WSR 02-09-043

PROPOSED RULES

DEPARTMENT OF HEALTH


[ Filed April 12, 2002, 1:07 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 01-10-131.

Title of Rule: Pediatric education requirements (PER) for designated trauma care services and pediatric trauma care services, WAC 246-976-500, 246-976-510, 246-976-560, 246-976-600, 246-976-610, 246-976-650, 246-976-720, 246-976-730, 246-976-770, 246-976-780, 246-976-810, 246-976-820 and 246-976-885, and new sections WAC 246-976-886 and 246-976-887.

Purpose: The purpose of the proposed rule change is to ensure that all level I, II, III, and IV designated trauma care facilities and all level I, II, and III designated pediatric trauma care facilities have the appropriate pediatric education pertinent to the level of care that they provide and relevant to each of the various types of providers.

Statutory Authority for Adoption: Chapter 70.168 RCW.

Statute Being Implemented: Chapter 70.168 RCW.

Summary: The current rule requires pediatric advanced life support (PALS) or equivalent training. This amendment will add two additional training methods for clinical personnel to obtain PER. There would now be three ways for clinical personnel in all designated trauma services to obtain PER.

Reasons Supporting Proposal: The amendments create a set of pediatric education requirements that are more relevant to the various types of providers and which will better meet the intent of the statute (chapter 70.168 RCW).

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Scott Hogan, 20435 72nd Avenue South, Suite 200, Mailstop TB-33A, Kent, WA 98032, (253) 395-7009.

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: The current rule requires PALS or equivalent training. This amendment will add two additional training methods for clinical personnel to obtain PER. There would now be three ways for clinical personnel in all designated trauma services to obtain PER.

The purpose of the proposed rule change is to ensure that all level I, II, III, and IV designated trauma care facilities and all level I, II, and III designated pediatric trauma care facilities have the appropriate pediatric education pertinent to the level of care that they provide and relevant to each of the various types of providers.

Pediatric trauma care is an important piece of the trauma system. With limited number and geographic distribution of children's hospitals, all injured pediatric patients cannot be cared for in these institutions; therefore, other institutions must also be available to provide this resource to the communities. By establishing pediatric education requirements that are pertinent to the level of care that the facility provides and relevant to each of the various types of providers we have established an efficient and well-coordinated statewide emergency medical services and trauma care system.

Proposal Changes the Following Existing Rules: In addition to the current requirement of a one-time completion of PALS, or a substantially equivalent training course, providers will now be able to choose from two additional methods for completing their PER. These two additional methods include (1) current certification in advanced trauma life support (ATLS) or (2) documentation of contact hours of pediatric trauma education during each designation period (five hours for nonpediatric designated facilities or seven hours for designated pediatric facilities).

Two new sections of WAC have been created (WAC 246-976-886 and 246-976-887) that clearly outline what methods may be used for completing the PER. WAC 246-976-886 outlines the PER methods for nonpediatric designated facilities and 246-976-887 outlines the methods for pediatric designated facilities. These WAC sections are referenced throughout WAC 246-976-500, 246-976-510, 246-976-560, 246-976-600, 246-976-610, 246-976-650, 246-976-720, 246-976-730, 246-976-770, 246-976-780, 246-976-810, 246-976-820, and 246-976-885 Designation of trauma care facilities.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The rule has been reviewed and analyzed, and it has been determined that no small business economic impact statement is required. The proposed rule amendment would reduce costs by expanding the options available for pediatric education requirements. To obtain a copy of the analysis contact Tami Schweppe, DOH, EMS and Trauma, P.O. Box 47853, Olympia, WA 98504-7853, (360) 705-6748, fax (360) 705-6706, e-mail tami.schweppe@doh.wa.gov.

RCW 34.05.328 applies to this rule adoption. The proposed rule is a significant legislative rule because it establishes, alters, or revokes any qualification or standard for the issuance, suspension, or revocation of a license or permit. In this instance it is the recognition as a designated pediatric or nonpediatric trauma care facility.

Hearing Location: Department of Health, Office of Emergency Medical and Trauma Prevention, Training Room, 2725 Harrison Avenue N.W., Suite 500, Olympia, WA 98504-7853, on Wednesday, May 22, 2002, at 9:00 a.m.

Assistance for Persons with Disabilities: Contact Tami Schweppe by Wednesday, May 15, 2002, TDD (800) 833-6388, or (360) 705-6748.

Submit Written Comments to: Tami Schweppe, P.O. Box 47853, Olympia, WA 98504-7853, fax (360) 705-6706, by Wednesday, May 15, 2002.

Date of Intended Adoption: May 22, 2002.

April 12, 2002

Mary C. Selecky

Secretary

OTS-5443.2


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

WAC 246-976-500   Designation standards for facilities providing level I trauma care service -- Administration and organization.   A facility with a designated level I trauma care service shall have:

(1)(a) Organization and direction by a general surgeon with special competence in care of the injured. The service may have as codirector another general surgeon with special competence in care of the injured;

(b) Ongoing coordination of the trauma care service by a registered nurse with special competence in care of the injured;

(c) A multidisciplinary trauma committee chaired by the trauma service director with input to hospital management, including:

(i) An emergency physician;

(ii) An emergency department registered nurse;

(iii) A general surgeon with special competence in trauma care;

(iv) A neurosurgeon;

(v) An orthopaedic surgeon;

(vi) A pediatrician;

(vii) An anesthesiologist;

(viii) The physician director of critical care service;

(ix) The trauma care service nurse coordinator;

(x) Critical care registered nurse; and

(xi) The trauma rehabilitation coordinator;

(d) The multidisciplinary trauma committee shall adopt an approved method to determine activation of the trauma team, as described in WAC 246-976-870.

(e) A trauma team to provide initial evaluation, resuscitation and treatment.

(i) The team shall be organized and directed by a general surgeon with special competence in care of the injured, and who assumes responsibility for coordination of overall care of the trauma patient. The surgeon shall be at least a ((post-graduate)) postgraduate year four resident;

(ii) All members of the team, including the surgeon, shall be available within five minutes of notification of team activation;

(iii) The team shall include an emergency physician who is:

(A) Responsible for activating the team, using an approved method as defined in WAC 246-976-870; and

(B) Responsible for providing team leadership and care for the trauma patient until the arrival of the general surgeon in the resuscitation area;

(iv) The trauma care service shall identify all other members of the team;

(f) Specific delineation of trauma surgery privileges by the medical staff.

(2) An emergency department with written standards of care to ensure immediate and appropriate care for adult and pediatric trauma patients.

(3) A surgery department, including:

(a) General surgery;

(b) A neurosurgical service. Coverage shall be available within five minutes of notification of team activation. Coverage shall be provided by:

(i) A neurosurgeon; or

(ii) A surgeon who has been judged competent by the neurosurgical consultants on staff to initiate measures to stabilize the patient, and to initiate diagnostic procedures, with a board-certified neurosurgeon on-call and available within thirty minutes of notification of team activation.

(c) The following surgical services on-call and available within thirty minutes of request by the trauma team leader:

(i) Cardiac surgery;

(ii) Gynecologic surgery;

(iii) Hand surgery;

(iv) Microsurgery;

(v) Obstetric surgery;

(vi) Ophthalmic surgery;

(vii) Oral/maxillofacial or otorhinolaryngologic surgery;

(viii) Orthopaedic surgery;

(ix) Pediatric surgery;

(x) Plastic surgery;

(xi) Thoracic surgery;

(xii) Urologic surgery; and

(xiii) Vascular surgery.

