Original Notice.

     Preproposal statement of inquiry was filed as WSR 02-23-069.

     Title of Rule: WAC 246-976-485 through 246-976-890, designation standards for trauma care services.

     Purpose: The Department of Health designates trauma care services as part of the comprehensive, statewide emergency medical services and trauma system. These sections describe the designation process and identify the standards for trauma services.

     Statutory Authority for Adoption: RCW 70.168.060 and 70.168.070.

     Statute Being Implemented: RCW 70.168.060 and 70.168.070.

     Summary: Changes have been made to the format of the current structure to create an organization that allows for ease of reading and comparability between levels, out-of-date standards have been modernized, current practice patterns have been standardized, and in many cases the intent of the current rule language has been clarified to avoid erroneous interpretation and implementation.

     Reasons Supporting Proposal: The proposed rule will improve clarity which will increase the usability of the rule.

     Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Kathy Schmitt, 310 Israel Road S.E., Building 5, Tumwater, WA, (360) 236-2869.

     Name of Proponent: Department of Health, governmental.

     Rule is not necessitated by federal law, federal or state court decision.

     Explanation of Rule, its Purpose, and Anticipated Effects: RCW 70.168.060 states that the Department of Health shall establish minimum standards for facility, equipment, and personnel for Levels I, II, III, IV, and V trauma care services. These rules establish the process and standards for the designation of trauma care services. The proposed rule change brings the designation standards up to date. They will provide clear rule writing, clarify intent of current rule language, allow for readability and comparability of levels, and modernized out-of-date standards to provide the most current practice patterns.

     Proposal Changes the Following Existing Rules: Changes have been made to the format of the current structure to create an organization that allows for readability and comparability between levels, out-of-date standards have been modernized, current practice patterns have been standardized, and in many cases the intent of the current rule language has been clarified to avoid erroneous interpretation and implementation.

     1. WAC 246-976-485: Addition of consideration requirements for joint designation, and delineate the department's on-site review response time.

     2. Repealing WAC 246-976-500 through 296-976-520, 296-976-550 through 246-976-615, and 246-976-640 through 246-976-690, and consolidating the current acute care facility standards into three tables, creating three new WACs; WAC 246-976-530 Administration and organization, 246-976-535 Basic resources and capabilities, and 246-976-540 Outreach, public education, provider education and research. Within the new WACs the following proposed changes have been made to current standards:

     a. Amendments have been made to the current standards to require written scope of trauma care.

     b. Strengthens the requirement for trauma service directors for Levels III facilities and adds language that now requires Levels IV-V facilities to have a trauma service director.

     c. Clarifies the intent of the use of the word "Co-director."

     d. Trauma service coordinators are now required for Level V facilities.

     e. For Levels I - V facilities, clarifies the intent that only one person should be identified as responsible for coordination of the trauma registry activities.

     f. Clarifies that an appropriately trained physician assistant or advanced registered nurse may initiate evaluation and treatment until arrival of the attending physician.

     g. A designated resuscitation area is now required in Level V facilities.

     h. Loosens the response requirements for radiologist for Levels I - III facilities.

     i. Adds necessary clinical laboratory services to Level IV services.

     j. Loosens the response time requirements for neurosurgeons for Level II services.

     k. Strengthens the standards for treatment of head and spinal cord injuries at Level II facilities.

     l. Modifies the list of surgery services for Levels I - III services by reducing the response time standards for those specialty surgical services that do not provide time critical intervention.

     m. Loosens the response requirements for anesthesiologist at Levels I - IV facilities.

     n. Raises the standards for postanesthetic recovery services at Levels III and IV facilities.

     o. Adds additional consultation and management services to Levels I - III facilities.

     p. Reduces the standards for ancillary services at Levels I - III facilities, and raises the ancillary services standards for Level IV facilities.

     q. Eliminates the requirement for a trauma rehabilitation coordinator at Level IV facilities.

     r. Adds an alternative option for public education/injury prevention for Levels I - III services.

     s. Level IV facilities are now required to make themselves available for prehospital training.

     3. WAC 246-976-620: The structure has been reformatted into a table, and equipment requirements for Levels IV and V services have been moved from WAC 246-976-650 and 246-976-690 and added to the table. Requirements have been both added and eliminated for all levels (Levels I - V acute care, and Levels I - III pediatric). In addition, language has been added to clarify when it is not practical for Level V clinics to comply and therefore making them exempt.

     4. Repealing WAC 246-976-720 through 246-976-740, and 246-976-770 through 246-976-822, and consolidating the current pediatric trauma care facility standards into three tables, creating three new WACs; WAC 246-976-750 Administration and organization, 246-976-755 Basic resources and capabilities, and 246-976-760 Outreach, public education, provider education and research. Within the new WACs the following proposed changes have been made to current standards:

     a. Amendments have been made to the current standards to require written scope of trauma care.

     b. Strengthens the requirements for trauma service directors for Levels III pediatric facilities.

     c. Clarifies the intent of the use of the word "Co-director."

     d. Levels I - III pediatric services are now required to include a board-certified pediatric physician as part of the full trauma team.

     e. For Levels I - III Pediatric facilities, clarifies the intent that only one person should be identified as responsible for coordination of the trauma registry activities.

     f. Reduces the response time requirements for radiological services for Levels I - III pediatric facilities.

     g. Loosens the response time requirements for neurosurgeons for Level II pediatric services, and allows for the use of postgraduate year four or above neurosurgery residents at Level I pediatric facilities.

     h. Modifies the list of surgery services for Levels I - III pediatric services by reducing the response time standards for those specialty surgical services that do not provide time critical intervention.

     i. Loosens the response time standards for anesthesiologist at Levels I - III pediatric facilities.

     j. Raises the standards for postanesthetic recovery services at Level III pediatric facilities.

     k. Adds and eliminates some consultation and management services to Levels I - III pediatric facilities.

     l. Adds to the list of ancillary services for Level III pediatric services.

     m. Adds an alternative option for public education/injury prevention for Levels I - III pediatric services.

     5. WAC 246-976-870: Clearly distinguishing between the requirements of a full trauma team and a modified trauma team.

     6. WAC 246-976-881: Linking the quality assessment and improvement program and the multidisciplinary trauma committee.

     7. WAC 246-976-885: Making changes that coincide with changes made in other sections.

     8. WAC 246-976-886: Grammatical change.

     9. WAC 246-976-887: Grammatical change.

     10. WAC 246-976-890: Making changes that coincide with changes made in other sections.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has reviewed and analyzed this proposal and has determined that no small business economic impact statement (SBEIS) is required. The Regulatory Fairness Act, under RCW 19.85.030 requires agencies to conduct an SBEIS if a rule imposes more than minor costs on businesses within an industry. Since this proposal does not impose more than minor costs to businesses, the department has not completed an SBEIS on this proposal.

     RCW 34.05.328 applies to this rule adoption. The proposed rule change creates, changes, and/or eliminates qualifications and/or standards for the issuance, suspension or revocation of trauma service designation.

     Hearing Location: Department of Health, 20435 72nd Avenue South, Suite 200, Conference Room #2, Kent, WA 98032-2358, on October 24, 2003, at 9:00 a.m.

     Assistance for Persons with Disabilities: Tami Schweppe by October 13, 2003, TDD (800) 833-6388 or (360) 236-2859.

     Submit Written Comments to: Tami Schweppe, P.O. Box 47853, Olympia, WA 98504-7853, fax (360) 236-2829, by October 17, 2003.

     Date of Intended Adoption: October 27, 2003.

September 16, 2003

Mary C. Selecky

Secretary

OTS-6568.1

AMENDATORY SECTION(Amending WSR 98-04-038, filed 1/29/98, effective 3/1/98)

WAC 246-976-485   Designation of facilities to provide trauma care services.   (1) The department designates trauma services as part of the comprehensive, statewide emergency medical services and trauma care system. This section and WAC 246-976-490 describe the designation process. WAC ((246-976-500)) 246-976-530 through 246-976-890 identify standards for trauma services. The department uses a competitive process to select designated services, including:

     (a) An application schedule. You will have at least ninety days to complete the application;

     (b) A description of the documents you must submit to demonstrate that you meet the standards;

     (c) An on-site review fee schedule. You must pay any required fees at least thirty days before an on-site review;

     (d) The department's evaluation criteria; and

     (e) The department's decision criteria.

