Since January 2020 Elsevier has created a COVID-19 resource centre with

free information in English and Mandarin on the novel coronavirus COVID-

19. The COVID-19 resource centre is hosted on Elsevier Connect, the
company's public news and information website.

Elsevier hereby grants permission to make all its COVID-19-related

research that is available on the COVID-19 resource centre - including this
research content - immediately available in PubMed Central and other
publicly funded repositories, such as the WHO COVID database with rights
for unrestricted research re-use and analyses in any form or by any means
with acknowledgement of the original source. These permissions are
granted for free by Elsevier for as long as the COVID-19 resource centre
remains active.
 Current Problems in Surgery 58 (2021) 100849

Contents lists available at ScienceDirect

Current Problems in Surgery

journal homepage: [Link]/locate/cpsurg

The impact of trauma systems on patient

outcomes
Jeff Choi, MD, MSc1, Garrison Carlos, MD1, Aussama K. Nassar, MD,
MSc, FRCSC, FACS, Lisa M. Knowlton, MD, MPH, FRCSC,
David A. Spain, MD, FACS∗

The burden of trauma

Trauma is a pressing public health epidemic. In 2016 alone, trauma accounted for 29.2
million emergency department visits and 39.5 million physician office visits in the United
States.1 Trauma is the leading cause of death for those aged 46 years and younger in the United
States; trauma-related mortality has increased by 23% between 20 0 0 and 2010 across nearly
all age groups.2 In particular, the growing elderly population—susceptible to injuries from even
minor mechanisms such as ground-level falls—has seen a 56% increase in trauma-related deaths
over the same decade.2 For those who survive, regaining health and returning to work requires
substantial postacute care and rehabilitation. Accounting for medical expenditures and lost
productivity, the annual burden of trauma care is approximately $670 billion in the United
States.3 Traumatic injuries also remain an important cause of morbidity and mortality globally,
for both developed and developing countries. In a recent update to the Global Burden of Disease
study—the most comprehensive epidemiological study to date—973 million individual healthcare
encounters and 4.8 million deaths were attributable to injuries in 2013 alone.4
The recognition of traumatic injuries as an addressable public health epidemic rather than
unavoidable accidents has led to the birth and expansion of trauma systems. Trauma systems
represent comprehensive infrastructures to provide optimal care for injured patients, encom-
passing a wide spectrum from injury prevention efforts and an integrated network of trauma
centers to concerted research agendas. The United States has led the development of this sys-
tematic infrastructure to tackle the burden of trauma. In this report, we review the history of
trauma systems in the United States, outline what constitutes a comprehensive trauma system,

From the Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA
∗
Address reprint requests to David A. Spain, MD, FACS, Division of General Surgery, Department of Surgery, Stanford
University, 300 Pasteur Drive, H-3591, Stanford, CA 94305.
E-mail address: dspain@[Link] (D.A. Spain).
1
Contributed equally for shared first-authorship.

[Link]
0011-3840/© 2020 Elsevier Inc. All rights reserved.
2 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849

provide an overview of trauma systems in other countries, and explore the cumulative impact
of trauma systems on the outcomes of patients who suffer traumatic injuries.

History of trauma systems in the United States

Military roots

A structured system to care for the injured arose amidst the chaos of military conflicts. The
American Civil War gave birth to the medical evacuation system, which was comprised of an
ambulance corps and placing of surgeons near battlefields to determine who could return to
battle or be transferred to field hospitals.5 The mass casualties of World War I propagated triage
through tiered echelons of increasingly capable treatment.6 Adoption of motorized transporta-
tion for evacuation (ie, helicopters in the Korean War) spurred more expeditious evacuation
throughout subsequent conflicts. By one estimate, the average injury-to-surgery time progres-
sively improved and mortality progressively decreased from 12 to 18 hours and 8.5% (World
War I), to 6 to 12 hours and 5.8% (World War II), 2 to 4 hours and 2.4% (Korean War), and 65
minutes and 1.7% (Vietnam War), respectively.7

First national spotlight

While systematic care for the injured took early roots in the military, the need for a struc-
tured trauma system did not receive civilian spotlight until the publication of “Accidental Death
and Disability: The Neglected Disease of Modern Society” in 1966.8 This landmark report high-
lighted accidental injury as a neglected epidemic and the “leading cause of death in the first half
of life’s span.”8 The report underscored our country’s deficient emergency medical care capac-
ity and urged the establishment of trauma registries, hospital trauma committees, and increased
funding for trauma research.8 The same year, the federal government launched the first national
effort to care for injured patients through “The National Traffic and Motor Vehicle Safety Act.”9
The mandate of vehicle standards (eg, seatbelts), improved road standards, and public education
of driver safety laws (eg, laws against driving while intoxicated) led to a rapid decrease in motor
vehicle fatalities by 1970, showcasing traumatic injuries to be a preventable epidemic.10
With the national spotlight on injury, local leaders advancing trauma systems emerged. The
Cook County Hospital in Chicago consolidated care of all trauma patients and developed a dedi-
cated trauma team unit, gaining recognition as one of the nation’s first trauma centers in 1966.11
At a similar time, University of Maryland Hospital established its shock trauma unit and popu-
larized the “golden hour” for trauma resuscitation. In collaboration with Maryland State Police,
the shock trauma unit birthed the Maryland Institute for Emergency Medical Services System.
This collaboration reduced trauma-related mortality by transporting critically injured patients
from the field or regional hospitals via police helicopters to a dedicated trauma unit.12 Although
not as well-recognized, the first “trauma center” may have been established at the University of
Louisville. In 1911, Dr William O Roberts (Chair of the Department of Surgery) assigned 4 Univer-
sity of Louisville medical students to be on hand at all times to provide accident victims with
instant attention. In the 1930s and 1940s, Dr R Arnold Griswold (Chair of the Department of
Surgery) developed autotransfusion, established Louisville’s first blood bank, and equipped po-
lice cars and fire trucks with medical supplies. This was the forerunner of emergency medical
services (EMS).13

Trauma Center to Trauma System

The “Emergency Medical Services Systems Act of 1973” allocated the first federal funds to
establish EMS systems.14 Illinois became the first state to receive a $4 million federal grant to
 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849 3

build upon Cook County Hospital’s trauma center and establish a statewide trauma system with
40 integrated trauma centers.15 The Illinois trauma system also instituted the first trauma reg-
istry, a dedicated database to document and monitor care delivered to trauma patients. Over the
next 8 years, $300 million in federal grants helped establish 304 EMS regions throughout the
United States.
In 1976, the American College of Surgeons “Optimal Hospital Resources for Care of the Injured
Patient” report detailed what constitutes a trauma center and presented a method to designate
trauma center levels based on capabilities.16 This classification—now ranging from level I (ter-
tiary center with 24-hour capability for definitive trauma care) to level IV/V (centers limited to
initial evaluation/stabilization prior to transfer)—mirrored the tiered echelons of increasing treat-
ment capacity conceptualized earlier in the military. Subsequent revisions expanded in scope
to emphasize the need to care for the injured in the prehospital setting. There was growing
recognition that optimal care of the critically injured mandates not only advancement of trauma
centers, but also their integration within a comprehensive trauma system.
Developing trauma systems has not been without challenges. The “Omnibus Budget Reconcil-
iation Act of 1981” ended federal government support of EMS due to budgetary constraints.17 In
a 20-year follow-up to the 1966 landmark report, “Injury in America: A continuing Public Health
Problem” elucidated persistent deficiencies in coordinated trauma systems and lack of trauma
research funding in the United States.18 A 1995 report similarly found that only 20 states had
adopted trauma systems, only 5 of which were fully functional.19 The following section details
components of a comprehensive trauma system that we are still striving for.

The comprehensive trauma system

Components

The modern comprehensive trauma system optimizes cost-effective and high-quality care of
the injured patient starting with injury recognition, triage to an appropriate trauma center, mul-
tidisciplinary inpatient care, and outpatient follow-up of long-term physical and psychosocial
sequelae. Beyond the clinical care continuum, a trauma system also prioritizes outreach, educa-
tion and advocacy, data collection through registries, research, funding, and disaster prepared-
ness and response. Coordination of comprehensive trauma care requires strong leadership and
community engagement at the trauma center, regional, state, and national levels (Fig. 1).

Leadership—American College of Surgeons Committee on Trauma

Since its inception in 1922, the American College of Surgeons Committee on Trauma (ACS
COT) has been integral in leading US trauma system development. ACS COT provides trauma
center verification and assessment of regional trauma systems and resources to support quality
improvement.20 Within the ACS COT, the Verification Review Committee (VRC) performs on-site
review of trauma centers.21 The ACS COT has spearheaded trauma education by offering courses
such as Advanced Trauma and Life Support (ATLS) and Advanced Surgical Skills for Exposure
in Trauma (ASSET). The ASC COT has also supported quality improvement through data collec-
tion and benchmarking using the National Trauma Data Bank (NTDB) and the Trauma Quality
Improvement Program (TQIP). In conjunction with the American Association for the Surgery of
Trauma, the Eastern Association for the Surgery of Trauma, the National Trauma Institute, and
the Western Trauma Association, ACS COT helped establish the Coalition for National Trauma
Research (CNTR) to advance trauma research. The coalition addresses gaps in trauma research
(eg, resuscitation, regenerative medicine, family support following major trauma) with plans to
update a national trauma research repository and formalize a national trauma research agenda.
Federal legislative advocacy is another effort led by the ACS COT. The committee’s ef-
forts have contributed to the successful passage of legislation, including 1 bill that provides
4 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849

Fig. 1. Components of a comprehensive trauma system.

$50 million of funding for firearm morbidity and mortality prevention research and the MISSION
ZERO Act that funds the embedding of military trauma professionals within civilian trauma cen-
ters to promote military-civilian collaborations. Ongoing advocacy efforts include support of the
Prevent Bleeding Loss with Emergency Devices (BLEEDing) Act to teach civilians life-saving skills
via bleeding control techniques and promoting nonpartisan public health approach to firearm
injury prevention.

