Interhospital variation in highest-level trauma activation and its association with mortality: A 37-center cohort study of level I and II trauma centers in the US

Document Type

Article

Publication Date

4-17-2026

Publication Title

Injury

Abstract

Background Trauma team activation protocols are critical for mobilizing resources in the care of severely injured patients. In the US, the American College of Surgeons (ACS) specifies minimum criteria for the highest-level (full) trauma activation (fTA), but hospitals retain discretion to add criteria, potentially leading to variability in activation practices and resource utilization. The extent of this variation and its impact on patient outcomes is unknown. The aim of this study was to quantify inter-hospital variability in fTA use and its relationship to mortality. Methods We conducted a multicenter, retrospective cohort study of adult trauma patients treated at 37 Level I and II trauma centers across the United States from 2017 to 2019; transfers were excluded. Mixed-effects logistic regression models were used to quantify inter-hospital variability in fTA utilization and total mortality (death+hospice), adjusting for 12 patient and hospital-level characteristics. Correlation analyses assessed the relationship between adjusted hospital-specific fTA rates and adjusted total mortality. Results Overall, 158,696 patients were included, with 34,374 (21.7%) receiving a fTA. The median age was 53 yrs, with 59% male, 71% White, 88% blunt, and a median Injury Severity Score of 9. Use of fTA varied widely (3.3% to 54.1%, median [IQR]=19.3% [13.6–27.3%]) and the adjusted odds of fTA varied significantly across hospitals (SD=0.88; coefficient of variation [CV]=0.53), with 83.7% of hospitals differing significantly from the average hospital. In contrast, adjusted odds of total mortality showed lower inter-hospital variation (SD=0.31; CV=0.22), with 35% of hospitals differing significantly from the average hospital. Overall, no statistically significant correlation was found between adjusted hospital-level fTA rates and total mortality (r = 0.07, b=0.01, p = 0.69). Age-stratified sensitivity analyses also confirmed substantially greater inter-hospital variability in fTA rates compared to mortality rates. Conclusions Substantial variation in fTA utilization exists across this sample of U.S. trauma centers. Importantly, higher fTA rates were not associated with improved mortality outcomes. These findings suggest that discretionary activation practices may lead to inconsistent resource utilization without measurable benefit on total mortality. Standardized evidence-based criteria for fTA may improve resource stewardship and trauma system efficiency.

PubMed ID

42025512

Rights

© 2026 Elsevier Ltd.

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