The biggest efforts to initiate standards for trauma care systems in the world were made in the 1970s in the United States of America. At first, the emphasis of trauma care was on high-level trauma centers within exclusive trauma care systems, since the 1990s American trauma systems have become more inclusive as a result of “The Model Trauma Care System Plan” released in 1992 by the Health Resources Services Administration [18].

The trauma care facilities within a trauma care system in the United States are classified and designated, by the American College of Surgery (ACS), Committee on Trauma into different levels of care (levels I–V) according to the updated criteria for trauma center verification listed in the Resources for Optimal Care of the Injured Patient: 2006. In some states, the process of evaluating trauma care facilities is performed by the state government or local emergency medical services, and in those cases, verification by the ACS is not necessary. Furthermore, some states still provide trauma care through a limited number of designated level I and level II trauma centers, whereas other states have classified every acute trauma hospital according to the levels of care they can provide.

In 2010, a total of over 1,600 trauma centers in 40 states were classified and certified. They included 203 level I, 271 level II, 393 level III, 765 level IV or V, and 43 pediatric trauma centers.

The trauma care in Canada is organized around the 17 medical universities across the country, and the designation of trauma centers is organized by every province. There is currently no nationwide designation and verification process.

The geographical situation of Canada resembles that of the United States, with major metropolitan areas sometimes having more than one trauma center, and large rural areas with no (pre-)hospital trauma care at all. The central areas and the districts in the Rocky Mountains particularly have problems with pre-­hospital transportation times.

Since 1999, several trauma managers and coordinators in Canada have been organizing meetings and programs to improve the trauma care organization in Canada. In 2008 they founded the Interdisciplinary Trauma Network of Canada.

The designation of trauma care facilities by the Trauma Association of Canada (TAC) started in 2005 and their guidelines were last updated in June 2011. Since 2005, 25 trauma centers have been accredited, of which 13 are level I, one is level II, five are level III, and four are level IV or V. Only four of the 10 provinces took part in the designation process and of the 13 level I centers, nine are situated in the province of Ontario, illustrating the geographical problems mentioned above. The trauma centers are all funded by the provinces and are responsible for leading the trauma care in their regions and act as referral facilities.

Even with the widespread education of ATLS^®, the high quality of in-hospital trauma care, and the efforts of the TAC, there is still no countrywide trauma care system in place.

The Australian mainland consists of five states and three territories, with two of the territories being very small (i.e., Australian Capital Territory and Jervis Bay Territory). The mainland has a nationwide trauma care system as all states have a trauma care system with designated trauma centers. The Northern Territory has only one major trauma center, located in Darwin; the Australian Capital Territory has one major trauma center located in Canberra, but only covers ca. 2,350 km² of the mainland and is fully enclosed within the state of New South Wales. The Jervis Bay Territory covers only 73 km² of land and has therefore no trauma care system.

The implementation of trauma care systems in Australia began in the early 1990s in New South Wales and is currently still developing. One of the biggest problems for trauma care systems in Australia is (as in Canada) the particular geography and demography of the nation. It is the sixth largest country in the world with just a little less surface area than the USA, but has only just over 21 million residents, who are concentrated in the urban and metropolitan areas in the coastal regions. In consequence, the ‘outback’ of Australia is large and not provided with health care. This causes a high mortality rate among traumatically injured patients, although the unique organization of the Royal Flying Doctor Service of Australia (RFDS) can reach every resident in the ‘outback’ within a 2 h flight, which puts the “golden hour” of trauma care in another perspective.

The trauma care systems in Australia are initiated and developed by individual states and the acute care facilities are designated by either the regional health service or the state Department of Health. Currently there are ca. 16 level I trauma centers for adult care and ca. seven level I trauma centers for pediatric care assigned throughout the five states and two territories. The Royal Darwin Hospital has also been designated as the National Critical Care and Trauma Response Centre because of the fact that it is the first Australian hospital accessible from South East Asia in the event of a mass casualty or disasterous event. This seems to be in keeping with the concept of many trauma care systems to designate one reference center per one million inhabitants, but when we look at the geographical location of these so-called major trauma services, we find the centers are concentrated in only one city or metropolis in almost every state or territory. Therefore, the organization of trauma care in rural areas is very important. There are six levels of acute trauma care in Australia, divided over two types of trauma networks (i.e., the metropolitan and the rural). In the metropolitan trauma network, the following levels of care are designated: Major Trauma Service (level I), which provides the full spectrum of care and function as a tertiary referral center; Metropolitan Trauma Service (level II), which provides initial assessment and stabilization, and when warranted, initiates transfer to a Major Trauma Service; and Urban Trauma Service (level III), which provides care to patients with minor-to-moderate injuries at local communities in urban areas. The rural trauma network is established on three other levels of care: the Regional Trauma Services provide definitive care of non-major trauma according to the availability of local expertise; the Rural Trauma Services, which have 24 h availability of an on-duty medical practitioner; and the Remote Trauma Services, serving people in remote areas from small hospitals with no immediately available general practitioners.

