Trauma System

In August of 1995, the New Hampshire legislature enacted a statewide Trauma System law. By doing so, the legislature embraced a voluntary effort to provide all residents and visitors to the state with access to the same standards of trauma care, regardless of where or how a patient becomes injured.

The NH Trauma System is an inclusive one, meaning that every acute care hospital in New Hampshire routinely provides services to traumatically injured persons and is thus included in the trauma system. Hospitals are encouraged and assisted to actively participate in the system, and to achieve their highest level of active participation based on an assessment of the hospital’s capability.

Hospitals, EMS agencies, and first responder groups throughout the state have worked alongside the system’s leadership – the Trauma Medical Review Committee and the NH Department of Safety, Division of Fire Standards and Training & Emergency Medical Services (FSTEMS) – to meet and exceed standards set forth for trauma care. Hospitals were asked to participate in a voluntary assessment of their administrative and clinical capabilities in trauma care by the system leadership. New Hampshire currently awards four levels of hospital assignment within the trauma system (Level I, Level II, Level III and Level IV) to those actively participating in the system.

Emergency Medical Services providers statewide were asked to utilize a uniform set of severity indicators when identifying high-risk trauma patients. Guidelines were introduced for how out-of-hospital providers communicate with the hospital about their trauma patients as well as guidelines for the transport decision making process.

Today, the trauma system is established throughout the state. Members of the Trauma Medical Review Committee and FSTEMS are working together, along with participating hospitals, to continuously improve the delivery of care to seriously injured persons in NH.

New Hampshire has four levels of trauma hospital identification. Each level refers to both the resources available within the hospital and the number of patients admitted annually. Two methods of identification are in use: verification and designation. A brief explanation of each follows:

—Verification is a process of evaluation done by the American College of Surgeons (ACS). The process includes review of policies, patient care, and performance improvement, and determination of commitment, readiness, and available resources.

—Designation is a process which has been developed and outlined by the NH Department of Safety, Division of Fire Standards and Training and Emergency Medical Services (FSTEMS). It is done by designated reviewers from FSTEMS and includes a review of criteria under which a hospital is characterized as a trauma hospital.

The levels of trauma hospital identification are:

— Level I: A comprehensive regional institution which provides tertiary care to patients referred from other hospitals within the trauma system. Level I trauma centers are capable of providing the entire spectrum of care, from injury prevention to rehabilitation. Examples of capabilities include 24-hour in-house coverage by general surgeons as well as prompt availability of care from other specialties including orthopedic surgery, neurosurgery, anesthesiology, radiology, emergency medicine, and critical care. Teaching, research, and education are significant components of capability within a Level I trauma hospital, as are comprehensive quality and performance improvement programs. In New Hampshire, Level I capability is determined by verification from the ACS.

— Level II: A regional institution able to provide definitive care for all injured patients and include many resources available to Level I trauma hospitals. Capabilities include 24-hour immediate coverage by general surgeons and coverage by various specialties including orthopedic surgery, neurosurgery, anesthesiology, radiology, emergency medicine, and critical care. Certain other care needs, including cardiac surgery, limb replantation, and hemodialysis may be referred to a Level I trauma center, depending on the resources available to the institution. A major difference between Level I and II trauma designation is that association with an educational institution (i.e. medical school) is not a requirement. In New Hampshire, Level II capability is determined by verification from the ACS.

— Level III: An institution operating within a given catchment area able to provide prompt assessment, resuscitation, and stabilization of injured patients. Features of a Level III trauma hospital include immediate 24-hour emergency medicine coverage and prompt availability of both general surgery and anesthesiology. Other features include a comprehensive quality and performance improvement program, the inclusion of transfer agreements with Level I or II trauma hospitals for those patients requiring a greater degree of care, an active injury prevention and outreach program, back-up care for community or critical access hospitals, and continuing education for both nursing and allied health personnel. In New Hampshire, Level III capability is determined either by verification from the ACS or designation review by FSTEMS personnel.

— Level IV: A community hospital able to provide advanced trauma life support and stabilization for patients requiring transfer to a higher level of care. Capabilities include 24-hour emergency department and laboratory coverage, established transfer agreements with Level I or II trauma hospitals, a comprehensive quality and performance improvement program, and active involvement with injury prevention efforts within the community. In New Hampshire, Level IV capability is determined through designation review by FSTEMS personnel.

(Source: American Trauma Society)

There are 26 acute care hospitals in New Hampshire. Of these hospitals, 11 actively participate as members of the state-wide trauma system. They include the following institutions:

• Dartmouth Hitchcock Medical Center, Lebanon, NH
  • • • • — Adult Level I
        • — Pediatric Level II
• Concord Hospital, Concord, NH
  • • • • — Adult Level II
        • — Pediatric Level III
• Elliot Hospital, Manchester, NH
  • • • • — Adult Level II
        • — Pediatric Level III
• Portsmouth Regional Hospital, Portsmouth, NH
  • • • • — Adult Level II
        • — Pediatric Level III
• Catholic Medical Center, Manchester, NH
  • • • • — Adult Level III
        • — Pediatric Level IV
• Southern New Hampshire Medical Center, Nashua, NH
  • • • • — Adult Level III
        • — Pediatric Level III
• St. Joseph Hospital, Nashua, NH
  • • • • — Adult Level III
        • — Pediatric Level III
• Parkland Medical Center, Derry, NH
  • • • • — Adult Level III
        • — Pediatric Level IV
• Exeter Hospital, Exeter, NH
  • • • • — Adult Level III
        • — Pediatric Level IV
• Wentworth-Douglass Hospital, Dover, NH
  • • • • — Adult Level III
        • — Pediatric Level III
• Cottage Hospital, Woodsville, NH
  • • • • — Adult Level IV
        • — Pediatric Level IV

Data collection is vital in the operation of any trauma system. Having up-to-date information allows leadership of hospital trauma programs to make decisions about performance improvement, resource management, and, ultimately, outcomes. At the state level, it allows for analysis of types of incidents resulting in injury. Gathering this information ultimately contributes to research in finding ways to prevent injuries from occurring.

According to the Centers for Disease Control and Prevention (CDC), unintentional injuries are the leading cause of death from infancy to age 44 nationwide. Suicide and homicide are second and third, respectively, between ages 10 and 34. New Hampshire’s leading causes of death due to injury are largely consistent with these nationwide statistics. Some of the specific types of unintentional injury include the following:

— Falls, especially in elderly populations

— Traumatic Injury, including concussions and traumatic brain injuries (TBI)

— Drowning

— Violence, including intimate partner and community violence

Efforts to prevent death and disability from injury are active and ongoing at the local, state, and federal level. These include enforcement of laws specific to injury prevention, education of both the public and and the healthcare community, and reinforcement of strategies which currently exist to prevent injuries. Traffic safety, falls prevention, seasonal safety, and suicide prevention are some of the efforts being undertaken by local, regional, and federal agencies responsible for promotion of injury prevention efforts. Resources surrounding these efforts are provided by organizations involved in injury prevention. A listing of links to some of these agencies can be found in the Frequently Asked Questions section of this page.