     (2) To apply for trauma service designation, you must:

     (a) Send a notice of intent to the department by the time required in the application schedule;

     (b) Submit a completed application by the time required in the application schedule. If you are applying for multiple designation, you must submit a separate application for each level and category of designation for which you are applying.

     If you represent more than one facility applying for joint designation, you must submit a single application for each level and category. The department's evaluation of joint applications will use the same criteria as for a single facility designation. To be considered for joint designation, your joint trauma service must have:

     (i) A single trauma service director;

     (ii) A single multidisciplinary committee with representation from all participating facilities;

     (iii) A single set of common policies and procedures;

     (iv) A predetermined facility rotation schedule;

     (v) A single, central trauma registry with a common methodology for abstraction and input of trauma data; and

     (vi) A single, joint QI program in keeping with the goals of WAC 246-976-881 including joint peer review and joint systems review.

     (c) Provide the department's on-site review team access to your facility, staff, and all documents concerning trauma care. This will include at least your standards of care, policy and procedures, patient care records, trauma quality assurance/improvement materials, and other relevant documents.

     (3) The department must conduct an on-site review of your facility before you can be designated as level I, II or III trauma care service, or level I, II or III pediatric trauma care service. The department will use a multidisciplinary team to conduct this review.

     (a) For level I and II services, the department will only choose members for the review team who live or work outside your state.

     (b) For level III services, the department will only choose members for the review team who live or work outside your region.

     (c) The department will provide you with the names of members of the review team. You should send any objections to the department within ten days of notification.

     (d) The team will give an oral report of preliminary findings before leaving your facility.

     (e) The department and the team will maintain confidentiality of information, records, and reports developed pursuant to on-site reviews in accordance with the provisions of RCW 70.41.200 and 70.168.070.

     (f) The department will conduct an on-site review within eighteen months of designating a joint service, to confirm that you meet the requirements of this chapter. This requirement shall not be construed to limit the department's right to conduct an on-site review at any earlier or later time, or to limit its authority under WAC 246-976-490 to suspend or revoke designation for cause at any time prior to the on-site review of the jointly designated trauma care service.

     (4) The department may conduct an on-site review of your facility if you applied for designation as a level IV or V trauma care service, as a level I-III trauma rehabilitation service, or as a level I-pediatric trauma rehabilitation service.

     (5) After designation as a trauma service, you may ask the department to conduct an on-site survey for technical assistance. The department may require you to reimburse its costs for conducting the survey.

     (6) The department will designate the health care facilities it considers most qualified to provide trauma care services. The decision to designate will be based on at least the following:

     (a) Evaluation of all applications submitted;

     (b) Recommendations from the on-site review team;

     (c) Trauma patient outcomes during the previous designation period;

     (d) The impact of designation on the effectiveness of the trauma care system;

     (e) Expected patient volume of the area;

     (f) The number, levels, and distribution of designated health care facilities established in the state and regional EMS/TC plans;

     (g) Ability of each applicant to comply with goals of the state and regional EMS/TC plans; and

     (h) Each applicant's compliance with its designation contract during the previous designation period.

     (7) The department will notify you in writing of its designation decision. It will also provide you with a written report summarizing its review of your application, any on-site review findings, and any decisions:

     (a) In regions where there is competition for designation, the department will send you the report within ninety days of announcing its decisions. There is competition for designation in any region where the number of applications for a level and type of designation is more than the maximum number of services identified in the state plan.

     (b) In regions where there is no competition, the department will send you the report within ninety days of the on-site review for levels I - III or within thirty days of announcing its designation decision for levels IV and V.

     (8) The department will notify regional EMS/TC councils of the name, location, and level of services that have been designated in their regions.

     (9) The department will not approve your application if it finds that your facility:

     (a) Is not the most qualified applicant, if there is competition for designation;

     (b) Does not meet the requirements of this chapter for the level you applied for;

     (c) Does not meet the requirements of the approved regional plan;

     (d) Has made a false statement about a material fact in its application for designation; or

     (e) Refuses to allow the department to inspect any part of your facility that relates to the delivery of trauma services, including records, documentation, or files.

     (10) If the department denies an application for trauma service designation, the department will notify you in writing, including the reasons for its action and explaining your rights. You may appeal the department's decisions. Your appeal must follow the requirements of chapter 34.05 RCW and chapter 246-10 WAC. Send your appeal to the adjudicative clerk's office at the address indicated on the notice of decision.

     (11) The department may:

     (a) Consider applications from facilities located and licensed in adjacent states in the same manner as applications received from facilities located and licensed in Washington;

     (b) Consider the administrative findings, conclusions and determination of an adjacent state to determine if you meet Washington standards. The department may request additional information. The department will base its decision on these considerations only if:

     (i) There is no competition in the region for designation at the level/category you applied for; and

     (ii) Your facility is located in an adjacent state that has an established trauma care system, with standards that meet or exceed Washington standards; and your facility is designated by your state to provide trauma service;

     (c) Provisionally designate trauma services that are not able to meet all the requirements of this chapter, if this is necessary to ensure adequate trauma care in an area. The provisional designation will not be for more than two years;

     (d) Consider additional applications without regard to the schedule, if this is needed to ensure adequate coverage according to the state plan.

     (12) You and the department must agree to a contract to provide trauma services. The contract will include at least:

     (a) Your authority to provide trauma services for a three-year period;

     (b) Both the department's and your contractual and financial requirements and responsibilities;

     (c) Allowance for the department to monitor your compliance with trauma service standards;

     (d) Allowance for the department access to discharge summaries for trauma patients, patient care logs, trauma patient care records, hospital trauma care quality assurance/improvement materials, including minutes, and other relevant documents;

     (e) A requirement for confidentiality of information relating to individual patient's, provider's, and facility's care outcomes.

     (13) The department will notify all interested parties of the application process and schedule at least one hundred fifty days before the expiration of designation in each region.

[Statutory Authority: Chapter 70.168 RCW. 98-04-038, § 246-976-485, filed 1/29/98, effective 3/1/98.]

	LEVELS
A facility with a designated trauma service must have:	I	II	III	IV	V
(1) A written scope of trauma service for both adult and pediatric trauma patients consistent with chapter 246-976 WAC, community needs and the approved regional plan. The written scope of trauma service must delineate the resources and capabilities available for trauma patient care twenty-four hours every day;	X	X	X	X	X
(2) A trauma service director responsible for organization and direction of the trauma service. The director must be:	X	X	X	X	X
(a) A general surgeon with special competence in care of the injured. The director may delegate duties to another surgeon (or for level II & III another physician with special competence in care of the injured), but the director must maintain responsibility for the trauma service;	X	X	X
(b) A general surgeon, or a physician with special competence in the care of the injured;				X
(c) A physician, physician assistant, or advanced registered nurse practitioner;					X
(3) A trauma service coordinator responsible for ongoing coordination of the trauma service. The coordinator must be a registered nurse with special competence in the care of the injured (for level V clinics the coordinator is not required to be a registered nurse);	X	X	X	X	X
(4) A multidisciplinary trauma committee chaired by the trauma service director with membership that reflects your written scope of trauma service. The multidisciplinary committee must have responsibility and authority for establishing and changing trauma care policy and procedure and for conducting the trauma service quality improvement program in accordance with WAC 246-976-881;	X	X	X	X	X
(5) A full trauma team to provide initial evaluation, resuscitation and treatment. The full trauma team must include:	X	X	X	X
(a) A general surgeon with special competence in care of the injured, who organizes and directs the team and assumes responsibility for coordination of overall care of the trauma patient. (For levels I and II - the surgeon must be at least a postgraduate year four resident);	X	X	X
(b) A general surgeon if general surgery services are included in your written scope of trauma service or a physician who has specific delineation of surgical privileges by the medical staff for resuscitation, stabilization and treatment of trauma patients. The surgeon or physician with surgical privileges organizes and directs the team and assumes responsibility for coordination of overall care of the trauma patient;				X
(c) An emergency physician who is responsible for providing team leadership and care for the trauma patient until the arrival of the general surgeon in the resuscitation area;	X	X	X
(d) An emergency physician or a physician with special competence in resuscitation, care and treatment of trauma patients who is responsible for providing team leadership and care for the trauma patient until the arrival of the general surgeon or physician with surgical privileges;				X
(e) The trauma service must identify all other members of the team to reflect your written scope of trauma service;	X	X	X	X
(6) A trauma team to provide initial evaluation, resuscitation and treatment. The team must include:					X
(a) A physician, physician assistant, or advanced registered nurse practitioner;					X
(b) The trauma service must identify all other members of the team to reflect your written scope of trauma service;					X
(7) A method and criteria for activating the trauma team consistent with WAC 246-976-870 and your written scope of trauma service;	X	X	X	X	X
(8) A written policy and procedures to divert patients to other designated trauma care services when the facility's resources are temporarily unavailable for trauma patient care. The policy must include:	X	X	X	X
(a) The facility and/or patient criteria used to decide when to divert a trauma patient;	X	X	X	X
(b) A process to coordinate trauma patient diversions with other area trauma services and prehospital agencies;	X	X	X	X
(c) A method for documenting trauma patient diversions, including: Date, time, duration, reason, and decision maker;	X	X	X	X
(9) Interfacility transfer guidelines and agreements consistent with your written scope of trauma service and consistent with WAC 246-976-890;	X	X	X	X	X
(10) A heli-stop, landing zone or airport located close enough to permit the facility to receive or transfer patients by fixed-wing or rotary-wing aircraft;	X	X	X
(11) A plan addressing receipt and transfer of patient by fixed-wing and rotary-wing aircraft;				X	X
(12) Participation in the state trauma registry as required in WAC 246-976-430, with a person identified as responsible for coordination of trauma registry activities;	X	X	X	X	X
(13) A quality assurance program conducted by the multidisciplinary committee and consistent with WAC 246-976-881;	X	X	X	X	X
(14) Participation in the regional quality assurance program in accordance with WAC 246-976-910.	X	X	X	X	X

