# Organization of French level 1 adult trauma centers: A national survey

Guillaume Bouhours, Lucas Dabouineau, Paer-Selim Abback, Eric Cesareo, Jonathan Charbit, Jean-Stéphane David, Pauline Devauchelle, Delphine Garrigue, Pauline Glasman, Sophie Hamada, et al.

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## To cite this version:

Guillaume Bouhours, Lucas Dabouineau, Paer-Selim Abback, Eric Cesareo, Jonathan Charbit, et al. "Organization of French level 1 adult trauma centers: A national survey." Anaesthesia Critical Care & Pain Medicine, 2026, 45 (2), pp.101624. 10.1016/j.accpm.2025.101624. hal-05326245

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Original Article

# Organization of French level 1 adult trauma centers: A national survey

<figure><img src="image_3.png" /></figure>

Guillaume Bouhours<sup>a</sup>, Lucas Dabouineau<sup>a</sup>, Paer-Selim Abback<sup>b</sup>, Eric Cesareo<sup>c</sup>,
Jonathan Charbit<sup>d</sup>, Jean-Stéphane David<sup>e,f</sup>, Pauline Devauchelle<sup>g</sup>, Delphine Garrigue<sup>h</sup>,
Pauline Glasman<sup>i</sup>, Sophie Hamada<sup>j</sup>, Antoine Lamblin<sup>k</sup>, Sébastien Mirek<sup>l</sup>,
Jean-Denis Moyer<sup>m</sup>, Hervé Quintard<sup>n</sup>, Pierre Pasquier<sup>o</sup>, Julien Pottecher<sup>p</sup>,
Véronique Ramonda<sup>q,r</sup>, Nathalie Zappella<sup>s</sup>, Thomas Clavier<sup>a,i,*</sup>

ARTICLE INFO

Article history:

Available online 26 September 2025

Keywords:

Trauma

Trauma center

Trauma system

Trauma bay

Benchmarking

Organization

ABSTRACT

**Introduction:** The specialized care of acute trauma patients is increasingly organized within networks, with the most critical patients referred to level 1 trauma centers (TC1). This French national survey aimed to evaluate the organizational and structural characteristics of these centers.

**Material and methods:** A 195-item survey was conducted across 40 centers classified as TC1 according to consensual criteria. It included a general analysis of the hospital, followed by an internal analysis of each department, specifically admitting severe acute trauma patients. The survey collected data on the architectural, human, and functional organization, activity, and general satisfaction regarding each department.

**Results:** All surveyed centers responded, 65% (26/40) of them were integrated into a trauma network. These TC1 admitted 409 (±332) severe trauma patients/year, including 90 (±75) grade A/very severe and 138 (±120) grade B/severe. Across the 40 TC1, a total of 46 reception areas were identified with a mean of 2.9 (±1.7) beds/area, and a surface of 20.4 (±8.9) m²/area. Their distances from the CT-scanner and operating room were 81 (±90) and 82 (±76) m, respectively. For grade A (unstable despite prehospital medical care) and B (stabilized after prehospital medical care and/or specific anatomic lesion) patients, the trauma team leader was an anesthesiologist-intensivist in 97.5% and 90.5% of admissions, respectively. Eleven (23.9%) reception areas reported multiple medical specialties involved in the admission of severe trauma patients, and 19 (41.3%) reported having dedicated nurses.

<footnote><sup>a</sup> Department of Anesthesia and Intensive Care, University Hospital of Angers, University of Angers, Angers, France</footnote>

<footnote><sup>b</sup> Department of Anesthesiology and Critical Care Medicine, Tours Regional University Hospital, Tours, France</footnote>

<footnote><sup>c</sup> SAMU 69, Hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d'Arsenal, F-69437 Lyon Cedex 03, France</footnote>

<footnote><sup>d</sup> Trauma and Polyvalent Critical Care Unit, Lapeyronie University Hospital, Montpellier, France</footnote>

<footnote><sup>e</sup> Department of Anesthesia and Intensive Care, Lyon Sud Hospital, Hospices Civils de Lyon, Pierre-Bénite, France</footnote>

<footnote><sup>f</sup> Pulmonary and Cardiovascular Aggression in Sepsis APCSe, Université de Lyon, UPSP 2021.A101, VetAgro Sup, Campus Vétérinaire de Lyon, Marcy L'Etoile, France</footnote>

<footnote><sup>g</sup> Department of Anaesthesiology and Critical Care, Hôpital Beaujon, AP-HP, Clichy, France</footnote>

<footnote><sup>h</sup> Department of Anesthesiology and Critical Care, Lille University Hospital, 59000, Lille, France</footnote>

<footnote><sup>i</sup> Assistance Publique Hôpitaux de Paris (APHP), Department of Anaesthesiology and Critical Care Medicine, Groupe Hospitalier Pitié Salpêtrière, Paris, France</footnote>

<footnote><sup>j</sup> Department of Anaesthesia and Critical Care, AP-HP, Hôpital Européen Georges Pompidou, Paris Cité University, Paris, France</footnote>

<footnote><sup>k</sup> Anaesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France</footnote>

<footnote><sup>l</sup> Anaesthesiology and Intensive Care Medicine, Hospices Civils de Beaune, Beaune, France</footnote>

<footnote><sup>m</sup> Department of Anesthesiology and Critical Care Medicine, Caen University Hospital, Caen, France</footnote>

<footnote><sup>n</sup> Division of Intensive Care Medicine, Department of Anesthesiology, Clinical Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospital, Geneva, Switzerland</footnote>

<footnote><sup>o</sup> French Military Medical Academy, École du Val-de-Grâce, Paris, France</footnote>

<footnote><sup>p</sup> Department of Anesthesiology and Intensive Care, Hautepierre Hospital, Strasbourg University Hospitals, Strasbourg, France</footnote>