Needs based assessment

There are more than 500 designated and verified level I-III trauma centers currently in the
United States tasked with providing timely care of patients who suffer traumatic injuries.22 Hos-
pitals may request trauma center designation by the governing body, which varies state by state,
then receive verification from the ACS COT’s VRC. For example, whereas California trauma center
designation is determined by local EMS agencies, Alabama and Georgia trauma centers receive
designation through their respective Departments of Public Health.23-25 Notably, some states
have no formal process or laws giving authority for trauma designation. Funding for trauma
systems is also dependent on the state, but some trauma systems receive no state funding.26
Interstate variability of trauma systems has resulted in suboptimal distribution of trauma
centers. A 2003 report found that despite a doubling of the number of trauma centers between
1991 and 2002, the number of level I and II trauma centers per million population varied from
0.19 to 7.8 by state.27 A recent study similarly revealed nonuniform access to trauma care in the
United States, with lower injury mortality rates in states that had a clustering of trauma centers
compared to states with dispersed trauma centers.28 In 2015, the ACS COT developed the Needs
 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849 5

Based Assessment of Trauma Systems (NBATS) tool to determine the number of trauma centers
per level designation needed in a region based on injury volume, accessibility, and population
characteristics.29 The tool is applied to preexisting trauma regions of interest and incorporates
community support, population, transport time, and the number of severely injured patients dis-
charged from non-level I-III trauma center hospitals.29 The algorithm outputs an estimate of the
number of levels I, II, and III trauma centers needed for the region. Application of the NBATS
tool to California and Georgia state trauma systems found that urban areas had proportionally
too many, and rural areas too few trauma centers.30 , 31 A similar optimization query in Florida
showed that adding 2 new trauma centers did not improve the state trauma system triage per-
formance, while a Pennsylvania study found that a rural hospital incorporation into the state
system as a level IV center would improve performance.32 , 33 An increasing number of states are
integrating level V trauma centers within their trauma systems. NBATS is continually utilized to
assess trauma center needs and direct growth within trauma regions. Although level V designa-
tion is not formally recognized by ACS COT, these hospitals are often located in rural areas and
focus on high-quality patient stabilization and strong transfer protocols to more comprehensive
trauma centers. For example, Washington has integrated 9 level V trauma centers as of January
2020.34 The optimal trauma system depends not only on a sufficient quantity of trauma centers,
but also on a strategically distributed cohort based upon regional needs.

Training programs

ACS COT and partner organizations engage in multiple educational efforts. ATLS is a premier
example. ATLS was established in 1978 by Dr James K. Styner, an orthopedic surgeon who at-
tributed the loss of his entire family to sub-par trauma care at a local hospital after a tragic
plane crash.35 Along with a local group of surgeons and physicians and the University of Ne-
braska, Dr Styner founded systematic courses aimed at teaching advanced trauma life support
skills. Since these courses were adopted by ACS COT in 1980, ATLS is now taught in more than
80 countries and has trained more than 1 million physicians.36 ATLS is comprised of a man-
ual, standardized lectures, and skills stations. Certification requires passing a written component
and successfully assessing and resuscitating multiple injured patients in a series of role-playing
scenarios. The global audience of the program has increased the standardization of care for the
critically injuries patient. Retrospective studies comparing mortality in the pre-ATLS vs post-
ATLS eras have shown a 20% reduction at one large international institution and a statistically
significant reduction in mortality within the first hour at 2 US community hospitals.37 , 38 Since
2009, the American Board of Surgery has required ATLS certification for general surgery resi-
dency graduates.
Educational infrastructures allow widespread dissemination of new trauma training curric-
ula. For example, focused assessment with sonography for trauma (FAST)—a bedside ultrasonog-
raphy technique to assess the presence of blood around the heart or abdominal organs after
trauma—was a new skill-based technology disseminated rapidly through the ATLS training cur-
riculum.39 After the first description of ultrasound to detect intraabdominal fluid in Europe dur-
ing the 1970s, FAST was formalized as a standardized series of steps and adopted in the United
States in the 1990s.40 Today, 96% of level I trauma centers report regular use of FAST for the
assessment of trauma patients.41 , 42
Since its introduction of ATLS, ACS COT’s repertoire of educational initiatives has expanded.
Trauma Evaluation and Management is a mini-ATLS course aimed at introducing medical
students to trauma management, and the ASSET course and the Advanced Trauma Operative
Management (ATOM) courses are aimed at increasing surgical competence and confidence in
the operative management of penetrating injuries.43 With decreasing national incidence of
penetrating injuries, recent surgical residency graduates reported having performed one half the
number of trauma operations compared to graduating surgical residents from 20 years ago, and
on average, report having performed only 2.1 major vascular repairs—a concerning experience
gap.43-45 ASSET and ATOM courses include advanced cadaver, simulation, and team-based
6 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849

training for various trauma explorations including the neck, chest, abdomen, and major vessels.
Both ATOM and ASSET courses have reported significant improvement in self-reported confi-
dence of participants in operatively managing penetrating trauma patients.43 , 46 , 47 Resuscitative
endovascular occlusion of the aorta (REBOA) is another technique newly being taught for trauma
trainees and surgeons. ACS COT’s Basic Endovascular Skills for Trauma (BEST) course and some
ASSET courses have integrated this new technique for temporizing life-threatening bleeding
within their curricula and provide simulation workshops. As with any new techniques, the
evidence and best practices for REBOA are continually evolving.48
In addition to skills-based education, organizational improvement is another educational mis-
sion of our trauma system. For example, the Disaster Management and Emergency Preparedness
course targets all healthcare providers, administrators, and public health personnel who may re-
spond to major disasters, and teaches organizational principles for responding to disasters rang-
ing from blast injuries to chemical attacks.49 The Rural Trauma Team Development course is
another organizational improvement course offered by the ACS COT that assists rural healthcare
professionals and administrators in developing communication strategies to allow rapid transfer
of trauma patients to more capable facilities.

Research

Scholarly trauma organizations form an integral part of trauma systems by advancing, synthe-
sizing, and disseminating trauma research. The American Association for the Surgery of Trauma
(AAST), founded in 1937, is the premier scholarly organization in the field of trauma and criti-
cally ill surgical patients. With approximately 1200 members from 30 countries, its annual meet-
ing is attended by trauma healthcare providers across the world and provides a medium for the
international community to exchange ideas and collaborate on scholarly ventures. The AAST pub-
lishes the Journal of Trauma and Acute Care Surgery (the leading source of peer-reviewed trauma
publications), provides research funding and grants, facilitates multi-institutional studies, and
provides mentorship opportunities for academic grant writing.50 Several other countries and re-
gions have scholarly trauma organizations that convene in regular meetings, such as the World
Trauma Congress, the International Association for Trauma Surgery and Intensive Care, and the
European Congress of Trauma and Emergency Surgery.
Other organizations focused on specific injury patterns are additional valuable academic as-
sets within trauma systems. Organizations such as the Chest Wall Injury Society, American Spinal
Injury Association, and the Brain Trauma Foundation provide the funding and medium for like-
minded researchers to make discoveries that advance care for trauma patients. For example,
the Chest Wall Injury Society publishes “Ribnars” that provide up-to-date evidence in manag-
ing patients with rib fractures, has completed multi-institutional studies to better inform best
practices, and publishes consensus guidelines on rib fracture management for trauma centers to
adopt.51-54

The Holy Grail: Zero preventable deaths after injury

The 2016 National Academies of Sciences, Engineering, and Medicine (NASEM) report, “A Na-
tional Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero
Preventable Deaths After Injury” estimated a 20% excess in mortality due to differential care
among trauma centers.55 This report underscored the need for a comprehensive national trauma
system that builds on the military’s knowledge of trauma patients gained during the Iraq and
Afghanistan War. The report made 11 major recommendations that outlined the committee’s
finding for the need of national federal leadership for both the implementation and execution
of a national trauma care system.55 The report called for the White House to lead a national
trauma system, designate authority to the Secretaries of the Department of Defense and the
 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849 7

Department of Health and Human Services, and coordinate military and civilian trauma system
leadership in pursuit of Zero Preventative Deaths.55 Civilian leaders were identified as ACS COT,
American College of Emergency Physicians, National Association of EMS Physicians, National As-
sociation of Emergency Medical Technicians, and the Trauma Center Association of America.55
In response to the report, the ACS COT highlighted ongoing leadership in regard to each of the
recommendations listed, from research and quality improvement (eg, NTDB, TQIP), to education
(eg, ATLS, ASSET, ATOM), and military engagement with the civilian trauma system through the
Military Health System Strategic Partnership.56 The ACS also published “The Blue Book: Military-
Civilian Partnership for Training, Sustainment, and Readiness,” which provides a template for
trauma centers or systems wishing to establish military and civilian relationships. In response
to NASEM’s call for federal leadership in pursuit of zero preventable deaths, the United States
Congress passed the 2019 Pandemic and All-Hazards Preparedness Act (PAHPA) which included
the Mission Zero Act, creating a grant to facilitate civilian trauma center and military partner-
ships in pursuit of trauma care quality improvement. Estimates suggest that such collaborations
may result in more than 15,0 0 0 lives saved each year.57

Impact of trauma systems on outcomes

Injury prevention

Primary injury prevention remains a cornerstone component of the modern trauma system
at all levels. In response to reports of growing motor vehicle accident mortality, the National
Traffic and Motor Vehicle Safety Act of 1966 established comprehensive motor vehicle standards
and safety goals. According to national data published by National Highway Traffic Safety Ad-
ministration (NHTSA), the fatality rate per 100 million motor vehicle miles traveled was more
than 5.0 at that time.58 Seatbelt, airbag, and crash performance regulations over subsequent
years have decreased the fatality rate to 1.27 per 100 million motor vehicle miles by 2008.59 To-
day, the Centers for Disease Control and Prevention’s (CDC) National Center for Injury Prevention
and Control maintains the Web-based Injury Statistics Query and Reporting System (WISQARS),
which provides fatal and nonfatal injury, violent death, and cost of injury data in the United
States.60 In a multipronged approach to reduce the burden of injury, the CDC has organized
public awareness campaigns and funded research in the fields of traumatic brain injury, violence
prevention, home and recreational safety, motor vehicle safety, and opioid overdose prevention.
Funded studies have led to many impactful changes in several local communities. A study on
the impact of low-cost repairs of abandoned buildings and vacant lots to prevent violence has
led to nearly 10,0 0 0 abandoned buildings throughout the United States being refurbished. These
improvements have shown a 39% decrease in gun assaults, 19% decrease in other assaults, and
long-term reductions in gun violence around remediated abandoned buildings.61 Another CDC-
funded study to identify the suicide burden in rural Iowa revealed that 76% of violent deaths
in the state were suicides.62 The research has elevated rural suicide into public spotlight and a
new federal bill that aims to provide stress management programs and public campaigns to curb
rural suicides is in the works. The CDC’s injury prevention mission has already met legislative
success, as its effort to build a national concussion surveillance system has led to passage of
the Traumatic Brain Injury Program Reauthorization Act of 2018. This bill now funds the foun-
dational data infrastructure to support the national concussion research agenda. In conjunction
with the CDC, ACS COT’s subcommittee on Injury Prevention and Control is establishing itself
as another centralized resource for injury prevention research and advocacy. The subcommit-
tee has published a “Gun Safety and Your Health” brochure for the general public to prevent
firearm injuries and has outlined a comprehensive approach to establish hospital-based violence
intervention programs.63
8 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849