[]

	LEVELS
A facility with a designated trauma service must have:	I	II	III	IV	V
(1) An emergency department, including:	X	X	X	X
(a) An area designated for adult and pediatric resuscitation;	X	X	X	X
(b) Written standards of care to ensure immediate and appropriate care for adult and pediatric trauma patients;	X	X	X	X
(c) A physician director who:	X	X	X
(i) Is board-certified in emergency medicine, surgery or other relevant specialty (or for level I, has documented experience as director of an emergency department which has been previously recognized as a level I trauma center either by a regional entity or as verified by the Committee on Trauma of the American College of Surgeons);	X	X	X
(ii) Is ATLS and ACLS trained, except this requirement does not apply to a physician board-certified in emergency medicine or surgery;	X	X	X
(iii) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-886, except that this requirement does not apply to a physician board-certified in pediatric emergency medicine;	X	X	X
(d) Physicians who:	X	X	X	X
(i) Are board-certified in emergency medicine, or board-certified in a specialty and practicing emergency medicine as their primary practice with special competence in care of trauma patients; (level I only - this requirement may be met by a surgical resident postgraduate year two who is ATLS and ACLS trained, has completed the PER as defined in WAC 246-976-886, and is working under the direct supervision of the attending emergency physician, until the arrival of the surgeon to assume leadership of the trauma team);	X	X
(ii) Have special competence in resuscitation, care and treatment of trauma patients;	X	X	X	X
(iii) Are available within five minutes of patient's arrival in the emergency department;	X	X	X
(iv) Are on-call and available within twenty minutes of notification of patient arrival. A physician assistant or advanced registered nurse practitioner who is ACLS and ATLS trained and has completed the PER requirement, may initiate evaluation and treatment upon the patient's arrival in the emergency department until the arrival of the attending physician;				X
(v) Are ATLS and ACLS trained, except this requirement does not apply to a physician board-certified in emergency medicine;	X	X	X	X
(vi) Have completed the PER as defined in WAC 246-976-886, except this requirement does not apply to a physician board-certified in pediatric emergency medicine (or emergency medicine for level IV);	X	X	X	X
(e) Registered nurses who:	X	X	X	X
(i) Are in the emergency department and available within five minutes of patient's arrival;	X	X	X
(ii) Are in-house and available within five minutes of notification of patient arrival;				X
(iii) Are ACLS trained;	X	X	X	X
(iv) Have completed the PER as defined in WAC 246-976-886;	X	X	X	X
(v) Have successfully completed a trauma life support course as defined in WAC 246-976-885;	X	X	X	X
(2) Emergency care services available twenty-four hours every day with:					X
(a) An area designated for adult or pediatric resuscitation;					X
(b) Written standards of care to ensure immediate and appropriate care of adult and pediatric trauma patients;					X
(c) A physician, physician assistant, or advanced registered nurse practitioner, on-call and available within twenty minutes of notification of team activation, who has ATLS training, except the ATLS requirement does not apply to a physician board-certified in emergency medicine or board-certified in surgery;					X
(3) Equipment for resuscitation and life support of pediatric and adult trauma patients, including equipment described in WAC 246-976-620;	X	X	X	X	X
(4) Radiological services, with:	X	X	X	X
(a) A radiologist on-call and available within twenty minutes of team leader's request;	X	X
(b) A radiologist on-call and available within thirty minutes of team leader's request;			X
(c) A technician able to perform routine radiological capabilities:	X	X	X	X
(i) Available within five minutes of notification of team activation;	X	X
(ii) On-call and available within twenty minutes of notification of team activation;			X	X
(d) A technician able to perform computerized tomography:	X	X	X
(i) Available within five minutes of team leader's request;	X
(ii) On-call and available within twenty minutes of team leader's request;		X	X
(e) A technician on-call and available within twenty minutes of team leader's request, able to perform the following:	X	X
(i) Angiography of all types;	X	X
(ii) Sonography;	X	X
(5) Respiratory therapy available within five minutes of notification of team activation;	X	X
(6) Respiratory therapy on-call and available within thirty minutes of notification of team activation;			X
(7) Clinical laboratory services, including:	X	X	X	X
(a) A clinical laboratory technologist available within five minutes of notification of team activation;	X	X	X
(b) A clinical laboratory technologist on-call and available within twenty minutes of notification of team activation;				X
(c) Standard analysis of blood, urine, and other body fluids;	X	X	X	X
(d) Coagulation studies;	X	X	X	X
(e) Blood gases and pH determination;	X	X	X	X
(f) Serum and urine osmolality;	X	X
(g) Microbiology;	X	X	X
(h) Serum alcohol determination;	X	X	X	X
(i) Drug or toxicology screening;	X	X	X	X
(8) Blood and blood-component services, including:	X	X	X	X
(a) Blood and blood components available from in-house or through community services, to meet patient needs;	X	X	X	X
(b) Noncrossmatched blood available on patient arrival in the emergency department;	X	X	X	X
(c) Ability to obtain blood typing and crossmatching;	X	X	X	X
(d) Policies and procedures for massive transfusion;	X	X	X	X
(e) Autotransfusion;	X	X	X
(f) Blood storage capability;	X	X	X	X
(9) A surgery department, including:	X	X	X	X
(a) General surgery services, with:	X	X	X
(i) An attending, board-certified general surgeon available within five minutes of notification of team activation. A postgraduate year four or above surgical resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until the arrival of the attending surgeon. In this case the attending surgeon must be available within twenty minutes of notification of team activation;	X
(ii) An attending, board-certified general surgeon on-call and available within twenty minutes of notification of team activation. A postgraduate year four or above surgical resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until the arrival of the attending surgeon. The attending surgeon must be available within twenty minutes upon notification of team activation;		X
(iii) An attending general surgeon, on-call and available within thirty minutes of notification of team activation;			X