<footnote><sup>q</sup> Department of Anesthesiology and Critical Care, Toulouse University Hospital, Toulouse, France</footnote>

<footnote><sup>r</sup> Department of Anaesthesiology and Surgical Intensive Care, DMU PARABOL, APHP, Hôpital Bichat, 75018, Paris, France</footnote>

<footnote><sup>s</sup> Department of Anesthesiology, Critical Care and Perioperative Medicine, CHU Rouen, F-76000 Rouen, France</footnote>

<footnote>* Corresponding author at: Department of Anesthesiology, Critical Care and Perioperative Medicine, Rouen University Hospital, 37 Boulevard Gambetta, 76000, Rouen, France.</footnote>

<footnote>E-mail address: thomas.clavier@chu-rouen.fr (T. Clavier).</footnote>
**Conclusion:** This survey highlights the variability of the functional, architectural, and human resource organization of French TC1.

© 2025 The Author(s). Published by Elsevier Masson SAS on behalf of Société Française d'Anesthésie et de Réanimation (SFAR). This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

## Introduction

Severe trauma remains a major cause of death and long-term disability, especially affecting young adults. It's a major cause of loss in healthy life years, or disability adjusted life years, underscoring its prolonged impact on quality of life [1]. The human and economic impacts are substantial, marking a critical public health challenge globally and in France, highlighting the importance of investing in effective solutions.

The organization and hospital admission of severe trauma patients critically influence their survival and functional outcomes [2-5]. In this context, the consolidation of specialized technical resources and specific human expertise has led to the concept of the "trauma center", whose effectiveness in improving care quality has been extensively demonstrated [6-8]. The care of severe trauma patients is increasingly organized within networks, with the most critically injured directed to level 1 trauma centers (TC1). TC1 concentrates all diagnostic and therapeutic capabilities necessary for the global management of severe trauma patients within a single healthcare facility [9,10]. The complexity and variability of these organizational models underscore the importance of standardization to achieve optimal outcomes.

Trauma center categorization and network organization first emerged in the United States in the 1970s and then in Europe during the 1990s [11]. The concept of a "Trauma System" has made a significant contribution to the reduction of overall and specific mortality rates in severe acute trauma patients [10,12-15]. Direct patient triage to appropriate care levels has progressively improved through facility and patient categorization [10]. However, the development of these networks and trauma centers remains uneven across our territory, raising questions about the need for harmonization of these structures. Moreover, while several guidelines exist in Anglo-Saxon countries, there is to date no French recommendation regarding the specific organization of TC1. While there is some data evaluating the organization of emergency structures, there is to date no exhaustive evaluation on a country scale of the structural, architectural, and functional organization of TC1 [16-19]. In the absence of such data, it is difficult to know how homogeneous or heterogeneous the organizations within these centers are, and therefore difficult to identify areas for collective (at a national level) or local (within each hospital) organizational improvement.

The objective of this national survey, conducted by the ACUTE committee (Comité Anesthésie-réanimation pour Chirurgie urgente, Urgences vitales et Traumatologie gravE) of the French Society of Anesthesia and Intensive Care Medicine, was to detail the structures and organizational models of the French TC1, and thus collect data to be able in the future to develop a framework for piloting organizational improvements.

## Methods

### Population selection

We conducted a prospective study in France using a self-reported survey between June and December 2022, with an addendum from January to September 2023, targeting hospitals

with adult TC1, according to criteria established by a group of French severe trauma experts (Table 1) [10]. All participants received information about the survey objectives that were recalled in the preface of the questionnaire. By voluntarily participating in the survey and sending it back by email after receiving adequate information on its purpose, responders' informed consent was implied. As this was not a study on clinical material, French legislation did not require approval from the Committee for the Protection of Persons (CPP) or the Institutional Review Board (IRB). The results are reported in accordance with the EQUATOR Checklist for Reporting Of Survey Studies (CROSS) [20].

### Objectives

The objectives of this survey were to exhaustively describe, in France:

- The technical, human, and material resources involved in the initial care of severe trauma patients.

- The architectural organization of trauma bays;

- The medical and nursing organization of teams involved in severe trauma patients' care at admission.

### Survey design

Data were collected using a digital questionnaire (in Word and/or PDF format) sent by e-mail to the lead physicians of the 40 TC1 identified according to the criteria established, in metropolitan France and overseas territories during the study period. Lead physicians contacted were either heads of the trauma department or national trauma referents working in the structure. The list of centers and correspondents is provided as supplementary data.

The 195-item questionnaire was divided into two distinct sections focused on the management of adult severe trauma patients (Appendix A (in French)):

- The first section included items focused on the overall organization of the hospital hosting the TC1, on medical-surgical and interventional resources (available both during regular hours and on-call hours), as well as on severe trauma and life-threatening emergency activities.

- The second section addressed the specific organization of each area within the hospital admitting severe trauma patients. A separate questionnaire was completed for each area within the TC1 designated for receiving severe trauma patients.

The items covered:

- Trauma patient categorization (A-B-C [10] or another categorization); the A-B-C system is a French prehospital classification splitting trauma patients into three categories: unstable despite prehospital medical care (grade A), stabilized after prehospital medical care and/or specific anatomic lesion (grade B), and stable (grade C). The A-B-C classification is detailed in Appendix B.