(4) Nonsurgical specialties including:

(a) Anesthesiology, with an anesthesiologist who ((is)):

(i) Is ACLS trained, except this requirement shall not apply to a physician board-certified in anesthesiology;

(ii) ((PALS or approved equivalent trained;)) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-886;

(iii) Is available within five minutes of notification of team activation;

(b) A radiologist on-call and available for patient service within twenty minutes of notification of team activation;

(c) The following services on-call and available for patient consultation or management:

(i) Cardiology;

(ii) Gastroenterology;

(iii) Hematology;

(iv) Infectious disease specialists;

(v) Internal medicine;

(vi) Nephrology;

(vii) Neurology;

(viii) Pathology;

(ix) Pediatrics; and

(x) Pulmonology.

(5) Written policy and procedures for access to ancillary services, including:

(a) Chemical dependency services;

(b) Child and adult protection services;

(c) Clergy or pastoral care;

(d) Nutritionist services;

(e) Occupational therapy services;

(f) Pharmacy services, with a pharmacist in-house;

(g) Physical therapy services;

(h) Rehabilitation services;

(i) Social services;

(j) Psychological services; and

(k) Speech therapy services.

(6) A pediatric trauma policy that:

(a) Provides for initial stabilization and resuscitation of pediatric trauma patients, including emergency department and surgical interventions; and

(b) If the facility is not designated as a pediatric trauma care service, identifies and establishes its scope of pediatric trauma care, including but not limited to:

(i) Criteria for admission of pediatric patients;

(ii) Written transfer guidelines and agreements for pediatric trauma patients requiring critical care services.

(7) A written policy and procedures to divert patients to other designated trauma care services. The policy shall be based on criteria which reflect the service's ability to resuscitate and stabilize each patient at a particular time.

(8) A trauma registry as required in WAC 246-976-430.

(9) A quality assurance program in accordance with WAC 246-976-880; and cooperate with regional trauma care quality assurance programs throughout the state established pursuant to WAC 246-976-910.

(10) Interfacility transfer guidelines and agreements consistent with WAC 246-976-890.

[Statutory Authority: Chapter 70.168 RCW. 98-04-038, 246-976-500, 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), 246-976-500, filed 12/23/92, effective 1/23/93.]


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

WAC 246-976-510   Designation standards for facilities providing level I trauma care service -- Basic resources and capabilities.   A facility with a designated level I trauma care service shall have:

(1) An emergency department with:

(a) A physician director who:

(i)(A) Is board-certified in emergency medicine, surgery or other relevant specialty; or

(B) 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;

(ii) Is ATLS and ACLS trained, except this requirement shall not apply to a physician board-certified in emergency medicine; and

(iii) ((Is PALS or approved equivalent trained)) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-886, except that this requirement shall not apply to a physician board-certified in pediatric emergency medicine.

(b) Physicians who:

(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; (this requirement may be met by a surgical resident post graduate year two who is ATLS, and ACLS trained, has completed the PER as defined in WAC 246-976-886, and ((PALS or approved equivalent trained,)) is working under the direct supervision of the attending emergency physician, until the arrival of the surgeon to assume leadership of the trauma team);

(ii) Are available within five minutes of patient's arrival in the emergency department;

(iii) Are ATLS and ACLS trained, except this requirement shall not apply to a physician board-certified in emergency medicine;

(iv) ((Are PALS or approved equivalent trained)) Have completed the PER as defined in WAC 246-976-886, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine; and

(v) Are designated as members of the trauma team;

(c) Registered nurses who:

(i) Are ACLS trained;

(ii) ((Are PALS or approved equivalent trained;)) Have completed the PER as defined in WAC 246-976-886;

(iii) Have successfully completed a trauma life support course as defined in WAC 246-976-885; and

(iv) Are in the emergency department and available within five minutes of patient's arrival in the emergency department;

(d) An area designated for adult and pediatric resuscitation, with equipment for resuscitation and life support of pediatric and adult trauma patients, including equipment described in WAC 246-976-620;

(e) Routine radiological capabilities by a technician available within five minutes of notification of team activation.

(2) A surgery department including:

(a) An attending general surgeon available within five minutes of notification of team activation, except as provided in (b) of this subsection. The attending surgeon shall:

(i) Provide trauma team leadership upon arrival in the resuscitation area;

(ii) Be board-certified;

(iii) Have trauma surgery privileges as delineated by the medical staff;

(b) A ((post-graduate)) 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 shall be available within twenty minutes of notification of team activation.

(c) All general surgeons and surgical residents who are responsible for care and treatment of trauma patients shall ((be trained in)):

(i) Be trained in ATLS and ACLS, except this requirement shall not apply to a physician board-certified in surgery; and

(ii) ((PALS or approved equivalent.)) Have completed the PER as defined in WAC 246-976-886.

(3) An operating room available within five minutes of notification of team activation, with:

(a) A registered nurse or designee of the operating room staff who is available within five minutes of notification of team activation to open the operating room, and to coordinate responsibilities to ensure the operating room is ready for surgery upon arrival of the patient, the surgeon, and the anesthesiologist;

(b) A written policy providing for mobilization of additional surgical teams for trauma patients; and

(c) Instruments and equipment appropriate for pediatric and adult surgery, including equipment described in WAC 246-976-620.

(4) A post anesthetic recovery unit with:

(a) Essential personnel, including at least one registered nurse available twenty-four hours a day;

(b) Nurses ACLS trained;

(c) Nurses ((PALS or approved equivalent trained)) who have completed the PER as defined in WAC 246-976-886; and

(d) Appropriate monitoring and resuscitation equipment.

(5) A critical care service with:

(a) A medical director of the surgical critical care unit who is:

(i) Board-certified in surgery with special competence in critical care;

(ii) ATLS and ACLS trained, except this requirement shall not apply to a physician board-certified in surgery;

(iii) Responsible for coordinating with the attending staff for the care of trauma patients, including:

(A) Development and implementation of policies;

(B) Coordination of medical care;

(C) Determination of patient isolation;

(D) Authority for patient placement decisions;

(E) Equipment;

(F) Coordination of staff education;

(G) Coordination of statistics;

(H) Identification of criteria for reviewing quality of care on all critical care unit trauma patients, in conjunction with the trauma service medical director;

(b) A physician with special competence in critical care available in the critical care unit within five minutes of notification;

(c) A physician directed code team;

(d) Critical care unit registered nurses with special competence in trauma care, who:

(i) Are ACLS trained; and

(ii) Have successfully completed a trauma life support course as defined in WAC 246-976-885;

(e) If the facility is not designated as a pediatric trauma care service, have a written transfer agreement and guidelines for pediatric trauma patients;

(f) Equipment as described in WAC 246-976-620.

(6) Respiratory therapy available within five minutes of notification.

(7) A clinical laboratory technologist available within five minutes of notification;

(8) Clinical laboratory services, including:

(a) Standard analysis of blood, urine, and other body fluids;

(b) Coagulation studies;

(c) Blood gases and pH determination;

(d) Serum and urine osmolality;

(e) Microbiology;

(f) Serum alcohol and toxicology determination;

(g) Drug screening; and

(h) Microtechnique.

