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JAMA
JAMA. 2022 Jul 26; 328(4): 391–393.
Published online 2022 Jul 26. doi:10.1001/jama.2022.8097
PMCID: PMC9327571
PMID: 35881133
Jeff Choi, MD, MSc,
1 Sarah Karr, MS,2 Arjun Jain,2 Taylor C. Harris, BS,3 Janelle C. Chavez, BAS,3 and David A. Spain, MD1
Author information Article notes Copyright and License information PMC Disclaimer
Associated Data
- Supplementary Materials
This study uses data from the American Trauma Society’s Trauma Information Exchange Program to evaluate trends in nationwide 60-minute access to American College of Surgeons Committee on Trauma–verified level I-IV trauma centers between 2013 and 2019.
A 2016 National Academies of Sciences, Engineering, and Medicine report highlighted timely trauma center access as a critical component of national health care infrastructure and essential to avoid preventable deaths after injury.1 Nationwide access to trauma centers by both ground and air transport has not been evaluated since 2010.2
We evaluated trends in nationwide access to American College of Surgeons Committee on Trauma (ACS-COT)–verified trauma centers between 2013 and 2019, hypothesizing that trauma center access has improved but geographic differences would be present.
Methods
The ACS-COT verifies trauma center levels based on the presence of resources to provide optimal care for injured persons. Level I trauma centers are tertiary centers with 24-hour capability for definitive trauma care, while level IV trauma centers can provide initial evaluation and resuscitation before providing appropriate transfers. We found ACS-COT verification levels and addresses of US trauma centers using the Trauma Information Exchange Program database (2013-2019) and encoded their geographic coordinates using Google Geocoding, ArcGIS, and MapQuest application programming interfaces. Three states (Washington, Pennsylvania, and Mississippi) did not have ACS-COT–verified trauma centers in the study period. We obtained the proportion of residents within each census block group (the smallest geographic census unit, typically comprising 600-3000 individuals) using American Community Survey data (2013-2019).
We calculated fastest travel time (ground or air) from each census block group’s population centroid to the nearest trauma center. Ground transport time included call-to-ambulance arrival time (national median, 7 minutes3), on-scene time (10 minutes; National Association of State Emergency Medical Services benchmark), and time from census block group population centroid to the nearest trauma center (accounting for road-specific speed limits and historic traffic data). For air transport time, we found geographic coordinates for air bases with 1 or more trauma transport rotor-wing aircraft using the Atlas & Database of Air Medical Services (2013-2019).4 Air transport time included call-to-takeoff time (national average, 3.5 minutes5), flight time from nearest air base to census block group population centroid, on-scene time (national average, 21.6 minutes5), and flight time to the nearest trauma center.
Primary outcome was the proportion of US residents with 60-minute access to a trauma center. Access trends throughout 2013-2019 were evaluated using the Mann-Kandall test. Secondary analysis delineated trauma center access by ground vs air medical transport, state, and trauma center levels (I-II vs I-IV) using descriptive statistics. We used R version 4.1.2 (R Foundation for Statistical Computing) for statistical analyses. A 2-sided P < .05 defined statistical significance. This study did not meet Stanford University institutional review board review criteria. The Supplement details methodology.
Results
A total of 457 trauma centers were ACS-COT verified in 2019 (increased from 315 centers in 2013).
Compared with 78% in 2013, 91% of US residents had 60-minute access to a trauma center in 2019 (Figure), a statistically significant trend (P = .002). In 2019, 89% of US residents had 60-minute access to a level I/II center; level III/IV centers provided 60-minute trauma center access to an additional 1% of residents (Figure, A and B; Table). Compared with 68% of US residents with 60-minute trauma center access by ground ambulance transport alone, air ambulance transport expanded 60-minute trauma center access to an additional 23% in 2019 (total, 91%) (Figure, C).
Figure.
Time to Nearest American College of Surgeons Committee on Trauma (ACS-COT)–Verified Trauma Center (by Ground or Air Ambulance Transport) and Regions With 60-Minute Trauma Center Access by Ambulance Transport Modality, 2019
Maps display county-level data; access times were averaged across census block groups within each county to provide visually discernible estimates at the county level.