(iv) All general surgeons (and surgical residents for level I and II) who are responsible for care and treatment of trauma patients must:	X	X	X
(A) Be trained in ATLS and ACLS, except this requirement does not apply to a physician board-certified in surgery; and	X	X	X
(B) Have completed the PER as defined in WAC 246-976-886; and	X	X	X
(C) Have specific delineation of trauma surgery privileges by the medical staff;	X	X	X
(b) Surgery services with a general surgeon or physician with specific delineation of surgical privileges by the medical staff for resuscitation, stabilization and treatment of trauma patients. The physician must be:				X
(i) On-call and available within thirty minutes of notification of team activation;				X
(ii) ATLS and ACLS trained, except this requirement does not apply to a physician board-certified in surgery;				X
(c) Neurosurgical services with:	X	X
(i) A neurosurgeon:	X	X
(A) Available within five minutes of team leader's request. A postgraduate year four or above neurosurgery resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until the arrival of the attending neurosurgeon. In this case the neurosurgeon must arrive within thirty minutes of team leader's request;	X
(B) On-call and available within thirty minutes of team leader's request;		X
(ii) Ability to provide acute and ongoing care for acute head and spinal cord injuries;	X	X
(d) Ability to resuscitate and stabilize acute head and/or spinal cord injuries;			X	X
(e) A neurosurgeon on-call and available within thirty minutes of team leader's request orwritten transfer guidelines and agreements for head and spinal cord injuries;			X	X
(f) The following surgical services on-call and available within thirty minutes as requested by the trauma team leader:	X	X	X
(i) Cardiac surgery;	X
(ii) Microsurgery;	X
(iii) Obstetric surgery (or, for level III, a plan to manage the pregnant trauma patient);	X	X	X
(iv) Orthopedic surgery;	X	X
(v) Thoracic surgery;	X	X
(vi) Urologic surgery;	X	X
(vii) Vascular surgery.	X	X
(g) The following surgical services on-call for patient consultation or management:	X	X	X
(i) Gynecologic surgery;	X	X
(ii) Ophthalmic surgery;	X	X
(iii) Oral/maxillofacial or otorhinolaryngologic surgery;	X	X
(iv) Plastic surgery;	X	X
(v) Orthopedic surgery;			X
(10) Anesthesiology, with an anesthesiologist (or certified registered nurse anesthetist for level III and IV) who:	X	X	X	X
(a) Is available within five minutes of team leader's request;	X
(b) Is on-call and available within twenty minutes of team leader's request;		X
(c) Is on-call and available within thirty minutes of team leader's request;			X	X
(d) Is ACLS trained, except this requirement does not apply to a physician board-certified in anesthesiology;	X	X	X	X
(e) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-886;	X	X	X
(11) An operating room and a registered nurse or designee responsible for opening and preparing the operating room, available within five minutes of notification of team activation, with:	X	X	X	X
(a) Other essential personnel as identified by the trauma service on-call and available within twenty minutes of notification of team activation;	X	X
(b) Other essential personnel as identified by the trauma service on-call and available within thirty minutes of notification of team activation;			X	X
(c) A written policy providing for mobilization of additional surgical teams for trauma patients; and	X	X	X
(d) Instruments and equipment appropriate for pediatric and adult surgery, including equipment described in WAC 246-976-620.	X	X	X	X
(12) A postanesthetic recovery service with:	X	X	X	X
(a) At least one registered nurse available twenty-four hours a day;	X
(b) At least one registered nurse on-call and available twenty-four hours a day;		X	X	X
(c) Nurses ACLS trained;	X	X	X	X
(d) Nurses who have completed the PER as defined in WAC 246-976-886; and	X	X	X
(13) A critical care service with:	X	X	X
(a) A medical director who is:
(i) Board-certified in surgery with special competence in critical care;	X
(ii) Board-certified in surgery, internal medicine, or anesthesiology, with special competence in critical care;		X	X
(iii) Responsible for coordinating with the attending staff for the care of trauma patients;	X	X	X
(b) A physician directed code team;	X	X	X
(c) Critical care registered nurses with special competence in trauma care, who:	X	X	X
(i) Are ACLS trained; and	X	X	X
(ii) Have successfully completed a trauma life support course as defined in WAC 246-976-885;	X	X	X
(d) Designation as a pediatric trauma service or written transfer guidelines and agreements for pediatric trauma patients requiring critical care services;	X	X	X
(e) Equipment as described in WAC 246-976-620;	X	X	X
(14) A critical care service which meets requirements for a level III trauma service, if critical care services are included in your written scope of trauma service, or written transfer guidelines and agreements for trauma patients requiring critical care services;				X
(15) Acute dialysis capability, or written transfer agreements for dialysis services;	X	X	X	X
(16) The following services on-call and available for patient consultation or management during the in-patient stay:	X	X	X
(a) Cardiology;	X	X
(b) Gastroenterology;	X	X
(c) Hematology;	X	X
(d) Infectious disease specialists;	X	X
(e) Internal medicine;	X	X	X
(f) Nephrology;	X	X
(g) Neurology;	X	X
(h) Pathology;	X	X	X
(i) Pediatrics;	X	X
(j) Pulmonology;	X	X
(k) Psychiatry or care plan for trauma patients requiring psychiatric management;	X	X
(17) Written policy and procedures for access to ancillary services for in-patient care, including:	X	X	X	X
(a) Chemical dependency services;	X	X	X
(b) Child and adult protection services;	X	X	X	X
(c) Clergy or pastoral care;	X	X	X	X
(d) Nutritionist services;	X	X	X	X
(e) Pharmacy services, with pharmacist in-house;	X
(f) Pharmacy services;		X	X	X
(g) Occupational therapy services;	X	X	X
(h) Physical therapy services;	X	X	X	X
(i) Speech therapy services;	X	X	X
(j) Social services;	X	X	X	X
(k) Psychological services;	X	X	X
(18) Ability to resuscitate and stabilize burn patients;	X	X	X	X	X
(19) A physician directed burn unit staffed by nursing personnel trained in burn care and equipped to care for extensively burned patients; orwritten transfer guidelines and agreements in accordance with the guidelines of the American Burn Association;	X	X	X	X	X
(20) A trauma rehabilitation coordinator to facilitate the trauma patient's access to rehabilitation services;	X	X	X
(21) A designated trauma rehabilitation service; or written agreements to transfer patients to a designated trauma rehabilitation service when medically feasible.	X	X	X

