Discussion: LVL 1 vs LVL 2

[TXmed]

hello all, im working night shift and am bored. So one thing that has been bugging me the last few months is it seems like so many Level 2 trauma centers are opening up (especially in Texas), and when patients are taken there they seem to not act as up to standard as I feel they should (report receiving, teamwork etc). I've also had a decent amount of transfers from level 2's to level 1's . So this has prompted me to research some things. As it sits I personally feel the 1) level 2's are better served in cities not in proximity to a metroplex and 2) any patient with obvious serious trauma should go to a level 1 (unless a level 2 is SUBSTANTIALLY closer). This is in contrast to what was taught to me in medic school " Theres no difference in a lvl 2 and lvl " which seems to still be the attitude. So i figured since i was bored i would try to create a discussion on the matter to find out everyone else feelings, dont be shy let me hear it. I attached a few studies and an article which reflect some of my reasoning.


https://www.ncbi.nlm.nih.gov/pubmed/19430234

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361150/

http://www.medscape.com/viewarticle/741146_1

http://khn.org/news/trauma-centers/

 

[VFlutter]

I do not think I have ever taken a patient to a LVL 2 but I take them out often. I agree that unless its a significant time difference then they should just go to a LVL 1. In a perfect world there would be no difference in a trauma admission between at a LVL 2 hospital and a "LVL 2" patient at a LVL 1 hospital but that is rarely the case. Level 2 ERs are usually not as experienced and fluid with resuscitation, massive transfusion etc and slow to recognize when they are over their head and need to transfer out. This is usually after numerous CTs and consults with their surgeons while the patient is circling the drain. At a LVL 1 a patient can be upgraded instantly and receive the full spectrum of services. It really is better for most trauma patients to be at a LVL 1. Then if you fly them out (within 24hrs) you usually can not bill for the second transport. I really hate when a scene call is taken by EMS to a level 2 when we could have just taken them straight to an appropriate facility.

 

[Carlos Danger]

The difference in clinical capabilities between a ACS verified level one and level two are minimal. The level one is required to see higher volumes of trauma admissions and conduct educational and research activities. There are certain surgical subspecialty capabilities that a level one is required to have that a level two is not. Otherwise they are the same. Personally I would much rather see my family transported to a level 2 unless they required one of the few resources not typically there.

States designate trauma centers though, and they don't necessarily have to meet the same standards as the ACS verification requires.

 

[EpiEMS]

As @Remi said, I thought the Level 1 vs. Level 2 ACS facilities are basically the same as far as clinical care goes - in general. Could it be that you're looking at Texas' "proprietary" designations?
Correction - Texas uses ACS criteria for Level 1 and 2, but not for 3 and 4...I think.

 

[TransportJockey]

Our county units take people to level 2 centers all the time. We have one just barely north of the county lines, whereas the level one is as far south as you can go in our county. They seem to be able to handle most things brought to them, with the majority of their transfers out being either patient request or transfer for true specialties (VAD centers, interventional neuro, transplants, etc)

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[DesertMedic66]

Everything goes to our level 2 due to our level 1 being anywhere from 1-4 hours away. The only things that I see them transport out are usually burns and pedi traumas. Transplants and LVAD will usually go to the big teaching hospitals that are around 3 hours away from us in LA and San Diego.

 

[Jim37F]

If you look at the LA County EMS Agency's hospital directory, they do list some as Level 1 and some as Level 2 Trauma Centers.....but as far as working in the field, the only difference was Adult vs Ped Trauma Centers....if you had a trauma patient that needed a trauma center, you simply went to the trauma center, no discussion of level 1 vs 2. Heck I'm honestly not sure I ever even really learned what the difference was, at least beyond "Level 1s are teaching hospitals, Level 2s aren't" and that seemed to be the only difference anyone ever mentioned, otherwise they were simply The Trauma Center or The Pediatric Trauma Center.

 

[Tigger]

There are three level Is in Colorado, all are in Denver. As such, anything remotely sick gets transported to the two Level IIs in Colorado Springs, which is already a 30 minute to two hour transport. It would not be feasible to tag on an additional hour (at least) to bring patients directly there. We have a local Level IV but take three times as many patients out as to them. 98% of their transfers are to the Level IIs. Even when we or the bandaid box fly patients (which is common in the super rural parts of our area), they almost all go to the Level IIs. One of them is the busiest ED in the state, is a comprehensive stroke center, a satellite campus for the CU medical school, and probably will end up with a Level I designation soon. The only reason it isn't is likely because the other Level II is nearby and while slightly less capable (less volume, not a teaching hospital, still a comprehensive stroke center) is still solid. If the smaller Level II did not exist, we could easily have a Level I.

This is a complete opinion piece but I have no issues with either of them. The fact that they are both catchment hospitals for very large areas (all of southern Colorado) I think means they are pretty solid. Transfers to Denver do happen, but usually for complex neuro and peds (the only peds trauma center is in denver). I agree that Level IIs in suburban areas do not often seem to do as good of a job, I think a lot of it comes down to how many high acuity patients they actually see when they a) aren't going to get any transfers from outlying areas and b) are bypassed often by local EMS. The Level IIIs in Colorado Springs are dangerous like you speak of, they sit on patients that they should not have and encourage EMS to bring them patients that they have business seeing. At least when the Level IV panics that gets the patient out of there faster.