. McCrum, MD, FACS, associate professor in the department of surgery at the University of Utah in Salt Lake City.
“Trauma systems are decentralized and managed at the state level. Currently, less than half of states have secondary triage guidelines that help clinicians determine who should be transferred to a Level I or Level II trauma center,” Dr. McCrum said.
There are three levels of ACS trauma center verification , each defined by specific standards and the spectrum of care that must be available to injured patients at the facility. Level III centers typically serve communities that may not have timely access to a Level I or II trauma center, providing definitive care to patients with mild to moderate injuries.
Using the 2019 Nationwide Emergency Department Sample of all adult trauma patients with an Injury Severity Score greater than 15 (indicating severe injury) who were first seen at a Level III or non-trauma center, researchers examined the relationship between non-transfer to higher level care, defined as admission to the Level III or non-trauma centers from the emergency department, and patient and hospital factors.
Key Findings
“Overall, Level III hospitals need to be brought into what we consider to be high-level trauma systems so that we can better support these centers in the trauma care that they do provide and ensure the best possible outcomes for all patients,” Dr. McCrum said.
Better care, closer to home
“The ACS Committee on Trauma is dedicated to ensuring that patients receive the right care in the right place based on their needs; in many cases, this might be care closer to home. These findings show that while Level III trauma centers play an important role for the communities in which they are located, we have work to do to strengthen our trauma systems to ensure all patients get the care they need,” said Avery B. Nathens, MD, PhD, FACS, medical director of the ACS Trauma Quality Programs. Dr. Nathens was not involved in the study. “By ensuring all trauma centers meet high standards of care and are part of an integrated trauma system, there is no compromise in the quality of trauma care and we can optimally care for all injured patients.”
While this analysis provides a big picture view of patterns of trauma treatment in the United States, information from this large database study cannot provide a detailed explanation as to why patients were transferred from Level III hospitals to Level I centers and why they weren’t, according to the study authors.
Co-authors are Jacoby R. Bryce, BS, MD; Stephanie E. Iantorno MD, MS; Jack H. Scaife, MD; Meng Yang, MS; and Brian T. Bucher, MD, MS, FACS.
The study is published as an article in press on the JACS website.
Author Disclosures: None
Citation : Bryce J R, Iantorno SE, Scaife JH, et al. Secondary Undertriage of Severely Injured Trauma Patients across the US. Journal of the American College of Surgeons , 2025 . DOI: 10.1097/XCS.0000000000001580
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About the American College of Surgeons
The American College of Surgeons (ACS) is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The ACS is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The ACS has approximately 90,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the ACS.
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Journal of the American College of Surgeons
Secondary Undertriage of Severely Injured Trauma Patients across the US
19-Aug-2025