Bystander intervention

The American Heart Association has exemplified the importance of bystander response ed-
ucation. Bystander CPR (cardiopulmonary resuscitation) has improved outcomes and increased
the chance of survival for patients suffering from cardiac arrest.64 The potential impact of by-
stander intervention is significant for trauma patients, given that the vast majority of deaths
occur before patients reach the hospital. For trauma patients younger than 65 years, there are
9 prehospital deaths for every in-hospital mortality. One estimate suggests that in 2014 alone,
30,0 0 0 of 147,0 0 0 trauma deaths may have been avoided with timely hemorrhage control.65
Building on the military’s success with tourniquets, local EMS and trauma centers continue to
lead successful public educational campaigns on using tourniquets to stop bleeding. These initia-
tives have translated into increased on-field tourniquet usage and better outcomes upon arrival
to trauma centers.66 , 67 In the aftermath of the tragic Sandy Hook Elementary School shooting in
2012, the ACS brought together a group of trauma surgery, emergency medical care, government,
and law enforcement experts to discuss how survival rates can be improved for injured patients
with severe bleeding. Their recommendations culminated in the Hartford Consensus, which cat-
apulted efforts to improve survival for mass violence victims by training potential bystanders. In
2015, the White House launched the STOP THE BLEED public awareness campaign.68 STOP THE
BLEED has now trained more than 1 million people around the world. The 1-hour training ses-
sion of non-medical persons has been shown to improve lay public confidence and proficiency
in controlling severe bleeding using tourniquets.69

Emergency medical services

EMS is vital for efficiently triaging and transporting injured patients. Delayed EMS transport
time from injury to the hospital has been associated with increased mortality.70 With roots in
the military, the modern day EMS started to take shape in the 1950s when a group including
hospitals, police/fire departments, and funeral homes started unregulated coordination of pa-
tient care and transport. Since the 1966 “National Highway Traffic Safety Act” that standardized
EMS training and the 1970 inception of the “National Registry of Emergency Medical Techni-
cians,” prehospital training and care have continued to evolve. In addition to basic life support
(BLS) techniques such as basic spine stabilization and bag-valve-mask ventilation, many emer-
gency medical technicians are now trained to provide advanced life support (ALS). ALS-certified
providers can perform advanced maneuvers ranging from rapid sequence induction and endo-
tracheal intubation to intravenous/intraosseous access and advanced medication administration.
Whether a trauma system with highly skilled emergency medical technicians improves
outcomes remains contentious. Since an early study reporting that severely injured patients
transported by EMS had worse survival compared to those transported by non-EMS providers
(ie, bystanders), several studies have debated the benefits of performing potentially time-
consuming invasive prehospital interventions compared to an expeditious “scoop and run”
approach.71 Several single-institutional studies in the United States and abroad have found
that advanced prehospital procedures and longer on-scene time either negatively influence
or do not impact survival for penetrating trauma victims in urban settings.72-75 A systematic
review of 46 studies comparing BLS vs ALS-level prehospital care reaffirmed that BLS appears
to be the favorable strategy for penetrating trauma victims.76 However, the quality of evidence
remains low; the literature is largely limited to retrospective single-center studies and the best
prehospital transport strategy for subgroups of trauma patients such as rural patients and blunt
trauma patients remain unclear.
Although modern day EMS is a decentralized system with considerable regional practice
variability, the National Highway Traffic Safety Administration (NHTSA) continues to set EMS
standards and lead research efforts. There are now 4 levels of national standard curricula for
prehospital EMS providers; in successive order of advanced training requirements, they include
 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849 9

first responders, basic emergency medical technicians (EMTs), intermediate EMTs, and EMT-
paramedics. NHTSA laid the groundwork to develop evidence-based guidelines for prehospital
care and has supported the development of several guidelines for trauma patients, including
guidelines for prehospital external hemorrhage control and for air medical transportation.77 , 78
NHTSA is also leading an effort to standardize data collection by EMS agencies through the Na-
tional EMS Information System (NEMSIS).79 NEMSIS now collects data on more than 30 million
EMS activations from more than 10,0 0 0 EMS agencies across the country every year. NEMSIS
can be queried by individual researchers who want to investigate their own ways to assess and
advance our EMS system, and also publish federal and state-level reports to inform the public.

Triage

Accurate triage is important to balance the delivery of cost-effective and appropriate level of
care. Trauma patients should be transported to trauma centers capable of addressing their in-
juries without risking long-transport times, yet unnecessary activation of costly trauma teams
should be minimized. ACS COT’s Triage Decision Scheme was first developed in 1986 and contin-
ues to form the basis for field triaging trauma patients across most EMS systems. The impor-
tance of correct field triage is well documented. Patients with moderate to severe injuries had
significant lower risk of death when triaged to level I trauma centers vs large nontrauma cen-
ters.80 On the other hand, the cost of care at a trauma center is nearly twice the cost of care
at a nontrauma center.81 Overtriage—inappropriate triage to a higher-level trauma center when
a patient does not require such resources—is not innocuous. Recent estimates suggested that a
30% overtriage rate is potentially costing trauma systems an excess of $136 million annually.82
Overtriage can overcrowd trauma centers and adversely impact patient care; in fact, a review
of mass casualties from terrorist bombings showed a direct correlation between overtriage rates
and the mortality rates of critically injured patients.83
ACS COT considers an undertriage rate of <5% and an overtriage rate of <35% to be accept-
able targets for trauma systems.84 Appropriate triage per ACS COT guidelines has been projected
to save $568 million per year.85 Unfortunately, both over- and undertriage remain prevalent.
A study of trauma patients in California revealed an average 35% undertriage rate, especially
among patients with older age, increasing co-comorbidities, or fall as a mechanism of injury.86 , 87
Undertriage was also associated with increased mortality.86 , 87 Although EMS providers are ex-
pected to follow triage protocols, a prospective cohort study found that EMS provider judgment
was the most common triage mechanism used.88 This has been partly attributed to poor validity
of the ACS COT triage decision scheme for pediatric and elderly patients.88 , 89 Compliance with
prehospital triage protocols vary widely across EMS systems around the world, ranging from 21%
to 94%.90 However, studies have shown that nearly all such protocols fail to accurately identify
severely injured patients, risking undertriage.90 , 91 System-wide efforts to optimize prehospital
triage continue, ranging from refining trauma team activation models within trauma centers to
reducing EMS helicopter overutilization.92 Locally, some EMS providers are now proactively con-
ducting epidemiologic studies to anticipate and adapt to evolving local trauma needs.93

Rural trauma

Rural patients face geographic and resource barriers to timely high-quality trauma care. Ap-
proximately 15.9% of the US population lives more than an hour away from a level I or II trauma
center.92 Rural trauma patients have increased likelihood of undertriage and decreased likelihood
of transportation to a level I or II trauma center.94 Inappropriate undertriage to a nondesignated
trauma center has been associated with a 30% increase in mortality within the first 48 hours.95
Prehospital care is especially important for rural communities, as transport times can exceed 2
hours and total prehospital times can exceed 4 hours.96 Although all EMS systems must have a
10 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849

physician in charge of overseeing the care provided by their prehospital providers, in rural ar-
eas with a shortage of physicians, EMS units may function without appropriate oversight. Amidst
these resource barriers, rural patients are at higher risk of suffering injuries. They are more likely
to be at higher risk for workplace injury (ie, involved in jobs that require operating machinery)
and two-thirds of all fatal motor vehicle accidents in the United States occur in rural areas.97
The rural paramedic paradox (rural areas farthest from appropriate hospitals have the greatest
EMS needs yet have the most trouble maintaining EMS services) is an unfortunate reality.96

Regionalized trauma networks

The regionalized trauma network (RTN) was first defined by The Department of Health and
Human Resources as “a pre-planned, comprehensive, and coordinated statewide and local in-
jury response network that includes all facilities with the capability to care for the injured. It
is the system’s inclusiveness, or range of pre-planned trauma center and non-trauma center re-
source allocation, that offers the public a cost-effective plan for injury treatment.”98 In short,
RTN is a single entity comprised of acute care hospitals within a region working to reduce
the burden of traumatic disease. To avoid ineffective distribution of resources and ensure suffi-
cient experience in managing trauma patients within a RTN, the ACS COT currently recommends
level I trauma centers admit at least 1200 trauma patients or 240 severely injured patients per
year.99
A RTN may be an inclusive or exclusive system. An inclusive system (wherein many hospitals
partake in trauma patient care to the extent of their capabilities and available resources) is
generally favored over exclusive trauma systems (wherein trauma patient care is limited to
several highly specialized tertiary and quaternary centers). In Ohio, inclusive RTN establishment
was associated with lower patient mortality and increased utilization of non-level I trauma
centers.100 The same Ohio RTN establishment was also associated with decreased mortality
for specific subgroups of injured patients, such as those who required trauma laparotomies or
suffered traumatic brain injuries.101 , 102 Similar findings were replicated in other US regions,
such as in a Pennsylvania study (where incorporating smaller level IV trauma centers led
to decreased mortality rates and better coordination among regional hospitals) and a study
evaluating 24 different state trauma systems (severely injured patients had greater survival
within inclusive trauma systems).15 , 103 RTN’s impact may come to fruition rapidly; one study
reported that reduced mortality was seen within 2 years of establishing a RTN.104
Foreseeing that RTNs may help close the gap in rural trauma care, ACS COT has recommended
incorporating existing rural hospitals within trauma systems as level III or IV trauma centers.
Trauma regionalization allows closer working relationships among regional hospitals and their
urban counterparts. Closer working relationships may entail more formalized transfer protocols
and increased availability of consultation; in Hawaii, providing resources for rural hospitals to
grow into level III trauma centers decreased the need to transfer rural trauma patients to re-
mote higher level centers without adversely affecting patient outcomes.105 However, the risk for
secondary over-triage (during patient transfer) that may occur with closer regional partnerships
should be remembered. A retrospective cohort study in Ohio found that a significant number
of patients transferred from level III to level I or II trauma centers were discharged without re-
quiring more intensive care within 48 hours.106 Minimizing trauma care redundancy requires
a streamlined data and imaging sharing system and active consultation infrastructure within
RTNs. In fact, increased telemedicine and real-time consultation adoption were specific needs
outlined by NASEM’s 2016 report. With RTNs, the broader choice of facilities a patient may be
transported to from injury site necessitates improvements to existing triage systems—which are
largely limited to assessing the degree of injury—to more comprehensive scoring systems (ie,
Need For Trauma Intervention, which accounts for a patient’s physical reserve).107
 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849 11