- Architectural and geographical organization of the care pathway at the reception phase: helipad, trauma bay, CT-scanner,
<table><caption>**Table 1**
Categorization of Trauma Centers by Technical Facilities.</caption><thead><tr><th rowspan="2">Admission area</th><th>Level 1 center</th><th>Level 2 center</th><th>Level 3 center</th></tr><tr><th>Resuscitation Room</th><th>Resuscitation Room/Emergency department</th><th>Emergency department</th></tr></thead><tbody><tr><td>Dedicated trauma team</td><td>Yes</td><td>Yes</td><td>No</td></tr><tr><td>Critical care level</td><td>ICU</td><td>ICU</td><td>Step Down Unit</td></tr><tr><td>Trauma ICU</td><td>Yes</td><td>No</td><td>No</td></tr><tr><td>24/7 operating room</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>Anesthesiologist</td><td>24/7</td><td>24/7</td><td>24/7</td></tr><tr><td>Digestive surgeon</td><td>24/7</td><td>24/7</td><td>24/7</td></tr><tr><td>Orthopedic surgeon</td><td>24/7</td><td>24/7</td><td>24/7</td></tr><tr><td>Neurosurgeon</td><td>24/7</td><td>No</td><td>No</td></tr><tr><td>Cardiac surgeon</td><td>24/7</td><td>No</td><td>No</td></tr><tr><td>Thoracic surgeon</td><td>24/7</td><td>No</td><td>No</td></tr><tr><td>Vascular surgeon</td><td>24/7</td><td>No</td><td>No</td></tr><tr><td>Ophthalmic surgeon</td><td>24/7</td><td>No</td><td>No</td></tr><tr><td>Urologic surgeon</td><td>24/7</td><td>24/7</td><td>No</td></tr><tr><td>Maxillofacial surgeon</td><td>24/7</td><td>No</td><td>No</td></tr><tr><td>Plastic surgeon</td><td>24/7</td><td>No</td><td>No</td></tr><tr><td>Gynecologist-obstetrician</td><td>24/7</td><td>24/7</td><td>24/7</td></tr><tr><td>Imaging within 30 min</td><td>CT/MRI</td><td>CT/MRI</td><td>CT</td></tr><tr><td>Arterial embolization within 30 min</td><td>Yes</td><td>No</td><td>No</td></tr><tr><td>Massive transfusion protocol</td><td>Yes</td><td>Yes</td><td>No</td></tr><tr><td>Mobile ICU ambulance</td><td>More than 2</td><td>At least 2</td><td>1</td></tr><tr><td>Helicopter</td><td>1</td><td>1</td><td>No</td></tr><tr><td>Helipad</td><td>Yes</td><td>No</td><td>No</td></tr><tr><td>Severe traumas admitted in the structure (/year)</td><td>>100</td><td>>50</td><td>No</td></tr><tr><td>Trauma-related research and teaching</td><td>Yes</td><td>No</td><td>No</td></tr></tbody></table>

Adapted from Evolution and Organization of Trauma Systems by David et al. [10].

24/7, resource available 24 h a day, 7 days a week (on call or on site); CT, Computed tomography scanner; ICU, Intensive Care Unit; MRI, Magnetic resonance imaging. The availability of surgical teams is understood to mean the availability of a senior physician in the specialty.

operating room, interventional radiology, intensive care unit, and the presence or absence of a “red pathway” (an identified, dedicated physical route to help pre-hospital teams find their way to the reception area);

* Material organization, area, and location of the reception structure;

* Medical and nursing organization of the reception area, care protocols;

* Educational, research, and publication activities;

* The lead physician's assessment of their structure and any planned architectural projects for the reception area.

## Statistical analyses

Responses were collected automatically or manually using Microsoft Excel spreadsheet software™. Results are expressed as absolute values (percentages) and as means (standard deviation) where applicable. If relevant, minimum and maximum values were added.

## Results

### General organization of level 1 trauma centers

All eligible structures (n = 40) that met the selected criteria responded to this survey, representing 46 different reception areas. Several facilities had more than one reception area dedicated to severe trauma patients. Twenty-six (65%) were part of a severe trauma network (“trauma system”), with a mean of 4 TC1 (±1.6) per network. Fig. 1 shows their distribution across the country. Thirty-six TC1 (90%) used a grading system of trauma patients’ severity, primarily A-B-C. These reference centers admitted a mean of 409 (±332) severe trauma patients per year, with the following distribution by grade: 90 (±75) grade A/very severe; 138 (±120) grade B/severe; and 173 (±185) grade C/moderate. Reporting of grade C cases was inconsistent in most facilities due to the absence of updated registries for this category (14/46

reception areas (30.4%) did not declare a number of grade C cases). Nineteen TC1 (48%) reported regularly admitting severely injured pediatric patients in their structure. Tables 2 and 3 detail the specialized organizational and human resources characterizing TC1.

### Organization of reception areas for critically injured patients in Level 1 trauma centers

Six TC1 (15%) reported having multiple dedicated reception areas for severe trauma patients within their facilities. Of the 46 reception areas designated for all severely injured patients (grade A, B, and C), the majority were specialized areas or “trauma bay” (TB; n = 23, 50%). Other areas included post-anesthesia care units (PACUs; n = 3, 6.5%), operating rooms (ORs; n = 2, 4.3%), emergency departments (n = 13, 28.3%), and intensive care units (ICUs; n = 5, 10.9%). Severe cases (grades A and B) were primarily admitted through anesthesia-intensive care departments (87.0%), with most areas associated with operating theaters (TB, PACU, OR; 80.5%) and a smaller portion with ICUs (6.5%).

