WSR 18-15-057
PROPOSED RULES
DEPARTMENT OF HEALTH
[Filed July 16, 2018, 11:33 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 17-06-044.
Title of Rule and Other Identifying Information: WAC 246-976-580 and 246-976-700, trauma designation process and service standards, the department of health (department) is proposing revising WAC 246-976-580 and 246-976-700 in order to align with current nationally recognized minimum standards of care.
Hearing Location(s): On August 29, 2018, at 10:00 a.m., at the Washington State Department of Health, Town Center 2, Conference Room 158, 111 Israel Road S.E., Tumwater, WA 98501.
Date of Intended Adoption: September 14, 2018.
Submit Written Comments to: Anthony Bledsoe, P.O. Box 47853, Olympia, WA 98504-4853, email https://fortress.wa.gov/doh/policyreview, fax 360-236-2830, by August 29, 2018.
Assistance for Persons with Disabilities: Contact Nicole Fernandez, phone 360-236-2802, fax 360-236-2830, TTY 360-833-6388 or 711, email nicole.fernandus@doh.wa.gov, by August 22, 2018.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: Nationally, the American College of Surgeons Committee on Trauma (ACS-COT) is widely considered the leading authority on trauma care and trauma care standards. The ACS-COT publishes their designation criteria in a book titled, Resources for optimal care for the injured patient. The newest version (referred to as the Orange Book), outlines the most current national minimum standards in the function and evaluation of trauma systems. In an effort to maintain current minimum standards and ensure the optimal care of the injured patient in Washington, it is important that the department look closely at the Orange Book to scrutinize and adopt these standards, when applicable.
Reasons Supporting Proposal: The current rules, WAC 246-976-700, have not been updated since 2009. Since then, the ACS-COT has made substantial changes to the criteria used in the verification of ACS-COT designated trauma centers. Through a stakeholder gap analysis, the department has determined that the existing rules need to be updated to more closely align with the Orange Book criteria. The updates will establish standards that will be used to evaluate trauma services to the most current and nationally recognized standards available.
The benefit of this proposal is it provides designated trauma centers with explicit, updated requirements that reflect current, nationally recognized minimum standards of care that will ensure trauma centers are providing optimal care to injured Washingtonians. The benefits to the public to ensure higher standards of care outweigh the potential costs associated with the proposed amendments.
Statutory Authority for Adoption: RCW 70.168.060.
Statute Being Implemented: RCW 70.168.070.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Department of health, governmental.
Name of Agency Personnel Responsible for Drafting, Implementation, and Enforcement: Anthony Bledsoe, 111 Israel Road S.E., Tumwater, WA 98501, 360-236-2871.
A school district fiscal impact statement is not required under RCW 28A.305.135.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Anthony Bledsoe, P.O. Box 47853, Olympia, WA 98504-7853, phone 360-236-2871, fax 360-236-2830, TTY 360-833-6388 or 711, email anthony.bledsoe@doh.wa.gov.
The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. It was determined that a small business economic impact statement was not required. The North American Industry Classification System (NAICS) code for general medical and surgical hospitals was used for threshold analysis. In total, there are one hundred facilities with 1,603,748 paid employees. The total annual payroll is 6,566,100 (in 1,000s). Threshold Calculation: (6,566,100*1000/100)*(0.01) = $656,610. The estimated costs of the proposed rule was determined to be between $0-$111,000, with an average expected fiscal impact of $38,774, which falls below the NAICS threshold of $656,610.
July 11, 2018
John Wiesman, DrPH, MPH
Secretary
AMENDATORY SECTION(Amending WSR 09-23-085, filed 11/16/09, effective 12/17/09)
WAC 246-976-580Trauma designation process.
The department designates health care facilities to provide adult and pediatric acute care trauma services ("trauma services") and adult and pediatric trauma rehabilitation services ("trauma rehabilitation services") as part of the statewide emergency medical services and trauma care (((EMS/TC)) EMS&TC) system. This section describes the designation process.
(1) The department must:
(a) Provide written notification to all licensed hospitals and to other health care facilities that a new designation period is beginning. The written notification and the ((EMS/TC)) EMS&TC regional plans are posted on the department's web site;
(b) Provide a trauma designation application schedule outlining the steps and timeline requirements for a facility to apply for trauma service designation. The schedule must provide each facility at least ninety days to complete an application for trauma designation. The application schedule is posted on the department's web site;
(c) Provide an application for each level, type and combination of designation. Designation applications are released region by region, according to the established schedule;
(d) Conduct a site review for any hospital applying for level I, II, or III adult ((and/or)) and pediatric trauma service designation to determine compliance with required standards;
(e) Initiate a three-year contract with successful applicants to authorize participation in the trauma system.
(2) To apply for trauma service designation the health care facility must do the following according to the application schedule:
(a) Request an application;
(b) Submit a letter of intent to apply for trauma service designation indicating what level they are applying for;
(c) Submit a completed application(s);
(d) For health care facilities applying for level I, II, III adult ((and/or)) and pediatric trauma service designation, the facility must complete a site review arranged and conducted by the department according to the following process:
(i) The department will contract with trauma surgeons and trauma nurses to conduct the site review. The review team members must:
(A) Work outside the state of Washington, for level I and II site reviews;
(B) Work outside the applicant's EMS&TC region, for level III site reviews;
(C) Maintain the confidentiality of all documents examined, in accordance with RCW 70.41.200 and 70.168.070. This includes, but is not limited to, all trauma patient data, staff discussions, patient, provider, and facility care outcomes, and any reports resulting from the site review;
(D) Present their preliminary findings to the health care facility at the end of the site review visit;
(ii) The department will provide the applicant the names of review team members prior to the site review. Any objections must be sent to the department within ten days of receiving the department's notification of review team members;
(iii) A site review fee, as established in WAC 246-976-990, is charged and must be paid by the health care facility to the department prior to the site review. A standard fee schedule is posted on the department's web site. For facilities applying for more than one type of designation or for joint designation, fee rates can be obtained by contacting the department;
(iv) The applicant must provide the department and the site review team full access to the facility, facility staff, and all records and documents concerning trauma care including trauma patient data, education, training and credentialing documentation, standards of care, policies, procedures, protocols, call schedules, medical records, quality improvement materials, receiving facility patient feedback, and other relevant documents;
(e) For health care facilities applying for level IV or V trauma service designation, level I((, II, or III)) or II trauma rehabilitation service designation or level I pediatric trauma rehabilitation service designation, the department may, at its discretion, conduct a site review as part of the application process to determine compliance with required standards. If a site review is conducted, the process will be the same as identified in (d) of this subsection, except a site review fee will not be charged.
(3) The department will designate the health care facilities it considers most qualified to provide trauma care services including when there is competition for trauma service designation within a region. There is competition for designation within a region when the number of applications for a level and type of designation is more than the maximum number of trauma services identified in the approved ((EMS/TC)) EMS&TC regional plan. The department will evaluate, at ((least)) a minimum, the following in making its decisions:
(a) The quality of the health care facility's performance((,)) based on:
(i) The submitted application, attachments, and any other information the department requests from the facility to verify compliance, or the ability to comply with trauma standards;
(ii) Recommendations from the site review team;
(iii) Trauma patient outcomes during the previous designation period, if applicable;
(iv) Compliance with the contract during the previous designation period, if applicable;
(b) The health care facility's conformity with the ((EMS/TC)) EMS&TC regional and state plans, based on:
(i) The impact of the facility's designation on the effectiveness of the trauma system;
(ii) Patient volumes for the area;
(iii) The number, level, and distribution of trauma services identified in the state and approved regional plans;
(iv) The facility's ability to comply with state and regional ((EMS/TC)) EMS&TC plan goals.
(4) After trauma service designation decisions are made in a region, the department will:
(a) Notify each applicant in writing of the department's designation decision;
(b) Send each applicant a written report summarizing the department's findings, recommendations and additional requirements to maintain designation. If a site review was conducted as part of the application process, the review team findings and recommendations are also included in the written report. Reports are sent:
(i) Within sixty days of announcing designation decisions for level IV and V trauma services and trauma rehabilitation services;
(ii) Within one hundred twenty days of the site review for level I, II and III adult and pediatric trauma services and any other facility that received a site review as part of the application process;
(c) Notify the ((EMS/TC)) EMS&TC regional council of designation decisions within the region and all subsequent changes in designation status;
(d) Initiate a trauma designation contract with successful applicants. The contract will include:
(i) Authority from the department to participate in the state trauma system, receive trauma patients from EMS agencies, and provide trauma care services for a three-year period;
(ii) The contractual and financial requirements and responsibilities of the department and the trauma service;
(iii) A provision to allow the department to monitor compliance with trauma service standards;
(iv) A provision to allow the department to have full access to trauma patient data((;)), the facility, equipment, staff and their credentials, education, ((and)) training documentation, and all trauma care documents such as: Standards of care, policies, procedures, protocols, call schedules, medical records, quality improvement documents, receiving facility patient feedback, and other relevant documents;
(v) The requirement to maintain confidentiality of information relating to individual patient's, provider's and facility's care outcomes under RCW 70.41.200 and 70.168.070;
(e) Notify the designated trauma service and other interested parties in the region of the next trauma designation application process at least one hundred fifty days before the contract expires.
(5) Designated trauma services may ask the department to conduct a site review for technical assistance at any time during the designation period. The department has the right to require reimbursement for the costs of conducting the site review.
(6) The department will not approve an application for trauma service designation if the applicant:
(a) Is not the most qualified, when there is competition for designation; or
(b) Does not meet the trauma care standards for the level applied for; or
(c) Does not meet the requirements of the approved ((EMS/TC)) EMS&TC regional plan; or
(d) Has made a false statement about a material fact in its designation application; or
(e) Refuses to permit the department to examine any part of the facility that relates to the delivery of trauma care services, including, but not limited to, records, documentation, or files.
(7) If the department denies an application, the department will send the facility a written notice to explain the reasons for denial and to explain the facility's right to appeal the department's decision in accordance with chapters 34.05 RCW and 246-10 WAC.
(8) To ensure adequate trauma care in the state, the department may:
(a) Provisionally designate health care facilities that are not able to meet all the requirements of this chapter. The provisional designation will not be for more than two years. A department-approved plan of correction must be prepared by the health care facility specifying steps necessary to bring the facility into compliance and an expected date of compliance. The department may conduct a site review to verify compliance with required standards. If a site review is conducted, the department has the right to require reimbursement for the cost of conducting the site review;
(b) Consider additional applications at any time, regardless of the established schedule, if necessary to attain the numbers and levels of trauma services identified in the approved ((EMS/TC)) EMS&TC regional and state plan;
(c) Consider applications from hospitals located and licensed in adjacent states. The department will evaluate an out-of-state application in the same manner as all other applications. However, if the out-of-state applicant is designated as a trauma service in an adjacent state with an established trauma system whose standards meet or exceed Washington's standards and there is no competition for designation at that level, then the department may use the administrative findings, conclusions, and decisions of the adjacent state's designation evaluation to make the decision to designate. Additional information may be requested by the department to make a final decision.
(9) The department may suspend or revoke a trauma designation if the facility or any owner, officer, director, or managing employee:
(a) Is substantially out of compliance with trauma care standards WAC 246-976-700 through 246-976-800 or chapter 70.168 RCW and has refused or is unwilling to comply after a reasonable period of time;
(b) Makes a false statement of a material fact in the designation application, or in any document required or requested by the department, or in a matter under investigation;
(c) Prevents, interferes with, or attempts to impede in any way, the work of a department representative in the lawful enforcement of chapter 246-976 WAC, 34.05 RCW, 246-10 WAC, or 70.168 RCW;
(d) Uses false, fraudulent, or misleading advertising, or makes any public claims regarding the facility's ability to care for nontrauma patients based on its trauma designation status;
(e) Misrepresents or is fraudulent in any aspect of conducting business.
(10) The Administrative Procedure Act, chapter 34.05 RCW, and chapter 246-10 WAC govern the suspension and revocation process. The department will use the following process to suspend or revoke a facility's trauma designation:
(a) The department will send the facility a written notice to explain the reasons it intends to suspend or revoke the designation and to explain the facility's right to a hearing to contest the department's intended action under WAC 246-10-201 through 246-10-205;
(b) The notice will be sent at least twenty-eight days before the department takes action, unless it is a summary suspension, as provided for in the Administrative Procedure Act, chapter 34.05 RCW and WAC 246-10-301 through 246-10-306;
(c) If a facility requests a hearing within twenty-eight days of the date the notice was mailed, a hearing before a health law judge will be scheduled. If the department does not receive the facility's request for a hearing within twenty-eight days of the date the notice was mailed, the facility will be considered in default under WAC 246-10-204;
(d) For nonsummary suspensions, in addition to its request for a hearing, the facility may submit a plan within twenty-eight days of receiving the notice of the department's intent to suspend, describing how it will correct deficiencies:
(i) The department will approve or disapprove the plan within thirty days of receipt;
(ii) If the department approves the plan, the facility must begin to implement it within thirty days;
(iii) The facility must notify the department when the problems are corrected;
(iv) If, prior to sixty days before the scheduled hearing, the facility is able to successfully demonstrate to the department that it is meeting the requirements of chapters 246-976 WAC and 70.168 RCW, which may require a site review at the facility's expense, the department will withdraw its notice of intent to suspend designation;
(e) The department will notify the regional EMS&TC council of the actions it has taken.
(11) A facility may seek judicial review of the department's final decision under the Administrative Procedure Act, RCW 34.05.510 through 34.05.598.
(12) A newly designated or upgraded trauma service must meet education requirements for all applicable personnel according to the following schedule:
(a) At the time of the new designation, twenty-five percent of all personnel must meet the education and training requirements in WAC 246-976-700 through 246-976-800;
(b) At the end of the first year of designation, fifty percent of all personnel must meet the education and training requirements in WAC 246-976-700 through 246-976-800;
(c) At the end of the second year of designation, seventy-five percent of all personnel must meet the education and training requirements defined in WAC 246-976-700 through 246-976-800;
(d) At the end of the third year of designation, and all subsequent designation periods, ninety percent of all personnel must meet the education and training requirements defined in WAC 246-976-700 through 246-976-800.
(13) All currently designated trauma services must have a written education plan with a process for tracking and assuring that new physicians and staff meet all trauma education requirements within the first eighteen months of employment.
AMENDATORY SECTION(Amending WSR 09-23-085, filed 11/16/09, effective 12/17/09)
WAC 246-976-700Trauma service standards.
WAC 246-976-700 Trauma Service Standards
Adult Levels
Pediatric Levels
A facility with a designated trauma service must have:
I
II
III
IV
V
I P
II P
III P
(1) A written trauma scope of service outlining the trauma care resources and capabilities available twenty-four hours every day for:
X
X
X
X
X
X
X
X
(a) Adult and pediatric trauma patient care;
X
X
X
X
X
 