(9) Blood and blood-component services, including:

(a) Blood and blood components available from in-house or through community services, to meet patient needs;

(b) Noncrossmatched blood available on patient arrival in the emergency department;

(c) Blood typing and cross-matching;

(d) Policies and procedures for massive transfusion;

(e) Autotransfusion; and

(f) Blood storage capability.

(10) Radiological services, including:

(a) A technician available within five minutes of notification, able to perform the following:

(i) Computerized tomography; and

(ii) Routine radiological capabilities;

(b) A technician on-call and available within twenty minutes of notification, able to perform the following:

(i) Angiography of all types;

(ii) Sonography; and

(iii) Nuclear scanning.

(11) Acute dialysis capability, or written transfer agreements.

(12)(a) A physician-directed burn unit staffed by nursing personnel trained in burn care; and is equipped to care for extensively burned patients; or

(b) Written transfer guidelines in accordance with the guidelines of the American Burn Association, and transfer agreements for burn care.

(13) The ability to manage acute head and/or spinal cord injuries. Early transfer to an appropriate designated trauma rehabilitation service shall be considered.

(14) A trauma rehabilitation coordinator to facilitate the trauma patient's access to rehabilitation services.

(15)(a) A designated trauma rehabilitation service; or

(b) Written agreements to transfer patients to a designated trauma rehabilitation service when medically feasible.

(16) 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.

[Statutory Authority: Chapter 70.168 RCW. 98-04-038, 246-976-510, filed 1/29/98, effective 3/1/98; 93-20-063, 246-976-510, filed 10/1/93, effective 11/1/93. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-510, filed 12/23/92, effective 1/23/93.]


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

WAC 246-976-550   Designation standards for facilities providing level II trauma care service -- Administration and organization.   A facility with a designated level II trauma care service shall have:

(1)(a) Organization and direction by a general surgeon with special competence in care of the injured. The service may have as codirector another physician with special competence in care of the injured;

(b) Ongoing coordination of the trauma care service by a registered nurse with special competence in care of the injured;

(c) A multidisciplinary trauma committee chaired by the trauma service director, with input to hospital management, including:

(i) An emergency physician;

(ii) An emergency department registered nurse;

(iii) A general surgeon with special competence in trauma care;

(iv) A neurosurgeon;

(v) An orthopaedic surgeon;

(vi) A pediatrician;

(vii) An anesthesiologist;

(viii) The physician director of the critical care service;

(ix) The trauma care service nurse coordinator;

(x) A critical care registered nurse; and

(xi) The trauma rehabilitation coordinator;

(d) The multidisciplinary trauma committee shall adopt an approved method to determine activation of the trauma team, as described in WAC 246-976-870;

(e) A trauma team to provide initial evaluation, resuscitation and treatment.

(i) The team shall be organized and directed by a general surgeon with special competence in care of the injured, and who assumes responsibility for coordination of overall care of the trauma patient;

(ii) All members of the team, except the surgeon and anesthesiologist, shall be available within five minutes of notification of team activation;

(iii) The team shall include:

(A) An emergency physician who is:

(I) Responsible for activating the team, using an approved method as defined in WAC 246-976-870; and

(II) Responsible for providing team leadership and care for the trauma patient until the arrival of the general surgeon in the resuscitation area;

(B) A general surgeon on-call and available within twenty minutes of notification of team activation, who shall assume responsibility for patient care upon arrival in the resuscitation area;

(iv) The trauma care service shall identify all other members of the team;

(f) Specific delineation of trauma surgery privileges by the medical staff.

(2) An emergency department with written standards of care to ensure immediate and appropriate care for adult and pediatric trauma patients.

(3) A surgery department, including:

(a) General surgery;

(b) A neurosurgical service. Coverage shall be available within five minutes of notification of team activation. In-house coverage shall be provided by:

(i) A neurosurgeon; or

(ii) A surgeon or other physician who has been judged competent by the neurosurgical consultants on staff to initiate measures to stabilize the patient, and to initiate diagnostic procedures; with a surgeon with neurosurgical privileges on-call and available within thirty minutes of notification of team activation;

(c) The following surgical services on-call and available within thirty minutes of request by the trauma team leader:

(i) Gynecologic surgery;

(ii) Hand surgery;

(iii) Obstetric surgery;

(iv) Ophthalmic surgery;

(v) Oral/maxillofacial or otorhinolaryngologic surgery;

(vi) Orthopaedic surgery;

(vii) Plastic surgery;

(viii) Thoracic surgery;

(ix) Urologic surgery; and

(x) Vascular surgery.

(4) Nonsurgical specialties, including:

(a) Anesthesiology, with an anesthesiologist who ((is)):

(i) Is ACLS trained, except this requirement shall not apply to a physician board-certified in anesthesiology;

(ii) ((PALS or approved equivalent trained; and)) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-886; and

(iii) Is on-call and available within twenty minutes of notification of team activation;

(b) A radiologist on-call and available for patient service within twenty minutes of notification of team activation; and

(c) The following services on-call and available for patient consultation or management:

(i) Cardiology;

(ii) Gastroenterology;

(iii) Hematology;

(iv) Infectious disease specialists;

(v) Internal medicine;

(vi) Nephrology;

(vii) Neurology;

(viii) Pathology;

(ix) Pediatrics; and

(x) Pulmonology.

(5) Written policy and procedures for access to ancillary services, including:

(a) Chemical dependency services;

(b) Child and adult protection services;

(c) Clergy or pastoral care;

(d) Nutritionist services;

(e) Occupational therapy services;

(f) Pharmacy;

(g) Physical therapy services;

(h) Rehabilitation services;

(i) Social services; and

(j) Speech therapy services.

(6) A pediatric trauma policy that:

(a) Provides for initial stabilization and resuscitation of pediatric trauma patients, including emergency department and surgical interventions; and

(b) If the facility is not designated as a pediatric trauma care service, identifies and establishes its scope of pediatric trauma care, including but not limited to:

(i) Criteria for admission of pediatric patients;

(ii) Written transfer guidelines and agreements for pediatric trauma patients requiring critical care services.

(7) A written policy and procedures to divert patients to other designated trauma care services. The policy shall be based on criteria which reflect the service's ability to resuscitate and stabilize each patient at a particular time.

(8) A trauma registry as required in WAC 246-976-430.

(9) A quality assurance program in accordance with WAC 246-976-880; and cooperate with regional trauma care quality assurance programs throughout the state established pursuant to WAC 246-976-910.

(10) Interfacility transfer guidelines and agreements consistent with WAC 246-976-890.

[Statutory Authority: Chapter 70.168 RCW. 98-04-038, 246-976-550, 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), 246-976-550, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending WSR 98-19-107, filed 9/23/98, effective 10/24/98)

WAC 246-976-560   Designation standards for facilities providing level II trauma care service -- Basic resources and capabilities.   A facility with a designated level II trauma care service shall have:

(1) An emergency department, with:

(a) A physician director who ((is)):

(i) Is board-certified in emergency medicine or other relevant specialty;

(ii) Is ATLS and ACLS trained, except this requirement shall not apply to a physician board-certified in emergency medicine; and

(iii) ((PALS or approved equivalent trained)) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-886, except that this requirement shall not apply to a physician board-certified in pediatric emergency medicine.