The architectural setup of these trauma reception areas included a mean of 2.9 (±1.7) beds, each covering an area of 20.4 (±8.9; [Min = 2; Max = 50]) square meters. A predefined pathway exclusively dedicated to trauma care, or “red pathway”, was available in 56.5% of the centers. Reception areas were located at the following distances from key acute care zones:

* 80.9 (±90; [5; 500]) meters and 2.6 (±1.9; [0.5; 10]) minutes from the CT scanner; 11 out of 46 zones had the CT scanner on a different floor (10 out of 11 with a dedicated elevator);

* 81.9 (±76; [0; 300]) meters and 2.8 (±1.8; [1; 8]) minutes from the OR; 17 out of 46 zones had OR on a different floor (12 out of 17 with a dedicated elevator);

* 132.7 (±94; [20; 400]) meters and 4.2 (±2.8; [1; 15]) minutes from interventional radiology; 21 out of 46 zones had interventional radiology on a different floor (11 out of 21 with a dedicated elevator);
<figure><img src="image_4.png" /><figcaption>Fig. 1. Distribution of Level 1 trauma centers in France (December 31, 2022) and their integration into a trauma system.</figcaption></figure>

<table><caption>**Table 2**

General characteristics of severe trauma reception areas in level 1 trauma centers (n = 46).</caption><thead><tr><th></th><th>Yes<br>n (%)</th></tr></thead><tbody><tr><td>Dedicated admission area<sup>a</sup></td><td>23 (50%)</td></tr><tr><td>Dedicated trauma team</td><td>38 (82.6%)</td></tr><tr><td>Trauma ICU</td><td>43 (93.5%)</td></tr><tr><td>24/7 operating room</td><td>46 (100%)</td></tr><tr><td>Imaging within 30 min (CT/MRI)</td><td>46 (100%)</td></tr><tr><td>Arterial embolization within 30 min</td><td>44 (95.6%)</td></tr><tr><td>Massive transfusion protocol</td><td>42 (91.3%)</td></tr><tr><td>Helipad</td><td>46 (100%)</td></tr><tr><td>Grade A trauma >100 cases/year</td><td>9 (25.7%)</td></tr><tr><td>Trauma-related research</td><td>37 (80.4%)</td></tr><tr><td>Trauma-related teaching</td><td>24 (52.2%)</td></tr></tbody></table>

24/7, resource available 24 h a day, 7 days a week (on call or on site); CT, Computed tomography scanner; ICU, Intensive Care Unit; MRI, Magnetic resonance imaging.

• 77.4 (±103.7; [0; 400]) meters and 3.4 (±5; [0; 15]) minutes from specialized ICU; 19 out of 46 zones had specialized ICU on a different floor (12 out of 19 with a dedicated elevator).

Individual data on the proximity of reception areas to other zones are provided as supplementary data.

*Equipment, human resources, and procedures related to severe acute trauma patients' reception*

The material and equipment of the 46 reception areas are described in Fig. 2.

Forty-two (91.3%) critical trauma reception areas had an established massive transfusion protocol, and 30 (65.2%) of them had procedures for the pre-thawing of fresh frozen plasma. Checklists were used daily in 42 (91.3%) of the reception areas, prior to each patient admission in 33 (71.7%), and during admission procedures in 14 (30.4%). A dedicated trauma hotline (allowing

<footnote>a Designated area for severe trauma patient reception.</footnote>
<table><caption>**Table 3**
Medical and surgical resources of level 1 trauma centers in France.</caption><thead><tr><th></th><th>Hospital's medical and surgical resources 24/7</th><th>Agreement with a neighboring hospital to transfer a specialized medical/surgical team on-site 24/7</th><th>Agreement with a neighboring hospital to transfer the patient for specialized care 24/7</th><th>No 24/7 coverage</th></tr></thead><tbody><tr><td>Anesthesiologist-intensivist</td><td>40 (100%)</td><td>0 (0%)</td><td>0 (0%)</td><td>0 (0%)</td></tr><tr><td>Digestive surgeon</td><td>40 (100%)</td><td>0 (0%)</td><td>0 (0%)</td><td>0 (0%)</td></tr><tr><td>Orthopedic surgeon</td><td>40 (100%)</td><td>0 (0%)</td><td>0 (0%)</td><td>0 (0%)</td></tr><tr><td>Neurosurgeon</td><td>36 (90%)</td><td>2 (5%)</td><td>1 (2.5%)</td><td>1 (2.5%)</td></tr><tr><td>Cardiac surgeon</td><td>28 (60%)</td><td>5 (12.5%)</td><td>1 (2.5%)</td><td>6 (15%)</td></tr><tr><td>Thoracic surgeon</td><td>34 (85%)</td><td>4 (10%)</td><td>1 (2.5%)</td><td>1 (2.5%)</td></tr><tr><td>Vascular surgeon</td><td>38 (95%)</td><td>2 (5%)</td><td>0 (0%)</td><td>0 (0%)</td></tr><tr><td>ENT surgeon</td><td>37 (92.5%)</td><td>3 (7.5%)</td><td>0 (0%)</td><td>0 (0%)</td></tr><tr><td>Ophthalmic surgeon</td><td>35 (87.5%)</td><td>1 (2.5%)</td><td>0 (0%)</td><td>4 (10%)</td></tr><tr><td>Pediatric surgeon</td><td>29 (72.5%)</td><td>1 (2.5%)</td><td>2 (5%)</td><td>8 (20%)</td></tr><tr><td>Maxillofacial surgeon</td><td>29 (72.5%)</td><td>1 (2.5%)</td><td>3 (7.5%)</td><td>7 (17.5%)</td></tr><tr><td>Plastic surgeon</td><td>30 (75%)</td><td>0 (0%)</td><td>1 (2.5%)</td><td>9 (22.5%)</td></tr><tr><td>Gynecologist-obstetrician</td><td>34 (85%)</td><td>1 (2.5%)</td><td>2 (5%)</td><td>3 (7.5%)</td></tr><tr><td>Interventional radiologist</td><td>38 (95%)</td><td>1 (2.5%)</td><td>0 (0%)</td><td>2 (5%)</td></tr></tbody></table>

Data are presented as absolute numbers (%). 24/7, resource available 24 h a day, 7 days a week (on call or on site); ENT: ear, nose, and throat.