Trauma registries and quality improvement

ACS COT-verified trauma centers participate in the NTDB and TQIP.108 NTDB is the largest
US trauma database, with more than 7.5 million electronic records from 900 trauma centers.109
NTDB aims to inform the “medical community, the public, and decision makers about a wide
variety of issues that characterize the current state of care for injured persons in our coun-
try.”109 This database is the primary source for outcomes research on US trauma patients. By
2010, NTDB was the data source for 286 peer-reviewed publications and has helped advance
various aspects of trauma research including clinical outcomes, public policy, quality improve-
ment, disparity assessment, and injury prevention.110 ACS COT also uses NTDB to publish annual
reports that highlight broad issues and trends characterizing the current state of care for injured
persons.
TQIP was established in 2008 to facilitate quality improvement for individual trauma cen-
ters.111 TQIP now collects data from more than 800 US trauma centers every year and creates
risk-adjusted benchmarks for various trauma patient outcomes. Individual trauma centers re-
ceive feedback on their performance against these national benchmarks, along with quality im-
provement training and education to address center-specific deficiencies. Institutions have used
TQIP for several practical improvements ranging from accurately assessing trauma readmission
rates and revamping hospital policies to curb venous thromboembolism rates.112 , 113 A recent
multicenter study including 93 centers participating in TQIP showed that both major complica-
tion rates and risk-adjusted mortality improved after implementing TQIP.114 The state of Michi-
gan has leveraged its existing relationship between its trauma centers and a private healthcare
payer (Blue Cross Blue Shield) and built the Michigan Trauma Quality Improvement on top of
TQIP. Under this initiative, the private healthcare payer has further incentivized quality improve-
ment by instituting a pay-for-participation rather than pay-for-performance model for trauma
centers.115
In addition to participating in the NTDB and TQIP, levels I, II, and III trauma centers must
institute hospital-run performance improvement and patient safety committees (PIPS). PIPS
committees include the trauma program manager, an EMS representative, and physician repre-
sentatives from surgery, emergency medicine, and radiology. The multidisciplinary team meets
regularly to track performance, conduct peer case reviews, monitor compliance, and correct
any hospital-specific problems of deficiencies. PIPS committees have reported various quality
improvement successes, such as significantly decreasing ionizing radiation exposure for pediatric
patients or reducing mortality through a multifaceted trauma program overhaul.116 , 117

Long-term outcomes

The impact of injury lasts well beyond hospitalization. Injured patients often face long-term
social dysfunction, post-traumatic stress disorder, and chronic pain.118-120 Patients with low re-
silience, low educational levels, and low household incomes are especially at risk of poor long-
term outcomes after injury.121 , 122 Identifying long-term sequelae for specific injuries is impor-
tant because early intervention opportunities for high-risk groups may exist. Both TQIP and
NTDB capture comprehensive hospitalization characteristics, but not long-term outcomes. Long-
term outcomes of trauma patients are difficult to monitor due to variable trauma system uti-
lization and poor follow-up.123 Injured patients do not always present to well-structured RTNs,
patients injured outside their immediate communities are less likely to follow up at their admit-
ting trauma center, and arranging follow-up with a local hospital may be difficult. Most impor-
tantly, a national effort to track long-term trauma outcomes is lacking; posthospitalization data
collection is left to the discretion of individual trauma registries.124
Minimizing readmissions is an important long-term outcome goal. Up to 50% of trauma
readmissions and postdischarge emergency departments visits are not captured when patients
present to hospitals different from their index trauma admission hospitals.125 Patients most
12 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849

commonly represent with superficial infectious complications and complications related to

firearm injuries.126 Although insurance status is less likely to affect trauma care provided during
index hospitalization, insurance status significantly impacts trauma readmissions. Those who are
poorly insured are less likely to follow up after trauma admissions, whereas Medicare patients
are more likely to be healthcare super-utilizers after trauma discharge.127 , 125 With an added
layer of complexity, up to 19% of trauma patients may undergo a change in insurance status
(gaining or losing coverage) after discharge, so discharge planning for trauma patients has an
evolving barrier.128 Nevertheless, studies have already identified many readmission risk factors
including older age and frailty, discharge to skilled nursing or extended care facilities, history
of falls, alcohol abuse, discharge against medical advice, firearm injuries requiring surgery, and
interpersonal stressors.126 , 129-131 Protective factors include access to home health services, early
cognitive behavior therapy for acute stress disorder, and early multidisciplinary patient and fam-
ily teaching.132 , 133 Trauma centers must undertake early identification of readmission risk fac-
tors and discharge planning to mitigate readmissions. Widespread postdischarge data collection
is needed to understand the true physiologic and psychologic burden of injury, better identify
opportunities to improve long-term outcomes, and track the impact of intervention efforts. Of
note, what constitutes a successful recovery after trauma requires further study. A recent study
suggested that those who maintain or regain a cohesive sense of self and those highly engaged
in their recovery process have positive assessments.134

Disaster preparedness

Disasters (both natural and unnatural) and mass casualties are inevitable in today’s society.
When disaster strikes, trauma systems are at the vanguard. Not even the largest and most re-
sourceful trauma center can handle sudden patient surges on its own. The September 11 terrorist
attacks and the Boston Marathon bombings remain vivid examples. Los Angeles County has pub-
lished how their trauma system’s disaster preparedness survived through tests of disasters.135 As
of 2009, Los Angeles county had 5 level I, 8 level II trauma centers, and other non-level I and II
centers with predetermined agreements on how to respond to multicasualty disasters. When a
multicasualty event occurs, an established central command alerts all these centers and receives
live-time updates on the number of beds available at each center. Every center has made a priori
agreements on the minimum number of patients it would take. This system has responded to
several disasters in recent decades. During the LAX US Air and SkyWest Airline collision of 1991,
all 30 injured patients who survived the crash were triaged efficiently throughout 13 trauma
centers; all 30 patients survived. The system was used again during the 2006 Santa Monica
farmer’s market car crash (51 injured patients transported) and the 2008 Chatsworth Metrolink
train crash (98 injured patients transported). A well-defined disaster plan allowed these patients
to be triaged throughout many trauma centers and managed without overwhelming any individ-
ual trauma center.135
Despite the clear role for trauma systems to respond to disasters and the inevitability of
disasters, the preparedness of most trauma systems within the United States are unclear. A sim-
ulation optimization study of disaster response in 25 major US cities was performed to see how
existing trauma system resources would fare under various mass-casualty scenarios.136 These
simulations showed that cities with more concentrated trauma centers would have lower to-
tal and out-of-hospital mortality rates, and found that longer wait and transport times needed
to transport patients to trauma centers predictably increased mortality and resource consump-
tion.136 Alarmingly, not all trauma systems had the capacity to provide adequate care. The need
to lay out well-defined disaster plans, regularly practice their enhancement, and the readiness
for postdisaster analysis all remain pressing needs of US trauma systems today.
The importance of disaster preparedness has been highlighted by the ongoing COVID-19
pandemic. The SARS-CoV-2 virus has pushed global healthcare systems to the limits of their
resources—and in some cases, past breaking points. In recent weeks, efforts to reduce mortality
have focused on “flattening the curve” wherein patients requiring hospitalization (in many cases
 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849 13

intensive care with ventilator support) do not supersede the healthcare systems’ resources (the
bar). With evolving projections portending national ventilator shortages, the ACS—within a few
weeks of the pandemic outbreak—has issued strong guidance to ensure quality care for surgical
and trauma patients amidst constrained resources. Building on the infrastructure and coordina-
tion already thriving in established trauma networks, the ACS has also provided a framework for
establishing Regional Medical Operation Centers (RMOC) for the COVID-19 pandemic.137 RMOC
is defined as “a single point of shared situational awareness and information that can imple-
ment effective command and control for the medical response to a large-scale mass casualty
incident or other scenario…[which] may involve a single county or scale up to an entire state
or multi-state region.”137 Similar to how coordination between multiple trauma centers, EMS,
and other entities that care for trauma patients have improved outcomes for injured patients,
RMOCs may prove vital for our healthcare system to endure this challenge of an unprecedented
scale in recent memory.