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	LEVELS
A facility with a designated trauma service must have:	I	II	III	IV	V
(1) An outreach program with telephone and on-site consultations with physicians of the community and outlying areas regarding trauma care;	X	X
(2) A public education program addressing injury prevention or documentation of participation in regional injury prevention activities;	X	X	X
(3) Training, including:	X
(a) A formal program of continuing trauma care education for:	X	X
(i) Staff physicians;	X	X
(ii) Nurses;	X	X
(iii) Allied health care professionals;	X	X
(iv) Community physicians;	X	X
(v) Prehospital personnel;	X	X
(b) Residency programs accredited by the accreditation council of graduate medical education, with a commitment to training physicians in trauma management;	X
(c) Make the facility available for initial and maintenance training of invasive manipulative skills for prehospital personnel;	X	X	X	X
(4) A trauma research program.	X

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     (viii) Provision for life support with emergency cardiopulmonary arrest cart.))

	LEVELS
A facility with a designated trauma service must:	I	IP	II	IIP	III	IIIP	IV	V
(1) Have the following equipment, both adult and pediatric sizes in the emergency department (or resuscitation area for level V):
(a) Airway control and ventilation equipment, including:
(i) Airways;	X	X	X	X	X	X	X	X
(ii) Laryngoscopes, including curved and straight blades;	X	X	X	X	X	X	X	X
(iii) Endotracheal tubes, with stylets available;	X	X	X	X	X	X	X	X
(iv) Bag-valve-mask resuscitator;	X	X	X	X	X	X	X	X
(v) Pulse oximeter;	X	X	X	X	X	X	X	X
(vi) CO2 measurement;	X	X	X	X	X	X	X	X
(vii) Sources of oxygen;	X	X	X	X	X	X	X	X
(viii) Ability to provide mechanical ventilation;	X	X	X	X	X	X
(b) Suction devices, including:	X	X	X	X	X	X
(i) Back-up suction source;	X	X	X	X	X	X	X	X
(ii) Suction catheters;	X	X	X	X	X	X	X	X
(iii) Tonsil tip suction (except level V clinics);	X	X	X	X	X	X	X	X
(c) Cardiac devices, including:
(i) Cardiac monitor;	X	X	X	X	X	X	X	X
(ii) Defibrillator;	X	X	X	X	X	X	X	X
(iii) Electrocardiograph;	X	X	X	X	X	X	X	X
(iv) Portable cardiac monitor;	X	X	X	X	X	X	X	X
(v) Blood pressure cuffs;	X	X	X	X	X	X	X	X
(vi) Doppler device;	X	X	X	X	X	X	X
(d) Intravenous supplies, including:
(i) Standard intravenous fluids and administering devices, including:	X	X	X	X	X	X	X	X
(A) IV access devices;	X	X	X	X	X	X	X	X
(B) Intraosseous needles;	X	X	X	X	X	X	X	X
(C) Infusion control device;	X	X	X	X	X	X	X	X
(ii) Drugs and supplies necessary for adult and pediatric emergency care;	X	X	X	X	X	X	X	X
(e) Sterile surgical sets for standard emergency department procedures, including:
(i) Thoracotomy set;	X	X	X	X	X	X	X
(ii) Chest tubes with closed drainage devices (except level V clinics);	X	X	X	X	X	X	X	X
(iii) Emergency transcutaneous airway set (except level V clinics);	X	X	X	X	X	X	X	X
(iv) Peritoneal lavage set;	X	X	X	X	X	X
(f) Nasogastric tubes (except level V clinics);	X	X	X	X	X	X	X	X
(g) Ability to provide thermal control equipment, including:
(i) Patient warming capability (except level V clinics);	X	X	X	X	X	X	X	X
(ii) Blood and fluid warming capability (except level V clinics);	X	X	X	X	X	X	X	X
(iii) Expanded scale thermometer capable of detecting hypothermia (except level V clinics);	X	X	X	X	X	X	X	X
(h) Immobilization devices, including:
(i) Cervical injury immobilization devices;	X	X	X	X	X	X	X	X
(ii) Long-bone immobilization devices, including traction splints; and	X	X	X	X	X	X	X	X
(iii) Backboard;	X	X	X	X	X	X	X	X
(i) Other equipment:
(i) Urinary bladder catheters (except level V clinics);	X	X	X	X	X	X	X	X
(ii) Infant scale for accurate weight measurement under twenty-five pounds;	X	X	X	X	X	X	X	X
(iii) Medication chart, tape, or other system to assure ready access to information on proper doses-per-kilogram for resuscitation drugs and equipment sizes for pediatric patients;	X	X	X	X	X	X	X	X
(iv) Two-way radio linked with EMS/TC vehicles;	X	X	X	X	X	X	X	X
(2) Have the following equipment, both adult and pediatric sizes, in the surgery department:
(a) Cardiopulmonary bypass;	X	X
(b) Ability to provide thermal control equipment for:
(i) Patient warming and cooling;	X	X	X	X	X	X	X
(ii) Blood and fluid warming;	X	X	X	X	X	X	X
(c) Rapid infusion capability;	X	X	X	X	X	X	X
(d) Autologous blood recovery and transfusion;	X	X	X	X	X	X
(e) Ability to provide bronchoscopic capability in the operating room;	X	X	X	X	X	X
(f) Ability to provide endoscopes;	X	X	X	X	X	X	X
(g) Craniotomy set;	X	X	X	X
(3) Have the following equipment, both adult and pediatric sizes, in the critical care unit:
NOTE for level III pediatric: If your written scope of trauma service includes critical care services, then your service must meet the level II pediatric critical care equipment standards.
NOTE for level IV: If your written scope of trauma service includes critical care services, then your service must meet the level III critical care equipment standards;
(a) Airway control and ventilation devices, including:
(i) Oral and nasopharyngeal airways;	X	X	X	X	X
(ii) Laryngoscopes with curved and straight blades;	X	X	X	X	X
(iii) Endotracheal tubes with stylets available;	X	X	X	X	X
(iv) Bag-valve-mask resuscitators;	X	X	X	X	X
(v) Ability to provide mechanical ventilator;	X	X	X	X	X
(vi) Noninvasive oximetry and capnometry;	X	X	X	X	X
(vii) Oxygen source with concentration controls;	X	X	X	X	X
(b) Suction devices, including:
(i) Suction machine;	X	X	X	X	X
(ii) Suction catheters;	X	X	X	X	X
(iii) Tonsil tip suction;	X	X	X	X	X
(c) Cardiac devices, including:
(i) Cardiac pacing capabilities;	X	X	X	X	X
(ii) Electrocardiograph;	X	X	X	X	X
(iii) Cardiac monitor/defibrillator with at least two pressure monitoring modules including cardiac output and hard copy recording and with capability to continuously monitor heart rate, respiration, temperature;	X	X	X	X	X
(iv) Portable transport monitor with ECG and pressure monitoring capability;	X	X	X	X	X
(v) Blood pressure cuffs;	X	X	X	X	X
(vi) Doppler device;	X	X	X	X	X
(vii) Noninvasive blood pressure machine;	X	X	X	X	X
(d) Intravenous supplies, including:
(i) Standard IV fluids and administration devices appropriate for pediatric patients including:	X	X	X	X	X
(A) IV catheters;	X	X	X	X	X
(B) Intraosseous needles;	X	X	X	X	X
(C) Infusion sets and pumps with micro-infusion capabilities;	X	X	X	X	X
(D) Infusion controllers;	X	X	X	X	X
(ii) Adult and pediatric dosages/dilutions of medications;	X	X	X	X	X
(e) Sterile surgical sets, including:	X	X	X	X	X
(i) Thoracotomy set;	X	X	X	X	X
(ii) Chest tubes;	X	X	X	X	X
(iii) Emergency surgical airway sets;	X	X	X	X	X
(iv) Peritoneal lavage set;	X	X	X	X	X
(f) Intracranial pressure monitoring devices;	X	X	X	X
(g) Gastric supplies, including NG tubes;	X	X	X	X	X
(h) Ability to provide thermal control equipment, including:
(i) Patient warming and cooling devices;	X	X	X	X	X
(ii) Blood and fluid warming device;	X	X	X	X	X
(iii) Expanded scale thermometer capable of detecting hypothermia;	X	X	X	X	X
(iv) Device for assuring warmth during transport;	X	X	X	X	X
(i) Other equipment, including:
(i) Ability to provide patient weighing devices;	X	X	X	X	X
(ii) Cardiac emergency cart.	X	X	X	X	X

[Statutory Authority: Chapter 70.168 RCW. 98-04-038, § 246-976-620, filed 1/29/98, effective 3/1/98.]

	LEVELS
A facility with a designated pediatric trauma care service must have:	I	II	III
(1) A written scope of trauma service for pediatric trauma patients consistent with chapter 246-976 WAC, community needs and the approved regional plan. The written scope of trauma service must delineate the resources and capabilities available for pediatric trauma patient care twenty-four hours every day;	X	X	X
(2) A trauma service director responsible for organization and direction of the trauma service. The director must be a general surgeon with special competence in care of the injured child. The director may delegate duties to another physician with special competence in care of the injured child, but the director must maintain responsibility for the trauma service;	X	X	X
(3) A trauma service coordinator responsible for ongoing coordination of the trauma service. The coordinator must be a registered nurse with special competence in the care of the injured child;	X	X	X
(4) A multidisciplinary trauma committee chaired by the trauma service director with membership that reflects your written scope of pediatric trauma service. The multidisciplinary trauma committee must have responsibility and authority for establishing and changing trauma care policy and procedure and for conducting the trauma service quality improvement program in accordance with WAC 246-976-881;	X	X	X
(5) A full trauma team to provide initial evaluation, resuscitation and treatment. The full trauma team must include:	X	X	X
(a) A board-certified pediatric surgeon or general surgeon with special competence in care of the injured child, who organizes and directs the team and assumes responsibility for coordination of overall care of the trauma patient (for level I the surgeon must be at least a postgraduate year four resident);	X	X	X
(b) An emergency physician with special competence in pediatric care who is responsible for providing team leadership and care for the trauma patient until the arrival of the general surgeon in the resuscitation area;	X	X	X
(c) A board-certified pediatric physician. This requirement is met if a pediatric intensivist or a pediatric emergency physician or a pediatrician responds to the full trauma team activation (for level I the pediatric physician must be a least a postgraduate year two resident). This requirement is also met if the surgeon responder is a board-certified pediatric surgeon. The pediatric board-certified physician must be:	X	X	X
(i) Available within five minutes of team leader's request;	X
(ii) On-call and available within twenty minutes of team leader's request;		X
(iii) On-call and available within thirty minutes of team leader's request;			X
(d) The trauma service must identify all other members of the team to reflect your written scope of pediatric trauma service;	X	X	X
(6) A method for activating the trauma team as described is consistent with WAC 246-976-870;	X	X	X
(7) A written policy and procedures to divert patients to other designated trauma care services when the facility's resources are temporarily unavailable for trauma patient care. The policy must include:	X	X	X
(a) The facility and/or patient criteria used to decide when to divert a trauma patient;	X	X	X
(b) A process to coordinate trauma patient diversions with other area trauma services and prehospital agencies;	X	X	X
(c) A method for documenting trauma patient diversions including: Date, time, duration, reason, and decision maker;	X	X	X
(8) Interfacility transfer guidelines and agreements consistent with your written scope of trauma service and consistent with WAC 246-976-890;	X	X	X
(9) A heli-stop, landing zone, or airport located close enough to permit the facility to receive or transfer patients by fixed-wing or rotary-wing aircraft;	X	X	X
(10) Participation in the state trauma registry as required in WAC 246-976-430, with a person identified as responsible for coordination of trauma registry activities;	X	X	X
(11) A quality assurance program conducted by the multidisciplinary committee with special focus of pediatric patient care and consistent with WAC 246-976-881;	X	X	X
(12) Participation in the regional quality assurance program consistent with WAC 246-976-910.	X	X	X