 
 
(b) Pediatric trauma patient care.
 
 
 
 
 
X
X
X
(2) A trauma medical director responsible for the organization and direction of the trauma service((,)) who:
X
X
X
X
X
X
X
X
(a) Is currently certified in advanced trauma life support (ATLS);
X
X
X
 
 
X
X
X
(((a))) (b) Is a board-certified general surgeon;
X
X
 
 
 
 
 
 
(((b))) (c) Is a board-certified general surgeon((,)) or ((a)) general surgeon trained in advanced cardiac life support (ACLS) ((trained with current certification in advanced trauma life support (ATLS)));
 
 
X
 
 
 
 
 
(((c))) (d) Is a board-certified general surgeon ((or)), emergency physician, ((or)) a general surgeon ACLS trained with current certification in advanced trauma life support (ATLS) or a physician ACLS trained ((with)) and current certification in ATLS;
 
 
 
X
 
 
 
 
(((d))) (e) Is a board-certified general surgeon ((or)), emergency physician, ((or)) a physician ACLS trained with current certification in ATLS, or a physician assistant or advanced registered nurse practitioner ACLS trained ((and)) who ((audits)) is currently certified in ATLS ((every four years));
 
 
 
 
X
 
 
 
(((e))) (f) Is a board-certified pediatric surgeon((,)) or a board-certified general surgeon((,)) with special competence in the care of pediatric patients;
 
 
 
 
 
X
X
 
(((f))) (g) Is a board-certified general surgeon((,)) with special competence in the care of pediatric patients((,)) or a general surgeon ACLS trained((, with current certification in ATLS)) and with special competence in the care of pediatric patients;
 
 
 
 
 
 
 
X
(h) Must complete thirty-six hours in three years of verifiable, external, trauma-related continuing medical education (CME);
X
X
 
 
 
X
X
 
(((g))) (i) Meets the pediatric education requirement (PER) as defined in subsection (27) of this section((.));
X
X
X
X
X
X
X
X
(j) Must have responsibility and authority for determining each general surgeon's ability to participate on the trauma call panel based on an annual review, conducted in conjunction with medical staffing and with authority through the trauma quality improvement program and hospital policy;
X
X
X
 
 
X
X
X
(k) Is a member of and actively participates in a regional or national trauma organizations.
X
X
 
 
 
