The number of people who die from injuries worldwide is tremendous, numbering in the millions annually. Trauma also constitutes a public health crisis in the United States and is responsible for 150,000 lives lost annually. Trauma is the fifth leading cause of death in the United States by 2006 statistics published by the Center for Disease Control (CDC). It is the leading cause of death in the young, ages 1 to 44. Trauma is responsible for more years of productive life lost than cancer and heart disease combined. On average 36 life years (productive years) are lost per one trauma death compared with 12 life years lost for a heart disease death and 16 life years for cancer. For every death from trauma, there are three individuals who suffer permanent disability and 75 who suffer temporary disability. The cost of injuries in terms of lost wages, direct and indirect medical expenses, and property damage is over $400 billion [1,2].

Trauma is a time-sensitive disease, perhaps more so than any other. Indeed, half of all injury deaths occur before any intervention. Patients who are bleeding have only minutes to live unless the hemorrhage can be controlled. This control often involves operative intervention. This time-sensitive nature is best described by the “Golden Hour” concept. Severely injured trauma patients have a “golden hour” during which they should be transported to a trauma center and their injuries addressed.

Baron Dominique Jean Larrey, Napoleon’s surgeon-in-chief, created the concept of the flying ambulance or “ambulance volantes.” The important concept was that soldiers injured on the battlefield should be treated in the field and evacuated for surgical treatment as soon as possible. To achieve this goal, Larrey instituted the use of a horse-drawn cart on the battlefield—the flying ambulance.

Trauma systems today are focused on the rapid transport of injured patients to the appropriate level of care. This should be a verified trauma center rather than simply the closest hospital with an emergency department. The goal of trauma systems is quite simple: get the right patient to the right facility at the right time. Delay in care may result in early effects such as hemorrhagic shock or late effects such as sepsis from open fractures.

Typically, trauma patients are individuals suffering from penetrating, blunt, or thermal trauma. Clearly combinations of mechanisms may occur, as well as special circumstances such as blast injury. Trauma patients should be triaged to the most appropriate facility for care. Triage should be based both on severity of injuries identified as well as on risk of severe injury. This is because the total sum of injuries is not known until the patient has been fully evaluated at the appropriate trauma center. Just because a patient is hemodynamically normal at a given point in time does not imply that he or she will remain that way.

Trauma centers are hospitals that have been designated by the state or other designating authority as qualified to care for injured patients. There are usually a limited number of trauma centers in a certain geographic area so that each receives an adequate volume of patients required to maintain clinical expertise. Most frequently, trauma centers are designated as Level I through Level IV (some states have also designated Level V trauma centers). Level I trauma centers provide the highest level of care, plus have research and teaching responsibilities. Level II trauma centers are intended to also provide for the full spectrum of trauma care, but do not have the research and teaching requirements. Level III facilities do not provide the full spectrum of trauma care; they usually do not provide neurosurgical services. Level IV trauma centers provide trauma care commensurate with their existing resources.

In 1966, the National Academy of Sciences and the National Research Council published “Accidental Death and Disability: The Neglected Disease of Modern Society,” which highlighted trauma as a major public health problem and made specific recommendations to reduce accidental death and disability. This led to national and state legislation including the Highway Safety Act and the National Traffic and Motor Vehicle Safety Act that was the first effort to regulate traffic safety and reduce automobile related death and injuries. The Emergency Medical Systems (EMS) program was also established. Later, in 1973, the EMS Systems Act identified trauma systems as one of 15 essential components of an EMS system and appropriated federal funds [3].

The trauma system encompasses the complete care of the injured patient from the point of injury prehospital to the completion of the rehabilitative process. Important activities of that system include injury prevention, education, research, and financial viability. For this, there needs to be a lead agency established by each state that has the authority to create and execute policy for the injured patients, as well as designate the trauma centers to manage the injured patients. In order to receive a designation, a hospital or medical center has to demonstrate the standards of care established by the designating authority to achieve the level of trauma center, I, II, III, or IV desired. The trauma center is then evaluated and verified by either an internal team or an external reviewer, such as the American
College of Surgeons (ACS), as meeting the necessary criteria to be a trauma center in the system. This verification is then recommended to the lead agency of the state for designation of a trauma center. The lead agency regulates the quality of trauma systems components and establishes trauma triage guidelines.

The American College of Surgeons Committee on Trauma wrote the “Optimal Hospital Resources for Care of the Seriously Injured” in 1976 and there is presently the fifth edition called the Resources for Optimal Care of the Injured Patient 2006. The ACS established this document and his since added greatly to it as a resource for quality of care and standards of both trauma centers and trauma systems. The ACS verification process consists of hospital site reviews to determine quality of care and appropriateness of the trauma PI process. This verification process can then be accepted by the state as the designating authority to either designate or maintain designation of the trauma center. The ACS-COT also reviews statewide trauma systems to make recommendations to the system as a whole [4,5,6,7,8].