Community and rural trauma centers in the U.S. face significant challenges in quality management, nurse staffing, standards compliance, physician coverage and program funding, according to a recent survey by Trauma System News.

The survey was conducted in May 2024, and it was sent to trauma program staff who work in trauma centers with a Level III, IV or V designation. More than 150 individuals responded to the survey.

Respondents were asked to indicate which issues (from a list of 15 potential concerns) represent their trauma center’s biggest challenges. Participants were also asked to explain their responses, and dozens of survey takers provided detailed comments clarifying their situation and concerns.

The results show that community and rural trauma leaders struggle most with five key challenges:

1. Maintaining an effective trauma performance improvement program

Nearly two-thirds (64%) of survey respondents indicated that maintaining an effective Performance Improvement and Patient Safety (PIPS) program was a challenge in their center.

Several individuals specified that loop closure was a significant hurdle:

• According to a respondent from a Level III trauma center, engaging physicians in loop closure can be a challenge: “We do not easily get responses back from physicians when there is a question about care.”
• A respondent from Level IV center noted the difficulty of closing the PI loop with other trauma centers: “Our regular facilities are good about getting us feedback, but other centers that we don’t send patients to very often do not send feedback.”

In addition, a state trauma system leader noted the challenge of facilitating peer review in a rural setting:

• “Peer review requirements are difficult to meet when you only have a very limited number of providers and sometimes they are related!”

According to a respondent from a Level IV program, the basic issue is resources:

• “The entire PI program takes up so much time from start to close. In a rural setting, one person has multiple jobs, and it’s difficult to really close the loop on all issues.”

2. Maintaining an adequate nursing staff

Nearly two out of five survey respondents (38%) said their center was challenged to maintain an adequate nursing staff.

• According to a respondent from a Level III trauma center: “We struggle to get nurses who have any trauma experience. In fact, after we got our trauma designation, a lot of the staff complained because they say they work at our six-bed ER because we don’t get trauma patients. Trying to train the nurses then keep them competent has proven to be a difficult task. Also, because we are chronically short staffed, our TNC is usually working the floor or filling in for the ER manager — and the trauma duties get pushed to the back burner.”

Several respondents commented that staffing challenges make it hard to maintain quality processes:

• A trauma leader from a Level III center wrote: “Staffing with travel nurses makes it difficult to maintain consistent compliance with trauma center standards.”
• Another Level III respondent noted: “There is an overall lack of education and many knowledge gaps in the staff. Staff ‘don’t know what they don’t know’ and there are few people with higher levels of experience to help mature the program.”

3. Preparing for trauma center designation or verification surveys

More than one-third (36%) of respondents indicated that preparing for state trauma center designation surveys, or American College of Surgeons (ACS) verification surveys, was a challenge for their team.

Most comments focused on the difficulty of meeting the requirements in Resources for Optimal Care of the Injured Patient: 2022 Standards (the ACS Grey Book):

• A respondent from a Level III center wrote: “The amount of work to prepare for an ACS survey has increased substantially. The PRQ is very time-consuming and some areas are difficult to obtain, like ATLS numbers and physician medical numbers.”

Several Level III respondents noted challenges with specific requirements:

• “We are a rural level III trauma center and with the new updates to the Grey Book, some items are very hard for us to obtain. Each person in the trauma program wears many hats, therefore it makes it difficult to meet all the requirements set by the ACS. A full-time trauma program manager is one those, as well as having the registrar be CAISS-certified.”
• “There are several Grey Book rules that are especially difficult for Level IIIs without teams of people — ortho response within 30 minutes, SBIRT/PTSD, etc.”
• “With the new CAISS requirements from the College, recruiting for a registrar has become increasingly difficult. We have now been forced to outsource our registry needs to a registry partner organization in order to maintain our chart completion rates and remain compliant with volume targets delineated in the Grey Book.”

4. Securing funding and resources for the trauma program

Approximately one out of every three respondents (35%) said they were challenged to secure adequate funding and resources for the trauma program.

Several respondents mentioned the difficulty of securing support from hospital administration:

• One respondent from a Level IV center explained: “Administration does not realize the amount of work that goes into trauma and does not support the additional FTEs needed — in spite of state reviewer recommendations at site visits specifically in this area.”
• Another Level IV leader wrote: “We have no budget, no recognition, no support, so we fight tooth and nail for every small victory. We struggle mightily to meet all the requirements for designation, including data submissions, review, PI projects and public outreach. There are only four of us, including a director who must also maintain his full medical practice. We do a great job, but we are one bad day from collapse.”