X
X
 
(3) A trauma program manager or trauma service coordinator responsible for the overall operation of trauma service((,)) who:
X
X
X
X
X
X
X
X
(a) Is a registered nurse;
X
X
X
X
X
X
X
X
(b) Has taken ACLS;
X
X
X
X
X
X
X
X
(c) Has successfully completed a trauma nursing core course (TNCC) or a department approved equivalent course, and ((thereafter completes twelve hours of trauma-related education every three-year designation period)) successfully completes thirty-six hours of trauma-related education every three years in either external continuing education or in an internal education process conducted by the trauma program. The trauma education must include, but is not limited to, the following topics:
X
X
X
X
X
X
X
X
(i) Mechanism of injury;
X
X
X
X
X
X
X
X
(ii) Shock and fluid resuscitation;
X
X
X
X
X
X
X
X
(iii) Initial assessment;
X
X
X
X
X
X
X
X
(iv) Stabilization and transport((;)).
X
X
X
X
X
X
X
X
(d) Has taken pediatric advanced life support (PALS) or emergency nursing pediatric course (ENPC), and thereafter meets the PER contact hours as defined in subsection (27) of this section;
X
X
X
X
X
 
 
 
(e) Has current PALS or ENPC certification;
 
 
 
 
 
X
X
X
(f) Has attended a trauma program manager orientation course provided by the department or a department approved equivalent, within the first eighteen months in the role((.));
X
X
X
X
X
X
X
X
(g) Must be employed in a full-time position dedicated to the trauma service if annual trauma registry volume is greater than five hundred trauma patients admissions and less than seven hundred fifty trauma patients admissions annually;
X
X
X
X
X
X
X
X
(h) Is responsible for the overall supervision of the trauma registry and the quality of data submitted to the registry.
X
X
X
X
X
X
X
X
(4) A multidisciplinary trauma quality improvement program that must:
X
X
X
X
X
X
X
X
(a) Be ((lead)) led by the multidisciplinary trauma service committee ((with the trauma medical director as chair of the committee;)):
X
X
X
X
X
X
X
X
(i) The trauma medical director serves as chair of the multidisciplinary trauma service committee;
X
X
X
X
X
X
X
X
(ii) The trauma medical director must attend a minimum of fifty percent of the peer review committee meetings;
X
X
X
X
X
X
X
X
(iii) The trauma medical director and trauma program manager must have the authority and be empowered by the hospital governing body to lead the program to ensure compliance with trauma service standards.
X
X
X
X
X
X
X
X
(b) Demonstrate a continuous quality improvement process supported by a reliable method of data collection that consistently obtains the information necessary to identify opportunities for improvement;
X
X
X
X
X
X
X
X
(c) Have membership representation and participation that reflects the facility's trauma scope of service;
X
X
X
X
X
X
X
X
(d) Have an organizational structure that facilitates the process of quality improvement((,)) with a reporting relationship to the hospital's administrative team and medical executive committee that ensures adequate evaluation of all aspects of trauma care;
X
X
X
X
X
X
X
X
(e) Have authority to establish trauma care standards and implement patient care policies, procedures, guidelines, and protocols throughout the hospital and the trauma service must use clinical practice guidelines, protocols, and algorithms derived from evidence-based validated resources;
X
X
X
X
X
X
X
X
(f) Have a current trauma quality improvement plan that outlines the trauma service's quality improvement process;
X
X
X
X
X
X
X
X
(((f))) (g) Have a process to monitor and track compliance with the trauma care standards using audit filters and benchmarks;
X
X
X
X
X
X
X
X
(((g))) (h) Have a process to evaluate the care provided to trauma patients and to resolve identified prehospital, physician, nursing, or system issues;
X
X
X
X
X
X
X
X
(i) Have a process in which outcome measures are documented within the trauma quality improvement program's written plan which must be reviewed and updated at least annually. Outcome measures will include, at a minimum:
 
 
 
 
 
 
 
 
(i) Mortality (with and without opportunities for improvement);
 
 
 
 
 
 
 
 
(ii) Trauma surgeon response time (level I-III);
 
 
 
 
 
 
 
 
(iii) Undertriage rate;
X
X
X
X
X
X
X
X
(iv) Emergency department length of stay greater than three hours for patients transferred out;
 
 
 
 
 
 
 
 
(v) Missed injuries;
 
 
 
 
 
 
 
 
(vi) Complications.
 
 
 
 
 
 
 
 
(((h))) (j) Have a process for correcting problems or deficiencies;
X
X
X
X
X
X
X
X
(((i))) (k) Have a process ((to analyze, evaluate, and measure the effect of corrective actions to determine whether issue resolution was achieved)) for problem resolution, outcome improvements, and assurance of safety. This process must be readily identifiable through methods of monitoring, reevaluation, benchmarking, and documentation;
X
X
X
X
X
X
X
X
(((j))) (l) Have a process to continuously evaluate compliance with full and modified (if used) trauma team activation criteria((;))as follows:
X
X
X
X
X
X
X
X
(i) The attending surgeon's arrival within fifteen minutes for level II and thirty minutes for level III services for patients with appropriate activation criteria must be monitored by the hospital's trauma quality improvement program;
X
X
X
 
 
X
X
X
(ii) All trauma team activations must be categorized by the level of response activation and quantified by number and percentage;
X
X
X
X
X
X
X
X
(iii) Trauma surgeon response time to full activations and for back-up call response must be determined and monitored. Variances should be documented and reviewed for reason for delay, opportunities for improvement, and corrective actions; and
X
X
X
 
 
X
X
X
(iv) Rates of undertriage must be monitored and reviewed quarterly.
X
X
X
X
X
X
X
X
(((k))) (m) Have assurance from other hospital quality improvement committees, including peer review if conducted separately from the multidisciplinary trauma service committee, that resolution was achieved on trauma-related issues((;)). The following requirements must also be satisfied:
X
X
X
X
X
X
X
X
(i) Peer review must occur at regular intervals to ensure that the volume of cases is reviewed in a timely fashion;
X
X
X
X
X
X
X
X
(ii) A process must be in place to ensure that the trauma program manager receives feedback from peer review for trauma-related issues;
X
X
X
X
X
X
X
X
(iii) All trauma-related mortalities must be systematically reviewed and those mortalities with opportunities for improvement identified for peer review;
X
X
X
X
X
X
X
X
(iv) This effort must involve the participation and leadership of the trauma medical director and any departments, such as: General surgery, emergency medicine, orthopedics, neurosurgery, anesthesia, critical care, lab and radiology; and
X
X
X
X
X
X
X
X
(v) The multidisciplinary trauma peer review committee must systematically review significant complications and process variances associated with unanticipated outcomes and determine opportunities for improvement.
X
X
X
X
X
X
X
X
(((l))) (n) Have a process to ensure the confidentiality of patient and provider information, in accordance with RCW 70.41.200 and 70.168.090;
X
X
X
X
X
X
X
X
(((m))) (o) Have a process to communicate with((,)) and provide feedback to((,)) referring trauma services and trauma care providers;
X
X
X
X
X
X
X
X
(((n) Have a current trauma quality improvement plan that outlines the trauma service's quality improvement process, as defined in this subsection;
X
X
X
X
X
X
X
X
(o) For level III, IV, V trauma services or level III pediatric trauma services with a total annual trauma volume of less than one hundred patients, the trauma service may)) (p) Be able to integrate trauma quality improvement into the hospital's quality improvement program for level III, IV, V trauma services or level III pediatric trauma services with a total annual trauma volume of less than one hundred patients; however, trauma care must be formally addressed in accordance with the quality improvement requirements in this subsection. In that case, the trauma medical director is not required to serve as chair((.));
 
 
X
X
X
 
 
X
(q) Have a pediatric-specific trauma quality improvement program for a trauma service admitting at least one hundred pediatric trauma patients annually. For a trauma service admitting less than one hundred pediatric trauma patients annually, or that is transferring trauma patients, the trauma service must review each case for timeliness and appropriateness of care;
X
X
X
X
X
X
X
X
(r) Be a multidisciplinary trauma quality improvement program that transcends normal department hierarchies and includes:
X
X
X
X
X
X
X
X
Identified medical staff representatives or their designees from departments of general surgery, emergency medicine, orthopedics, neurosurgery, anesthesiology, critical care, and radiology who must participate actively in the multidisciplinary trauma quality improvement program with at least fifty percent attendance at peer review committee meetings.
X
X
X
 
 
X
X
X
(s) Use risk-adjusted data for benchmarking and performance improvement:
X
X
X
X
X
X
X
X
(i) The risk-adjusted benchmarking system to measure performance must be the American College of Surgeons Trauma Quality Improvement Program (TQIP);
X
X
 
 
 
X
X
 
(ii) Data must be collected in compliance with the National Trauma Data Standard (NTDS) and submitted to the National Trauma Data Bank® (NTDB®) every year in a timely fashion so that data can be aggregated and analyzed at the national level;
X
X
 
 
 
X
X
 
(iii) Use risk-adjusted data provided by the state for the purposes of benchmarking and performance improvement.
 
 
X
X
X
 
 
X
(5) Written trauma service standards of care to ensure appropriate care throughout the facility for:
X
X
X
X
X
X
X
X
(a) Adult and pediatric trauma patients;
X
X
X
X
X
 
 
 
(b) Pediatric trauma patients.
 
