“There may be a few reasons for the difference in ED mortality between ACS and non-ACS centers among severely injured patients,” he explained. “First, although all are severely injured, the expected mortality across the range of ISS 25 to 74 is approximately 10 percent to upwards of 80 percent or 90 percent. So it may be that ACS centers are seeing the higher end of the injury severity spectrum for those patients. Also, as the authors note, ACS verification establishes a significant minimum of resources across the spectrum of care, and those centers may be mobilizing and expending more resources in the initial resuscitation of patients in extremis, rather than declaring them dead on arrival.”

“The take home message is that trauma systems have become very good at keeping patients alive overall, and that we need to look at high-risk populations to further our pursuit of improving outcomes,” Dr. Brown said. “The ACS has set a high standard, and it will be these marginal populations where we can really make an impact through things like ACS verification to raise the bar on trauma care.”

Molly Jarman, a doctoral candidate at Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, who has investigated geographic disparities in trauma mortality, told Reuters Health by email, “Hospitals can replicate ACS standards without completing the formal verification process, but an institution’s decision to seek ACS verification may indicate a culture of care at the hospital or state level that also prevents some complications.”

“Variability in trauma care services and the institutional culture may contribute to differences in complications and ACS and non-ACS centers,” she said.

Differences in patient populations at ACS and non-ACS centers may also contribute to differences in outcomes, she said, “especially if hospitals serving high risk communities are less likely to seek ACS verification.”

Jarman added, “Patients with serious injuries typically do not get to choose their trauma center. If variability in the quality of trauma center care disproportionately impacts vulnerable populations, it may contribute to disparities in injury mortality and long-term disability.”

Dr. Lynne Moore from Universite Laval, Quebec, Canada recently investigated the impact of trauma center designation level on outcomes following hemorrhagic shock. She told Reuters Health by email, “If observed differences are truly related to ACS-accreditation, the next step would be to acquire a better understanding of how the accreditation process influences trauma center structure and more so, processes of care; i.e. high use of effective clinical practices and low use of low-value clinical practices.”