International trauma systems

Global overview

The burden of injury is global. According to the World Health Organization (WHO), more
than 5 million deaths annually are attributed to traumatic injuries; more than 90% of these
deaths occur in mid-to-low-income countries.138 The WHO Trauma System Maturity Index clas-
sifies various national trauma systems into 4 categories based on the level of maturity and
resources from level I (least mature) to level IV (most mature).139 The index is evaluated on
the domains of prehospital trauma care, facility based trauma care, education and training, and
quality assurance. As expected, many high-income countries report mature trauma systems and
lower trauma-related mortality compared to mid-to-low-income countries.140 In an effort to re-
duce this disparity, the WHO has released a how-to guide for national quality improvement
in trauma care through its “Guidelines for Trauma Quality Improvement Programmes.”139 Many
mid-to-low-income countries have referred to these guidelines to conduct need assessments and
inform policy development. However, only a minority of these countries have implemented these
guidelines.141 Even high-income countries have yet to establish truly comprehensive trauma sys-
tems. For example, many lack nationally implemented trauma registries.140 Despite these short-
comings, the global burden of trauma as measured by disability adjusted life years (DALY)—a
summative index that includes premature mortality and nonfatal outcomes measured as years
lived with disability—is improving. Global DALY rates for injuries have decreased by 31%, and
the rate of decline in DALY rates has been significant for all major injuries between 1990 and
2013.142

Prehospital systems

Middle-to-low-income countries often lack organized prehospital trauma systems at a na-

tional scale. Field-to-hospital transport is often undertaken in non-EMS specialized vehicles by
individuals who lack certified training.143-145 However, local efforts for organized prehospital
care have improved outcomes in resource-constrained settings. For example, a gradual expan-
sion of a skeleton prehospital system throughout Northern Iraq (including 135 paramedics and
70 0 0 lay trauma responders who received 2-day courses in basic life support measures) led to a
13% reduction in trauma-related mortality over a 10-year period.146 A rural Uganda community
was able to build a new, highly utilized, and affordable EMS at an estimated cost of $0.93 per
capita, and instituting formalized guidelines for trauma dispatch systems has led to decreased
response time and optimal dispatch in Monterrey (Mexico) and Tehran (Iran), respectively.147-149
Many high-income countries have national EMS systems with certified first responders who
can provide basic and advanced life support. Many, such as the United Kingdom in 2012, have
14 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849

turned to the US trauma system as a model to replicate.150 High-income countries do have

system-wide variability in prehospital management strategies.150 For instance, whereas the US
prehospital model prioritizes rapid patient transport to trauma centers through a “scoop and
run” approach, France’s prehospital model more heavily emphasizes in-field triage and assess-
ment by physicians.151 Japan and Hong Kong’s EMS systems are entirely run by paramedics,
whereas many European countries have ambulances staffed by paramedics and specially trained
physicians.152-155 Similar to the United States, geography attributes to regional differences within
national prehospital systems, with lower level of life support available in rural regions and less
densely populated regions reliant on EMS support by helicopter.140

Trauma center care

The impact of an integrated trauma system on improved trauma patient outcomes is clear.
One estimate suggests that if global survival rates for severe injuries mirror those in high-income
countries, up to 2 million lives could be saved annually.156 Optimally managing injured patients
within the trauma facility is the pillar of every trauma system. Most mid-to-low-income coun-
tries lack formal hospital trauma care pathways and 24/7 availability of qualified surgeons to
manage injured patients. Some countries such as Saudi Arabia and India do have well-equipped
facilities and well-trained personnel, but this is limited to large urban hospitals.157 , 158 Improving
care pathways has shown early success within individual centers. A tertiary hospital in Thailand
reported reduced mortality among thoracic trauma patients after establishing a dedicated rapid
response team, while a tertiary hospital in China reduced mortality rates for severely injured
patients through an interdisciplinary evaluation and resuscitation pathway, and a hospital in
Colombia decreased mortality for traumatic injury patients through standardized trauma proto-
cols.159-161
High-income countries have implemented coordinated trauma center care to varying degrees.
Nearly 90% of hospitals in Norway that receive trauma patients had dedicated trauma teams,
whereas only 20% of such hospitals in Finland had organized trauma teams.162 , 163 Some high-
income countries such as Ireland, Belgium, and France have yet to implement formalized man-
agement, transfer, and triage protocols among its trauma centers.155 , 164 , 165 Others, such as the
United States, Canada, and Hong Kong, have well-established trauma centers with dedicated pro-
tocols and dedicated trauma teams, built in accordance with the ACS-COT guidelines. Similar to
US evidence, international data have shown that trauma systems improve outcomes of injured
patients. A study of Canadian trauma systems across several provinces found that mortality was
lower in provinces with high compliance to trauma system guidelines, particularly in patients
with severe or acutely life-threatening injuries.166 This association between adherence to for-
mal trauma system guidelines and improved survival after injury has been replicated in other
countries such as Hong Kong and Australia.167 , 168

Other components

Trauma registries rarely exist in mid-to-low-income countries due to the lack of digital re-
sources to maintain a costly registry.169 As of 2017, many countries with major trauma burden—
including India, South Africa, Spain, China, and Brazil—have yet to develop nationwide trauma
registries.140 High-income countries have implemented national trauma registries to varying de-
grees. Several countries collaborate to form multinational registries, such as the Trauma Audit
& Research Network (United Kingdom and Ireland), the National Trauma Registry Consortium
(Australia and New Zealand), and the Scandinavian Trauma Registry (Scandinavian countries).
Others, such as Spain and Greece, are still building their nationwide trauma registries, while
Canada closed its national trauma registry in 2014. With respect to trauma education, a system-
atic review on the impact of trauma care systems in low and middle income countries reported
 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849 15

Table 1
Successful impact of trauma systems in the United States.

Domains Organizations/programs Successful impact

Injury prevention National Highway Traffic Safety National Traffic and Motor Vehicle Safety
Administration Act: decreased motor vehicle accident
Centers for Disease Control National Center mortality
for Injury Prevention and Control Injury database: WISQARS
American College of Surgeons Committee Injury prevention research funding
on Trauma Public awareness campaigns
Legislative advocacy
Bystander intervention American College of Surgeons Committee Hartford Consensus
on Trauma STOP THE BLEED campaign: >1 million
Federal government trained on tourniquet use
Emergency medical National Highway Traffic Safety Establishes EMS organizational and training
services (EMS) Administration standards
Local EMS systems NEMSIS database & EMS research
expeditious field-to-hospital transport
Triage American College of Surgeons Committee Triage decision scheme publication
on Trauma Strategies to minimize over and
Local EMS systems under-triage
Regionalized trauma Local regionalized trauma networks Co-ordinated care between high-level and
networks other regional trauma centers
Decreased mortality and other adverse
outcomes
Trauma registries and American College of Surgeons Committee Trauma research foundation
quality improvement on Trauma: National updates on state of trauma care
National Trauma Data Bank Benchmarks for individual trauma centers
Trauma Quality Improvement Program to reduce mortality and morbidity
Performance Improvement and Patient
Safety committee
NEMSIS, National Emergency Medical Services Information System; WISQARS, Web-based Injury Statistics Query and
Reporting System.

Table 2
Unmet opportunities for trauma systems in the United States.

Domains Unmet Opportunities

Injury prevention Federal funding for gun violence research

Emergency medical Evidence for “scoop and run” vs invasive prehospital interventions
services (EMS) Support for rural EMS
Triage Adherence to triage decision scheme rather than individual judgment
More comprehensive triage decision scheme that captures patients’ functional reserves
Triage protocols to minimize over- and under-triage
Regionalized trauma Further adoption of telemedicine and real-time consultation with trauma networks
networks
Long-term outcomes Database to track long-term outcomes
Long-term outcomes research for specific injuries
Disaster preparedness Well-defined disaster response protocols within trauma networks

that 18 of 32 assessed countries have published on the beneficial impact of trauma training pro-
grams.170 ATLS courses are offered in many high income countries, but variations exist (ie, Japan
Advanced Trauma Evaluation and Care course—Japan, European Trauma Course—Belgium).

Conclusion

The modern US trauma system has evolved over the course of a century. From surgeons near
battlefields who decided who could and could not return to the heat of war, an intricate trauma
system that spans the entire continuum of clinical care, research, education, advocacy, and dis-
aster preparedness has emerged. Trauma systems across the globe have proven their ability to
16 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849

improve patient outcomes. Despite the successful impact (Table 1), unmet needs and opportuni-
ties exist for trauma systems in the United States (Table 2).
The work has yet to be completed. Despite recognition of the burden of trauma and our
system’s critical role in improving patient outcomes, trauma remains severely underfunded; in
2016, trauma accounted for only 2.9% of the National Institutes of Health’s extramural budget.171
Accomplishing the mission Zero Preventable Deaths After Injury will require funding to match
the scope of the continued injury epidemic and a ceaseless march to a truly comprehensive
trauma system.

Acknowledgments

The Neil and Claudia Doerhoff Fund supports scholarly activities of Dr Choi. We would like
to thank Dr Beatrice Sun for assistance with initial literature searches.

References
1. Accidents or Unintentional Injuries. CDC. 2019 Centers for Disease Control and Prevention website [Internet]. [cited
2019 Dec 3]. Available from: [Link]
2. Rhee P, Joseph B, Pandit V, et al. Increasing trauma deaths in the United States. Ann Surg. 2014;260:13–21.
3. Cost of Injury [Internet]. The American Association for the Surgery of Trauma website. [cited 2019 Oct 12]. Available
from: [Link]
4. Haagsma JA, Graetz N, Bolliger I, et al. The global burden of injury: incidence, mortality, disability-adjusted life
years and time trends from the Global Burden of Disease study 2013. Inj Prev. 2016;22:3–18.
5. Swanson R. The Development of Triage. National Museum of Civil War Medicine; 2014 [Internet][cited 2019 Sep 27].
Available from: http:// [Link]/ surgeons-call/ triage1/ .
6. Mullins RJ. A historical perspective of trauma system development in the United States. J Trauma Acute Care Surg.
1999;47:S8.
7. Trunkey DD. Trauma. Accidental and intentional injuries account for more years of life lost in the U.S. than cancer
and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further
research. Sci Am. 1983;249:28–35.
8. National Academy of Sciences (US) and National Research Council (US) Committee on Trauma, National Academy
of Sciences (US) and National Research Council (US) Committee on Shock. Accidental Death and Disability: The Ne-
glected Disease of Modern Society. WashingtonDC: National Academies Press (US); 1966 [Internet][cited 2019 Sep 2].
Available from: http:// [Link]/ books/ NBK222962/ .
9. Public Law 89-563. National Traffic and Motor Vehicle Safety Act of 1966; 1966 [Internet]Available from: [Link]
[Link]/ statutes/ pl/ 89/ [Link] .
10. Hoskin AF, Fearn KT, Porretta K, Predovich M. Accident Facts. 1998 Edition; 1998 [Internet][cited 2020 Mar 28].
Available from: https:// [Link]/ view/ 537584.
11. Lowe RJ, Baker RJ. Organization and function of trauma care units. J Trauma. 1973;13:285–290.
12. Cowley RA, Hudson F, Scanlan E, et al. An economical and proved helicopter program for transporting the emer-
gency critically ill and injured patient in Maryland. J Trauma. 1973;13:1029–1038.
13. Department of Surgery-University of Louisville [Internet]. [cited 2020 Apr 7]. Available from: http://
[Link]/[Link].
14. Cranston A. S.2410 - 93rd Congress (1973-1974): Emergency Medical Services Systems Act [Internet]. 1973 [cited
2020 Mar 28]. Available from: [Link]
15. Boyd DR. A total emergency medical service system for Illinois. IMJ Ill Med J. 1972;142:486–488.
16. Optimal hospital resources for care of the seriously injured. Bull Am Coll Surg. 1976;61:15–22.
17. Jones JR. H.R. 3982 - 97th Congress (1981-1982): Omnibus Budget Reconciliation Act of 1981 [Internet]. 1981 [cited
2020 Mar 28]. Available from: [Link] congress/house- bill/3982.
18. Institute of Medicine (US) and National Research Council (US) Committee on Trauma Research. Injury in America:
A Continuing Public Health Problem [Internet]. WashingtonDC: National Academies Press (US); 1985 [cited 2020 Mar
28]. Available from: http:// [Link]/ books/ NBK217490/ .
19. Bazzoli GJ, Madura KJ, Cooper GF, MacKenzie EJ, Maier RV. Progress in the development of trauma systems in the
United States: results of a national survey. JAMA. 1995;273:395–401.
20. Committee on Trauma [Internet]. American College of Surgeons. [cited 2019 Oct 24]. Available from: [Link]
[Link]/about- acs/governance/acs- committees/committee- on- trauma.
21. About the Verification, Review, and Consultation Program [Internet]. American College of Surgeons. [cited 2020 Mar
31]. Available from: [Link]
22. Trauma Centers [Internet]. American College of Surgeons. [cited 2020 Mar 31]. Available from: [Link]
org/search/trauma-centers.
23. California State Trauma System [Internet]. [cited 2020 Mar 8]. Available from: [Link]
health/trauma_systems/[Link].
24. Georgia State Trauma System [Internet]. [cited 2020 Mar 8]. Available from: [Link]
health/trauma_systems/[Link].
 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849 17