(b) Physicians who:

(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;

(ii) Are available within five minutes of patient's arrival in the emergency department;

(iii) Are ATLS and ACLS trained, except this requirement shall not apply to a physician board-certified in emergency medicine;

(iv) ((Are PALS or approved equivalent trained)) Have completed the PER as defined in WAC 246-976-886, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine; and

(v) Are designated as members of the trauma team;

(c) Registered nurses who:

(i) Are ACLS trained;

(ii) ((Are PALS or approved equivalent trained;)) Have completed the PER as defined in WAC 246-976-886;

(iii) Have successfully completed a trauma life support course as defined in WAC 246-976-885; and

(iv) Are in the emergency department and available within five minutes of patient's arrival in the emergency department;

(d) An area designated for adult and pediatric resuscitation, with equipment for resuscitation and life support of pediatric and adult trauma patients, including equipment as described in WAC 246-976-620;

(e) Routine radiological capabilities by a technician available within five minutes of notification of team activation.

(2) A surgery department, including:

(a) An attending general surgeon on-call and available within twenty minutes of notification of team activation. The attending surgeon shall:

(i) Provide trauma team leadership upon arrival in the resuscitation area;

(ii) Be board-certified;

(iii) Have trauma surgery privileges as delineated by the medical staff; or

(b) A ((post-graduate)) 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 shall be available within twenty minutes upon notification of team activation. The resident shall have ATLS training and ((PALS or approved equivalent training)) have completed the PER as defined in WAC 246-976-886;

(c) All general surgeons who are responsible for care and treatment of trauma patients shall ((be trained in)):

(i) Be trained in ATLS and ACLS, except this requirement shall not apply to a physician board-certified in surgery; and

(ii) ((PALS or approved equivalent.)) Have completed the PER as defined in WAC 246-976-886.

(3) An operating room available within five minutes of notification of team activation, with:

(a) A registered nurse or designee of the operating room staff who is available within five minutes of notification of team activation to open the operating room, and to coordinate responsibilities to ensure the operating room is ready for surgery upon arrival of the patient, the surgeon, and the anesthesiologist;

(b) Other essential personnel on-call and available within twenty minutes of notification of team activation;

(c) A written policy providing for mobilization of additional surgical teams for trauma patients; and

(d) Instruments and equipment appropriate for pediatric and adult surgery, including equipment as described in WAC 246-976-620.

(4) A post anesthetic recovery unit with:

(a) Essential personnel, including at least one registered nurse, on-call and available twenty-four hours a day;

(b) Nurses ACLS trained;

(c) Nurses ((PALS or approved equivalent trained; and)) who have completed the PER as defined in WAC 246-976-886; and

(d) Appropriate monitoring and resuscitation equipment.

(5) A critical care service, with:

(a) A medical director who is:

(i) Board-certified in surgery, internal medicine, or anesthesiology, with special competence in critical care; and

(ii) Responsible for coordinating with the attending staff for the care of trauma patients, including:

(A) Development and implementation of policies;

(B) Coordination of medical care;

(C) Determination of patient isolation;

(D) Authority for patient placement decisions;

(E) Equipment;

(F) Coordination of staff education;

(G) Coordination of statistics;

(H) Identification of criteria for reviewing quality of care on all critical care unit trauma patients, in conjunction with the trauma service medical director;

(b) A physician available in the critical care unit within five minutes of notification;

(c) A physician directed code team;

(d) Critical care unit registered nurses with special competence in trauma care, who:

(i) Are ACLS trained;

(ii) Have successfully completed a trauma life support course as defined in WAC 246-976-885;

(e) If the facility is not designated as a pediatric trauma care service, have a written transfer agreement and guidelines for pediatric trauma patients;

(f) Equipment as described in WAC 246-976-620.

(6) Respiratory therapy available within five minutes of notification.

(7) A clinical laboratory technologist available within five minutes of notification.

(8) Clinical laboratory services, including:

(a) Standard analysis of blood, urine, and other body fluids;

(b) Coagulation studies;

(c) Blood gases and pH determination;

(d) Serum and urine osmolality;

(e) Microbiology;

(f) Serum alcohol and toxicology determination;

(g) Drug screening; and

(h) Microtechnique.

(9) Blood and blood-component services, including:

(a) Blood and blood components available from in-house or through community services, to meet patient needs;

(b) Noncrossmatched blood available on patient arrival in emergency department;

(c) Blood typing and cross-matching;

(d) Policies and procedures for massive transfusion;

(e) Autotransfusion; and

(f) Blood storage capability.

(10) Radiological services, including:

(a) A technician available within five minutes of notification, able to perform routine radiological procedures;

(b) A technician on-call and available within twenty minutes of notification, able to perform the following:

(i) Computerized tomography;

(ii) Angiography of all types; and

(iii) Sonography.

(11) Acute dialysis capability, or written transfer agreements.

(12)(a) A physician-directed burn unit staffed by nursing personnel trained in burn care; and equipped to care for extensively burned patients; or

(b) Written transfer guidelines in accordance with the guidelines of the American Burn Association, and transfer agreements for burn care.

(13)(a) The ability to manage acute head and/or spinal cord injuries or;

(b) Have written transfer guidelines and agreements for head and spinal cord injuries.

(c) Early transfer to an appropriate designated trauma rehabilitation service shall be considered.

(14) A trauma rehabilitation coordinator to facilitate the trauma patient's access to rehabilitation services.

(15)(a) A designated trauma rehabilitation service; or

(b) Written agreements to transfer patients to a designated trauma rehabilitation service when medically feasible.

(16) 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.

[Statutory Authority: Chapter 70.168 RCW. 98-19-107, 246-976-560, filed 9/23/98, effective 10/24/98; 98-04-038, 246-976-560, filed 1/29/98, effective 3/1/98; 93-20-063, 246-976-560, filed 10/1/93, effective 11/1/93. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-560, filed 12/23/92, effective 1/23/93.]


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

WAC 246-976-600   Designation standards for facilities providing level III trauma care service -- Administration and organization.   A facility with a designated level III trauma care service shall have:

(1)(a) Organization and direction by a general surgeon or other physician with special competence in care of the injured. The service may have as codirector another physician with special competence in care of the injured;

(b) Ongoing coordination of the trauma care service by a registered nurse with special competence in care of the injured;

(c) A multidisciplinary trauma committee chaired by the trauma service director, with input to hospital management, including:

(i) An emergency physician;

(ii) An emergency department registered nurse;

(iii) A general surgeon with special competence in trauma care;

(iv) An orthopaedic surgeon;

(v) A pediatrician;

(vi) An anesthesiologist;

(vii) The physician director of the critical care service;

(viii) The trauma care service nurse coordinator;

(ix) A critical care registered nurse; and

(x) The trauma rehabilitation coordinator.

(d) The multidisciplinary trauma committee shall adopt an approved method to determine activation of the trauma team, as described in WAC 246-976-870.

(e) A trauma team to provide initial evaluation, resuscitation and treatment.