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	LEVELS
A facility with a designated pediatric trauma service must have:	I	II	III
(1) An emergency department, including:	X	X	X
(a) An area designated for pediatric resuscitation;	X	X	X
(b) Written standards of care to ensure immediate and appropriate care for pediatric trauma patients;	X	X	X
(c) A physician director who:	X	X	X
(i) Is board-certified in emergency medicine, pediatric emergency medicine, surgery or other relevant specialty (or for level I, has documented experience as director of an emergency department which has been previously recognized as a level I trauma center either by a regional entity or as verified by the Committee on Trauma of the American College of Surgeons);	X	X	X
(ii) Is ATLS and ACLS trained, except this requirement does not apply to a physician board-certified in emergency medicine, pediatric emergency medicine or surgery; and	X	X	X
(iii) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-887, except that this requirement does not apply to a physician board-certified in pediatric emergency medicine;	X	X	X
(d) Physicians who:	X	X	X
(i) Are board-certified in emergency medicine, or pediatric emergency medicine, or board-certified in a specialty and practicing emergency medicine as their primary practice with special competence in care of pediatric trauma patients; (level I only - this requirement may be met by a surgical resident postgraduate year two who is ATLS and ACLS trained, has completed the PER as defined in WAC 246-976-887, and is working under the direct supervision of the attending emergency physician, until the arrival of the surgeon to assume leadership of the trauma team);	X	X
(ii) Have special competence in resuscitation, care and treatment of pediatric trauma patients;			X
(iii) Are available within five minutes of patient's arrival in the emergency department;	X	X	X
(iv) Are ATLS and ACLS trained, except this requirement does not apply to a physician board-certified in emergency medicine or pediatric emergency medicine;	X	X	X
(v) Have completed the PER as defined in WAC 246-976-887, except this requirement does not apply to a physician board-certified in pediatric emergency medicine;	X	X	X
(e) Registered nurses who:	X	X	X
(i) Are in the emergency department and available within five minutes of patient's arrival in the emergency department;	X	X	X
(ii) Have completed the PER as defined in WAC 246-976-887;	X	X	X
(iii) Have successfully completed a trauma life support course as defined in WAC 246-976-885;	X	X	X
(f) Equipment for resuscitation and life support of pediatric trauma patients, including equipment described in WAC 246-976-620;	X	X	X
(2) Radiological services, with:	X	X	X
(a) A radiologist on-call to interpret images within twenty minutes of notification of team activation;	X	X
(b) A radiologist on-call to interpret images within thirty minutes of notification of team activation;			X
(c) A technician able to perform routine radiological capabilities available within:
(i) Five minutes of notification of team activation;	X	X
(ii) Twenty minutes of notification of team activation;			X
(d) A technician able to perform computerized tomography and available within:
(i) Five minutes of team leader's request;	X
(ii) Twenty minutes of team leader's request;		X	X
(e) A technician on-call and available within twenty minutes of team leader's request, able to perform the following:
(i) Angiography of all types;	X	X
(ii) Sonography;	X	X
(3) Respiratory therapy available within five minutes of notification of team activation;	X	X	X
(4) Clinical laboratory services, including:	X	X	X
(a) A clinical laboratory technologist available within five minutes of notification of team activation;	X	X	X
(b) Standard analysis of blood, urine, and other body fluids;	X	X	X
(c) Coagulation studies;	X	X	X
(d) Blood gases and pH determination;	X	X	X
(e) Serum and urine osmolality;	X	X
(f) Microbiology;	X	X	X
(g) Serum alcohol determination;	X	X	X
(h) Drug or toxicology screening;	X	X	X
(5) Blood and blood-component services, including:	X	X	X
(a) Blood and blood components available from in-house or through community services, to meet patient needs;	X	X	X
(b) Noncrossmatched blood available on patient arrival in the emergency department;	X	X	X
(c) Ability to obtain blood typing and crossmatching;	X	X	X
(d) Policies and procedures for massive transfusion;	X	X	X
(e) Autotransfusion; and	X	X	X
(f) Blood storage capability;	X	X	X
(6) A surgery department, including:	X	X	X
(a) General surgery services, with:	X	X	X
(i) An attending, board-certified pediatric surgeon or board-certified general surgeon with special competence in pediatric care who is available within five minutes of notification of team activation. A postgraduate year four or above surgical resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until the arrival of the attending surgeon. In this case the attending surgeon must be available within twenty minutes of notification of team activation;	X
(ii) An attending, board-certified pediatric surgeon, or board-certified general surgeon with special competence in pediatric care, who is on-call and available within twenty minutes of notification of team activation;		X
(iii) An attending general surgeon, with competence in pediatric care, on-call and available within thirty minutes of notification of team activation;			X
(iv) All general surgeons (and surgical residents for level I) who are responsible for care and treatment of trauma patients must:	X	X	X
(A) Be trained in ATLS, except this requirement does not apply to a physician board-certified in surgery or pediatric surgery;	X	X	X
(B) Have completed the PER as defined in WAC 246-976-887;	X	X	X
(C) Have specific delineation of trauma surgery privileges by the medical staff;	X	X	X
(b) Neurosurgical services with:	X
(i) A neurosurgeon:	X
(A) Available within five minutes of team leader's request. A postgraduate year four or above neurosurgery resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until arrival of the attending neurosurgeon. In this case the neurosurgeon must arrive within thirty minutes of team leader's request;	X
(B) On-call and available within thirty minutes of team leader's request;		X
(ii) Ability to provide acute and ongoing care for acute head and spinal cord injuries;	X	X
(c) Ability to resuscitate and stabilize acute head and spinal cord injuries;			X
(d) A neurosurgeon on-call and available within thirty minutes of team leader's request; or written transfer guidelines and agreements for head and spinal cord injuries;			X
(e) The following surgical services on-call and available within thirty minutes as requested by the trauma team leader:
(i) Cardiac surgery;	X
(ii) Microsurgery;	X
(iii) Obstetric surgery (or for level III, a plan to manage the pregnant trauma patient);	X	X	X
(iv) Orthopedic surgery;	X	X
(v) Pediatric surgery;	X	X
(vi) Thoracic surgery;	X	X
(vii) Urologic surgery; and	X	X
(viii) Vascular surgery;	X	X
(f) The following surgical services on-call for patient consultation or management:	X	X	X
(i) Gynecologic surgery;	X	X
(ii) Ophthalmic surgery;	X	X
(iii) Oral/maxillofacial or otorhinolaryngologic surgery;	X	X
(iv) Plastic surgery;	X	X
(v) Orthopedic surgery;			X
(7) Anesthesiology, with an anesthesiologist (or a certified registered nurse anesthetist for level III) who:	X	X	X
(a) Is available within five minutes of team leader's request;	X
(b) Is available within twenty minutes of team leader's request;		X
(c) Is available within thirty minutes of team leader's request;			X
(d) Is ACLS trained, except this requirement does not apply to a physician board-certified in anesthesiology;	X	X	X
(e) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-887;	X	X	X
(8) An operating room and a registered nurse or designee responsible for opening and preparing the operating room, available within five minutes of notification of team activation, with:	X	X	X
(a) Other essential personnel as identified by the trauma service on-call and available within twenty minutes of notification of team activation;	X	X
(b) Other essential personnel as identified by the trauma service on-call and available within thirty minutes of notification of team activation;			X
(c) A written policy providing for mobilization of additional surgical teams for trauma patients; and	X	X	X
(d) Instruments and equipment appropriate for pediatric surgery, including equipment described in WAC 246-976-620;	X	X	X
(9) A postanesthetic recovery service with:
(a) At least one registered nurse available twenty-four hours a day;	X
(b) At least one registered nurse on-call and available twenty-four hours a day;		X	X
(c) Nurses ACLS trained;	X	X	X
(d) Nurses who have completed the PER as defined in WAC 246-976-887;	X	X	X
(10) A pediatric critical care service with:	X	X
(a) A medical director who is board-certified in pediatrics, with sub-board certification in critical care and who is responsible for coordinating with the attending staff for the care of pediatric trauma patients;	X	X
(b) Patient isolation capacity;	X	X
(c) A physician directed code team;	X	X
(d) Pediatric critical care registered nurses, who have special competence in pediatric trauma care and who have completed the PER as defined in WAC 246-976-887;	X	X
(e) Equipment as described in WAC 246-976-620;	X	X
(11) A pediatric critical care service which meets requirements for a level II pediatric critical care service if critical care services are included in your written scope of trauma service (except the medical director must be board-certified in pediatrics or another relevant specialty with special competence in pediatric critical care), or written transfer guidelines and agreements for pediatric trauma patients requiring critical care services;			X
(12) Acute dialysis capability, or written transfer agreements for dialysis services;	X	X	X
(13) The following services on-call and available for pediatric patient consultation or management during the in-patient stay:	X	X	X
(a) Cardiology;	X	X
(b) Gastroenterology;	X	X
(c) General pediatrics;	X	X	X
(d) Hematology;	X	X
(e) Infectious disease specialists;	X	X
(f) Nephrology;	X	X
(g) Pediatric neurology;	X	X
(h) Pathology;	X	X	X
(i) Pulmonology; and	X	X
(j) Psychiatry or a plan for management of the psychiatric trauma patient;	X	X
(14) Written policy and procedures for access to ancillary services, specific for in-patient care of pediatric patients, including:	X	X	X
(a) Chemical dependency services;	X	X	X
(b) Child and adult protection services;	X	X	X
(c) Clergy or pastoral care;	X	X	X
(d) Nutritionist services;	X	X	X
(e) Pharmacy services, with pharmacist in-house;	X
(f) Pharmacy services;		X	X
(g) Occupational therapy services;	X	X	X
(h) Pediatric therapeutic recreation/child life specialist;	X	X
(i) Physical therapy services;	X	X	X
(j) Speech therapy services;	X	X	X
(k) Social services;	X	X	X
(l) Psychological services;	X	X	X
(15) Ability to resuscitate and stabilize burn patients;	X	X	X
(16) A physician-directed burn unit staffed by nursing personnel trained in burn care and equipped to care for extensively burned patients; or written transfer guidelines and agreements in accordance with the guidelines of the American Burn Association;	X	X	X
(17) A trauma rehabilitation coordinator to facilitate the pediatric trauma patient's access to pediatric rehabilitation services;	X	X	X
(18) A designated pediatric trauma rehabilitation service; or written agreements to transfer patients to a designated trauma rehabilitation service when medically feasible.	X	X	X