Respondents also noted underlying challenges with trauma revenue cycle management:

• A Level III respondent wrote: “There is a lack of understanding regarding coding and billing for maximum reimbursement.”
• And a Level IV respondent noted: “I strongly think that if we could bill more accurately for our activations, we would have better backup for funding our program.”

One survey respondent from a Level III center described the unique community dynamics that many smaller trauma centers face:

• “I recently assumed the TPM position here, and I’ve learned that community hospital teams are concerned about the high bills patients may receive and are therefore hesitant to upgrade or even activate some injured patients.”

5. Securing specialty physician coverage

More than one-third (35%) of respondents indicated that securing specialty physician coverage was a challenge in their center.

Several respondents described the difficulty:

• A respondent from a Level III center wrote: “We are in a rural area and this makes it harder to secure surgeons to stay in this area and work. Most are travel physicians, which also makes it difficult for them to learn and abide by our policies and procedures.”
• And another respondent noted: “Surgeon response is a challenge as our affiliated Level I center makes it clear the Level I is the priority and physicians cannot effectively cover the Level III.”

Additionally, a respondent from a Level III center noted the difficulty of engaging general surgeons in trauma team activations:

• “Basically general surgery will only respond if the activation is a level 1 GSW.”

Another significant challenge: trauma patient transfers

Approximately one out of four respondents (26%) said “efficiently managing patient transfers” was a challenge in their facility. This issue ranks ninth on the list, but survey respondents commented extensively on this issue.

Several respondents noted the challenge of coordinating with higher-level centers:

• “In our state, beds are very tight and transferring patients who need a higher level of care has been challenging. Making decisions on the appropriate patients is difficult — not overwhelming the tertiary centers but also not keeping a patient that may need higher-level care.” (Level III)
• “We are having difficulty with transferring patient to a higher level of care. The Level I is expecting us to keep patients that we do not have the resources to keep, often going against our current policies.” (Level III)

Many respondents described the logistical challenges of trauma transfers:

• “The transfer of patients to a higher-level facility is often delayed due to weather and distance. Currently a fixed wing transfer is used more frequently, but patients are lined up to be sent out.” (Level III)
• “Transfers out are still a challenge as they often take greater than 120 minutes. And waiting on transportation to get the patients out has become overwhelmingly extended as our ambulance services are inundated.” (Level III)
• “We are sorely lacking in EMS services in our area and transfers out can sometimes take as much as a day. When flying is even an option, it sometimes happens when it isn’t really necessary, inflating costs and, in a way, abusing resources. We have more and more patients transferring out by private vehicle, which is also not a good plan.” (Level IV)

Survey participants believe that solving this issue is critical. A respondent from a Level IV center wrote:

• “Although there are many Level IV trauma centers across the nation, I honestly think the system as a whole still has a stigma about Level IVs and is not really sure there is a need for them — but for the rural trauma patient who is challenged by long transport times, Level IVs are their lifeline.”

Full survey results

The survey was available online from May 21 to May 31, 2024, and it was distributed by email to community and rural trauma center leaders.

A total of 168 individuals responded to the survey. More than half (58%) of respondents worked at a Level III trauma center, and about one-third (30%) were at a Level IV center. A small number (2%) worked at a Level V trauma center. The remainder of respondent hospitals were “other” (5%) and “not designated” (4%).

Respondents’ top challenges, ranked by frequency, are:

1. Effective PIPS (action planning, loop closure, etc.) / 64%
2. Maintaining adequate nursing staff / 38%
3. Preparing for state (or ACS) surveys / 36%
4. Securing funding and resources for the trauma program / 35%
5. Securing specialty physician coverage / 35%
6. Coding and billing for trauma patients / 31%
7. Ensuring trauma data quality / 30%
8. Gaining support from hospital administration / 29%
9. Efficiently managing patient transfers / 26%
10. Maintaining a concurrent trauma registry / 21%
11. Ensuring timely surgeon response / 13%
12. Other issue or challenge / 13%
13. Executing a designation upgrade (e.g., going from Level IV to Level III) / 12%
14. Working within your state/regional trauma system / 8%
15. Responding to calls for a designation downgrade (e.g., III to IV) / 3%