(i) The team shall be organized and directed by a general surgeon with special competence in care of the injured, and who assumes responsibility for coordination of overall care of the trauma patient;

(ii) All members of the team, except the surgeon and anesthesiologist or CRNA (if a member of the team), shall be available within five minutes of notification of team activation;

(iii) The team shall include:

(A) An emergency physician who is:

(I) Responsible for activating the trauma team, using an approved method as defined in WAC 246-976-870; and

(II) Responsible for providing team leadership and care for the trauma patient until the arrival of the general surgeon in the resuscitation area;

(B) A general surgeon on-call and available within thirty minutes of notification of team activation, who shall assume responsibility for patient care upon arrival in the resuscitation area;

(iv) The trauma care service shall identify all other members of the team.

(f) Specific delineation of trauma surgery privileges by the medical staff.

(2) An emergency department with written standards of care to ensure immediate and appropriate care for adult and pediatric trauma patients.

(3) A surgery department, including:

(a) General surgery;

(b)(i) Written transfer guidelines and agreements for head and spinal cord injuries; or

(ii) Neurosurgery, with a neurosurgeon on-call and available within thirty minutes of notification of team activation.

(c)(i) Have written transfer guidelines and procedures for patients requiring orthopaedic surgery; or

(ii) Orthopaedic surgery, with an orthopaedic surgeon on-call and available within thirty-minutes of request by the trauma team leader.

(4) Nonsurgical specialties, including:

(a) Anesthesiology, with an anesthesiologist or certified registered nurse anesthetist who ((is)):

(i) Is ACLS trained, except this requirement shall not apply to a physician board-certified in anesthesiology;

(ii) ((PALS or approved equivalent trained;)) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-886;

(iii) Is on-call and available within thirty minutes of notification of team activation;

(b) A radiologist on-call and available for patient service within thirty minutes of notification of team activation.

(c) The following services on-call and available for patient consultation or management:

(i) Internal medicine; and

(ii) General pediatrics, with board-certified pediatricians available for pediatric patient consultation or management.

(5) Written policy and procedures for access to ancillary services, including:

(a) Chemical dependency services;

(b) Child and adult protection services;

(c) Clergy or pastoral care;

(d) Nutritionist services;

(e) Occupational therapy services;

(f) Pharmacy services;

(g) Physical therapy services;

(h) Rehabilitation services;

(i) Social services.

(6) A pediatric trauma policy that:

(a) Provides for initial stabilization and resuscitation of pediatric trauma patients including emergency department and surgical interventions; and

(b) If the facility is not designated as a pediatric trauma care service, identifies and establishes its scope of pediatric trauma care, including but not limited to:

(i) Criteria for admission of pediatric patients;

(ii) Written transfer guidelines and agreements for pediatric trauma patients requiring critical care services.

(7) A written policy and procedure to divert patients to other designated trauma care services. The policy shall be based on criteria which reflect the service's ability to resuscitate and stabilize each patient at a particular time.

(8) A trauma registry as required in WAC 246-976-430.

(9) A quality assurance program in accordance with WAC 246-976-880; and cooperate with regional trauma care quality assurance programs throughout the state established pursuant to WAC 246-976-910.

(10) Interfacility transfer guidelines and agreements consistent with WAC 246-976-890.

[Statutory Authority: Chapter 70.168 RCW. 98-04-038, 246-976-600, filed 1/29/98, effective 3/1/98; 93-20-063, 246-976-600, filed 10/1/93, effective 11/1/93. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-600, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending WSR 98-19-107, filed 9/23/98, effective 10/24/98)

WAC 246-976-610   Designation standards for facilities providing level III trauma care service -- Basic resources and capabilities.   A facility with a designated level III trauma care service shall have:

(1) An emergency department with:

(a) A physician director who ((is)):

(i) Is board-certified in emergency medicine, or other relevant specialty;

(ii) Is ATLS and ACLS trained, except this requirement shall not apply to a physician board-certified in emergency medicine;

(iii) ((PALS or approved equivalent training)) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-886, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine.

(b) Physicians who:

(i) Have special competence in the resuscitation and care of trauma patients;

(ii) Are available within five minutes of patient's arrival in the emergency department;

(iii) Are ATLS and ACLS trained, except this requirement shall not apply to a physician board-certified in emergency medicine;

(iv) ((Are PALS or approved equivalent trained)) Have completed the PER as defined in WAC 246-976-886, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine; and

(v) Are designated as members of the trauma team;

(c) Registered nurses who:

(i) Are ACLS trained;

(ii) ((Are PALS or approved equivalent trained;)) Have completed the PER as defined in WAC 246-976-886;

(iii) Have successfully completed a trauma life support course as defined in WAC 246-976-885; and

(iv) Are in the emergency department and available within five minutes of patient's arrival in the emergency department;

(d) An area designated for adult and pediatric resuscitation, with equipment for resuscitation and life support of pediatric and adult trauma patients, including equipment as described in WAC 246-976-620.

(e) Routine radiological capabilities by a technician available within twenty minutes of notification of team activation.

(2) A surgery department, including an attending general surgeon who:

(a) Is on-call and available within thirty minutes of notification of team activation;

(b) Has general surgery privileges;

(c) Has ATLS and ACLS training, except this requirement shall not apply to a physician board-certified in surgery; and

(d) ((Has PALS or approved equivalent training.)) Has completed the PER as defined in WAC 246-976-886.

(3) An operating room available within five minutes of notification of team activation, with:

(a) A registered nurse or designee of the operating room staff who is available within five minutes of notification of team activation to open the operating room, and to coordinate responsibilities to ensure the operating room is ready for surgery upon arrival of the patient, the surgeon, and the anesthesiologist;

(b) Other essential personnel on-call and available within thirty minutes of notification of team activation;

(c) A written policy providing for mobilization of additional surgical teams for trauma patients; and

(d) Instruments and equipment appropriate for pediatric and adult surgery, including equipment as described in WAC 246-976-620.

(4) A post anesthetic recovery unit with:

(a) Essential personnel on-call and available twenty-four hours a day;

(b) Nurses ACLS trained;

(c) Nurses ((PALS or approved equivalent trained; and)) who have completed the PER as defined in WAC 246-976-886; and

(d) Appropriate monitoring and resuscitation equipment.

(5) A critical care service, with:

(a) A medical director who is:

(i) Board-certified in surgery, internal medicine, or anesthesiology, with special competence in critical care;

(ii) Responsible for coordinating with the attending staff for the care of trauma patients, including:

(A) Development and implementation of policies;

(B) Coordination of medical care;

(C) Determination of patient isolation;

(D) Authority for patient placement decisions;

(E) Equipment;

(F) Coordination of staff education;

(G) Coordination of statistics;

(H) Identification of criteria for reviewing quality of care on all critical care unit trauma patients, in conjunction with the trauma service medical director;

(b) A physician-directed code team;

(c) Critical care unit registered nurses with special competence in trauma care, who:

(i) Are ACLS trained; and

(ii) Have successfully completed a trauma life support course as defined in WAC 246-976-885;

(d) If the facility is not designated as a pediatric trauma care service, have a written transfer agreement and guidelines for pediatric trauma patients requiring critical care services;

(e) Equipment as described in WAC 246-976-620.

(6) Respiratory therapy on-call and available within thirty minutes of notification.

(7) A clinical laboratory technologist available within twenty minutes of notification.