25. Alabama State Trauma System [Internet]. [cited 2020 Mar 8]. Available from: [Link]
health/trauma_systems/[Link].
26. Trauma EMS Interactive Map [Internet]. [cited 2020 Mar 8]. Available from: [Link]
trauma- ems- interactive- [Link].
27. MacKenzie EJ, Hoyt DB, Sacra JC, et al. National inventory of hospital trauma centers. JAMA. 2003;289:1515–1522.
28. Brown JB, Rosengart MR, Billiar TR, Peitzman AB, Sperry JL. Geographic distribution of trauma centers and injury
related mortality in the United States. J Trauma Acute Care Surg. 2016;80:42–50.
29. Needs Based Assessment of Trauma Systems [Internet]. American College of Surgeons. [cited 2019 Sep 28]. Available
from: [Link]
30. Ashley DW, Pracht EE, Garlow LE, et al. Evaluation of the Georgia trauma system using the American College of
Surgeons Needs Based Assessment of Trauma Systems tool. Trauma Surg Acute Care Open. 2018;3. Available from:.
[Link]
31. Uribe-Leitz T, Esquivel MM, Knowlton LM, et al. The American College of Surgeons (ACS) Needs-Based Assessment
of Trauma Systems (NBATS): estimates for the state of California. J Trauma Acute Care Surg. 2017;82:861–866.
32. Ciesla DJ, Pracht EE, Leitz PT, Spain DA, Staudenmayer KL, Tepas JJI. The trauma ecosystem: the impact and eco-
nomics of new trauma centers on a mature statewide trauma system. J Trauma Acute Care Surg. 2017;82:1014.
33. Vernon T, Cook A, Horst M, et al. A preliminary analysis of Level IV trauma centers within an organized trauma
system. J Trauma Acute Care Surg. 2019;87:666–671.
34. Trauma Designation :: Washington State Department of Health [Internet]. Trauma Facility Designa-
tion. [cited 2020 Mar 8]. Available from: [Link]
EmergencyMedicalServicesEMSSystems/TraumaSystem/TraumaDesignation.
35. Carmont MR. The Advanced Trauma Life Support course: a history of its development and review of related litera-
ture. Postgrad Med J. 2005;81:87–91.
36. Rotondo M. Advanced Trauma Life Support [Internet]. Advanced Trauma Life Support. [cited 2020 Mar 28]. Available
from: [Link]
37. Ali J, Adam R, Butler AK, et al. Trauma outcome improves following the advanced trauma life support program in a
developing country. J Trauma Acute Care Surg. 1993;34. Available from:. [Link]
1993/060 0 0/TRAUMA_OUTCOME_IMPROVES_FOLLOWING_THE_ADVANCED.[Link].
38. van Olden GDJ, Dik Meeuwis J, Bolhuis HW, Boxma H, Goris RJA. Clinical impact of advanced trauma life support.
Am J Emerg Med. 2004;22:522–525.
39. Plummer D. Whose turf is it, anyway? Diagnostic ultrasonography in the emergency department. Acad Emerg Med.
20 0 0;7:186–187.
40. Rozycki GS. Abdominal ultrasonography in trauma. Surg Clin N Am. 1995;75:175–191.
41. Richards JR, McGahan JP. Focused Assessment with Sonography in Trauma (FAST) in 2017: what radiologists can
learn. Radiology. 2017;283:30–48.
42. Scaife ER, Fenton SJ, Hansen KW, Metzger RR. Use of focused abdominal sonography for trauma at pediatric and
adult trauma centers: a survey. J Pediatr Surg. 2009;44:1746–1749.
43. Bowyer MW, Kuhls DA, Haskin D, et al. Advanced surgical skills for exposure in trauma (ASSET): the first 25 courses.
J Surg Res. 2013;183:553–558.
44. Drake FT, Van Eaton EG, Huntington CR, Jurkovich GJ, Aarabi S, Gow KW. ACGME case logs: surgery resident expe-
rience in operative trauma for two decades. J Trauma Acute Care Surg. 2012;73:1500–1506.
45. . General Surgery Case Logs. Accreditation Council for Graduate Medical Education; 2011 [Internet][cited 2020 Mar
27]. Available from: http:// [Link]/ Portals/ 0/ PDFs/ [Link] .
46. Ali J, Sorvari A, Haskin D, Luchette F, Bowyer M. Potential role of the Advanced Surgical Skills for Exposure in
Trauma (ASSET) course in Canada. J Trauma. 2011;71:1491–1493.
47. Mackenzie CF, Tisherman SA, Shackelford S, Sevdalis N, Elster E, Bowyer MW. Efficacy of trauma surgery technical
skills training courses. J Surg Educ. 2019;76:832–843.
48. Bulger EM, Perina DG, Qasim Z, et al. Clinical use of resuscitative endovascular balloon occlusion of the aorta (RE-
BOA) in civilian trauma systems in the USA, 2019: a joint statement from the American College of Surgeons Com-
mittee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical
Services Physicians and the National Association of Emergency Medical Technicians. Trauma Surg Acute Care Open.
2019;4. [cited 2020 Mar 31]Available from:. [Link]
49. Disaster Management and Emergency Preparedness [Internet]. American College of Surgeons. [cited 2020 Mar 31].
Available from: [Link]
50. About - The American Association for the Surgery of Trauma [Internet]. [cited 2020 Mar 31]. Available from: https://
[Link]/About/[Link].
51. Edwards JG, Clarke P, Pieracci FM, et al. Taxonomy of multiple rib fractures: results of the chest wall injury society
international consensus survey. J Trauma Acute Care Surg. 2020;88:e40–e45.
52. Pieracci FM, Leasia K, Bauman Z, et al. A multicenter, prospective, controlled clinical trial of surgical stabilization
of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL). J Trauma
Acute Care Surg. 2020;88:249–257.
53. Sarani B, Allen R, Pieracci FM, et al. Characteristics of hardware failure in patients undergoing surgical stabilization
of rib fractures: a Chest Wall Injury Society multicenter study. J Trauma Acute Care Surg. 2019;87:1277–1281.
54. Pieracci FM, Agarwal S, Doben A, et al. Indications for surgical stabilization of rib fractures in patients without flail
chest: surveyed opinions of members of the Chest Wall Injury Society. Int Orthop. 2018;42:401–408.
55. National Academies of Sciences, Engineering, and Medicine. A National Trauma Care System: Integrating Military and
Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington (DC): The National Academies
Press; 2016.
56. Jenkins DH, Winchell RJ, Coimbra R, et al. Position statement of the American College of Surgeons Committee on
Trauma on the National Academies of Sciences, Engineering and Medicine Report, A National Trauma Care System:
18 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849

Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. J Trauma Acute
Care Surg. 2016;81:819.
57. Hashmi ZG, Haut ER, Efron DT, Salim A, Cornwell EE, Haider AH. A target to achieve zero preventable trauma deaths
through quality improvement. JAMA Surg. 2018;153:686–689.
58. National Highway Traffic Safety Administration (NHTSA) NHTSA Traffic Safety Facts Crash Stats. 2009. DOT HS 811
172 A Brief Statistical Summary June 2009 2008 Traffic Safety Annual Assessment – Highlights [Internet]. [cited
2019 Oct 3]. Available from: [Link]
59. Centers for Disease Control and Prevention (CDC)Motor-vehicle safety: a 20th century public health achievement.
MMWR Morb Mortal Wkly Rep. 1999;48:369–374.
60. WISQARS (Web-based Injury Statistics Query and Reporting System)|Injury Center|CDC [Internet]. 2020 [cited 2020
Mar 31]. Available from: [Link]
61. Kondo MC, Keene D, Hohl BC, MacDonald JM, Branas CC. A difference-in-differences study of the effects of a new
abandoned building remediation strategy on safety. PLoS One. 2015;10.
62. Iowa Violent Death Reporting System Special Report on Suicide in Iowa, 2019 [Internet]. [cited 2020 Mar 31].
Available from: [Link]
[Link].
63. Violence intervention programs: A primer for developing a comprehensive program for trauma cen-
ters [Internet]. The Bulletin. 2017. [cited 2020 Mar 31]. Available from:. [Link]
violence- intervention- programs- a- primer- for- developing- a- comprehensive- program- for- trauma- centers/.
64. Herlitz J, Svensson L, Holmberg S, Angquist K-A, Young M. Efficacy of bystander CPR: intervention by lay people
and by health care professionals. Resuscitation. 2005;66:291–295.
65. Gedeborg R, Chen L-H, Thiblin I, et al. Prehospital injury deaths–strengthening the case for prevention: nationwide
cohort study. J Trauma Acute Care Surg. 2012;72:765–772.
66. Smith A, Ochoa J, Wong S, et al. Prehospital tourniquet use in penetrating extremity trauma: decreased blood trans-
fusions and limb complications. J Trauma Acute Care Surg. 2019;86:43–51.
67. Goodwin T, Moore KN, Pasley JD, Troncoso RJ, Levy MJ, Goolsby C. From the battlefield to main street: Tourniquet
acceptance, use, and translation from the military to civilian settings. J Trauma Acute Care Surg. 2019;87(1S):S35.
68. Our Story | Stop The Bleed [Internet]. [cited 2020 Mar 31]. Available from: [Link]
69. Schroll R, Smith A, Martin MS, et al. Stop the bleed training: rescuer skills, knowledge, and attitudes of hemorrhage
control techniques. J Surg Res. 2019;245:636–642.
70. Gonzalez RP, Cummings GR, Phelan HA, Mulekar MS, Rodning CB. Does increased emergency medical ser-
vices prehospital time affect patient mortality in rural motor vehicle crashes? A statewide analysis. Am J Surg.
2009;197:30–34.
71. Demetriades D, Chan L, Cornwell E, et al. Paramedic vs private transportation of trauma patients. Effect on outcome.
Arch Surg. 1996;131:133–138.
72. Seamon MJ, Fisher CA, Gaughan J, et al. Prehospital procedures before emergency department thoracotomy: “scoop
and run” saves lives. J Trauma. 2007;63:113–120.
73. Seamon MJ, Doane SM, Gaughan JP, et al. Prehospital interventions for penetrating trauma victims: a prospective
comparison between Advanced Life Support and Basic Life Support. Injury. 2013;44:634–638.
74. Funder KS, Petersen JA, Steinmetz J. On-scene time and outcome after penetrating trauma: an observational study.
Emerg Med J. 2011;28:797–801.
75. Aydin S, Overwater E, Saltzherr TP, et al. The association of mobile medical team involvement on on-scene times
and mortality in trauma patients. J Trauma. 2010;69:589–594 discussion 594.
76. Ryynänen O-P, Iirola T, Reitala J, Pälve H, Malmivaara A. Is advanced life support better than basic life support in
prehospital care? A systematic review. Scand J Trauma Resusc Emerg Med. 2010;18:62.
77. Bulger EM, Snyder D, Schoelles K, et al. An evidence-based prehospital guideline for external hemorrhage control:
American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014;18:163–173.
78. Thomas SH, Brown KM, Oliver ZJ, et al. An evidence-based guideline for the air medical transportation of prehos-
pital trauma patients. Prehosp Emerg Care. 2014;18(suppl 1):35–44.
79. Office of EMS: NEMSIS [Internet]. [cited 2020 Mar 31]. Available from: [Link]
80. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality.
N Engl J Med. 2006;354:366–378.
81. Durham R, Pracht E, Orban B, Lottenburg L, Tepas J, Flint L. Evaluation of a mature trauma system. Ann Surg.
2006;243:775–785.
82. Newgard CD, Staudenmayer K, Hsia RY, et al. The cost of overtriage: more than one-third of low-risk injured pa-
tients were taken to major trauma centers. Health Aff (Millwood). 2013;32:1591–1599.
83. Frykberg ER. Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J
Trauma. 2002;53:201–212.
84. Davis JW, Dirks RC, Sue LP, Kaups KL. Attempting to validate the overtriage/undertriage matrix at a Level I trauma
center. J Trauma Acute Care Surg. 2017;83:1173–1178.
85. Faul M, Wald MM, Sullivent EE, et al. Large cost savings realized from the 2006 Field Triage Guideline: reduction
in overtriage in U.S. trauma centers. Prehosp Emerg Care. 2012;16:222–229.
86. Delgado MK, Yokell MA, Staudenmayer KL, Spain DA, Hernandez-Boussard T, Wang NE. Factors associated with the
disposition of severely injured patients initially seen at non–trauma center emergency departments: disparities by
insurance status. JAMA Surg. 2014;149:422–430.
87. Staudenmayer K, Lin F, Mackersie R, Spain D, Hsia R. Variability in California triage from 2005 to 2009: a popula-
tion-based longitudinal study of severely injured patients. J Trauma Acute Care Surg. 2014;76:1041–1047.
88. Newgard CD, Fu R, Zive D, et al. Prospective validation of the national field triage guidelines for identifying seriously
injured persons. J Am Coll Surg. 2016;222:146–158.
 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849 19

89. Lerner EB, Drendel AL, Cushman JT, et al. Ability of the physiologic criteria of the field triage guidelines to identify
children who need the resources of a trauma center. Prehosp Emerg Care. 2017;21:180–184.
90. van Rein EAJ, van der Sluijs R, Raaijmaakers AMR, Leenen LPH, van Heijl M. Compliance to prehospital trauma triage
protocols worldwide: a systematic review. Injury. 2018;49:1373–1380.
91. van Rein EAJ, Houwert RM, Gunning AC, Lichtveld RA, Leenen LPH, van Heijl M. Accuracy of prehospital triage
protocols in selecting severely injured patients: a systematic review. J Trauma Acute Care Surg. 2017;83:328–339.
92. Branas CC, MacKenzie EJ, Williams JC, et al. Access to trauma centers in the United States. JAMA.
2005;293:2626–2633.
93. Farah J, Goebel M, Pierce J, Donofrio JJ. Epidemiology of prehospital care at the San Diego (USA) - Tijuana (Mexico)
International Border Crossing. Prehosp Emerg Care. 2020;24(3):335–340.
94. Newgard CD, Fu R, Bulger E, et al. Evaluation of rural vs urban trauma patients served by 9-1-1 emergency medical
services. JAMA Surg. 2017;152:11–18.
95. Haas B, Stukel TA, Gomez D, et al. The mortality benefit of direct trauma center transport in a regional trauma
system: a population-based analysis. J Trauma Acute Care Surg. 2012;72:1510–1515 discussion 1515-1517.
96. Trauma System-Agenda for the Future [Internet]. [cited 2020 Mar 31]. Available from: [Link]
advancing- ems- systems/Provider-Resources/EMS_Trauma_Agenda.pdf.
97. Baker SP, Whitfield RA, O’Neill B. Geographic variations in mortality from motor vehicle crashes. N Engl J Med.
1987;316:1384–1387.
98. United States Department of Health and Human Services. Model Trauma System Planning and Evaluation. 2006 Jan
31 [cited 2020 Mar 30]; Available from: [Link]
99. VRC Standards FAQs [Internet]. American College of Surgeons. [cited 2020 Apr 1]. Available from: [Link]
org/quality-programs/trauma/tqp/center-programs/vrc/faq/standards.
100. He JC, Kreiner LA, Sajankila N, Allen DL, Claridge JA. Performance of a regional trauma network: a state-wide anal-
ysis. J Trauma Acute Care Surg. 2016;81:190–195.
101. Schechtman D, He J, Zosa B, Allen D, Claridge J. Trauma system regionalization improves mortality in patients
requiring trauma laparotomy. J Trauma Acute Care Surg. 2017;82:58–64.
102. Kelly ML, Banerjee A, Nowak M, Steinmetz M, Claridge JA. Decreased mortality in traumatic brain injury following
regionalization across hospital systems. J Trauma Acute Care Surg. 2015;78:715–720.
103. Utter GH, Maier RV, Rivara FP, Mock CN, Jurkovich GJ, Nathens AB. Inclusive trauma systems: do they improve
triage or outcomes of the severely injured? J Trauma. 2006;60:529–535 discussion 535-537.
104. Claridge JA, Allen D, Patterson B, et al. Regional collaboration across hospital systems to develop and implement
trauma protocols saves lives within 2 years. Surgery. 2013;154:875–882 discussion 882-884.
105. Galanis DJ, Steinemann S, Rosen L, Bronstein AC, Biffl WL. Rural level III centers in an inclusive trauma system
reduce the need for interfacility transfer. J Trauma Acute Care Surg. 2018;85:747–751.
106. Parikh PP, Parikh P, Mamer L, McCarthy MC, Sakran JV. Association of system-level factors with secondary over-
triage in trauma patients. JAMA Surg. 2019;154:19–25.
107. Roden-Foreman JW, Rapier NR, Foreman ML, et al. Rethinking the definition of major trauma: the need for trauma
intervention outperforms injury severity score and revised trauma score in 38 adult and pediatric trauma centers.
J Trauma Acute Care Surg. 2019;87:658.
108. Shafi S, Nathens AB, Cryer HG, et al. The trauma quality improvement program of the American College of Surgeons
Committee on Trauma. J Am Coll Surg. 2009;209:521–530.
109. Hashmi ZG, Kaji AH, Nathens AB. Practical guide to surgical data sets: National Trauma Data Bank (NTDB). JAMA
Surg. 2018;153:852–853.
110. Haider AH, Saleem T, Leow JJ, et al. Influence of the National Trauma Data Bank on the study of trauma outcomes:
is it time to set research best practices to further enhance its impact? J Am Coll Surg. 2012;214:756–768.
111. Trauma Quality Improvement Program (TQIP) [Internet]. American College of Surgeons. [cited 2020 Apr 2]. Available
from: [Link]
112. Shapiro DS, Umer A, Marshall WT, et al. Use of a modified American College of Surgeons trauma quality improve-
ment program to enhance 30-day post-trauma readmission detection. J Am Coll Surg. 2016;222:865–869.
113. Machado-Aranda DA, Jakubus JL, Wahl WL, et al. Reduction in venous thromboembolism events: trauma perfor-
mance improvement and loop closure through participation in a state-wide quality collaborative. J Am Coll Surg.
2015;221:661–668.
114. Hemmila MR, Cain-Nielsen AH, Jakubus JL, Mikhail JN, Dimick JB. Association of hospital participation in a regional
trauma quality improvement collaborative with patient outcomes. JAMA Surg. 2018;153:747–756.
115. Nathens AB, Cryer HG, Fildes J. The American College of Surgeons trauma quality improvement program. Surg Clin
N Am. 2012;92:441–454.
116. Connelly CR, Yonge JD, Eastes LE, et al. Performance improvement and patient safety program-guided quality im-
provement initiatives can significantly reduce computed tomography imaging in pediatric trauma patients. J Trauma
Acute Care Surg. 2016;81:278–284.
117. Sarkar B, Brunsvold ME, Cherry-Bukoweic JR, et al. American College of Surgeons’ Committee on trauma per-
formance improvement and patient safety program: maximal impact in a mature trauma center. J Trauma.
2011;71:1447–1453 discussion 1453-1454.
118. Herrera-Escobar JP, Rivero R, Apoj M, et al. Long-term social dysfunction after trauma: what is the prevalence, risk
factors, and associated outcomes? Surgery. 2019;166:392–397.
119. Herrera-Escobar JP, Al Rafai SS, Seshadri AJ, et al. A multicenter study of post-traumatic stress disorder after injury:
mechanism matters more than injury severity. Surgery. 2018;164:1246–1250.
120. Carrie C, Guemmar Y, Cottenceau V, et al. Long-term disability after blunt chest trauma: don’t miss chronic neuro-
pathic pain!. Injury. 2019;50:113–118.
121. Herrera-Escobar JP, Seshadri AJ, Rivero R, et al. Lower education and income predict worse long-term outcomes
after injury. J Trauma Acute Care Surg. 2019;87:104–10.
20 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849