Table.
Changes in Proportion of State-Level Populations With Access to Level I/II vs Levels I-IV Trauma Center Within 60 Minutes by Ground or Air Ambulance
| State | Level I/II, % | Levels I-IV, % | ||||
|---|---|---|---|---|---|---|
| 2013 | 2019 | Absolute difference | 2013 | 2019 | Absolute difference | |
| Northeast | ||||||
| Connecticut | 100 | 100 | 0 | 100 | 100 | 0 |
| Maine | 43.9 | 89.3 | 45.4 | 75.6 | 89.3 | 13.7 |
| Massachusetts | 99.7 | 99.7 | 0 | 99.7 | 99.7 | 0 |
| New Hampshire | 92.4 | 96.7 | 4.3 | 95.1 | 96.7 | 1.6 |
| New Jersey | 100 | 100 | 0 | 100 | 100 | 0 |
| New York | 73.8 | 99.2 | 25.4 | 75.5 | 100 | 24.5 |
| Pennsylvaniaa | 86.1 | 90.6 | 4.5 | 90.6 | 94.8 | 4.2 |
| Rhode Island | 100 | 100 | 0 | 100 | 100 | 0 |
| Vermont | 79.9 | 88.9 | 9 | 82.6 | 91.1 | 8.5 |
| Midwest | ||||||
| Illinois | 91.9 | 91.6 | −0.3 | 91.9 | 91.8 | −0.1 |
| Indiana | 98.4 | 99.7 | 1.3 | 98.4 | 100 | 1.6 |
| Iowa | 33.1 | 87.8 | 54.7 | 33.5 | 88.2 | 54.7 |
| Kansas | 78.4 | 81.9 | 3.5 | 91.3 | 90.2 | −1.1 |
| Michigan | 94.3 | 94.8 | 0.5 | 94.7 | 95.3 | 0.6 |
| Minnesota | 90.2 | 91.5 | 1.3 | 91.7 | 92.9 | 1.2 |
| Missouri | 75.0 | 75.8 | 0.8 | 86.8 | 87.8 | 1 |
| Nebraska | 82.1 | 90.0 | 7.9 | 84.6 | 92.5 | 7.9 |
| North Dakota | 64.9 | 68.4 | 3.5 | 65.3 | 68.7 | 3.4 |
| Ohio | 100 | 100 | 0 | 100 | 100 | 0 |
| South Dakota | 54.7 | 58.1 | 3.4 | 67.0 | 68.2 | 1.2 |
| Wisconsin | 95.7 | 97.9 | 2.2 | 95.7 | 97.9 | 2.2 |
| South | ||||||
| Alabama | 54.0 | 44.5 | −9.5 | 54.0 | 44.5 | −9.5 |
| Arkansas | 2.4 | 45.7 | 43.3 | 12.3 | 57.2 | 44.9 |
| Delaware | 100 | 100 | 0 | 100 | 100 | 0 |
| Florida | 35.3 | 93.1 | 57.8 | 35.3 | 93.1 | 57.8 |
| Georgia | 4.0 | 84.1 | 80.1 | 4.0 | 84.1 | 80.1 |
| Kentucky | 91.9 | 96.4 | 4.5 | 95.0 | 96.9 | 1.9 |
| Louisiana | 83.9 | 94.9 | 11.0 | 83.9 | 94.9 | 11 |
| Maryland | 98.9 | 99.0 | 0.1 | 100 | 100 | 0 |
| Mississippia | 4.2 | 17.9 | 13.7 | 4.2 | 21.4 | 17.2 |
| North Carolina | 92.6 | 93.6 | 1.0 | 92.6 | 93.6 | 1 |
| Oklahoma | 83.7 | 87.1 | 3.4 | 85.3 | 88.7 | 3.4 |
| South Carolina | 85.4 | 99.1 | 13.7 | 85.3 | 99.2 | 13.9 |
| Tennessee | 14.8 | 69.9 | 55.1 | 17.7 | 70.2 | 52.5 |
| Texas | 87.7 | 93.9 | 6.2 | 87.7 | 93.9 | 6.2 |
| Virginia | 86.8 | 94.8 | 8.0 | 89.7 | 95.1 | 5.4 |
| West Virginia | 92.5 | 97.0 | 4.5 | 98.3 | 98.6 | 0.3 |
| West | ||||||
| Alaska | 58.4 | 59.0 | 0.6 | 58.4 | 59.0 | 0.6 |
| Arizona | 91.3 | 92.1 | 0.8 | 91.5 | 94.0 | 2.5 |
| California | 97 | 97.9 | 0.9 | 97.0 | 98.9 | 1.9 |
| Colorado | 90.7 | 93.6 | 2.9 | 90.7 | 93.6 | 2.9 |
| Hawaii | 71.3 | 68.7 | −2.6 | 71.3 | 73.3 | 2 |
| Idaho | 63.7 | 68.3 | 4.6 | 63.6 | 85.8 | 22.2 |
| Montana | 49.0 | 52.8 | 3.8 | 71.5 | 76.5 | 5 |
| Nevada | 94.4 | 96.2 | 1.8 | 94.4 | 96.2 | 1.8 |