(8) Clinical laboratory services, including:

(a) Standard analysis of blood, urine, and other body fluids;

(b) Coagulation studies;

(c) Blood gases and pH determination;

(d) Microbiology;

(e) Serum alcohol and toxicology determination; and

(f) Microtechnique.

(9) Blood and blood-component services, including:

(a) Blood and blood components available from in-house or through community services, to meet patient needs;

(b) Noncrossmatched blood available on patient arrival in emergency department;

(c) Blood typing and cross-matching;

(d) Policies and procedures for massive transfusion;

(e) Autotransfusion; and

(f) Blood storage capability.

(10) Radiological services with a technician on-call and available within twenty minutes of notification, able to perform:

(a) Routine radiological procedures; and

(b) Computerized tomography.

(11) Acute dialysis capability, or written transfer agreements.

(12) Ability to resuscitate and stabilize burn patients, and have written transfer guidelines in accordance with the guidelines of the American Burn Association, and transfer agreements for burn care.

(13) Ability to resuscitate and stabilize head and spinal cord injuries, and have:

(a) Written transfer guidelines and agreements for patients with head or spinal cord injuries; or

(b) Neurosurgery, with a neurosurgeon on-call and available within thirty minutes of request by the trauma team leader.

(c) Early transfer to an appropriate designated trauma rehabilitation service shall be considered.

(14) A trauma rehabilitation coordinator to facilitate the trauma patient's access to rehabilitation services.

(15)(a) A designated trauma rehabilitation service; or

(b) Written agreements to transfer patients to a designated trauma rehabilitation service when medically feasible.

(16)(a) A heli-stop, landing zone, or airport located close enough to permit the facility to receive or transport patients by fixed-wing or rotary-wing aircraft; or

(b) A written policy and procedures addressing the receipt of patients by air, and transfer of patients to other designated trauma services by ground or air.

[Statutory Authority: Chapter 70.168 RCW. 98-19-107, 246-976-610, filed 9/23/98, effective 10/24/98; 98-04-038, 246-976-610, filed 1/29/98, effective 3/1/98; 93-20-063, 246-976-610, filed 10/1/93, effective 11/1/93. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-610, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending WSR 98-19-107, filed 9/23/98, effective 10/24/98)

WAC 246-976-650   Designation standards for facilities providing level IV trauma care services -- Basic resources and capabilities.   A facility with a designated level IV trauma care service shall have:

(1) An emergency department with:

(a) A physician with special competence in resuscitation, care and treatment of trauma patients, who ((is)):

(i) Is on-call and available within twenty minutes of notification;

(ii) Is responsible for activating trauma-response personnel;

(iii) Is ATLS and ACLS trained, except this requirement shall not apply to a physician board-certified in emergency medicine; and

(iv) ((PALS or approved equivalent trained)) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-886, except this requirement shall not apply to a physician board-certified in emergency medicine or pediatric emergency medicine;

(b) A registered nurse in-house and available within five minutes of notification, who:

(i) Is ACLS trained;

(ii) Has successfully completed a trauma life support course as defined in WAC 246-976-885; and

(iii) ((Is PALS or approved equivalent trained;)) Has completed the PER as defined in WAC 246-976-886;

(c) Basic emergency services including:

(i) Assessment of the patient's condition;

(ii) Determination of the nature and urgency of the patient's medical need, including the timing and place of care; and

(iii) Diagnosis and treatment of any life threatening condition, including procedures to minimize aggravation of the patient's condition during transport to another designated trauma care service;

(d) Equipment available for resuscitation and life support of adult and pediatric trauma patients, including:

(i) Airway control and ventilation equipment including:

(A) Airways, neonatal to adult;

(B) Laryngoscope, including curved and straight blades, sizes 0-4;

(C) Endotracheal tubes sizes 2.5 to 8.0, with stylets;

(D) Bag-valve-mask resuscitator sizes neonatal, child and adult;

(E) Sources of oxygen;

(F) Pulse oximeter with infant, child and adult probes; and

(G) Suction devices;

(ii) Cardiac monitoring devices, including:

(A) Electrocardiograph;

(B) Cardiac monitor;

(C) Defibrillator with pediatric paddles;

(iii) Standard intravenous fluids and administering devices, including:

(A) Intravenous catheters, size 24g to 14g;

(B) Intraosseous needles;

(C) Infusion control device;

(iv) Gastric lavage equipment;

(v) Drugs and supplies necessary for adult and pediatric emergency care;

(vi) Medication chart, tape, or other system to assure ready access to information on proper dose-per-kilogram for resuscitation drugs and equipment sizes for pediatric patients;

(vii) Immobilization devices, including:

(A) Cervical injury immobilization devices, adult and pediatric sizes;

(B) Long-bone stabilization device; and

(C) Backboard;

(viii) Ability to provide thermal control equipment for:

(A) Patient warming and cooling;

(B) Blood warming and cooling;

(ix) Other equipment:

(A) Sterile surgical sets for procedures standard for emergency department;

(B) Two-way radio linked with EMS/TC vehicles;

(e) Routine radiological capabilities by a technician available within twenty minutes of notification of activation of trauma response personnel.

(2) If the service's scope of trauma care defined under WAC 246-976-640(2) includes surgery and/or critical care capabilities, it shall have:

(a) Staff, including:

(i) A physician on-call and available within thirty minutes of notification of activation of trauma response personnel, who:

(A) Has specific delineation of surgical privileges by the medical staff for resuscitation, stabilization and treatment of major trauma patients;

(B) ((Is PALS or approved equivalent trained;

(C))) Is ATLS and ACLS trained, except this requirement shall not apply to a physician board-certified in surgery; and

(((D))) (C) Is responsible for coordinating care and transfer of trauma patients;

(ii) Anesthesiology, with an anesthesiologist or certified registered nurse anesthetist, who:

(A) Has ACLS training, except this requirement shall not apply to a physician board-certified in anesthesiology; and

(B) ((Has PALS or approved equivalent training; and

(C))) Is on-call and available within thirty minutes of notification of activation of trauma response personnel;

(b) An operating room with a registered nurse or designee of the operating room staff who is available within five minutes of notification of activation of trauma response personnel, to open the operating room, and to coordinate responsibilities to ensure the operating room is ready for surgery upon arrival of the patient, the surgeon, and the anesthesiologist;

(c) Other essential personnel on-call and available within thirty minutes of notification;

(d) The operating room shall have available:

(i) Ability to provide thermal control equipment for:

(A) Patient warming;

(B) Blood and fluid warming;

(ii) Radiological capabilities;

(iii) Ability to provide endoscopes appropriate to trauma resuscitation; and

(iv) Monitoring equipment;

(e) Post anesthetic recovery services, with:

(i) Essential personnel on-call and available twenty-four hours every day;

(ii) Nurses ACLS trained;

(iii) Appropriate monitoring and resuscitation equipment;

(3)(a) A critical care unit which meets requirements for a designated level III trauma service as described in WAC 246-976-610; or

(b) Written transfer guidelines and agreements with designated trauma care services for patients requiring critical care;

(4) Clinical laboratory services available, for:

(a) Standard analysis of blood, urine, and other body fluids;

(b) Blood gases and pH determination;

(5) Blood and blood-component services, including:

(a) Blood and blood components available in-house or through community services, to meet patient needs in a timely fashion;

(b) Policies and procedures for massive transfusions; and

(c) Blood storage capability;

(6) Acute dialysis capabilities, or have written transfer guidelines and agreements for dialysis service;

(7) Ability to resuscitate and stabilize burn patients; and have written transfer guidelines in accordance with the guidelines of the American Burn Association, and agreements for burn care;

(8) Ability to resuscitate and stabilize acute head and/or spinal cord injuries; and

(a) Written transfer guidelines and agreements for patients with head or spinal cord injuries; or

(b) Have neurosurgery, with a neurosurgeon on-call and available within thirty minutes of request by the emergency department physician; or

(c) Early transfer to an appropriate designated trauma rehabilitation facility shall be considered;

(9) A qualified person assigned to coordinate trauma rehabilitation activities and referrals;

(10) A written plan addressing receipt and transfer of patients by fixed-wing and rotary-wing aircraft.