122. Nehra D, Herrera-Escobar JP, Al Rafai SS, et al. Resilience and long-term outcomes after trauma: an opportunity for
early intervention? J Trauma Acute Care Surg. 2019;87:782–789.
123. Rosenberg GM, Shearer EJ, Zion SR, et al. Implementation challenges using a novel method for collecting patien-
t-reported outcomes after injury. J Surg Res. 2019;241:277–284.
124. Rios-Diaz AJ, Lam J, Zogg CK. The need for postdischarge, patient-centered data in trauma. JAMA Surg.
2016;151:1101–1102.
125. Petrey LB, Weddle RJ, Richardson B, et al. Trauma patient readmissions: why do they come back for more? J Trauma
Acute Care Surg. 2015;79:717–724 discussion 724-725.
126. Parreco J, Buicko J, Cortolillo N, Namias N, Rattan R. Risk factors and costs associated with nationwide nonelective
readmission after trauma. J Trauma Acute Care Surg. 2017;83:126–134.
127. Hansen L, Shaheen A, Crandall M. Outpatient follow-up after traumatic injury: challenges and opportunities. J Emerg
Trauma Shock. 2014;7:256–260.
128. Rajasingh CM, Weiser TG, Knowlton LM, Tennakoon L, Spain DA, Staudenmayer KL. Trauma-induced insurance in-
stability: variation in insurance coverage for patients who experience readmission after injury. J Trauma Acute Care
Surg. 2018;84:876–884.
129. Strosberg DS, Housley BC, Vazquez D, Rushing A, Steinberg S, Jones C. Discharge destination and readmission rates
in older trauma patients. J Surg Res. 2017;207:27–32.
130. Rattan R, Parreco J, Namias N, Pust GD, Yeh DD, Zakrison TL. Hidden costs of hospitalization after firearm injury:
national analysis of different hospital readmission. Ann Surg. 2018;267:810–815.
131. Hall C, Essler S, Dandashi J, et al. Impact of frailty and anticoagulation status on readmission and mortality rates
following falls in patients over 80. Proc (Bayl Univ Med Cent). 2019;32:181–186.
132. Visser E, Gosens T, Den Oudsten BL, De Vries J. The course, prediction, and treatment of acute and posttraumatic
stress in trauma patients: a systematic review. J Trauma Acute Care Surg. 2017;82:1158–1183.
133. Gerrish AW, Hamill ME, Locklear TM, et al. Trauma recidivism postdischarge mortality: important differences exist
between the adult and geriatric populations. Am Surg. 2019;85:685–689.
134. Rosenberg G, Zion SR, Shearer E, et al. What constitutes a ‘successful’ recovery? Patient perceptions of the recovery
process after a traumatic injury. Trauma Surg Acute Care Open. 2020;5.
135. Cryer HG, Hiatt JR. Trauma system: the backbone of disaster preparedness. J Trauma. 2009;67(2 Suppl):S111–S113.
136. Carr BG, Walsh L, Williams JC, Pryor JP, Branas CC. A geographic simulation model for the treatment of trauma
patients in disasters. Prehosp Disaster Med. 2016;31:413–421.
137. Stewart RMR, Bulger EM, Epley E, Mitchell SH How to set up a regional medical operations center to man-
age the COVID-19 pandemic [Internet]. American College of Surgeons. 2020;[cited 2020 Apr 4]. Available from:
[Link] 19/clinical- guidance/rmoc- setup.
138. Murray CJL, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions,
1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197–2223.
139. World Health Organization. Guidelines for Trauma Quality Improvement Programmes. International Society of Surgery,
International Association of Trauma Surgery and Intensive Care eds.. Geneva, Switzerland: World Health Organiza-
tion; 2009.
140. Dijkink S, Nederpelt CJ, Krijnen P, Velmahos GC, Schipper IB. Trauma systems around the world: a systematic
overview. J Trauma Acute Care Surg. 2017;83:917.
141. LaGrone L, Riggle K, Joshipura M, et al. Uptake of the World Health Organization’s trauma care guidelines: a sys-
tematic review. Bull World Health Organ. 2016;94:585–598C.
142. Murray CJ. Quantifying the burden of disease: the technical basis for disability-adjusted life years. Bull World Health
Organ. 1994;72:429–445.
143. Thomson N. Emergency medical services in Zimbabwe. Resuscitation. 2005;65:15–19.
144. Mock CN, Tiska M, Adu-Ampofo M, Boakye G. Improvements in prehospital trauma care in an African country with
no formal emergency medical services. J Trauma. 2002;53:90–97.
145. Bavonratanavech S. Trauma care systems in Thailand. Injury. 2003;34:720–721.
146. Murad MK, Larsen S, Husum H. Prehospital trauma care reduces mortality. Ten-year results from a time-cohort and
trauma audit study in Iraq. Scand J Trauma Resusc Emerg Med. 2012;20:13.
147. de Ramirez SS, Doll J, Carle S, et al. Emergency response in resource-poor settings: a review of a newly-imple-
mented EMS system in rural Uganda. Prehosp Disaster Med. 2014;29:311–316.
148. Arreola-Risa C, Mock CN, Lojero-Wheatly L, et al. Low-cost improvements in prehospital trauma care in a Latin
American city. J Trauma. 20 0 0;48:119–124.
149. Alizadeh R, Panahi F, Saghafinia M, Alizadeh K, Barakati N, Khaje-Daloee M. Impact of trauma dispatch algorithm
software on the rate of missions of emergency medical services. Trauma Mon. 2012;17:319–322.
150. Morrissey BE, Delaney RA, Johnstone AJ, Petrovick L, Smith RM. Do trauma systems work? A comparison of major
trauma outcomes between Aberdeen Royal Infirmary and Massachusetts General Hospital. Injury. 2015;46:150–155.
151. Nathens AB, Brunet FP, Maier RV. Development of trauma systems and effect on outcomes after injury. Lancet.
2004;363:1794–1801.
152. Tanigawa K, Tanaka K. Emergency medical service systems in Japan: past, present, and future. Resuscitation.
2006;69:365–370.
153. Lo CB, Lai KK, Mak KP. Prehospital care in Hong Kong. Hong Kong Med J. 20 0 0;6:283–287.
154. Kristiansen T, Søreide K, Ringdal KG, et al. Trauma systems and early management of severe injuries in Scandinavia:
review of the current state. Injury. 2010;41:444–452.
155. Nijs SJB, Broos PLO. Trauma care systems in Belgium. Injury. 2003;34:652–657.
156. Mock C, Joshipura M, Arreola-Risa C, Quansah R. An estimate of the number of lives that could be saved through
improvements in trauma care globally. World J Surg. 2012;36:959–963.
157. Al-Naami MY, Arafah MA, Al-Ibrahim FS. Trauma care systems in Saudi Arabia: an agenda for action. Ann Saudi
Med. 2010;30:50–58.
 J. Choi, G. Carlos and A.K. Nassar et al. / Current Problems in Surgery 58 (2021) 100849 21

158. Joshipura MK. Trauma care in India: current scenario. World J Surg. 2008;32:1613–1617.
159. Kesinger MR, Nagy LR, Sequeira DJ, Charry JD, Puyana JC, Rubiano AM. A standardized trauma care protocol de-
creased in-hospital mortality of patients with severe traumatic brain injury at a teaching hospital in a middle-in-
come country. Injury. 2014;45:1350–1354.
160. Li N, Fang W, Gu Y, et al. First aid strategy for severe traumatic patients in hospital. Chin J Traumatol.
2007;10:357–359.
161. Chittawatanarat K, Ditsatham C, Chandacham K, Chotirosniramit N. Effects of rapid response trauma team in tho-
racic injuries in northern trauma center level I. J Med Assoc Thai. 2013;96:1319–1325.
162. Handolin L, Leppäniemi A, Vihtonen K, Lakovaara M, Lindahl J. Finnish trauma audit 2004: current state of trauma
management in Finnish hospitals. Injury. 2006;37:622–625.
163. Dehli T, Gaarder T, Christensen BJ, Vinjevoll OP, Wisborg T. Implementation of a trauma system in Norway: a
national survey. Acta Anaesthesiol Scand. 2015;59:384–391.
164. Masmejean EH, Faye A, Alnot JY, Mignon AF. Trauma care systems in France. Injury. 2003;34:669–673.
165. Balasubramanian I, Mohan HM, Whelan RJ, McDermott F, Winter DC. Restructuring an evolving Irish trauma system:
what can we learn from Europe and Australia? Surgeon. 2016;14:44–51.
166. Moore L, Evans D, Hameed SM, et al. Mortality in Canadian trauma systems: a multicenter cohort study. Ann Surg.
2017;265:212–217.
167. Gabbe BJ, Biostat GD, Lecky FE, et al. The effect of an organized trauma system on mortality in major trauma involv-
ing serious head injury: a comparison of the United kingdom and Victoria, Australia. Ann Surg. 2011;253:138–143.
168. Cheng CH, Graham CA, Gabbe BJ, et al. Trauma care systems: a comparison of trauma care in Victoria, Australia,
and Hong Kong, China. Ann Surg. 2008;247:335–342.
169. O’Reilly GM, Gabbe B, Moore L, Cameron PA. Classifying, measuring and improving the quality of data in trauma
registries: a review of the literature. Injury. 2016;47:559–567.
170. Reynolds TA, Stewart B, Drewett I, et al. The impact of trauma care systems in low- and middle-income countries.
Annu Rev Public Health. 2017;38:507–532.
171. Davis KA, Fabian TC, Cioffi WG. The toll of death and disability from traumatic injury in the United States—the
“Neglected Disease” of modern society, still neglected after 50 years. JAMA Surg. 2017;152:221–222.