The statewide trauma system in Germany is one of the best organized trauma systems in Europe and includes all aspects of trauma care: prevention, (pre-)hospital care system, trauma center designation, rehabilitation units, and a quality control system. According to the current information of the German Society for Trauma Surgery (DGU), there are over 850 acute care facilities registered, forming 57 regionalized trauma networks, of which 17 are already officially certified. Although the overall improvement of trauma patients after the establishment of the trauma system in 1970 is remarkable, the trauma register shows great differences between different trauma care systems throughout Germany due to geographic, demographic, and organizational infrastructure differences. This is why in 2004, the DGU laid the foundation for an improved structure of the statewide trauma systems, the TraumaNetwork^D. The main aims were to increase the quality of trauma care, improve cooperation among acute care facilities, and shorten the pre-hospital time to less than 30 min. This was enforced in 2006 by the ‘White Paper on Trauma care’, in which recommendations and strict guidelines for all aspects of acute trauma care are listed.

After the establishment of the Birmingham Accident Hospital as the first trauma center, which functioned from 1941 until the 1990s, the first pilot trauma care system was launched at the North Staffordshire Hospital in Stoke-on-Trent. This study was initiated by the Royal College of Surgeons in England, and showed bad outcomes in major trauma care in acute care hospitals [25]. The results of the study were not convincing [26], although it showed a decreasing trend in mortality, and in consequence there was much criticism. The development of trauma care was postponed until after the Military Medical Services returned from their missions in Afghanistan and Iraq with proof of excellent results of the trauma care they provided to severely injured soldiers [27]. This led to the establishment of the London trauma system in 2010. This system encompasses four inclusive trauma care systems with approximately four level I trauma centers and facilities with a lower care level. Initiatives to develop a trauma care system at the Birmingham Accident Hospital have also been taken.

Since the first impetus given by the Dutch Trauma Society in the early 1990s, The Netherlands have developed an excellent, functioning, nationwide, inclusive trauma care system. In 1997, the Ministry of Health, Welfare and Sport established 11 level I trauma centers that are the reference centers in 10 inclusive trauma care systems that cover The Netherlands. The reference centers play a key role in the development of guidelines for trauma care and quality control within each region. Every reference center has a specialized Medical Mobile Team that provides pre-hospital care for polytraumatized patients in addition to the normal paramedic-based ambulance system.

Although this has resulted in enhanced quality of care in all aspects, from pre-hospital care to improvement of facility coordination to the foundation of a national trauma registration, the system also has its imperfections. The biggest concerns in The Netherlands are the shortage of intensive care beds and the organizational shortcomings of pre-­hospital care.

In France, the emphasis of the trauma care systems is on pre-hospital care, with well- organized physician-based emergency care. The designation of hospitals in France is different from that in the USA but there is also a difference in the level of care. There are three different types of emergency departments: (1) The Service d’Accueil des Urgences (SAU) can provide a high level of care because they can rely on the following 24 h specialties: intensive care, internal medicine, cardiology, anesthesia/intensive care, and visceral-, gynecological-, and orthopedic surgery. These SAU departments are situated in the Hôpital de reference (level I trauma center) or Hôpital de recours (level II trauma center), and the centers are found in university hospitals (32 in France) or bigger general hospitals throughout France. (2) The Pôle Spécialisé d’Accueil des Urgences can provide the same high level of care as the SAU departments but are specialized in a certain area of health care, for instance, pediatrics. (3) The Unité de Proximité d’Accueil, d’Orientation et de Traitement des Urgences are found in smaller district hospitals, the Hôpital de proximité (level III trauma centers) where at least one physician (24 h/day), a state-registered nurse, and technical facilities enabling standard imaging and laboratory tests are available. The facilities have limited resources but can stabilize critically ill patients before transferring them to facilities with higher levels of care. The role of the level IV and level V trauma centers is overtaken by the physician-based Service d’Aide Médicale Urgente (SAMU) Organizations.

There are no specialized hospitals in France for trauma care but the designated trauma centers each other at the regional level throughout France.

Prevention of trauma is the first, and possibly most important, component of trauma care systems. This part of the trauma care system can intervene in the first peak of the trimodal death distribution of trauma, in which one third to one half of all traumatic deaths occur. Although the implementation of trauma care centers can make a big difference in death and disability rates from trauma injuries, trauma prevention has more opportunities for decreasing the impact of trauma on both the personnel and community level [8]. Because the trauma care systems we discuss in this chapter are systems in developed Western countries, the main issues of prevention have already been dealt with. In both Europe and North America, traffic safety is improved by safety measures such as traffic rules, road signs, safer cars, seatbelts, and motor helmets. Such prevention prevents injuries from blunt trauma, which is the main cause of death and disability in European countries.

In North America, and particularly in the United States, penetrating injuries continue to be the greatest cause of death and disability resulting from trauma. Prevention of penetrating injuries is a difficult issue to address in the American community, where the ­possession of weapons is still common. Even after ­several tragedies over the past 20 years (e.g., the mass­acres at Waco, Columbine, and Virginia Tech), it is still not really a point of discussion.

In conclusion, prevention of blunt trauma continues to evolve even though it is highly developed in all the countries discussed here. On the other hand, prevention of penetrating injuries is a difficult issue, particularly in the United States, where it is common.

The pre-hospital care plays a very important role in the second peak of the trimodal death distribution in trauma. It is being repeatedly proved that reduced pre-hospital time results in favorable outcomes for severely injured patients.

In some remote areas of countries with extended rural regions such as Australia, Canada, and the USA, there is no professional acute care system present. In some of these areas, there are groups of motivated people, sometimes organized in special occupational groups, who are trained to provide first aid in a basic or even advanced form. In some areas, some of these groups can even transport seriously injured patients to an acute care facility in special vehicles; it is the only possible alternative to a professional pre-hospital care system in such areas.