[Statutory Authority: Chapter 70.168 RCW. 98-19-107, 246-976-650, filed 9/23/98, effective 10/24/98; 98-04-038, 246-976-650, filed 1/29/98, effective 3/1/98; 93-20-063, 246-976-650, filed 10/1/93, effective 11/1/93. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-650, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending WSR 98-19-107, filed 9/23/98, effective 10/24/98)

WAC 246-976-720   Designation standards for facilities providing level I pediatric trauma care service -- Administration and organization.   A facility with a designated level I pediatric trauma care service shall have:

(1)(a) Organization and direction by a general surgeon with special competence in care of the injured child. The service may have as codirector another physician or general surgeon with special competence in care of the injured child;

(b) Ongoing coordination of the trauma care service by a registered nurse with special competence in care of the injured child;

(c) A multidisciplinary trauma committee chaired by the trauma service director, with input to hospital management, including:

(i) A pediatric emergency physician;

(ii) An emergency department registered nurse;

(iii) A pediatric surgeon or general surgeon with special competence in pediatric trauma care;

(iv) A neurosurgeon;

(v) An orthopaedic surgeon;

(vi) An anesthesiologist;

(vii) The physician director of pediatric critical care service;

(viii) A pediatrician with special competence in critical care;

(ix) The pediatric trauma care service nurse coordinator;

(x) A pediatric critical care registered nurse;

(xi) A pediatric intensivist; and

(xii) The trauma rehabilitation coordinator;

(d) The multidisciplinary trauma committee shall adopt an approved method to determine activation of the trauma team, as described in WAC 246-976-870;

(e) A trauma team to provide initial evaluation, resuscitation and treatment.

(i) The team shall be organized and directed by a pediatric surgeon or general surgeon with special competence in care of the injured child, and who assumes responsibility for coordination of overall care of the pediatric trauma patient. The surgeon shall be at least a PGY4.

(ii) All members of the team, including the surgeon, shall be available within five minutes of notification of team activation.

(iii) The team shall include an emergency physician with special competence in pediatric care, who is:

(A) Responsible for activating the trauma team, using an approved method as defined in WAC 246-976-870; and

(B) Responsible for providing team leadership and care for the pediatric trauma patient until the arrival of the general surgeon with special competence in pediatric care in the resuscitation area.

(iv) The trauma care service shall identify all other members of the team.

(v) The team shall work in conjunction with a pediatric intensivist or pediatric emergency physician.

(f) Specific delineation of pediatric trauma surgery privileges by the medical staff.

(2) An emergency department with written standards of care to ensure immediate and appropriate care for pediatric trauma patients.

(3) A surgery department, including:

(a) General surgery with special competence in care of the pediatric trauma patient;

(b) A neurosurgical service. Coverage shall be available within five minutes of notification of team activation, provided by:

(i) A neurosurgeon; or

(ii) A surgeon who has been judged competent by the neurosurgical consultants on staff to initiate measures to stabilize the pediatric patient, and to initiate diagnostic procedures, with a board-certified neurosurgeon on call and available within thirty minutes of notification of team activation.

(c) The following surgical services on-call and available within thirty minutes of request by the trauma team leader:

(i) Cardiac surgery;

(ii) Gynecologic surgery;

(iii) Hand surgery;

(iv) Microsurgery;

(v) Obstetric surgery;

(vi) Ophthalmic surgery;

(vii) Oral/maxillofacial or otorhinolaryngologic surgery;

(viii) Orthopaedic surgery;

(ix) Pediatric surgery;

(x) Plastic surgery;

(xi) Thoracic surgery;

(xii) Urologic surgery; and

(xiii) Vascular surgery.

(4) Nonsurgical specialties with special competence in pediatric care, including:

(a) Anesthesiology, with an anesthesiologist who ((is)):

(i) Is ACLS trained, except this requirement shall not apply to a physician board-certified in anesthesiology;

(ii) ((PALS or approved equivalent trained; and)) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-887; and

(iii) Available within five minutes of team activation;

(b) A radiologist on-call and available for patient service within twenty minutes of notification of team activation;

(c) The following services on-call and available for pediatric patient consultation or management:

(i) Cardiology;

(ii) Gastroenterology;

(iii) General pediatrics;

(iv) Hematology;

(v) Infectious disease specialists;

(vi) Nephrology;

(vii) Pediatric neurology;

(viii) Pathology;

(ix) Pediatric critical care;

(x) Pulmonology; and

(xi) Psychiatry;

(5) Written policy and procedures for access to ancillary services specific for pediatric patients, including:

(a) Chemical dependency services;

(b) Child and adult protection services;

(c) Clergy or pastoral care;

(d) Nutritionist services;

(e) Occupational therapy services;

(f) Pediatric therapeutic recreation;

(g) Pharmacy, with a pharmacist in-house;

(h) Physical therapy services;

(i) Psychological services;

(j) Rehabilitation services;

(k) Social services;

(l) Speech therapy services;

(6) A written policy and procedures to divert patients to other designated trauma care services. The policy shall be based on criteria which reflect the service's ability to resuscitate and stabilize each patient at a particular time.

(7) A trauma registry as required in WAC 246-976-430;

(8) A quality assurance program in accordance with WAC 246-976-881, and cooperate with regional trauma care quality assurance programs throughout the state established pursuant to WAC 246-976-910;

(9) Interfacility transfer guidelines and agreements consistent with WAC 246-976-890.

