In July 2025, the American College of Surgeons (ACS) released the third update of Resources for Optimal Care of the Injured Patient: 2022 Standards.

As reported earlier, the new July 2025 Revision of the resources manual relaxed the requirements in four trauma center standards.

In addition to these material changes, the document also added wording that clarifies trauma program requirements in 10 separate standards:

Shared orthopedic liaison must be credentialed for peds

Standard 4.5 requires all trauma centers to have an orthopedic trauma surgeon liaison to the trauma program.

The previous (December 2023) version of this standard stated that Level I pediatric trauma centers could meet this requirement by sharing the adult ortho trauma liaison from an adult Level I center.

The July 2025 update has sharpened this requirement. The standard now specifies that the shared orthopedic trauma surgeon liaison must be “credentialed to care for pediatric patients at the pediatric trauma center” in addition to being credentialed at the adult trauma center.

More detail on the who, what and how of IR response

Standard 4.15 states that Level I and II centers must ensure the continuous availability of the necessary human and physical resources to enable endovascular or IR bleeding control procedures to begin within 60 minutes of request.

The July 2025 update now specifies that human resources refers to “physicians, nurses, and technologists” and facility resources refers to an “angiograph suite or hybrid operating room”.

The updated standard also provides new specifics about which patients require a rapid hemorrhage control response: “Patients requiring a rapid response for hemorrhage control as defined above are those where blood transfusion has been initiated and there is a confirmed blood pressure less than 90 mm Hg at any time prior to angioembolization in adults, or age-specific hypotension in children.”

Finally, in addition to a request-to-puncture-time report and call schedules, the Measures of Compliance section now requires a narrative description of the process for mobilizing interventional personnel to ensure procedures can begin within the 60-minute timeframe.

Call schedules no longer required to demonstrate specialist availability

Standard 4.26 lists the medical specialists that must be available in all trauma centers.

Previously, trauma programs were required to submit physician call schedules to demonstrate specialist availability.

Under the July 2025 update, call schedules are no longer required. Instead, the Measures of Compliance section now states that specialist availability will be “[e]valuated during the site visit process”.

Renal replacement therapy terminology clarified

Standard 4.29 covers the availability of renal replacement therapy services in all trauma centers.

The previous version of the standard noted that this therapy might include any form of “continuous renal replacement therapy”.

The recent update has been revised to clarify that the therapy being referenced is the specific modality known as “Continuous Renal Replacement Therapy (CRRT)”. Along with this change, the line defining “continuous availability” has been dropped from the standard.

Clarification that registry work may be outsourced

Standard 4.31 establishes required trauma registry staffing levels for all trauma centers. The 2025 update has added language clarifying that trauma centers can meet the registry staffing requirement with the help of outsourced registry support.

The definition of Standard 4.31 now reads [emphasis added to denote new text]: “In all trauma centers, there must be at least 0.5 FTE (either on- or off-site) dedicated to the trauma registry per 200-300 annual patient entries.”

The Additional Information section includes a new paragraph that establishes two expectations for managing outsourced registry activities:

“Data collection might be outsourced to off-site personnel with the expectation that i) data are readily available for local performance improvement; ii) the center has oversight on data quality and opportunities for data quality improvement are identified and actioned.”

Brief intervention requirement also applies to Level III centers

Standard 5.31 requires all trauma centers to provide a brief intervention to at least 80% of patients who screen positive for alcohol misuse.

Because of the way the standard definition was laid out in the previous version (with separate paragraphs for Level I-II centers and Level III centers), it appeared that the 80% requirement did not apply to Level III centers.

The 2025 update clarifies that the 80% threshold applies to Level III centers as well as others.

Terminology clarified for hospital-level quality program

Standard 7.1 describes the expected relationship between the trauma performance improvement and patient safety (PIPS) program and the overall hospital quality program.

Previously, the standard referred to this higher level of quality management with the ambiguous term “the hospital or departmental PI program”.

To avoid confusion, the updated standard now refers simply to the “hospital quality program”.

Revised wording of two required PIPS audit filters

Standard 7.2 lists the minimum required audit filters that must be included in a trauma center’s written PIPS plan.

In the 2025 update, two audit filters have been slightly modified to add clarity [emphasis added to denote new text]:

• “Accuracy of trauma team activation protocols” has been replaced with “Accuracy of trauma team activation protocols (over and under triage rates)”
• “Unanticipated transfer to the ICU or intermediate care” has been changed to “Unanticipated transfer the ICU or higher level of care”

Nelson Score added to NSA review criteria

Standard 7.8 lists the criteria that define levels of review for nonsurgical trauma admissions. Since the first edition of the Grey Book, these criteria have included:

• Trauma or surgical consultation (yes or no)
• Injury Severity Score (≤ 9 or > 9)
• Cases with an OFI identified at primary review (no or yes)

In the 2025 update, the Nelson Score has been added to the NSA review criteria:

• NSA cases with a Nelson Score ≥ 6 may be closed at primary review, if no OFI has been identified
• NSA cases with a Nelson Score ≤ 5 must be reviewed by the TMD as part of a secondary review

Clarification of research article requirements

Standard 9.1 lists the requirements for research and scholarly activities of adult and pediatric Level I trauma centers.

The previous version of the standard stated that at least three research articles must be authored by “general/pediatric trauma surgeons”.

• In the updated standard, this phrase has been replaced with “adult or pediatric trauma surgeons”.

In addition, the previous version of the standard stated that for a published case series to be counted toward the 10-article requirement, it must include “more than five patients”.

• In the July 2025 update, this standard now clarifies that a published case series must include “more than five trauma patients” [emphasis added to denote new text].

Resources available

To download the latest version of the ACS trauma center standards, visit Resources for Optimal Care of the Injured Patient: 2022 Standards.

To access the change log for the July 2025 Revision, visit the 2022 Standards Resources Repository.

To read the Trauma System News summary of material changes in the July 2025 Revision, read ACS relaxes requirements in 4 trauma center standards.