| New Mexico | 69.3 | 72.0 | 2.7 | 69.3 | 72.0 | 2.7 |
| Oregon | 64.0 | 80.4 | 16.4 | 64.0 | 80.4 | 16.4 |
| Utah | 86.7 | 94.3 | 7.6 | 86.7 | 94.3 | 7.6 |
| Washingtona | 8.4 | 8.4 | 0 | 8.3 | 16.5 | 8.2 |
| Wyoming | 44.6 | 29.7 | −14.9 | 45.0 | 35.9 | −9.1 |
| US total | 77.2 | 89.2 | 12.0 | 78.4 | 90.5 | 12.1 |
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aPennsylvania, Washington, and Mississippi did not have American College of Surgeons Committee on Trauma (ACS-COT)–verified trauma centers, but their populaces could access out-of-state ACS-COT–verified trauma centers nearby (eg, in Camden, New Jersey, approximately 10 minutes by ground transport from Philadelphia, Pennsylvania).
Over the study period, trauma center access improved within 38 states and decreased in 4 states (Table). The greatest absolute improvements were in Georgia (+80%), Florida (+58%), and Iowa (+55%).
Discussion
In this study, trauma center access improved from 2013 to 2019, but there were geographic differences. A limitation of the study was restricting analysis to ACS-COT–verified trauma centers, underestimating access but facilitating standardized comparison nationwide. State-level access estimates should be interpreted with the understanding that residents could access out-of-state trauma centers.
The US maintains a geographically fragmented trauma network model (injury response coordinated at state or local levels), which challenges efforts to ensure all US residents access to timely, quality management of traumatic injuries. A nationalized trauma network that can monitor and expand equitable trauma center access for all US residents should be considered.
Notes
Section Editors: Jody W. Zylke, MD, Deputy Editor; Kristin Walter, MD, Associate Editor.
Notes
Supplement.
eMethods
eReferences
Click here for additional data file.(143K, pdf)
References
1. National Academy of Sciences, Engineering, and Medicine . A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Published 2016. Accessed January 11, 2022. https://nap.nationalacademies.org/catalog/23511/a-national-trauma-care-system-integrating-military-and-civilian-trauma
2. Carr BG, Bowman AJ, Wolff CS, et al.. Disparities in access to trauma care in the United States: a population-based analysis. Injury. 2017;48(2):332-338. doi: 10.1016/j.injury.2017.01.008 [PMC free article] [PubMed] [CrossRef] [Google Scholar]
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5. Carr BG, Caplan JM, Pryor JP, Branas CC. A meta-analysis of prehospital care times for trauma. Prehosp Emerg Care. 2006;10(2):198-206. doi: 10.1080/10903120500541324 [PubMed] [CrossRef] [Google Scholar]
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