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	LEVELS
A facility with a designated pediatric trauma service must have:	I	II	III
(1) An outreach program with telephone and on-site consultations with physicians of the community and outlying areas regarding pediatric trauma care;	X	X
(2) A public education program addressing injury prevention or documentation of participation in regional injury prevention activities;	X	X	X
(3) Training, including:	X
(a) A formal program of continuing trauma care education for:	X	X
(i) Staff physicians;	X	X
(ii) Nurses;	X	X
(iii) Allied health care professionals;	X	X
(iv) Community physicians; and	X	X
(v) Prehospital personnel;	X	X
(b) Residency programs accredited by the accreditation council of graduate medical education, with a commitment to training physicians in trauma management;	X
(c) Make the facility available for initial and maintenance training of invasive manipulative skills for prehospital personnel;	X	X	X
(4) A trauma research program.	X

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     (a) Patient status ((shall)) must be reported from the field by prehospital providers to the emergency department in the receiving trauma ((care)) service;

     (i) It is the responsibility of the prehospital providers to ((determine)) record all relevant information and report it to the receiving ((facility)) trauma service;

     (ii) It is the responsibility of the receiving ((facility)) trauma service to request any relevant information that is not volunteered by the prehospital providers.

     (b) The trauma service ((shall)) must use the prehospital information to determine activation of a trauma team and/or resources appropriate for the care of the patient.

     (c) The presence of the general surgeon, when included in ((the service's)) your written scope of ((practice)) trauma service, is necessary ((both)) to direct resuscitation, to exercise ((his or her)) professional judgment that immediate surgery is not indicated, as well as to perform surgery when it is indicated, and to direct ((resuscitation and)) patient transfer if necessary.

     (2) ((Each designated trauma care service shall use an approved method to determine activation of its trauma team. The method shall include information obtained from prehospital providers and other sources appropriate to the circumstances.

     (a) The method shall use notification by a prehospital provider that the patient meets trauma patient triage criteria, as defined in WAC 246-976-370; and

     (b) A scoring system such as the Prehospital Index, or patient-based criteria, which includes evaluation of each patient's:

     (i) Vital signs and level of consciousness;

     (ii) Anatomy of injury, including evaluation;

     (iii) Mechanism of injury; and

     (iv) Comorbid factors.

     (c) If a methodology is used for modified trauma team response, it shall:

     (i) Provide a mechanism to upgrade the level of trauma team response based on newly acquired information; and

     (ii) Be approved by the department.

     (d) The method may include a response by a neurosurgeon in place of response by a general surgeon when, based on prehospital information, the mechanism of injury clearly indicates isolated penetrating trauma to the brain.)) A facility designated to provide trauma services must adopt and use a method for activating its full trauma team. The method must:

     (a) Be based on patient information obtained from prehospital providers and other sources appropriate to the circumstances;

     (b) Include mandatory presence of the general surgeon for levels I - III and for level IV if general surgery services are included in your written scope of trauma service (the surgeon must be at least a postgraduate year four for level I and II);

     (c) Specify patient criteria for determining mandatory activation of the full trauma team. At a minimum, the full trauma team must be activated for patients with a confirmed systolic blood pressure less than ninety millimeters Hg in adults and age specific hypotension for children. The trauma service may identify additional full team activation criteria;

     (d) Be applied regardless of time postinjury or previous care, whether delivered by EMS or other means, and whether transferred from the scene or from another hospital;

     (e) The method for activation of the full trauma team may include response by a neurosurgeon instead of a general surgeon when, based on prehospital information, the mechanism of injury clearly indicates isolated penetrating trauma to the brain;

     (f) The trauma service must adopt a trauma quality improvement audit filter to monitor the appropriateness of and compliance with your full trauma team activation criteria.

     (3) A facility designated to provide trauma services may adopt and use a method for activating a modified trauma team. The method must:

     (a) Specify patient criteria for determining activation of the modified trauma team;

     (b) Include a mechanism to upgrade the level of trauma team response to full based on newly acquired information;

     (c) The trauma service must adopt a trauma quality improvement audit filter to monitor the appropriateness of and compliance with your modified trauma team activation criteria.

[Statutory Authority: Chapter 70.168 RCW. 98-04-038, § 246-976-870, filed 1/29/98, effective 3/1/98.]

     (a) An organizational structure that facilitates the process of quality assurance and improvement and identifies the authority to change policies, procedures, and protocols that address the care of the trauma patient;

     (b) ((Participation of members of the trauma team;

     (c))) Developments of standards of quality care;

     (((d))) (c) A process for monitoring compliance with or adherence to the standards;

     (((e))) (d) A process of peer review to evaluate specific cases or problems identified by the monitoring process;

     (((f))) (e) A process for correcting problems or deficiencies;

     (((g))) (f) A process to analyze and evaluate the effect of corrective action;

     (((h))) (g) A process to insure that confidentiality of patient and provider information is maintained according to the standards of RCW 70.41.200 and 70.168.090.

     (2) Designated levels I and II trauma rehabilitation services and level I pediatric trauma rehabilitation services shall have a quality assessment and improvement program that reflects and demonstrates a process for continuous quality improvement in the delivery of trauma care, with:

     (a) An organizational structure and plan that facilitates the process of quality assurance and improvement and identified the authority to change policies, procedures, and protocols that address the care of the major trauma patient;

     (b) Participation of members of the multidisciplinary trauma rehabilitation team, including involvement of the trauma rehabilitation coordinator of the referring acute trauma care service;

     (c) Development of outcome standards;

     (d) A process for monitoring compliance with or adherence to the outcome standards;

     (e) A process of internal peer review to evaluate specific cases or problems identified by the outcome monitoring process;

     (f) A process for implementing corrective action to address problems or deficiencies;

     (g) A process to analyze and evaluate the effect of corrective action;

     (h) A process to insure that confidentiality of patient and provider information is maintained according to the standards of RCW 70.41.200 and 70.168.090.