 
 
 
 
X
X
X
(6) Participation in the regional quality improvement program as defined in WAC 246-976-910.
X
X
X
X
X
X
X
X
(7) Participation in the Washington state trauma registry as defined in WAC 246-976-430.
X
X
X
X
X
X
X
X
(8) Written transfer-in guidelines consistent with the facility's designation level and trauma scope of service. The guidelines must identify the type, severity and complexity of injuries the facility can safely accept, admit, and provide with definitive care.
X
X
X
X
X
X
X
X
(9) Written transfer-out guidelines consistent with the facility's designation level and trauma scope of service. The guidelines must identify the type, severity and complexity of injuries that exceed the resources and capabilities of the trauma service.
X
X
X
X
X
X
X
X
(a) Collaborative treatment and transfer guidelines reflecting facilities' capabilities must be developed and regularly reviewed, with input from higher-level trauma services that receive these patients;
 
 
X
X
X
 
 
 
(b) The decision to transfer an injured patient to a specialty care facility in an acute situation must be based solely on the needs of the patient and not on the requirements of the patient's specific provider network, health maintenance organization, a preferred provider organization, or the patient's ability to pay;
X
X
X
X
X
X
X
X
(c) Acute transfers out must be subjected to individual case review to determine the rationale for transfer, appropriateness of care, and opportunities for improvement. Follow-up from the center to which the patient was transferred should be obtained as part of the case review; and
X
X
X
X
X
X
X
X
(d) Trauma patients must not be admitted or transferred by a primary care physician without the knowledge and consent of the trauma service. The quality improvement program should monitor adherence to this guideline.
X
X
X
 
 
X
X
X
(10) Written interfacility transfer agreements with all trauma services that receive the facility's trauma patients. Agreements must ((have)) include a process to identify medical control during the interfacility transfer, and address the responsibilities of the trauma service, the receiving hospital, and the verified prehospital transport agency. All trauma patients must be transported by a trauma verified prehospital transport agency.
X
X
X
X
X
X
X
X
(11) An air medical transport plan addressing the receipt or transfer of trauma patients with a heli-stop, landing zone, or airport located close enough to permit the facility to receive or transfer trauma patients by fixed-wing or rotary-wing aircraft.
X
X
X
X
X
X
X
X
(12) A written diversion protocol for the emergency department to divert trauma patients from the field to another trauma service when resources are temporarily unavailable. The process must include:
X
X
X
X
X
X
X
X
(a) Trauma service and patient criteria used to decide when diversion is necessary;
X
X
X
X
X
X
X
X
(b) How the divert status will be communicated to the nearby trauma services and prehospital agencies;
X
X
X
X
X
X
X
X
(c) How the diversion will be coordinated with the appropriate prehospital agency;
X
X
X
X
X
X
X
X
(d) A method of documenting/tracking when the trauma service is on trauma divert, including the date, time, duration, reason, and decision maker((.));
X
X
X
X
X
X
X
X
(e) Assurance that the decision to divert patients from the emergency department is communicated to the trauma surgeon on-call;
X
X
X
 
 
X
X
X
(f) Involvement of the trauma surgeon in the decision regarding diversion each time the center goes on bypass;
X
X
 
 
 
X
X
 
(g) Routine monitoring, documenting and reporting of trauma center diversion hours, including the reason for initiating the diversion policy. Trauma center diversion must not exceed five percent of the time.
X
X
X
 
 
X
X
X
(13) A trauma team activation protocol consistent with the facility's trauma scope of service. The protocol must:
X
X
X
X
X
X
X
X
(a) Define the physiologic, anatomic, and mechanism of injury criteria used to activate the full and modified (if used) trauma teams;
X
X
X
X
X
X
X
X
(b) Identify members of the full and modified (if used) trauma teams consistent with the provider requirements of this chapter;
X
X
X
X
X
X
X
X
(c) Define the process to activate the trauma team. The process must:
X
X
X
X
X
X
X
X
(i) Consistently apply the trauma service's established criteria;
X
X
X
X
X
X
X
X
(ii) Use information obtained from prehospital providers or an emergency department assessment for patients not delivered by a prehospital agency;
X
X
X
X
X
X
X
X
(iii) Be applied regardless of time post injury or previous care, whether delivered by prehospital or other means and whether transported from the scene or transferred from another facility;
X
X
X
X
X
X
X
X
(iv) Include a method to upgrade a modified activation to a full activation when newly acquired information warrants additional capabilities and resources;
X
X
X
X
X
X
X
X
(v) ((For full trauma team activations,)) Include the mandatory presence of a general surgeon for full trauma team activations. The general surgeon assumes leadership and overall care ((-)) using professional judgment regarding the need for surgery ((and/or)) or transfer;
X
X
X
 
 
X
X
X
(vi) ((For full trauma team activations,)) Include the mandatory presence of a general surgeon if general surgery services are included in the facility's trauma scope of service. The general surgeon assumes leadership and overall care ((-)) using professional judgment regarding the need for surgery ((and/or)) or transfer;
 
 
 
X
 
 
 
 
(vii) For trauma team activations in pediatric designated trauma services (within five minutes for level I, twenty minutes for level II or thirty minutes for level III), one of the following pediatric physician specialists must respond:
 
 
 
 
 
X
X
X
(()) (A) A pediatric surgeon;
 
 
 
 
 
 
 
 
(()) (B) A pediatric emergency medicine physician;
 
 
 
 
 
 
 
 
(()) (C) A pediatric intensivist;
 
 
 
 
 
 
 
 
(()) (D) A pediatrician;
 
 
 
 
 
 
 
 
(()) (E) A postgraduate year two or higher pediatric resident.
 
 
 
 
 
 
 
 
(viii) Require multisystem injured patients to be admitted to or evaluated by an identifiable surgical service staffed by credentialed trauma providers.
X
X
X
 
 
 
 
 
(14) Emergency care services available twenty-four hours every day((,)) with:
X
X
X
X
X
X
X
X
(a) An emergency department (except for level V clinics);
X
X
X
X
X
X
X
X
(b) The ability to resuscitate and stabilize adult and pediatric trauma patients in a designated resuscitation area;
X
X
X
X
X
 
 
 
(c) The ability to resuscitate and stabilize pediatric trauma patients in a designated resuscitation area;
 
 
 
 
 
X
X
X
(d) A medical director, who:
X
X
X
 
 
X
X
X
(i) Is board-certified in emergency medicine ((or)), board-certified in general surgery, or is board-certified in another relevant specialty practicing emergency medicine as their primary practice;
X
X
X
 
 
 
 
 
(ii) Is board-certified in pediatric emergency medicine, ((or)) board-certified in emergency medicine with special competence in the care of pediatric patients ((or)), board-certified in general surgery with special competence in the care of pediatric patients, or board-certified in a relevant specialty practicing emergency medicine as their primary practice with special competence in the care of pediatric patients((;)).
 
 
 
 
 
X
X
X
(e) Emergency physicians who:
X
X
X
X
X
X
X
X
(i) Are board-certified in emergency medicine or board-certified in a relevant specialty practicing emergency medicine as their primary practice. This requirement can be met by a postgraduate year two or higher emergency medicine or general surgery resident working under the direct supervision of the attending emergency physician. The resident must be available within five minutes of notification of the patient's arrival to provide leadership and care until arrival of the general surgeon;
X
X
 
 
 
 
 
 
(ii) Are board-certified in pediatric emergency medicine, ((or)) are board-certified in emergency medicine with special competence in the care of pediatric patients, or are board-certified in a relevant specialty practicing emergency medicine as their primary practice with special competence in the care of pediatric patients. This requirement can be met by a postgraduate year two or higher emergency medicine or general surgery resident with special competence in the care of pediatric trauma patients and working under the direct supervision of the attending emergency physician. The resident must be available within five minutes of notification of the patient's arrival((,)) to provide leadership and care until arrival of the general surgeon;
 
 
 
 
 
X
X
 
(iii) Are board-certified in emergency medicine or another relevant specialty practicing emergency medicine as their primary practice((,)) or physicians practicing emergency medicine as their primary practice with current certification in ACLS and ATLS;
 
 
X
 
 
 
 
 
(iv) Are board-certified in pediatric emergency medicine, ((or)) are board-certified in emergency medicine or surgery, with special competence in the care of pediatric patients, ((or)) are board-certified in a relevant specialty practicing emergency medicine as their primary practice, with special competence in the care of pediatric patients, or are physicians with current certification in ATLS((,)) who are practicing emergency medicine as their primary practice((,)) with special competence in the care of pediatric patients;
 
 
 
 
 
 
 
