What is a Level 1 Trauma Center?

Babak Sarani, MD, FACS, FCCM, explains what the designation of a Level I Trauma Center means to patients in need of emergency care. He discusses the staffing, equipment and procedures that go into providing care for the most critically injured patients.
What is a Level 1 Trauma Center?
Featured Speaker:
Babak Sarani, MD
Babak Sarani, MD, FACS, FCCM is Director of Trauma and Acute Care Surgery at the George Washington University Hospital and Associate Professor of Surgery at GWU School of Medicine. He is Co-Medical Director of Critical Care at The George Washington University Hospital and is affiliated with The George Washington University Hospital and GW Medical Faculty Associates.

Learn more about Babak Sarani, MD
What is a Level 1 Trauma Center?

Dr. Mike Smith (Host): Welcome to GW Healthcast. I’m Dr. Mike Smith and today’s topic is, “What is a Level One Trauma Center?” My guest is Dr. Babak Sarani. He is the Director of the Center for Trauma and Critical Care at the George Washington University Hospital and is affiliated with The George Washington University Hospital and GW Medical Faculty Associates. Dr. Sarani, welcome to the show.

Dr. Babak Sarani (Guest): Thank you, very much.

Dr. Smith: Let’s talk a little bit first about what is a Level One Trauma Center? What makes up a center like that?

Dr. Sarani: The levels of designation are levels that the American College of Surgeons uses to determine the type of capability a hospital has to take care of injured patients. There’s a bunch of criteria and regulations that go into obtaining verification at a particular trauma level. Level One is the highest or most capable level a trauma center can – a hospital can achieve in terms of its trauma status. A Level One Trauma Center basically means you can take care of any form of the injured patient that may present to the hospital. Whether it’s injuries to the heart, the lungs, any of the organs in the abdomen, the bone, the brain, spinal cord, whatever may show up, the hospital has the capability in terms of equipment as well as personnel to take care of that patient.

Dr. Smith: It sounds like the most severe cases of trauma would go to a Level One Trauma Center, is that right?

Dr. Sarani: Correct, correct. This is something that the paramedics are also trained on, so they know where to take a patient depending on their particular assessment of the injuries that that patient may have sustained. They’ll take into account how that person looks, what their vital signs are, what the mechanism of injury was, how likely is it that this person is severely injured, and they’ll make a determination. Should we go to a trauma center, yes or no? Then if we’re going to go to a trauma center, should we go to a level one, level two, or level three trauma center?

Dr. Smith: You had mentioned that there’s a lot of criteria and requirements for a hospital to be designated level one, so how many levels one trauma centers are in the country, or at least maybe in the D.C. Area?

Dr. Sarani: In the Washington D.C. Area – in Washington D.C. itself there are currently two adult level one verified trauma centers. There is one pediatric verified level one trauma center. That’s within the District, itself. In the surrounding region around Washington D.C., there are two level two trauma centers, and an additional – I’m sorry, three -- three level two trauma centers and an additional level one trauma center. Once you get outside of our ring specifically around D.C. and head up into Baltimore there would be other centers but in the D.C. Metropolitan Region, that’s basically the lay of the land.

Being a level one – or level two for that matter – center is not easy. One of the most important aspects of these trauma centers is that the operating room is staffed 24 hours a day, 7 days a week with a dedicated team that is in the house. Anesthesiologists, operating room nurses, operating room techs, trauma surgeons themselves literally spend the night in the hospital so that within 15 minutes, the OR can open up and receive any patient who needs to be cared for in the operating room itself. That requires a lot of personnel and a lot of ongoing training. It requires just a lot of dedication in both visions, as well as financial resources to staff a level one or a level two trauma center.

Dr. Smith: Yeah, and so you bring up a really good point. In a level one trauma center then, we’re not having to transport a patient who maybe is very severe to another place to have surgery. They can actually have whatever surgery they need, correct? In that level one trauma center.

Dr. Sarani: That’s exactly right. Part of the criteria are do you have all the specialists that may be needed to care for a patient? For a level one, we have anything from cardiac surgery, immediate open-heart surgery, to neurosurgery, orthopedic surgery, trauma surgery, plastic surgery, urology, ear, nose, and throat surgery – it goes on and on. There’s really no specialty that a level one trauma center doesn’t have. They should be able to care for anything that walks into the hospital – well, in reality, doesn’t walk into the hospital, is brought in by paramedics – and the entirety of the care stays in that hospital from beginning to end.

Some trauma centers, such as ours, have a build-in rehab unit, as well. Our patients would actually stay at George Washington for ongoing rehabilitation once their acute care needs have been met. Other trauma centers aren’t like that. Other trauma centers have agreements with free-standing rehabilitation center and would only transfer a patient out of the hospital when it’s time for the individual to undergo rehabilitation.

Dr. Smith: Right. Somebody listening to this, they might be thinking to themselves, “Well, if I have an emergency, I’m going to go to the best place where all the doctors are,” but not everybody has to go to a level one trauma center. Can you give us a little bit of background on who goes and who doesn’t go to a level one trauma center?