     (3) A designated level III trauma rehabilitation service shall have an organized trauma rehabilitation quality assessment and improvement program that reflects and demonstrates a process for continuous quality improvement in the delivery of trauma care, with:

     (a) A special audit process for rehabilitation trauma patients to identify the trauma rehabilitation outcome standards and indicators which monitor this program;

     (b) A multidisciplinary team, to include the physician identified as responsible for coordination of rehabilitation trauma activities;

     (c) A process to insure that confidentiality of patient and provider information is maintained according to the standards of RCW 70.41.200 and 70.168.090.

[Statutory Authority: Chapter 70.168 RCW. 98-04-038, § 246-976-881, filed 1/29/98, effective 3/1/98.]

     (a) At the time of initial designation, twenty-five percent of all personnel meet the education and training requirements defined in this chapter;

     (b) At the end of the first year of designation, fifty percent of all personnel meet the education and training requirements defined in this chapter;

     (c) At the end of the second year of designation, seventy-five percent of all personnel meet the education and training requirements defined in this chapter; and

     (d) At the end of the third year of designation, and in all subsequent designation periods, ninety percent of all personnel meet the education and training requirements defined in this chapter.

     (2) To meet the requirements for a trauma life support course:

     (a) Emergency department registered nurses in levels I, II, III and IV trauma care services, and in levels I, II, and III pediatric trauma care services, shall have successfully completed a trauma nurse core course (TNCC), or a department-approved equivalent that includes a minimum of sixteen contact hours of trauma-specific education on the following topics:

     (i) Mechanism of injury;

     (ii) Shock and fluid resuscitation;

     (iii) Initial assessment;

     (iv) Pediatric trauma;

     (v) Stabilization and transport;

     (b) Registered nurses in critical care units in level I or II trauma care services shall have successfully completed a minimum of eight contact hours of trauma-specific education;

     (c) Registered nurses in critical care units in level III trauma care services shall have successfully completed a minimum of four contact hours of trauma-specific education;

     (d) For level IV services, if ((the service's)) your written scope of ((care defined in WAC 246-976-640(2))) trauma service includes critical care for trauma patients, registered nurses in critical care units shall have successfully completed a minimum of four contact hours of trauma-specific education.

[Statutory Authority: Chapter 70.168 RCW. 98-04-038, § 246-976-885, filed 1/29/98, effective 3/1/98. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), § 246-976-885, filed 12/23/92, effective 1/23/93.]

     (2) In designated levels I, II, and III general trauma care services general surgeons, anesthesiologists, CRNAs and PACU RNs who are involved in the resuscitation and stabilization of pediatric trauma patients shall have PER, as provided in subsection (3) of this section, appropriate to their scope of trauma care.

     (3) PER can be met by the following methods:

     (a) One-time completion of pediatric advanced life support (PALS) or a substantially equivalent training course; or

     (b) Current certification in ATLS; or

     (c) Completion of a least five contact hours of pediatric trauma education during each designation period. PER contact hours will:

     (i) Include the following topics:

     (A) Initial stabilization and transfer of pediatric trauma;

     (B) Assessment and management of pediatric airway and breathing;

     (C) Assessment and management of pediatric shock, including vascular access;

     (D) Assessment and management of pediatric head injuries;

     (E) Assessment and management of pediatric blunt abdominal trauma;

     (ii) Be accomplished through one or more of the following methods:

     (A) Review and discussion of individual pediatric trauma cases within the trauma QA/QI program;

     (B) Staff meetings;

     (C) Classes, formal or informal;

     (D) Web-based learning; or

     (E) Other methods of learning which appropriately communicate the required topics listed in this section.

[Statutory Authority: Chapter 70.168 RCW. 02-12-107, § 246-976-886, filed 6/5/02, effective 7/6/02.]

     (2) PER can be met by the following methods:

     (a) One-time completion of pediatric advance life support (PALS) or a substantially equivalent training course; or

     (b) Current certification in ATLS; or

     (c) Completion of at least seven contact hours of pediatric trauma education during each designation period. PER contact hours will:

     (i) Include the following topics:

     (A) Initial stabilization and transfer of pediatric trauma;

     (B) Assessment and management of pediatric airway and breathing;

     (C) Assessment and management of pediatric shock, including vascular access;

     (D) Assessment and management of pediatric head injuries;

     (E) Assessment and management of pediatric blunt abdominal trauma;

     (F) Pediatric sedation and analgesia;

     (G) Complications of pediatric multiple system trauma;

     (ii) Be accomplished through one or more of the following methods:

     (A) Review and discussion of individual pediatric trauma cases within the trauma QA/QI program;

     (B) Staff meetings;

     (C) Classes, formal or informal;

     (D) Web-based learning; or

     (E) Other methods of learning which appropriately communicate the required topics listed in this section.

[Statutory Authority: Chapter 70.168 RCW. 02-12-107, § 246-976-887, filed 6/5/02, effective 7/6/02.]

     (1) Have written guidelines ((for the identification)) consistent with your written scope of trauma service to identify and transfer ((of)) patients with special care needs exceeding the capabilities of the trauma service.

     (2) Have written transfer agreements with other designated trauma services. The agreements must address the responsibility of the transferring hospital, the receiving hospital, and the prehospital transport agency, including a mechanism to assign medical control during interhospital transfer.

     (3) Have written guidelines consistent with your written scope of trauma service to identify trauma patients who are transferred in from other facilities, whether admitted through the emergency department or directly into other hospital services.

     (4) Use verified prehospital trauma services for interfacility transfer of trauma patients.

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, § 246-976-890, filed 4/5/00, effective 5/6/00. Statutory Authority: Chapter 70.168 RCW. 98-04-038, § 246-976-890, filed 1/29/98, effective 3/1/98. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), § 246-976-890, filed 12/23/92, effective 1/23/93.]

     The following sections of the Washington Administrative Code are repealed:

WAC 246-976-500	Designation standards for facilities providing level I trauma care service -- Administration and organization.
WAC 246-976-510	Designation standards for facilities providing level I trauma care service -- Basic resources and capabilities.
WAC 246-976-520	Designation standards for facilities providing level I trauma care service -- Outreach, public education, trauma care education, and research.
WAC 246-976-550	Designation standards for facilities providing level II trauma care service -- Administration and organization.
WAC 246-976-560	Designation standards for facilities providing level II trauma care service -- Basic resources and capabilities.
WAC 246-976-570	Designation standards for facilities providing level II trauma care service -- Outreach, public education and trauma care education.
WAC 246-976-600	Designation standards for facilities providing level III trauma care service -- Administration and organization.
WAC 246-976-610	Designation standards for facilities providing level III trauma care service -- Basic resources and capabilities.
WAC 246-976-615	Designation standards for facilities providing level III trauma care service -- Trauma care education.
WAC 246-976-640	Designation standards for facilities providing level IV trauma care services -- Administration and organization.
WAC 246-976-650	Designation standards for facilities providing level IV trauma care services -- Basic resources and capabilities.
WAC 246-976-680	Designation standards for facilities providing level V trauma care services -- Administration and organization.
WAC 246-976-690	Designation standards for facilities providing level V trauma care service -- Basic resources and capabilities.
WAC 246-976-720	Designation standards for facilities providing level I pediatric trauma care service -- Administration and organization.
WAC 246-976-730	Designation standards for facilities providing level I pediatric trauma care services -- Resources and capabilities.
WAC 246-976-740	Designation standards for facilities providing level I pediatric trauma care service -- Outreach, public education, trauma care education, and research.
WAC 246-976-770	Designation standards for facilities providing level II pediatric trauma care service -- Administration and organization.
WAC 246-976-780	Designation standards for facilities providing level II pediatric trauma care service -- Basic resources and capabilities.
WAC 246-976-790	Designation standards for facilities providing level II pediatric trauma care service -- Outreach, public education, and trauma care education.
WAC 246-976-810	Designation standards for facilities providing level III pediatric trauma care service -- Administration and organization.
WAC 246-976-820	Designation standards for facilities providing level III pediatric trauma care service -- Basic resources and capabilities.
WAC 246-976-822	Designation standards for facilities providing level III pediatric trauma care service -- Trauma care education.

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