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The Optimal Resources Document (ORD) mandates trauma activation based on injury mechanism, physiologic and anatomic criteria and recommends using the over/undertriage matrix (Matrix) to evaluate the appropriateness of trauma team activation. The purpose of this study was to assess the effectiveness of the Matrix method by comparing patients appropriately triaged with those undertriaged. We hypothesized that these two groups are different and Matrix does not discriminate the needs or outcomes of these different groups of patients.Trauma registry data, from 1/2013-12/2015, at a Level I trauma center were reviewed. Over and undertriage rates were calculated by Matrix. Patients with ISS ≥16 were classified by activation level (full, limited, consultation), and triage category by Matrix. Patients in the limited activation and consultation groups were compared to patients with full activation by demographics, injuries, initial vital signs, procedures, delays to procedure, ICU admission, length of stay, and mortality.7031 patients met activation criteria. Compliance with ACS tiered activation criteria was 99%. The Matrix overtriage rate was 45% and undertriage was 24%. Of 2282 patients with an ISS ≥16, 1026 were appropriately triaged (full activation), and 1256 were under triaged. Undertriaged patients had better GCS, blood pressure, and BD than patients with full activation. ICU admission, hospital stays, and mortality were lower in the undertriaged group. The under triaged group required fewer operative interventions with fewer delays to procedure.Despite having an ISS ≥ 16, patients with limited activations were dissimilar to patients with full activation. Level of activation and triage are not equivalent. The ACS-COT full and tiered activation criteria are a robust means to have the appropriate personnel present based on available pre-hospital information. Evaluation of the process of care, regardless of level of activation should be used to evaluate trauma center performance.Level III Therapeutic and Care managementThis is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.