X
(v) Are board-certified in emergency medicine or another relevant specialty and practicing emergency medicine as their primary practice((,)) or physicians with current certification in ACLS and ATLS. A physician assistant (PA) or advanced registered nurse practitioner (ARNP) current in ACLS and ((who audits)) ATLS ((every four years)) may initiate evaluation and treatment upon the patient's arrival in the emergency department until the arrival of the physician;
 
 
 
X
 
 
 
 
(vi) Are board-certified or qualified in emergency medicine, surgery, or other relevant specialty and practicing emergency medicine as their primary practice((,)) or are physicians with current certification in ACLS and ATLS, or ((physician assistants (PAs), or advanced registered nurse practitioners (ARNPs))) are PAs or ARNPs with current certification in ACLS and ((who audit)) ATLS ((every four years));
 
 
 
 
X
 
 
 
(vii) Are available within five minutes of notification of the patient's arrival in the emergency department;
X
X
X
 
 
X
X
X
(viii) Are on-call and available within twenty minutes of notification of the patient's arrival in the emergency department;
 
 
 
X
X
 
 
 
(ix) Are currently certified in ACLS and ATLS. This requirement applies to all emergency physicians and residents who care for trauma patients in the emergency department except this requirement does not apply to physicians who are board-certified in emergency medicine or board-certified in another relevant specialty and practicing emergency medicine as their primary practice;
X
X
X
X
X
 
 
 
(x) Are currently certified in ATLS. This requirement applies to all emergency physicians and residents who care for pediatric patients in the emergency department except this requirement does not apply to physicians who are board-certified in pediatric emergency medicine ((or)), board-certified in emergency medicine, or board-certified in another relevant specialty and practicing emergency medicine as their primary practice;
 
 
 
 
 
X
X
X
(xi) Meet the PER as defined in subsection (27) of this section;
X
X
X
X
X
X
X
X
(xii) If the liaison or designee from emergency medicine, must complete thirty-six hours of trauma-related CME every three years in either external CME or in an internal educational process conducted by the trauma program or meet the requirements for participation in maintenance of certification of a member board of the American Board of Medical Specialties at the time of renewal;
X
X
 
 
 
X
X
 
(xiii) If they are emergency physicians who participate on the trauma team, they must be knowledgeable and current in the care of injured patients. This requirement may be met by completing thirty-six hours of trauma-related CME every three years in either external CME or in an internal educational process conducted by the trauma program or meet the requirements for participation in maintenance of certification of a member board of the American Board of Medical Specialties at the time of renewal;
X
X
 
 
 
X
X
 
(xiv) Nonboard-certified emergency physicians and advanced practitioners who participate in the initial care or evaluation of trauma activated patients in the emergency department must have current ATLS certification;
X
X
X
X
X
X
X
X
(xv) Must be able to provide initial resuscitative care to known trauma activated patients;
X
X
X
 
 
X
X
X
(xvi) Have completed appropriate orientation, credentialing, initial ED management/evaluation processes, and skill maintenance for advanced practitioners who participate in the initial assessment of trauma patients.
X
X
X
X
X
X
X
X
(f) Emergency care registered nurses (RNs)((,)) who:
X
X
X
X
X
X
X
X
(i) Are in the emergency department and available within five minutes of notification of patient's arrival;
X
X
X
 
 
X
X
X
(ii) Are in-house((,)) and available within five minutes of notification of the patient's arrival (((except for level V clinics)));
 
 
 
X
X
 
 
 
(iii) Have current certification in ACLS;
X
X
X
X
X
 
 
 
(iv) Have successfully completed ((a trauma nurse core course ())TNCC(())) or a department approved equivalent course;
X
X
X
X
X
X
X
X
(v) Have completed twelve hours of trauma related education every designation period. The trauma education must include, but is not limited to, the following topics:
 
 
 
 
 
 
 
 
(()) (A) Mechanism of injury;
X
X
X
X
 
X
X
X
(()) (B) Shock and fluid resuscitation;
 
 
 
 
 
 
 
 
(()) (C) Initial assessment;
 
 
 
 
 
 
 
 
(()) (D) Stabilization and transport((;)).
 
 
 
 
 
 
 
 
(vi) Meet the PER as defined in subsection (27) of this section.
X
X
X
X
X
X
X
X
(g) Standard emergency equipment for the resuscitation and life support of adult and pediatric trauma patients, including:
X
X
X
X
X
X
X
X
(i) Immobilization devices:
X
X
X
X
X
X
X
X
(()) (A) Back board;
X
X
X
X
X
X
X
X
(()) (B) Cervical injury;
X
X
X
X
X
X
X
X
(()) (C) Long-bone((;)).
X
X
X
X
X
X
X
X
(ii)(A) Infusion control device:
X
X
X
X
X
X
X
X
(()) (B) Rapid infusion capability((;)).
X
X
X
 
 
X
X
X
(iii) Intraosseous ((needles)) devices;
X
X
X
X
X
X
X
X
(iv) Sterile surgical sets:
X
X
X
X
X
X
X
X
((■ Chest tubes)) (A) Thoracostomy with closed drainage devices;
X
X
X
X
X
X
X
X
(()) (B) Emergency transcutaneous airway;
X
X
X
X
X
X
X
X
((■ Peritoneal lavage)) (C) Bedside ultrasound;
X
X
X
X
 
X
X
X
(()) (D) Thoracotomy;
X
X
X
 
 
X
X
X
(v) Thermal control equipment:
X
X
X
X
X
X
X
X
(()) (A) Blood and fluid warming;
X
X
X
X
X
X
X
X
((■ Devices for assuring warmth during transport;
X
X
X
X
X
X
X
X
■ Expanded scale)) (B) Thermometer capable of detecting hypothermia;
X
X
X
X
X
X
X
X
(()) (C) Patient warming and cooling((;)).
X
X
X
X
X
X
X
X
(vi) Other equipment:
X
X
X
X
X
X
X
X
(()) (A) 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
(()) (B) Pediatric emergency airway equipment readily available or transported in-house with the pediatric patient for evaluation, treatment or diagnostics, including((:
• Bag-valve masks;
• Face masks;
• Oral/nasal airways)) bag-valve masks, face masks, and oral/nasal airways.
X
X
X
X
X
X
X
X
(15) Respiratory therapy services, with a respiratory care practitioner available within five minutes of notification of patient's arrival.
X
X
X
 
 
X
X
X
(16) Diagnostic imaging services (except for level V clinics)((,)) with:
X
X
X
X
X
X
X
X
(a) A radiologist in person or by teleradiology, who is:
X
X
X
 
 
X
X
X
(i) On-call and available within twenty minutes of the trauma team leader's request;
X
X
 
 
 
X
X
 
(ii) On-call and available within thirty minutes of the trauma team leader's request;
 
 
X
 
 
 
 
X
(iii) Board certified or eligible for certification by an appropriate radiology board according to current requirements for licensed radiologists who take trauma call.
X
X
 
 
 
X
X
 
(b) Personnel able to perform routine radiological capabilities((,)) who are:
X
X
X
X
X
X
X
X
(i) Available within five minutes of notification of the patient's arrival;
X
X
 
 
 
X
X
 
(ii) On-call and available within twenty minutes of notification of the patient's arrival((;)).
 
 
X
X
X
 
 
X
(c) A technologist able to perform computerized tomography((,)) who is:
X
X
X
 
 
X
X
X
(i) Available within five minutes of the trauma team leader's request;
X
 
 
 
 
X
 
 
(ii) On-call and available within twenty minutes of the trauma team leader's request((;)).
 
X
X
 
 
 
X
X
(d) A radiologic peer review process that reviews routine interpretations of images for accuracy. Determinations related to trauma patients must be communicated to the trauma program quality committee;
X
X
X
 
 
X
X
X
(((d))) (e) Angiography with a technologist on-call and available within thirty minutes of the trauma team leader's request;
X
X
 
 
 
X
X
 
(((e))) (f) Magnetic resonance imaging((,)) with a technologist on-call and available within sixty minutes of the trauma team leader's request;
X
X
 
 
 
X
X
 
(((f))) (g) Sonography with a technologist on-call and available within thirty minutes of the trauma team leader's request;
X
X
 
 
 
X
X
 
(((g))) (h) Interventional radiology services on-call and available within thirty minutes of the trauma team leader's request((.));
X
X
 
 
 
X
X
 
(i) Radiologists who are involved, at a minimum, in protocol development and trend analysis that relate to diagnostic imaging;
X
X
X
 
 
X
X
X
(j) Facilities that have a mechanism in place to view radiographic imaging from referring hospitals that are within their catchment area.
X
X
 
 
 
X
X
 
(17) Clinical laboratory services (except for level V clinics), with:
X
X
X
X
X
X
X
X
(a) Lab services available within five minutes of notification of the patient's arrival;
X
X
X
 
 
X
X
X
(b) Lab services on-call and available within twenty minutes of notification of the patient's arrival;
 
 
 
X
X
 
 
 
