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A Twelve-Year Retrospective Analysis of a Journey Towards Rural Level I Trauma Center Verification
Lanny C Orr1, Alexa L Peterson2, Tessa C Savell1
1Trauma Services, Billings Clinic, Billings, MT, USA.
Purpose:
This study describes the transformation of a rural trauma center in the Upper Mountain West, which expanded from 280 to 305 beds between 2011 and 2022, and from an American College of Surgeons (ACS) verified Level II to Level I facility, serving a four-state region.
Patients And Methods:
A retrospective analysis of all 8947 trauma activations from 2011-2022 was conducted using the institution's trauma registry. A structured gap analysis assessed alignment with ACS Level I principles.
Results:
The gap analysis identified four priority areas for growth and development of our trauma program to become an ACS Level I Trauma Center: patient volumes, absence of a Surgical Intensive Care Unit (SICU), lack of a surgical residency program, and limited trauma research infrastructure. Targeted interventions led to the establishment of a dedicated SICU, initiation of PGY-4 surgical rotations, and the development of trauma-focused research capacity. By 2023, the number of severely injured patients (Injury Severity Score (ISS) ≥16) exceeded ACS thresholds despite total admissions remaining below 1200. Between 2011 and 2022, 8947 trauma patients were treated. Mean patient age increased from 42.6 to 51.8 years (p <0.0001), with geriatric cases rising from 19.8% to 37.1% and female patients from 33.3% to 41.2%. Overall injury severity decreased (mean ISS 10.4 to 9.7; p <0.0001), but ICU patient acuity rose (ISS 15.9 to 17.9; p <0.0001). Mortality remained stable (3.3-4.0%). ICU admissions declined from 33.1% to 22.6%, while length of stay and patient acuity increased (49.6% and 4.7%, respectively). Interfacility transfer rates decreased from 2.8% to 1.1% (p=0.0372), reflecting improved system capacity.
Conclusion:
Strategic investments in infrastructure, workforce development, education, and research enabled this rural trauma center to achieve Level I criteria while adapting to changing patient demographics and clinical demands. These implementation strategies may inform similar resource-constrained rural trauma systems pursuing ACS Level I verification.