<figure><img src="image_5.png" /><figcaption>**Fig. 2.** Equipment available in severely injured trauma patients' reception areas. Data are expressed in %. REBOA, Resuscitative Endovascular Balloon Occlusion of the Aorta.</figcaption></figure>

direct access to the trauma specialist managing patient admission) was set up in 41 (89.1%) reception areas, with a call-in procedure 15 min prior to arrival from the pre-hospital team in 31 (67.4%) reception areas.

Thirty-eight reception areas (82.6%) were organized with a physician dedicated to the reception and management of severe trauma patients. The rate of presence and exclusive trauma leader was as follows: anesthesiologist-intensivists 87% (40/46) and 63%, emergency physicians 30% (14/46) and 13%, medical intensivists 13% (6/46) and 0%, respectively. Patient care was occasionally multidisciplinary, with 11 (23.9%) reception areas reporting multiple specialties (primarily anesthesiologist-intensivists or intensivists and emergency physicians) involved in the care of severe trauma patients.

Nineteen TC1 reception areas (41.3%) reported having dedicated nurses, distributed as follows: 54.3% nurses not working in ICU, 39.1% nurses working in ICU, 30.4% nurse anesthetists, and 2.2% OR nurses.

*Description of reception organization according to trauma severity categorization and the number of admissions per year*

Reception areas within the TC1, as well as the medical specialties involved in the initial care, varied according to the severity and corresponding grading of severely trauma patients (Figs. 3 and 4). Trauma bay was the reception area for the majority of grades A, 76% of cases, while the rate decreased to 66% for grades B. Corresponding rates for the emergency department were in
<figure><img src="image_6.png" /><figcaption>Fig. 3. Reception areas of Grade A (A) and B (B) trauma patients. No illustration was created for Grade C patients due to incomplete data for this category.</figcaption></figure>

<figure><img src="image_7.png" /><figcaption>Fig. 4. Medical specialty of the physicians involved in the initial management according to the severity/grading of severely injured trauma patients. The results are expressed as the absolute value (%) of the total annual number of patients with a given injury grade. *incomplete data.</figcaption></figure>

contrast, 10% and 15%, respectively. Based on the number of grade A trauma patients per year, three sub-groups of TC1 were identified, and their organization as an activity was analyzed (Table 4).

## Respondents' perspectives on local organizational structures

It should be noted that 35.7% (15/42) of TC1 expressed a desire to modify their protocol and/or architectural organization, and 31%
<table><caption>**Table 4**
Activity and organization of reception areas based on the number of Grade A trauma cases admitted per year: 50 or fewer per year (n = 14).</caption><thead><tr><th></th><th>&lt;50 per year (n = 14)</th><th>Between 51 and 100 (n = 12)</th><th>&gt;100 per year (n = 9)</th></tr></thead><tbody><tr><td>Number of severe acute trauma patient admissions per year</td><td>232 (±128.6)</td><td>361.5 (±140.9)</td><td>671.6 (±522)</td></tr><tr><td>Dedicated trauma phone line</td><td>12 (85.7%)</td><td>11 (91.7%)</td><td>9 (100%)</td></tr><tr><td>Number of reception beds</td><td>2.6 (±1.8)</td><td>1.8 (±0.9)</td><td>4 (±1.3)</td></tr><tr><td>Dedicated CT-scanner</td><td>9 (64.3%)</td><td>9 (75%)</td><td>9 (100%)</td></tr><tr><td>Bedside blood gas analyzer</td><td>9 (64.3%)</td><td>8 (66.7%)</td><td>7 (77.8%)</td></tr><tr><td>Pediatric kit</td><td>7 (50%)</td><td>8 (66.7%)</td><td>9 (100%)</td></tr><tr><td>Anesthesiologist-intensivist involved in trauma care</td><td>10 (71.4%)</td><td>12 (100%)</td><td>9 (100%)</td></tr><tr><td>Emergency physician involved in trauma care</td><td>6 (42.8%)</td><td>1 (8.3%)</td><td>1 (11.1%)</td></tr><tr><td>Intensivist involved in trauma care</td><td>3 (21.4%)</td><td>0 (0%)</td><td>0 (0%)</td></tr><tr><td>Physician stationed at trauma reception</td><td>12 (85.7%)</td><td>9 (75%)</td><td>9 (100%)</td></tr><tr><td>Dedicated paramedical staff exclusively for trauma reception</td><td>5 (35.7%)</td><td>2 (16.7%)</td><td>5 (55.6%)</td></tr><tr><td>Existence of massive transfusion protocol</td><td>12 (85.7%)</td><td>12 (100%)</td><td>9 (100%)</td></tr><tr><td>Teaching activities</td><td>5 (35.7%)</td><td>4 (33.3%)</td><td>8 (88.9%)</td></tr><tr><td>Research activities</td><td>9 (64.3%)</td><td>11 (91.7%)</td><td>9 (100%)</td></tr><tr><td>Inclusion in trauma database</td><td>13 (92.9%)</td><td>11 (91.7%)</td><td>9 (100%)</td></tr></tbody></table>

Between 51 and 100 per year (n = 12); more than 100 per year (n = 9). We lacked the data concerning Grade A patients volume for 5 centers. Our distribution into three groups is based on Adapted from Evolution and Organization of Trauma Systems by David et al. [10].

(13/42) wished to change the local human resources organization. More than half (22/42) of the TC1 were considering an architectural project for their admission area.

## Discussion

This original survey confirms the trend toward a common structure for the care of severe trauma patients in France. However, this comprehensive study highlights significant heterogeneities in the functional, architectural, human resources, and specialized services within TC1.

Several common features emerged from the analysis of severe trauma patient reception areas. Admission and immediate management are primarily coordinated by anesthesia-intensive care teams, particularly for severe trauma patients (grades A and B). Such patients often require emergency surgery and/or interventional radiology under anesthesia. Continuous management by anesthesia-intensive care physicians is logical and confirmed by our findings. Nurses typically assigned to these units strengthen the competencies and coherence of trauma teams [21,22]. These reception areas are typically organized around a "red trauma pathway" with proximity to both a CT scanner and an OR. They are equipped with specialized resources for managing severe acute trauma patients, including protocols (e.g., massive transfusion, traumatic brain injury) and a dedicated trauma hotline.

