A Re-Evaluation of the Effect of Trauma Center Verification Level on the Early Risk of Death in Hemodynamically Unstable Patients


Far West


Riverside Community Hospital

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Publication Date



mortality, trauma center, verification, american college of surgeons, unstable trauma


Epidemiology | Quality Improvement | Trauma



Studies show increased early and overall mortality at level II compared to level I trauma centers in hemodynamically unstable patients. We hypothesize there is no mortality difference between level I and level II centers applying more contemporary data.

Study design

Utilizing the 2017 Trauma Quality Program Participant Use File (TQP-PUF), we identified adult patients (age >14 years) who presented to an American College of Surgeons (ACS) verified level I or II center with hypotension (systolic blood pressure [SBP] < 90 mmHg). Logistic regression was performed to identify adjusted associations with mortality.


A total of 7,264 patients met the inclusion criteria, of whom most were males (4,924 [67.8%]) with blunt trauma (5,924 [81.6%]) being predominated. Mean admission SBP was 73.2 (±13.0) mmHg. There were 1,097 (15.1%) deaths. Level I admissions (4,931 (67.9%]) were more likely male (3,389 [68.7%] vs. 1,535 [65.8]; p=0.012), non-white (3,119 [63.3%] vs. 1,664 [71.3%]; p<0.001), a victim of penetrating trauma (933 [18.9%] vs. 385 [16.5%]; p=0.015), and more severely injured (mean Injury Severity Score: 19.3 [±15] vs. 16.7 [±13.7]; p<0.001). Level II admissions (2,333 [32.1%]) were older (46.8 [±18.5] vs. 50.3 [±20.1] years; p<0.001) with more co-morbidities (mean Charlson Comorbidity Index: 1.43 [±2] vs. 1.77 [±2.2]; p<0.001). Adjusted mortality between level I and II admissions was similar (766 [15.5%] vs. 331 [14.2%]; p=0.918). Early hourly mortality also did not differ.


There is no overall or hourly mortality discrepancy between ACS-verified level I and II centers for patients presenting with hypotension. This potentially relates to the use of more contemporary data gathered after implementation of updated verification requirements.

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