Activation Levels: Who Gets Paged and Why

When trauma rolls through the ED doors, you want a response system that's as smooth as a jazz ensemble—but with more scrubs and fewer saxophones. Trauma activation levels exist to make sure the right people show up at the right time, with the right resources, without turning every sprained ankle into an all‑staff flash mob.

But here’s the twist most people don’t realize: not all trauma centers use the same activation levels, and not all even have a “Level III” activation tier.

Let’s break it down.

Why Trauma Activation Levels Exist

Trauma activation tiers are designed to guide resource mobilization so hospitals can respond proportionally to patient severity—avoiding the chaos of under‑activation and the inefficiency of over‑activation. Trauma programs and state systems create these tiered structures to ensure timely, organized, and appropriate care (Washington State Department of Health, 2024).

However, there is no national standard for how many activation levels a trauma center must have. Trauma centers develop tiered response systems based on their resources, staffing, and state regulatory framework (American Trauma Society, n.d.).

This is why some hospitals have two tiers, some have three, some have four—and some use custom naming conventions altogether.

Clarifying a Common Misconception: Do All Trauma Centers Have Level III TTAs?

Absolutely not.

Trauma center designation (Levels I–V) is determined at a state/regional level and does not dictate how many trauma team activation tiers a hospital must use. Activation tiers—like “Level 1,” “Level 2,” and “Level 3”—are developed internally and vary widely.

• States and hospitals may use different terminology and different numbers of activation levels.
  (Michigan Department of Health & Human Services, n.d.).

• Even Level III trauma centers (hospital designation) are not required to have a “Level III activation” as part of their paging structure.
  (Minnesota Department of Health, 2023).

• Trauma activation tiers are built around institution‑specific resources, not designation level.
  (American Trauma Society, n.d.).

So, a trauma center might be:

• A Level II facility using a two‑tier activation model, or

• A Level III facility using a three‑tier model, or

• A Level I facility using four tiers

The trauma designation does not equal the number of activation levels.

Level 1 Activation: “All Hands on Deck”

This is the highest level of response, reserved for the most critical patients—those at war with their own physiology.

Why It’s Triggered

Common criteria include:

• SBP < 90 mmHg

• GCS < 9

• Significant penetrating trauma

• Severe uncontrolled bleeding

• Emergent or threatened airway
  (Michigan Department of Health & Human Services, n.d.; UAMS Department of Surgery, 2018).

Who Gets Paged

A fully mobilized team:

• Trauma attending

• Senior and junior surgical residents

• EM attending and residents

• Respiratory therapy

• ED nursing

• Radiology

• Blood bank support
  (McGovern Medical School, 2025).

Think of Level 1 as the trauma world's equivalent of the Bat‑Signal.

Level 2 Activation: “This Could Get Interesting”

These patients are stable for now, but concerning enough to require rapid evaluation.

Why It’s Triggered

Triggers often include:

• High‑risk mechanisms (falls, MVCs, pedestrian strikes)

• Moderate anatomic injuries

• Special populations (elderly, anticoagulated, pregnant)
  (Michigan Department of Health & Human Services, n.d.; Young, 2020).

Who Gets Paged

A more streamlined team than Level 1:

• Trauma surgeon or resident

• ED team

• Selected specialty responders
  (McGovern Medical School, 2025).

Level 2 is the “we’re not panicking, but let’s not get comfortable” tier.

Level 3 Activation: “Let’s Keep an Eye on This One”

Level 3 activations support patients with possible injuries but reassuring vitals and presentation.

Why It’s Triggered

• Mechanism concerning enough for evaluation

• Stable vital signs

• No overt life‑threatening involvement
  (UAMS Department of Surgery, 2018).

Who Gets Paged

A lower‑intensity response:

• ED attending

• ED charge nurse

• Possible trauma consult
  (Washington State Department of Health, 2024).

Level 3 is the “just in case—because trauma is sneaky” tier.

Big Picture: Activation Levels Are Not One‑Size‑Fits‑All

Trauma activation structures vary because:

• State systems differ

• Resource availability differs

• Trauma designation does not dictate number of activation tiers
  (American Trauma Society, n.d.; Michigan DHHS, n.d.).

• Performance improvement (PI) drives ongoing customization
  (Young, 2020).

The goal is always the same:
mobilize the right people at the right time to provide the right care.

Everything else is tailored—because no two trauma centers look exactly alike.

References

American Trauma Society. (n.d.). Trauma center levels explained. https://www.amtrauma.org/page/traumalevels

McGovern Medical School. (2025). Trauma team activation policy. https://med.uth.edu/surgery/trauma-team-activation-policy/

Michigan Department of Health & Human Services. (n.d.). Highest-level activation FAQ. https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Trauma/Trauma-FAQ/Levels_of_Activation_FAQ10118_634669_7.pdf?rev=923272c604204e90930c4b9571d5ec4e&hash=C2EB5363A54F623510D6E6A72138669D

Minnesota Department of Health. (2023). Level 3 trauma hospital designation criteria. https://www.health.state.mn.us/facilities/traumasystem/documents/criteria_level3.pdf

UAMS Department of Surgery. (2018). Trauma team activation and evaluation criteria. https://medicine.uams.edu/surgery/wp-content/uploads/sites/5/2016/12/Trauma-Team-Activation-Criteria.pdf

Washington State Department of Health. (2024). Trauma team activation guideline. https://doh.wa.gov/sites/default/files/legacy/Documents/Pubs/689164.pdf

Young, K. (2020). Tailoring trauma team activation levels and criteria.https://www.kdhe.ks.gov/DocumentCenter/View/11842/Tailoring-Trauma-Team-Activation-TTA-Levels-and-Criteria-by-Kenna-Young-LMH-2020-PDF