However, there are many differences between all the facilities studied. A significant portion of trauma cases, primarily grades B or C but not exclusively, are managed in the emergency department (mainly, in France, in the Emergency Shock room (Salle d'Accueil des Urgences Vitales, SAUV) under the leadership of emergency physicians. These management practices vary across institutions and, in some cases, within the same institution, based on subjective criteria. Some TC1s have multiple distinct reception areas for severe acute trauma patients within the same facility. These observed differences in reception areas and/or medicalization may be due to the specific historical development of severe trauma care at each center and limitations in human or architectural resources. Thus, in some centers, severely injured patients are taken to the OR or ICU, which may seem unusual. Some (sometimes intricate) organization may explain this result: localization of the trauma bay in a dedicated room positioned geographically within an OR/ICU, separate areas but administratively linked to an OR or ICU. These results probably reflect the historical disparities (and sometimes related to geography)

between centers. However, the fundamental elements for trauma management are present regardless of the reception area: dedicated team, equipment, nursing resources, etc. Organizational differences are also observed according to the annual volume of grade A patients, suggesting a possible impact of the patient volume and the trauma teams' expertise on the organization of severe trauma patients' admission [23,24].

Despite the benefits associated with establishing trauma systems, 35% of TC1 in France were not integrated into these networks at the time of this study [10,12-15,25,26]. While it may suggest some disorganization in these regions, it is also possible that some hospitals are not part of an administratively structured network (e.g., an association), but have a "networked" functioning based on triage habits or consensual local protocols.

In contrast to North American systems, trauma leadership in France is not assigned to surgeons [21]. Instead, the medical specialties of anesthesia-intensive care and emergency medicine are the most involved in the management of severe trauma patients during the early in-hospital phase. All French anesthetists have dual competence in anesthesia and intensive care (the official name of the specialty being "Anesthesia, Intensive Care and Perioperative Medicine"), and are trained 50% in each area during their residency. For grade A and B trauma, at 97.5% and 90.5% respectively, the trauma leader is almost exclusively a physician specialized in anesthesia and intensive care. These results are consistent with French practice, which has historically placed anesthetists-intensivists in charge of intra-hospital severe trauma care in TC1. Given their technical expertise in trauma care (e.g., neuro-resuscitation, hemorrhagic shock management, airway and vascular access) and experience in managing multidisciplinary teams, anesthetists-intensivists are positioned as leaders for managing these complex situations. They are present throughout the critical phase (thus preserving the continuity of care in critical situations), oversee access to emergency operating rooms, and maintain strong collaborative relationships with surgical and interventional radiology teams [27]. Even if our data are incomplete for grade C patients, they appear to be primarily managed by emergency medicine physicians in TC1, which probably allows immediate availability of technical and human specialized resources for more severely injured patients. Emergency medicine, due to its expertise in pre-hospital and organizational aspects, is an essential link in the care pathway for these patients [28].

The most severely injured patients are predominantly admitted to a structure centered around or linked to an emergency OR. These emergency ORs are used for other emergency surgeries, but can be
made available quickly in the event of the arrival of a severe trauma patient. This observation highlights the need for a dedicated unit, characterized by cross-disciplinary architectural and human resource organization, centered on an immediate intervention-based multidisciplinary trauma response [29]. Our results raise the question of the relevance of recommendations from institutional and professional bodies regarding both architectural layout and recognition of medical procedures performed.

The classification of French trauma centers into three levels is currently based primarily on criteria validated by experts and adapted within each regional network [10]. However, our study reveals that certain centers designated as TC1 may lack a full surgical suite available or formal inter-hospital agreements, particularly in cardiac surgery (15%), neurosurgery (2.5%), or thoracic surgery (2.5%). This finding should be interpreted with caution, taking into account territorial coverage and recruitment challenges. Specific situations may necessitate that some TC1s, serving as regional reference centers, do not meet all validated criteria. It seems reasonable that these facilities should have inter-hospital agreements within one or more trauma networks to ensure optimal care. Some centers reported not having a massive transfusion protocol, which raises concerns for structures admitting severe trauma patients who may have severe hemorrhagic shock. Even though there is no national massive transfusion protocol in France, the existence of local protocols shows that a center has considered the issue and developed an approach suited to its specificities. Ideally, trauma center levels should be assigned through a structured and consensus-based national accreditation process that outlines structural requirements, as well as national key performance and quality indicators [30]. Beyond categorization, it has been shown that patients' volume (especially grade A patients) seems to influence organizations and patients' outcomes [23,24,31]. Our study shows that centers admitting more than 100 grade A patients/year have more human and technical resources, as well as are also more active in teaching, research, and inclusion of patients in trauma databases. Nevertheless, given the disparity in population density across France, some hospitals may have a limited volume but are nevertheless geographically essential to ensure that all residents in the region have access to a nearby TC1. As each region has specific geographic (urbanization rate, landforms, etc.) and population characteristics (human density, age, etc.), it seems important to take these factors into account when defining national standards or recommendations for TC1.

