Key takeaways
- One in three severely injured patients in the United States are first treated at Level III or non-trauma centers; of those, about half do not get transferred to higher-level trauma centers when they should.
- Hospital factors such as urban location and Level III designation, and patient characteristics such as older age and public insurance, independently predict non-transfer.
- Study authors advocate for the development of inclusive state trauma systems that incorporate all acute care hospitals in trauma registries.
CHICAGO (August 27, 2025) — One third of severely injured trauma patients in the United States are first treated at hospitals designated as Level III or non-trauma centers, and less than half of those patients get transferred out to a Level I trauma center where they can receive more comprehensive trauma care, according to a study published in the Journal of the American College of Surgeons (JACS).
"This study provides an updated assessment of our national trauma system. There is wide variation in access to trauma care across our country. We need to develop state systems that are inclusive of all hospitals so that every person, regardless of where they are, gets optimal care and is treated at the right place for their injuries," said study co-author Marta L. McCrum, MD, FACS, associate professor in the department of surgery at the University of Utah in Salt Lake City.
"Trauma systems are decentralized and managed at the state level. Currently, less than half of states have secondary triage guidelines that help clinicians determine who should be transferred to a Level I or Level II trauma center," Dr. McCrum said.
There are three levels of ACS trauma center verification , each defined by specific standards and the spectrum of care that must be available to injured patients at the facility. Level III centers typically serve communities that may not have timely access to a Level I or II trauma center, providing definitive care to patients with mild to moderate injuries.
Using the 2019 Nationwide Emergency Department Sample of all adult trauma patients with an Injury Severity Score greater than 15 (indicating severe injury) who were first seen at a Level III or non-trauma center, researchers examined the relationship between non-transfer to higher level care, defined as admission to the Level III or non-trauma centers from the emergency department, and patient and hospital factors.
Key Findings
- In total, 146,816 patient encounters at Level III and non-trauma centers were included in the analysis; of those, 84,695 (58%) were not transferred to a Level I or Level II trauma center even when they may have benefitted from higher-level care, representing secondary undertriage.
- Independent patient predictors of non-transfer included older age (80 years and older increased odds of non-transfer by 68%) and public insurance. Medicare recipients had a 76% increased chance of not being transferred, while Medicaid recipients had 44% increased odds of not being transferred to a higher-level care center.
- Hospital characteristics strongly associated with non-transfer were Level III trauma designation, which nearly tripled the odds of not being transferred, and urban location, which increased the chances of non-transfer by more than five times.
"Overall, Level III hospitals need to be brought into what we consider to be high-level trauma systems so that we can better support these centers in the trauma care that they do provide and ensure the best possible outcomes for all patients," Dr. McCrum said.
Better care, closer to home
"The ACS Committee on Trauma is dedicated to ensuring that patients receive the right care in the right place based on their needs; in many cases, this might be care closer to home. These findings show that while Level III trauma centers play an important role for the communities in which they are located, we have work to do to strengthen our trauma systems to ensure all patients get the care they need," said Avery B. Nathens, MD, PhD, FACS, medical director of the ACS Trauma Quality Programs. Dr. Nathens was not involved in the study. "By ensuring all trauma centers meet high standards of care and are part of an integrated trauma system, there is no compromise in the quality of trauma care and we can optimally care for all injured patients."
While this analysis provides a big picture view of patterns of trauma treatment in the United States, information from this large database study cannot provide a detailed explanation as to why patients were transferred from Level III hospitals to Level I centers and why they weren't, according to the study authors.
Co-authors are Jacoby R. Bryce, BS, MD; Stephanie E. Iantorno MD, MS; Jack H. Scaife, MD; Meng Yang, MS; and Brian T. Bucher, MD, MS, FACS.
The study is published as an article in press on the JACS website.
Author Disclosures: None
Citation: Bryce J R, Iantorno SE, Scaife JH, et al. Secondary Undertriage of Severely Injured Trauma Patients across the US. Journal of the American College of Surgeons, 2025. DOI: 10.1097/XCS.0000000000001580