Dr. Sarani: Yeah, the ones that definitely go to a level one trauma center are the ones that are very severely injured and at imminent risk of death. That might be someone who was in a high-speed car crash, or in a motorcycle crash, or God forbid, has been shot someplace vital, like their abdomen or their chest. Those patients would all go to a level one trauma center because they need the capabilities that are immediately available should they actually have a severe injury.

Patients that are a little bit less injured don’t need to go to a level one trauma center. Patients who might be in a low-speed motor vehicle crash, patients who have fallen, but not from great height – maybe fall off of a ladder – fall from standing for our elderly population. Those patients would do fine in a level two or a level 3, perhaps, trauma center. They still would benefit from the services that a trauma center can offer – probably, they would do better in a trauma center than in a non-trauma center, but they don’t necessarily need to be in a level one.

The level one’s need to be a little bit careful about which patients they actively go out and talk to paramedics about receiving. The reason is we don’t want to be in a position where we are overrun with patients who are less severely injured, and then when someone who is very severely injured shows up, our resources have already been expended on the less injured. We try our best to find this sweet spot where we only have, let’s say about a 1% chance, maybe a 2% chance of missing somebody who is severely injured. In return, we’ll take a good number that are not severely injured – we’ll take maybe 30%, but we don’t want to get that number to be too much higher. If we start taking people – let’s say, if half the patients who come to a level one trauma center are in fact, not severely injured, then there’s not many resources left for the ones that show up that are severely injured. That’s how we try to do this.

Dr. Smith: Right.

Dr. Sarani: All trauma centers look at these numbers very carefully on either a month-by-month or a quarterly basis to try to make sure that we’re working well with our paramedics in determining who should come here and who would be equally well-served going elsewhere.

Dr. Smith: And you mentioned before that the paramedics are trained in knowing who really should go to a level one trauma center versus a different level. If a listener hears this and they’re injured, they can put some trust and faith in the paramedic that they will also make that correct designation for them, right? That’s how it works, right?

Dr. Sarani: That’s absolutely accurate. Remember that the paramedics are ultimately overseen by a physician – they have a medical command. If that medical director that is telling the paramedics who through the protocols he or she writes what they should do if this happens or if that happens. Ultimately, the guidance for all of this triage comes from the Centers for Disease Control, the Federal Government when they look and say, “Okay, if this injury has occurred, or if that is your vital sign, if this is the kind of physical exam you have, what’s the probability you’re going to be injured?” They issue guidance that if someone has had this particular event occur like a car crash or a fall from height, and their blood pressure is this, and their heart rate is that, and this is what you find on your physical exam, then we, the CDC, would recommend transfer to a trauma center. That guidance is then translated into protocols by the medical directors who oversee paramedics, and so when we, the trauma center, are interacting with our paramedics, in reality, we are interacting with the medical directors, giving them feedback on what happened when those protocols were implemented. In that way, we have a nice, closed system where we’re all talking to each other and making sure that the resources that we have, are used appropriately.

Dr. Smith: When somebody is admitted to a level one trauma center, and they are stabilized – they are no longer in that emergency – is it common for some people at that point then to be transferred to another community hospital?

Dr. Sarani: Not very commonly, no. More often than not – much more often than not, once you arrive at a trauma center, if you need to be admitted, we will admit you to our own hospital. The reason is, you are being admitted for a reason. You have a bona fide injury, and we will take care of that for you. There’s a good number of patients that come to the trauma center, they’re evaluated in the Emergency Department and are ultimately discharged home and told you to have either very minor injury that doesn’t require admission. Or, the good news is, you don’t have any injury at all.

Once you get to the point where you require admission, you’re probably better off staying in the same hospital – we have your test results -- we have your blood test results, we have your radiology results. We’ve established a relationship, so we now know who that individual is, and we can care for that person. Certainly, we’ll reach out to their primary care physician at some point and let them know that their patient is here and get a better feel for the patient, but at that moment in time, we will admit to ourselves.

Dr. Smith: Dr. Sarani, in summary, what would you like people to know about a level one trauma center?

Dr. Sarani: I think a couple things that would be worthwhile is, a level one trauma center is a true asset to any community. Having a level one trauma center near you does nothing but increase your safety by allowing you to have immediate access to 2017, cutting-edge medicine. That’s probably the most important thing, but please appreciate that that trauma center comes with a cost, and that cost is what the hospital determines it wants to expend in creating all of these resources. I really think of the trauma center as your friendly neighbor. I know the place is a big ruckus, it’s a bit busy, but it really is a safety net. I think working with the community to try to prevent injuries wherever possible as well as provide care when an injury does occur, is the fundamental mission of a trauma center regardless of level one, level two, level three.

Dr. Smith: Dr. Sarani, thank you for the work that you’re doing, and also, thank you for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Sarani or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment.

This is Dr. Mike Smith. Thanks for listening.