(c) Blood gases and pH determination;
X
X
X
X
 
X
X
X
(d) Coagulation studies;
X
X
X
X
X
X
X
X
(e) Drug or toxicology measurements;
X
X
X
X
X
X
X
X
(f) Microbiology;
X
X
X
X
X
X
X
X
(g) Serum alcohol determination;
X
X
X
X
X
X
X
X
(h) Serum and urine osmolality;
X
X
 
 
 
X
X
 
(i) Standard analysis of blood, urine, and other body fluids.
X
X
X
X
X
X
X
X
(18) Blood and blood-component services (except for level V clinics)((,)) with:
X
X
X
X
X
X
X
X
(a) Ability to obtain blood typing and crossmatching;
X
X
X
X
X
X
X
X
(b) Autotransfusion;
X
X
X
 
 
X
X
X
(c) Blood and blood components available from in-house or through community services, to meet patient needs;
X
X
X
X
X
X
X
X
(d) Blood storage capability;
X
X
X
X
 
X
X
X
(e) Noncrossmatched blood available on patient arrival in the emergency department;
X
X
X
X
X
X
X
X
(f) Policies and procedures for massive transfusion.
X
X
X
X
 
X
X
X
(19) General surgery services((,)) with:
X
X
X
 
 
X
X
X
(a) Surgeons who meet the following requirements:
X
X
X
 
 
X
X
X
(i) Are board-certified in general surgery and available within ((five)) fifteen minutes of notification of the patient's arrival when the full trauma team is activated. This requirement can be met by a postgraduate year four or higher surgery resident. The resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until arrival of the general surgeon. In this case the general surgeon must be available within ((twenty)) fifteen minutes of notification of patient's arrival;
X
 
 
 
 
 
 
 
(ii) Are board-certified in pediatric surgery or board-certified in general surgery with special competence in the care of pediatric patients and are available within ((five)) fifteen minutes of notification of the patient's arrival when the full trauma team is activated. This requirement can be met by a post graduate year four or higher pediatric surgery resident or a general surgery resident with special competence in the care of pediatric patients. The resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until arrival of the pediatric or general surgeon. In this case the pediatric or general surgeon must be available within ((twenty)) fifteen minutes of notification of patient's arrival;
 
 
 
 
 
X
 
 
(iii) Are board-certified in general surgery. For full trauma team activations, the surgeon must be in the emergency department upon patient arrival when prehospital estimated time of arrival (ETA) is ((twenty)) fifteen minutes or more. Otherwise the surgeon must be in the emergency department within ((twenty)) fifteen minutes of notification of patient's arrival. This requirement can be met by a postgraduate year four or higher surgery resident. The resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until arrival of the general surgeon;
 
X
 
 
 
 
 
 
(iv) Are board-certified in pediatric surgery or board-certified in general surgery with special competence in the care of pediatric patients. For full trauma team activations, the surgeon must be in the emergency department upon patient arrival when prehospital estimated time of arrival (ETA) is ((twenty)) fifteen minutes or more. Otherwise the surgeon must be in the emergency department within ((twenty)) fifteen minutes of notification of patient's arrival. This requirement can be met by a postgraduate year four or higher pediatric surgery resident or a general surgical resident with special competence in the care of pediatric patients. The resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until arrival of the pediatric or general surgeon;
 
 
 
 
 
 
X
 
(v) Are board-certified or trained in ACLS and currently certified in ATLS. For full trauma team activations, the surgeon must be in the emergency department upon patient arrival when prehospital estimated time of arrival (ETA) is thirty minutes or more. Otherwise the surgeon must be in the emergency department within thirty minutes of notification of patient's arrival;
 
 
X
 
 
 
 
 
(vi) Are board-certified or board-qualified((,)) with special competence in the care of pediatric patients. For full trauma team activations, the surgeon must be in the emergency department upon patient arrival when prehospital estimated time of arrival (ETA) is thirty minutes or more. Otherwise the surgeon must be in the emergency department within thirty minutes of notification of patient's arrival;
 
 
 
 
 
 
 
X
(vii) Are trained in ACLS and currently certified in ATLS. This requirement applies to all surgeons and residents caring for trauma patients except this requirement does not apply to surgeons who are board certified in general surgery;
X
X
X
 
 
 
 
 
(viii) Are currently certified in ATLS. This requirement applies to all surgeons and residents caring for pediatric trauma patients except this requirement does not apply to surgeons who are board certified in pediatric or general surgery;
 
 
 
 
 
X
X
X
(ix) Meet the PER as defined in subsection (27) of this section;
X
X
X
 
 
X
X
X
(x) Have privileges in general surgery;
X
X
X
 
 
 
 
 
(xi) Maintain at least eighty percent attendance at activations with a mechanism for documenting this attendance record, as required for full trauma activations. The expectation is for one hundred percent attendance at activations;
X
X
X
 
 
X
X
X
(xii) The attending surgeon is expected to be present in the operating room for all operations. A mechanism for documenting this presence is required;
X
X
X
 
 
X
X
X
(xiii) A surgeon from the trauma call panel must participate in the hospital's disaster planning process;
X
X
X
 
 
X
X
X
(xiv) Each member of the group of general surgeons must attend at least fifty percent of the peer review committee meetings;
X
X
 
 
 
X
X
 
(xv) If at least fifty percent of the general surgeons did not attend the peer review committee meetings, then the trauma service must be able to demonstrate that there is a formal process for communicating information from the committee meetings to the group of general surgeons.
 
 
X
 
 
 
 
X
(b) A published schedule for first call with a written plan for ((general)) surgery coverage((,)) if the ((general)) surgeon on call for trauma is otherwise clinically engaged. The plan must take into consideration the trauma service's total patient volume, patient acuity, geographic proximity to other trauma services, depth of trauma care resources, and the trauma scope of service. Diversion or transfer to definitive care should be the last option. The plan must be monitored through the trauma service's trauma quality improvement program((;)). In addition:
X
X
X
 
 
X
X
X
(i) Surgical commitment is required for a properly functioning trauma center;
X
X
X
 
 
X
X
X
(ii) The trauma surgeon on call must be dedicated to a single trauma center while on duty;
X
X
 
 
 
X
X
 
(iii) The liaison from general surgery must complete thirty-six hours of trauma-related CME every three years in either external CME or in an internal educational process conducted by the trauma program or meet the requirements for participation in maintenance of certification of a member board of the American Board of Medical Specialties at the time of renewal;
X
X
 
 
 
X
X
 
(iv) Other general surgeons who participate on the trauma team must be knowledgeable and current in the care of injured patients. This requirement may be met by completing thirty-six hours of trauma-related CME every three years in either external CME or in an internal educational process conducted by the trauma program or meet the requirements for participation in maintenance of certification of a member board of the American Board of Medical Specialties at the time of renewal.
X
X
 
 
 
X
X
 
(c) ((For level IV,)) General surgery services that meet all level III general surgery service standards if the facility's trauma scope of service includes general surgery services twenty-four hours every day((,)) or transfer trauma patients who need general surgery services to a designated trauma service with general surgery services available.
 
 
 
X
 
 
 
 
(20) Neurosurgery services with neurosurgeons((,)) who ((are)) meet the following requirements:
X
X
 
 
 
X
X
 
(a) Are board-certified, and((:)) available within five minutes of the trauma team leader's request;
X
 
 
 
 
X
 
 
(((i) Available within five minutes of the trauma team leader's request;
 
 
 
 
 
 
 
 
(ii))) This requirement can be met by a postgraduate year four or higher neurosurgery resident. The resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until arrival of the neurosurgeon. In this case the neurosurgeon must be available within thirty minutes of the trauma team leader's request((;)).
X
 
 
 
 
X
 
 
(b) Are board-certified or board-qualified and on-call and available within thirty minutes of the trauma team leader's request;
 
X
 
 
 
 
X
 
(c) ((For level III and IV,)) Are board-certified or board-qualified and on-call and available within thirty minutes of the trauma team leader's request if the facility's trauma scope of service includes neurosurgery services twenty-four hours every day or transfer trauma patients who need neurosurgery services to a designated trauma service with neurosurgery services available((.));
 
 
X
X
 
 
 
X
(d) The liaison from neurosurgery must complete thirty-six hours of trauma-related CME every three years in either external CME or in an internal educational process conducted by the trauma program or meet the requirements for participation in maintenance of certification of a member board of the American Board of Medical Specialties at the time of renewal;
X
X
 
 
 
X
X
 
(e) Other neurosurgeons who participate on the trauma team must be knowledgeable and current in the care of injured patients. This requirement may be met by completing thirty-six hours of trauma-related CME every three years in either external CME or in an internal educational process conducted by the trauma program or meet the requirements for participation in maintenance of certification of a member board of the American Board of Medical Specialties at the time of renewal;
X
X
 
 
 
X
X
 
(f) The facility must have a predefined and thoroughly developed neurotrauma diversion plan that is implemented when the neurosurgeon on call becomes encumbered. A neurotrauma diversion plan must include the following:
X
X
 