This study presents several limitations that must be acknowledged, primarily its self-reported nature, particularly regarding activity levels. The absence of registries limited data accuracy and completeness, especially concerning grade C activity, creating interpretation challenges. There is a national registry for severe trauma in France (the Traumabase), but not all centers participate in it. Some centers have regional, local registries, or registries within a trauma network. Some centers have no registry at all. There is no harmonization of these registries, which are purely dedicated to research and activity monitoring. Finally, grade C patients are not managed by a specific trauma team in some centers but are handled in a regular emergency department. It is therefore very difficult to have visibility on this category of "stable" patients. Despite expert-established criteria, notable field-level variations persist, with certain regional reference centers presenting unique structural characteristics. These specific organizational features may reflect historical, relational, or spatial factors, which likely warrant a detailed local analysis. Although focused on TC1, future studies should also examine other levels of trauma centers and pediatric trauma centers to have a reliable and comprehensive national overview. Thus, it is possible that a significant proportion of grade A or B patients were taken in charge

in other hospitals than TC1, potentially resulting in an underestimation of the national volume for these patients. As it is known, the management of pediatric trauma remains particularly challenging and warrants dedicated focus, with the difficulty in defining what constitutes a "pediatric trauma center" [32]. One of our future studies will be focused on a similar benchmarking applied to a trauma center admitting pediatric population. Although not evaluated here, assessing the impact of various organizational models on patient outcomes would provide valuable insights. On an initial survey of 195 items, we were unable to present and discuss all the results. We arbitrarily chose to present the results we felt were most relevant to the specific organizational and architectural characteristics of French TC1. For example, we specify whether or not the reception area is on the same floor as the CT-scanner, but without specifying how many floors separate them. All answers to all the questions of the 195 items (some items having several questions/answers) are provided in Appendix C. Finally, this survey was conducted exclusively in France, which limits the applicability of the results to other countries.

## Conclusion

This study highlights a significant variability in the organizational structures of Level 1 trauma centers in France. Our study raises the question of whether it would be worth developing French recommendations regarding the specific organization of TC1 to standardize structures and organizations across our country. Our data may help identify areas with significant disparities between centers, which could be prioritized for such recommendations.

## CRediT authorship contribution statement

LD was involved in acquisition of data, in statistical analysis, in analysis and interpretation of data and in manuscript draft.

PSA, EC, JC, JSD, PD, DG, PG, SH, AL, SM, JDM, HQ, PP, JP, VR and NZ were involved in the study conception and design, in acquisition of data and in manuscript revision.

GB and TC were involved in the study conception and design, in study coordination, in interpretation of data and in manuscript draft.

All authors have read and approved the final manuscript.

## Ethical statement

Organization of French level 1 adult trauma centers: a national survey

All participants received information about the survey objectives that were recalled in the preface of the questionnaire. By voluntarily participating in the survey and sending it back by email after receiving adequate information on its purpose, responders' informed consent was implied. This was not a study on clinical material, French legislation does not require approval from the Committee for the Protection of Persons (CPP) or the Institutional Review Board (IRB).

## Funding

None.

## Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships which have or could be perceived to have influenced the work reported in this article.
# Appendix A. Supplementary data

Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.accpm.2025.101624.

## References

[1] GBD 2021 Diseases and Injuries Collaborators. Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 Diseases and Injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 2024;403:2133-61. http://dx.doi.org/10.1016/S0140-6736(24)00757-8.

[2] Gauss T, Ageron F-X, Devaud M-L, Debaty G, Travers S, Garrigue D, et al. Association of prehospital time to in-hospital trauma mortality in a physician-staffed emergency medicine system. JAMA Surg 2019;154:1117-24. http://dx.doi.org/10.1001/jamasurg.2019.3475.

[3] Gräff I, Ghamari S, Schacher S, Glien P, Fimmers R, Baehner T, et al. Improvement of polytrauma management-quality inspection of a newly introduced course concept. J Eval Clin Pract 2017;23:1381-6. http://dx.doi.org/10.1111/jep.12802.

[4] Piagnerelli M, Van Nuffelen M, Maetens Y, Lheureux P, Vincent JL. A "shock room" for early management of the acutely ill. Anaesth Intensive Care 2009;37:426-31. http://dx.doi.org/10.1177/0310057X0903700307.

[5] Polytrauma Guideline Update Group. Level 3 guideline on the treatment of patients with severe/multiple injuries: AWMF Register-Nr. 012/019. Eur J Trauma Emerg Surg 2018;44:3-271. http://dx.doi.org/10.1007/s00068-018-0922-y.

[6] Trunkey DD. Trauma centers and trauma systems. JAMA 2003;289:1566-7. http://dx.doi.org/10.1001/jama.289.12.1566.

[7] Stelfox HT, Khandwala F, Kirkpatrick AW, Santana MJ. Trauma center volume and quality improvement programs. J Trauma Acute Care Surg 2012;72:962-7. http://dx.doi.org/10.1097/TA.0b013e31824a7bd8.

[8] Chiara O, Cimbanassi S. Organized trauma care: does volume matter and do trauma centers save lives? Curr Opin Crit Care 2003;9:510-4. http://dx.doi.org/10.1097/00075198-200312000-00008.

[9] Gauss T, Quintard H, Bijok B, Bouhours G, Clavier T, Cook F, et al. Intrahospital trauma flowcharts - cognitive aids for intrahospital trauma management from the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French Society of Emergency Medicine (SFMU). Anaesth Crit Care Pain Med 2022;41101069. http://dx.doi.org/10.1016/j.accpm.2022.101069.

[10] David JS, Bouzat P, Raux M. Evolution and organisation of trauma systems. Anaesth Crit Care Pain Med 2019;38:161-7. http://dx.doi.org/10.1016/j.accpm.2018.01.006.

[11] MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354:366-78. http://dx.doi.org/10.1056/NEJMsa052049.

[12] Mullins RJ, Veum-Stone J, Helfand M, Zimmer-Gembeck M, Hedges JR, Southard PA, et al. Outcome of hospitalized injured patients after institution of a trauma system in an urban area. JAMA 1994;271:1919-24. http://dx.doi.org/10.1001/jama.1994.03510480043032.

[13] Alharbi RJ, Shrestha S, Lewis V, Miller C. The effectiveness of trauma care systems at different stages of development in reducing mortality: a systematic review and meta-analysis. World J Emerg Surg 2021;16:38. http://dx.doi.org/10.1186/s13017-021-00381-0.

