Level 3 ER, Level 4- Can you PLEASE clarify!!!

ERRNTraveler, RN · Nov 11, 2007

The only levels of Trauma Centers officially recognized & certified by the American College of Surgeons are Levels 1 & 2. Any ER calling itself a Level 3 or 4 is doing so as a self-designation. That being said, here are the major differences:

Level 1: Large teaching hospital affiliated with a medical college. Has residents and attendings ON SITE 24-7 from all major trauma-related specialties (trauma surgeons, neurosurgery, ortho, etc.).

Level 2: Usually a larger hospital, not directly affiliated with a medical college. Has 24-7 on-call trauma specialists (trauma surgeon, ortho, neuro...) that will respond to the hospital within 15 minutes of being paged for a trauma.

Level 3 & 4: Not certified as a trauma center by The American College of Surgeons, do not have all specialties available on-call at all times. I have found that the on-call specialty missing from most "level 3" hospitals is 24-7 neurosurgery coverage- seems to be a shortage of neuros.....

As far as the acuity of patients seen at these different types of ER's, obviously you will see more high-acuity patients at a Level 1 trauma center than at a "Level 3". BUT, that does not mean you won't occasionally see the same types of high-acuity cases at the smaller non-trauma hospitals- especially if there is not a major trauma center nearby. Hope that helps!

Larry77, RN · Nov 11, 2007

The only levels of Trauma Centers officially recognized & certified by the American College of Surgeons are Levels 1 & 2. Any ER calling itself a Level 3 or 4 is doing so as a self-designation.

While this is not completely untrue it is not completely true either. At least in WA and OR no hospital can just call themselves a level 3 or 4 trauma center as a self designation we have a state regulated trauma designation system in place, not unlike JAHCO. During out designation survey there is a trauma nurse, surgeon, pharmacist and others who tour the facility examine charts and employee files to decide what designation they will give the hospital whether it be Level 1, 2, 3, or 4.

I understand this system is different in other states but in the northwest this is how we role..:)

ERRNTraveler, RN · Nov 12, 2007

While this is not completely untrue it is not completely true either. At least in WA and OR no hospital can just call themselves a level 3 or 4 trauma center as a self designation we have a state regulated trauma designation system in place, not unlike JAHCO. During out designation survey there is a trauma nurse, surgeon, pharmacist and others who tour the facility examine charts and employee files to decide what designation they will give the hospital whether it be Level 1, 2, 3, or 4.
I understand this system is different in other states but in the northwest this is how we role..:)

Maybe your state has it's own trauma designation system, but I was speaking of the NATIONAL certification of trauma centers done by the American College of Surgeons- they do not recognize level 3 & 4 as official certifiable designations.....

Larry77, RN · Nov 12, 2007

I'm not arguing with your statement about the American College of Surgeons, but you said that a level 3 or 4 was simply a "self designation" which again is untrue in all states that I'm aware of. There is still a process with the state to become designated as a trauma center...national "no" but with the state "yes".

BTW there are a few level 3's recognized by the ACS according to their website Trauma Centers List

To the OP I would look into your state's trauma designation system to research the difference between the two. One thing I've noticed about the 3 and 4 trauma center's that I've worked in is that you call Lifeflight and transfer instead of sending the trauma patient to surgery--in both cases your goal is to stabilize and get the pt out of your dept.

I found one example of the difference between level 3 and level 4 for you:

"A Level III trauma center does not have the full availability of specialists, but does have resources for the emergency resuscitation, surgery and intensive care of most trauma patients. A Level III center has transfer agreements with Level I and/or Level II trauma centers that provide back-up resources for the care of exceptionally severe injuries."

"A Level IV trauma center provides the stabilization and treatment of severely injured patients in remote areas where no alternative care is available." Website

taapple · Nov 12, 2007

Thank you all for your help. makes sense. In Texas, I believe the state regulates the designation of ER status. I will check out that link. Thanks a million!

Medic/Nurse, BSN, RN · Nov 12, 2007

I think Larry and ERTraveller give good advice. Larry nails the ACS perspective. The ACS one is the the one that can impact the flow of federal money. Plus it is easy to compare an apple to an apple in the ACS designation system.

Now, can the states add additional designations? Maybe, but it could get confusing.

Some states (err..Most) have some type of trauma plan in place. I have no idea if they have their own levels or if they have a state system that details the levels - but... The designation's main function impacts where you (EMS and HEMS) can take certain types of patients.

The OP seems to be interested in the L3 L4 "designation" of the hospital that is the prospective employer. First, I think you will be okay - that is not to say you will not see "some" trauma at the L3 - but, most of "those patients" will never darken your door.

The only time I would stop at a Level 3 out of the helicopter would be with a patient that I could not get to a Level 1 or 2 because of "new" weather that prevented me from reaching my original destination. Also, I might "divert to Level 3" with a massive blunt trauma that goes into arrest with a long ETA to the Level 1 or 2. Read: Rarely, if ever would this happen. Don't worry - the HEMS crew stays and plays if necessary. You will not be abandoned.

Anyway, trauma is a surgical disease. (Actually, I think trauma is a bit easy for the seasoned nurse) Lots of procedures and then off BAM! to surgery in warp time (I hope!). I think this would be a good environment to learn in - providing that you have some resources - experienced nurses, good ratios, an educator, a detailed orientation.

Good Luck!

Practice SAFE!

RunnerRN, BSN, RN · Nov 12, 2007

Other thing to remember about Level I/II vs lower levels of trauma care are the number of resources. No, I'm not a huge fan of traumas and pts bleeding out, but I stay at my Lvl I because I have all the resources there to care for them. I would hate to work at a small community hospital that has the potential to get patients for whom they cannot care. Good example - last week, I took care of an older lady who had an aortic dissection. She was "stable" (as stable as a dissection can be) but it was only a matter of time. As soon as her daughter gave the "go ahead" for surgery, we were in the OR in less than 5 minutes. I would go insane working at a smaller hospital where the necessary resources aren't 2 floors up, but 60 miles away and requiring a helicopter transport to obtain.

Also, Level I/II vs lower does not change the walk ins you get, or the fact that if you have a nursing home 3 blocks away and someone codes there, you'll be getting that patient (arrests go to closest available facility). Again, I just like the fact that I don't have to worry about who I "might" be getting in the next hour. My hospital can handle anything that walks through the door (or wheels, or crawls, or flies.....)

jojotoo, RN · Nov 12, 2007

One thing to keep in mind - it's true that you shouldn't be getting the truly acute trauma via EMS, but I've seen some pretty bad stuff that was just "dropped off" at the back door. Those "drop offs" and what others may consider "minor" trauma may actually be more difficult for you to deal with because you won't have the needed resources that would be available at a Level 1 or Level 2 Trauma Center.

I think that ALL ER nurses should take TNCC to be better prepared for what's going to come through their back door.

SDS_RN, RN · Dec 27, 2007

I work in a level 3 hospital and we have a lot of what is listed above. We have a trauma surgeon on call, orhto on call, pharmacy on call but no neurosurgeon. All of them are on call overnoc but not in the facility round the clock. They are however there in record time if needed or some of them will just sleep at the hospital. Our closest resources for a major trauma or crisis is 1 hour away and we have 2 careflight teams that fly in if needed. Most of what we get in we can handle but there are those few that need a higher level of care than we can provide. It's a good learning environment and allows you the experience of handling minor to major crisies.