 
 
X
X
 
(i) Emergency medical services notification of neurosurgery advisory status/divert;
X
X
 
 
 
X
X
 
(ii) A thorough review of each instance by the quality improvement program; and
X
X
 
 
 
X
X
 
(iii) Monitoring of the efficacy of the process by the quality improvement program.
X
X
 
 
 
X
X
 
(g) A published schedule for first call with a written plan for neurosurgery coverage is required, for when the neurosurgeon on call for trauma is otherwise clinically engaged. The plan must take into consideration the trauma services total patient volume, patient acuity, geographic proximity to other trauma services, depth of trauma care resources, and the trauma scope of service. Diversion or transfer to definitive care should be the last option. The plan must be monitored through the trauma services trauma quality improvement program;
X
X
 
 
 
X
X
 
(h) If one neurosurgeon covers two trauma services within the same limited geographic area, there must be a contingency plan.
X
X
 
 
 
X
X
 
(21) Surgical services on-call and available within thirty minutes of the trauma team leader's request for:
X
X
X
 
 
X
X
X
(a) Cardiac surgery;
X
 
 
 
 
X
 
 
(b) Microsurgery;
X
 
 
 
 
X
 
 
(c) Obstetric surgery or for level III trauma services, a plan to manage the pregnant trauma patient;
X
X
X
 
 
X
X
X
(d) Orthopedic surgery((;)) including the following:
X
X
X
 
 
X
X
X
(i) Orthopedic team members must have dedicated call at their institution or have an effective backup call system;
X
X
 
 
 
X
X
 
(ii) If the on-call orthopedic surgeon is unable to respond promptly, a backup consultant on-call surgeon must be available;
X
X
 
 
 
X
X
 
(iii) If the orthopedic surgeon is not dedicated to a single facility while on call, then a published backup schedule is required;
 
 
X
 
 
 
 
X
(iv) A published schedule for first call with a written plan for orthopedic surgery coverage is required for when the orthopedic surgeon on call for trauma is otherwise clinically engaged. The plan must take into consideration the trauma services total patient volume, patient acuity, geographic proximity to other trauma services, depth of trauma care resources, and the trauma scope of service. Diversion or transfer to definitive care should be the last option. The plan must be monitored through the trauma services trauma quality;
X
X
X
 
 
X
X
X
(v) The liaison from orthopedic surgery must complete thirty-six hours of trauma-related CME every three years in either external CME or in an internal educational process conducted by the trauma program or meet the requirements for participation in maintenance of certification of a member board of the American Board of Medical Specialties at the time of renewal;
X
X
 
 
 
X
X
 
(vi) Other orthopedic surgeons who participate on the trauma team must be knowledgeable and current in the care of injured patients. This requirement may be met by completing thirty-six hours of trauma-related CME every three years in either external CME or in an internal educational process conducted by the trauma program or meet the requirements for participation in maintenance of certification of a member board of the American Board of Medical Specialties at the time of renewal.
X
X
 
 
 
X
X
 
(e) ((For level IV,)) Orthopedic surgery services on-call and available within thirty minutes of the trauma team leader's request if the facility's trauma scope of service includes orthopedic surgery services twenty-four hours every day((,)) or transfer trauma patients who need orthopedic surgery services to a designated trauma service with orthopedic surgery services available;
 
 
 
X
 
 
 
 
(f) Thoracic surgery;
X
X
 
 
 
X
X
 
(g) Urologic surgery;
X
X
 
 
 
X
X
 
(h) Vascular surgery.
X
X
 
 
 
X
X
 
(22) Surgical services on-call for patient consultation or management at the trauma team leader's request for:
X
X
 
 
 
X
X
 
(a) Cranial facial surgery;
X
X
 
 
 
X
X
 
(b) Gynecologic surgery;
X
X
 
 
 
X
X
 
(c) Ophthalmic surgery;
X
X
 
 
 
X
X
 
(d) Plastic surgery.
X
X
 
 
 
X
X
 
(23) Anesthesiology services((,)) with board-certified anesthesiologists or certified registered nurse anesthetists (CRNAs)((,)) who meet the following requirements:
X
X
X
 
 
X
X
X
(a) Are available within five minutes of the trauma team leader's request;
X
 
 
 
 
X
 
 
(b) Are on-call and available within twenty minutes of the trauma team leader's request;
 
X
 
 
 
 
X
 
(c) Are on-call and available within thirty minutes of the trauma team leader's request;
 
 
X
 
 
 
 
X
(d) Are ACLS trained except this requirement does not apply to physicians board-certified in anesthesiology;
X
X
X
 
 
X
X
X
(e) Are highly experienced and committed to the care of injured patients; who organize and supervise the anesthetic care of injured patients; and who serve as the designated liaison to the trauma program;
X
X
 
 
 
X
X
 
(f) When anesthesiology senior residents or CRNAs are used to fulfill availability requirements, the attending anesthesiologist on call must be advised, available within thirty minutes at all times, and present for all operations;
X
X
 
 
 
X
X
 
(g) A published schedule for first call, with a written plan for anesthesia coverage is required for when the anesthesia provider on call for trauma is otherwise clinically engaged. The plan must take into consideration the trauma services total patient volume, patient acuity, geographic proximity to other trauma services, depth of trauma care resources, and the trauma scope of service. Diversion or transfer to definitive care should be the last option. The plan must be monitored through the trauma services trauma quality improvement program;
X
X
X
 
 
X
X
X
(((e))) (h) Meet the PER as defined in subsection (27) of this section((.));
X
X
X
 
 
X
X
X
(((f) For level IV,)) (i) Meet all level III anesthesiology service standards((,)) if the facility's trauma scope of service includes surgery services twenty-four hours every day or transfer trauma patients who need surgery services to a designated trauma service with surgery services available.
 
 
 
X
 
 
 
 
(24) Operating room services((,)) with:
X
X
X
 
 
X
X
X
(a) Hospital staff responsible for opening and preparing the operating room available within five minutes of notification;
X
X
X
 
 
X
X
X
(b) Operating room staff on-call and available within ((twenty)) fifteen minutes of notification;
X
X
 
 
 
X
X
 
(c) Operating room staff on-call and available within thirty minutes of notification;
 
 
X
 
 
 
 
X
(d) A written plan to mobilize additional surgical team members for trauma patient surgery;
X
X
X
 
 
X
X
X
(e) Delays in operating room availability routinely monitored. Any case that is associated with a significant delay or adverse outcome must be reviewed for reasons for delay and opportunity for improvement;
X
X
X
 
 
X
X
X
(((e))) (f) Standard surgery instruments and equipment needed to perform operations on adult and pediatric patients, including:
X
X
X
 
 
X
X
X
(i) ((Autologous)) Blood recovery and transfusion;
X
X
X
 
 
X
X
X
(ii) ((Bronchoscopic capability)) Bronchoscopy equipment;
X
X
X
 
 
X
X
X
(iii) Cardiopulmonary bypass;
X
X
 
 
 
X
X
 
(iv) Craniotomy set;
X
X
 
 
 
X
X
 
(v) ((Endoscopes)) Endoscopy equipment;
X
X
X
 
 
X
X
X
(vi) Rapid infusion capability;
X
X
X
 
 
X
X
X
(vii) Thermal control equipment:
X
X
X
 
 
X
X
X
(()) (A) Blood and fluid warming;
X
X
X
 
 
X
X
X
(()) (B) Patient warming and cooling((;)).
X
X
X
 
 
X
X
X
(((f) For level IV,)) (g) Operating room services that meet all level III operating room service standards if the facility's trauma scope of care includes surgery services twenty-four hours every day or transfer trauma patients who need surgery services to a designated trauma service with surgery services available.
 
 
 
X
 
 
 
 
(25) Post anesthesia care (PACU) services with:
X
X
X
 
 
X
X
X
(a) At least one registered nurse available twenty-four hours every day;
X
 
 
 
 
X
 
 
(b) At least one registered nurse on-call and available twenty-four hours every day;
 
X
X
 
 
 
X
X
(c) Registered nurses who are ACLS trained;
X
X
X
 
 
X
X
X
(d) PACU equipment to monitor and resuscitate patients, including:
 
 
 
 
 
 
(i) Pulse oximetry;
 
 
 
 
 
 
 
 
(ii) End-tidal carbon dioxide detection;
X
X
X
 
 
X
X
X
(iii) Arterial pressure monitoring;
 
 
 
 
 
 
 
 
(iv) Patient rewarming.
 
 
 
 
 
 
 
 
(((d) For level IV,)) (e) Post anesthesia care services that meet all level III post anesthesia care service standards if the facility's trauma scope of care includes general surgery services twenty-four hours every day or transfer trauma patients who need surgery services to a designated trauma service with surgery services available.
 