[14] Muguruma T, Toida C, Gakumazawa M, Yogo N, Shinohara M, Takeuchi I. Effects of establishing a trauma center on the mortality rate among injured pediatric patients in Japan. PLoS One 2019;14:e0217140. http://dx.doi.org/10.1371/journal.pone.0217140.

[15] Bouzat P, Broux C, Ageron F-X, Gros I, Levrat A, Thouret J-M, et al. Impact of a trauma network on mortality in patients with severe pelvic trauma. Ann Fr Anesth Reanim 2013;32:827-32. http://dx.doi.org/10.1016/j.ann-far.2013.10.018.

[16] Krötz M, Bode PJ, Häuser H, Linsenmaier U, Pfeifer KJ, Reiser M. [Interdisciplinary shock room management: personnel, equipment and spatial logistics in 3 trauma centers in Europe]. Radiologe 2002;42:522-32. http://dx.doi.org/10.1007/s00117-002-0762-x.

[17] Beck A, Gebhard F, Fleiter T, Pfenninger E, Kinzl L. Time optimized modern shock room management using digital techniques. Unfallchirurg 2002;105:292-6. http://dx.doi.org/10.1007/s00113-001-0391-2.

[18] Quintard H, Severac M, Martin C, Ichai C, Emergency Intensive Care Group of the French Society of Anesthesiology, Intensive Care (Société française d'anesthésie et de réanimation "SFAR"). In-hospital organization of primary care of patients presenting a life-threatening emergency: a French national survey in 32 university hospitals. Anaesth Crit Care Pain Med 2015;34:225-30. http://dx.doi.org/10.1016/j.accpm.2015.04.001.

[19] Oberlin M, Douay B, Desclefs J-P, Depil-Duval A, Ganansia O, Giraud L, et al. Emergency department architecture (2024). Ann Fr Med Urgence 2024;14:121-35. http://dx.doi.org/10.1684/afmu.2024.0570.

[20] Sharma A, Minh Duc NT, Luu Lam Thang T, Nam NH, Ng SJ, Abbas KS, et al. A Consensus-Based Checklist for Reporting of Survey Studies (CROSS). J Gen Intern Med 2021;36:3179-87. http://dx.doi.org/10.1007/s11606-021-06737-1.

[21] Bento A, Ferreira L, Yánez Benitez C, Koleda P, Fraga GP, Kozera P, et al. Worldwide snapshot of trauma team structure and training: an international survey. Eur J Trauma Emerg Surg 2023;49:1771-81. http://dx.doi.org/10.1007/s00068-022-02166-9.

[22] Tiel Groenestege-Kreb D, van Maarseveen O, Leenen L. Trauma team. Br J Anaesth 2014;113:258-65. http://dx.doi.org/10.1093/bja/aeu236.

[23] Nathens AB, Jurkovich GJ, Maier RV, Grossman DC, MacKenzie EJ, Moore M, et al. Relationship between trauma center volume and outcomes. JAMA 2001;285:1164-71. http://dx.doi.org/10.1001/jama.285.9.1164.

[24] Minei JP, Fabian TC, Guffey DM, Newgard CD, Bulger EM, Brasel KJ, et al. Increased trauma center volume is associated with improved survival after severe injury: results of a Resuscitation Outcomes Consortium study. Ann Surg 2014;260:456-64. http://dx.doi.org/10.1097/SLA.00000000000000873. discussion 464-465.

[25] Celso B, Tepas J, Langland-Orban B, Pracht E, Papa L, Lottenberg L, et al. A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma 2006;60:371-8. http://dx.doi.org/10.1097/01.ta.0000197916.99629.eb. discussion 378.

[26] Choi J, Carlos G, Nassar AK, Knowlton LM, Spain DA. The impact of trauma systems on patient outcomes. Curr Probl Surg 2021;58100849. http://dx.doi.org/10.1016/j.cpsurg.2020.100849.

[27] Lepercq D, Gauss T, Godier A, Bellet J, Bouhours G, Bouzat P, et al. Association of Organizational Pathways With the Delay of Emergency Surgery. JAMA Netw Open 2023;6:e238145. http://dx.doi.org/10.1001/jamanetworkopen.2023.8145.

[28] Cesareo E, Sapir D, Lhcène F, Hocine F, Tazarourte K. Enjeux du tri et de l'orientation en pré-hospitalier pour les traumatisés graves. Available at: https://www.sfmu.org/upload/70_formation/02_eformation/02_congres_Urgences/urgences2013/donnees/pdf/040_Cesareo_Tazarourte.pdf

[29] Glen J, Constanti M, Brohi K, Guideline Development Group. Assessment and initial management of major trauma: summary of NICE guidance. BMJ 2016;353i3051. http://dx.doi.org/10.1136/bmj.i3051.

[30] Gauss T, Balandraud P, Prandon J, Abba J, Ageron FX, Albaladejo P, et al. Strategic proposal for a national trauma system in France. Anaesth Crit Care Pain Med 2019;38:121-30. http://dx.doi.org/10.1016/j.accpm.2018.05.005.

[31] Roden-Foreman JW, Rapier NR, Foreman ML, Zagel AL, Sexton KW, Beck WC, et al. Rethinking the definition of major trauma: the need for trauma intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric Trauma centers. J Trauma Acute Care Surg 2019;87:658-65. http://dx.doi.org/10.1097/TA.00000000000002402.

[32] Ageron F-X, Evain J-N, Chifflet J, Vallot C, Grèze J, Mortamet G, et al. Improving paediatric undertriage in a regional trauma network — a registry cohort study. Anaesth Crit Care Pain Med 2025;44101497. http://dx.doi.org/10.1016/j.accpm.2025.101497.