 
 
X
 
 
 
 
(26) Critical care services((,)) with:
X
X
X
 
 
X
X
 
(a) A critical care medical director((,)) who is:
X
X
X
 
 
X
X
 
(i) Board-certified in:
X
 
 
 
 
 
 
 
(A) Surgery and critical care;
X
 
 
 
 
 
 
 
(B) Pediatric critical care((;)).
 
 
 
 
 
X
 
 
(ii) Board-certified in critical care or board-certified in surgery, internal medicine, or anesthesiology with special competence in critical care;
 
X
X
 
 
 
 
 
(iii) Board-certified in critical care((,)) with special competence in pediatric critical care or is board-certified in surgery, internal medicine, or anesthesiology((,)) with special competence in pediatric critical care;
 
 
 
 
 
 
X
 
(iv) Responsible for coordinating with the attending physician for trauma patient care((;)).
X
X
X
 
 
X
X
 
(b) Physician coverage of critically ill trauma patients in the intensive care unit (ICU) by appropriately trained physicians who meet the following requirements:
X
X
X
 
 
X
X
X
(i) Must be available in-house within fifteen minutes, twenty-four hours per day;
X
 
 
 
 
X
 
 
(ii) Must be available within fifteen minutes, twenty-four hours per day;
 
X
 
 
 
 
X
 
(iii) Must be available within thirty minutes with a formal plan in place for emergency coverage.
 
 
X
 
 
 
 
X
(c) For all levels of trauma service, the quality improvement program must ensure timely and appropriate ICU coverage is provided;
X
X
X
 
 
X
X
X
(d) The timely response of credentialed providers to the ICU must be continuously monitored as part of the quality improvement program;
X
X
X
 
 
X
X
X
(e) A designated ICU physician liaison or designee to the trauma service. This liaison must attend at least fifty percent of the multidisciplinary peer review meetings with documentation by the trauma quality improvement program;
X
X
X
 
 
X
X
X
(f) The physician liaison or designee from the ICU must complete thirty-six hours of trauma-related CME every three years in either external CME or in an internal educational process conducted by the trauma program or meet the requirements for participation in maintenance of certification of a member board of the American Board of Medical Specialties at the time of renewal;
X
X
 
 
 
X
X
 
(g) Other ICU physicians who participate on the trauma team must be knowledgeable and current in the care of injured patients. This requirement may be met by completing thirty-six hours of trauma-related CME every three years in either external CME or in an internal educational process conducted by the trauma program or meet the requirements for participation in maintenance of certification of a member board of the American Board of Medical Specialties at the time of renewal;
X
X
 
 
 
X
X
 
(((b))) (h) Critical care registered nurses((,)) who:
X
X
X
 
 
X
X
 
(i) Are ACLS trained;
X
X
X
 
 
 
 
 
(ii) Have special competence in pediatric critical care;
 
 
 
 
 
X
X
 
(iii) Have completed a minimum of six contact hours of trauma specific education every three-year designation period;
X
X
 
 
 
X
X
 
(iv) Have completed a minimum of three contact hours of trauma specific education every three-year designation period((;)).
 
 
X
 
 
 
 
 
(((c))) (i) A physician directed code team;
X
X
X
 
 
X
X
 
(((d))) (j) Pediatric patient isolation capacity;
 
 
 
 
 
X
X
 
(((e))) (k) General surgery consults for critical care trauma patients or if intensivists are the primary admitting nonsurgical physician caring for trauma patients, the intensivists must complete a minimum of twelve hours of external or internal trauma critical care specific ((continuing medical education ())CME(())) every three-year designation period;
X
X
X
 
 
X
X
X
(((f))) (l) Standard critical care equipment for adult and pediatric trauma patients, including:
X
X
X
 
 
X
X
 
(i) Cardiac devices:
X
X
X
 
 
X
X
 
(()) (A) Cardiac pacing capabilities;
X
X
X
 
 
X
X
 
(()) (B) Cardiac monitor with at least two pressure monitoring modules (cardiac output and hard copy recording), with the capability to continuously monitor heart rate, respiratory rate, and temperature((;)).
X
X
X
 
 
X
X
 
(ii) Intracranial pressure monitoring devices;
X
X
 
 
 
X
X
 
(iii) Intravenous supplies:
X
X
X
 
 
X
X
 
(()) (A) Infusion control device;
X
X
X
 
 
X
X
 
(()) (B) Rapid infusion capability((;)).
X
X
X
 
 
X
X
 
(iv) Sterile surgical sets:
X
X
X
 
 
X
X
 
((■ Chest tubes)) (A) Thoracostomy;
X
X
X
 
 
X
X
 
(()) (B) Emergency surgical airway;
X
X
X
 
 
X
X
 
((■ Peritoneal lavage)) (C) Bedside ultrasound;
X
X
X
 
 
X
X
 
(()) (D) Thoracotomy((;)).
X
X
X
 
 
X
X
 
(v) Thermal control equipment:
X
X
X
 
 
X
X
 
(()) (A) Blood and fluid warming;
X
X
X
 
 
X
X
 
(()) (B) Devices for assuring warmth during transport;
X
X
X
 
 
X
X
 
(()) (C) Expanded scale thermometer capable of detecting hypothermia;
X
X
X
 
 
X
X
 
(()) (D) Patient warming and cooling((;)).
X
X
X
 
 
X
X
 
(((g))) (m) A written policy to transfer all pediatric trauma patients who need critical care services to a pediatric designated trauma service with critical care services available;
X
X
X
 
 
 
 
 
(n) Surgical collaboration to set and implement policies and administrative decisions impacting trauma patients admitted to the ICU;
X
X
X
 
 
X
X
X
(((h) For level IV,)) (o) Critical care services that meet all level III critical care service standards, if the facility's trauma scope of service includes critical care services for trauma patients twenty-four hours every day or transfer trauma patients who need critical care services to a designated trauma service with critical care services available;
 
 
 
X
 
 
 
 
(((i) For level III pediatric trauma services,)) (p) Critical care services that meet all level II pediatric critical care service standards if the facility's trauma scope of care includes pediatric critical care services for trauma patients twenty-four hours every day or transfer pediatric trauma patients who need critical care services to a designated pediatric trauma service, with pediatric critical care services available.
 
 
 
 
 
 
 
X
(27) Pediatric education requirement (PER):
X
X
X
X
X
X
X
X
(a) The pediatric trauma medical director and the liaisons from neurosurgery, orthopedic surgery, emergency medicine, and critical care medicine must complete thirty-six hours of trauma-related CME every three years in either external CME or in an internal educational process conducted by the trauma program or meet the requirements for participation in maintenance of certification of a member board of the American Board of Medical Specialties at the time of renewal;
 
 
 
 
 
X
X
 
(((a))) (b) PER must be met by the following providers who are directly involved in the initial resuscitation and stabilization of pediatric trauma patients:
X
X
X
X
X
X
X
X
(i) Emergency department physicians;
X
X
X
X
X
X
X
X
(ii) Emergency department registered nurses;
X
X
X
X
X
X
X
X
(iii) Physician assistants or ARNPs who ((initiate evaluation and treatment prior to the arrival of the physician in the emergency department)) participate in the initial care or evaluation of trauma activated patients in the emergency department;
X
X
X
X
X
X
X
X
(iv) Emergency medicine or surgical residents who initiate care prior to the arrival of the emergency physician;
X
X
 
 
 
X
X
 
(v) General surgeons;
X
X
X
 
 
X
X
X
(vi) Surgical residents who initiate care prior to the arrival of the general surgeon;
X
X
 
 
 
X
X
 
(vii) Anesthesiologists and CRNAs;
X
X
X
 
 
X
X
X
(viii) General surgeons, anesthesiologists, and CRNAs if the facility's trauma scope of service includes general surgery services twenty-four hours every day;
 
 
 
X
 
 
 
 
(ix) Intensivists involved in the resuscitation, stabilization and in-patient care of pediatric trauma patients((;)).
 
 
 
 
 
X
X
X
(((b))) (c) PER must be met by completing pediatric specific contact hours as defined below:
X
X
X
X
X
X
X
X
(i) Five contact hours per provider during each three-year designation period;
X
X
X
X
X
 
 
 
(ii) Seven contact hours per provider during each three-year designation period;
 
 
 
 
 
X
X
X
(iii) Contact hours should include, but are not limited to, the following topics:
X
X
X
X
X
X
X
X
(()) (A) Initial stabilization and transfer of pediatric trauma;
X
X
X
X
X
X
X
X
(()) (B) Assessment and management of pediatric airway and breathing;
X
X
X
X
X
X
X
X
(()) (C) Assessment and management of pediatric shock, including vascular access;
X
X
X
X
X
X
X
X
(()) (D) Assessment and management of pediatric head injuries;
X
X
X
X
X
X
X
X
(()) (E) Assessment and management of pediatric blunt abdominal trauma((;)).
X