[Statutory Authority: Chapter 70.168 RCW. 98-19-107, 246-976-720, filed 9/23/98, effective 10/24/98; 98-04-038, 246-976-720, filed 1/29/98, effective 3/1/98; 93-20-063, 246-976-720, filed 10/1/93, effective 11/1/93. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-720, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending WSR 98-19-107, filed 9/23/98, effective 10/24/98)

WAC 246-976-730   Designation standards for facilities providing level I pediatric trauma care services -- Resources and capabilities.   A facility with a designated level I pediatric trauma care service shall have:

(1) An emergency department with:

(a) A physician director who:

(i) Is board-certified in emergency medicine, pediatric emergency medicine, surgery or other relevant specialty; or

(ii) 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;

(iii) Is ATLS and ACLS trained, except this requirement shall not apply to a physician board-certified in emergency medicine or in surgery; and

(iv) ((Is PALS or approved equivalent trained)) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-887, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine;

(b) Emergency physicians who:

(i) Are board-certified in emergency medicine, or pediatric emergency medicine, or in a specialty practicing emergency medicine as their primary practice with special competence in care of pediatric trauma patients; (this requirement may be met by a surgical resident post graduate year two who is ATLS((,)) and ACLS trained, ((and PALS or approved equivalent trained,)) has completed the PER as defined in WAC 246-976-887, and is working under the direct supervision of the attending emergency department physician, until the arrival of the surgeon to assume leadership of the trauma team);

(ii) Are available within five minutes of the patient's arrival in the emergency department;

(iii) Are ATLS and ACLS trained, except this requirement shall not apply to a physician board-certified in emergency medicine;

(iv) ((Are PALS or approved equivalent trained)) Have completed the PER as defined in WAC 246-976-887, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine; and

(v) Are designated members of the trauma team;

(c) Registered nurses who:

(i) ((Are PALS or approved equivalent trained;)) Have completed the PER as defined in WAC 246-976-887;

(ii) Have successfully completed a trauma life support course as defined in WAC 246-976-885;

(iii) Are in the emergency department and available within five minutes of patient's arrival in the emergency department;

(d) An area designated for pediatric resuscitation, with equipment for resuscitation and life support of pediatric patients, including equipment as described in WAC 246-976-620;

(e) Routine radiological capabilities by a technician available within five minutes of notification of team activation;

(2) A surgery department including:

(a) An attending pediatric surgeon or general surgeon with special competence in pediatric care who is available within five minutes of notification of team activation, except as provided in (b) of this subsection. The attending surgeon shall:

(i) Provide trauma team leadership upon arrival in the resuscitation area;

(ii) Be board-certified;

(iii) Have trauma surgery privileges as delineated by the medical staff;

(b) A ((post-graduate)) 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 shall be available within twenty minutes of notification of team activation.

(c) All general surgeons and surgical residents who are responsible for care and treatment of trauma patients shall ((be trained in)):

(i) Be trained in ATLS and ACLS, except this requirement shall not apply to a physician board-certified in surgery;

(ii) ((PALS or approved equivalent;)) Have completed the PER as defined in WAC 246-976-887;

(3) An operating room available within five minutes of notification of team activation, with:

(a) A registered nurse or designee of the operating room staff who is available within five minutes of team activation to open the operating room, and to coordinate responsibilities to ensure the operating room is ready for surgery upon arrival of the patient, the surgeon, and the anesthesiologist;

(b) A written policy providing for mobilization of additional surgical teams for pediatric trauma patients;

(c) Instruments and equipment appropriate for pediatric surgery, including equipment as described in WAC 246-976-620;

(4) A post-anesthetic recovery unit with:

(a) Essential personnel, including at least one registered nurse available twenty-four hours a day;

(b) Nurses ACLS trained;

(c) Nurses ((PALS or approved equivalent trained)) who have completed the PER as defined in WAC 246-976-887;

(d) Appropriate monitoring and resuscitation equipment.

(5) A pediatric critical care service, with:

(a) A pediatric critical care unit, including patient isolation capacity;

(b) A medical director or codirector who is board-certified in pediatrics, with sub-board certification in critical care, with responsibility for coordinating with the attending staff for the care of pediatric trauma patients, including:

(i) Development and implementation of policies;

(ii) Coordination of medical care;

(iii) Determination of patient isolation;

(iv) Authority for patient placement decisions;

(v) Equipment;

(vi) Coordination of staff education;

(vii) Coordination of statistics; and

(viii) Identification of criteria for reviewing quality of care on all pediatric critical care unit trauma patients in conjunction with the trauma service medical director;

(c) A physician with special competence in pediatric critical care available within five minutes of notification;

(d) A physician-directed code team;

(e) Pediatric critical care nursing with registered nurses who have:

(i) Special competence in pediatric trauma care; and

(ii) ((Successfully completed PALS or approved equivalent training;)) Completed the PER as defined in WAC 246-976-887;

(f) Equipment as described in WAC 246-976-620 and 246-976-825;

(6) Respiratory therapy available within five minutes of notification;

(7) A clinical laboratory technologist available within five minutes of notification;

(8) Clinical laboratory services, including:

(a) Standard analyses of blood, urine, and other body fluids;

(b) Coagulation studies;

(c) Blood gases and pH determination;

(d) Serum and urine osmolality;

(e) Microbiology;

(f) Serum alcohol and toxicology determination;

(g) Drug screening; and

(h) Microtechnique.

(9) Blood and blood-component services, including:

(a) Blood and blood components available from in-house or through community services, to meet patient needs;

(b) Noncrossmatched blood available on patient arrival in the emergency department;

(c) Blood typing and cross-matching;

(d) Policies and procedures for massive transfusion;

(e) Autotransfusions; and

(f) Blood storage capability;

(10) A radiological service, including:

(a) A technician available within five minutes of notification, able to perform the following:

(i) Routine radiological procedures; and

(ii) Computerized tomography;

(b) A technician on-call and available within twenty minutes of notification, able to perform the following:

(i) Angiography of all types;

(ii) Sonography;

(iii) Nuclear scanning;

(11) Acute dialysis capability, or written transfer agreements.

(12)(a) A physician-directed burn unit staffed by nursing personnel trained in burn care, and equipped to care for extensively burned pediatric patients; or

(b) Written transfer guidelines and agreements for burn care, in accordance with the guidelines of the American Burn Association.

(13) The ability to manage acute head and/or spinal cord injuries. Early transfer to an appropriate pediatric trauma rehabilitation service shall be considered.

(14) A trauma rehabilitation coordinator to facilitate the trauma patient's access to pediatric rehabilitation services.

(15)(a) A designated pediatric trauma rehabilitation service; or

(b) Written agreements to transfer patients to designated pediatric trauma rehabilitation services when medically feasible.

(16) 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.

[Statutory Authority: Chapter 70.168 RCW. 98-19-107, 246-976-730, filed 9/23/98, effective 10/24/98; 98-04-038, 246-976-730, filed 1/29/98, effective 3/1/98; 93-20-063, 246-976-730, filed 10/1/93, effective 11/1/93. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-730, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending WSR 98-19-107, filed 9/23/98, effective 10/24/98)

WAC 246-976-770   Designation standards for facilities providing level II pediatric trauma care service -- Administration and organization.   A facility with a designated level II pediatric trauma care service shall have:

(1)(a) Organization and direction by a general surgeon with special competence in care of the injured child. The service may have as codirector another physician with special competence in care of the injured child;

(b) Ongoing coordination of the trauma care service by a registered nurse with special competence in care of the injured child;

(c) A multidisciplinary trauma committee chaired by the trauma service director, with input to hospital management, including:

(i) An emergency physician with special competence in pediatric care;

(ii) An emergency department registered nurse;

(iii) A pediatric surgeon or general surgeon with special competence in pediatric trauma care;

(iv) A neurosurgeon;

(v) An orthopaedic surgeon;

(vi) An anesthesiologist;

(vii) The physician director of pediatric critical care service;

(viii) A pediatrician with special competence in critical care;

(ix) The pediatric trauma care service nurse coordinator;

(x) A pediatric critical care registered nurse;

(xi) Pediatric intensivist; and

(xii) The trauma rehabilitation coordinator;

(d) The multidisciplinary trauma committee shall adopt an approved method to determine activation of the trauma team, as described in WAC 246-976-870;

(e) A trauma team to provide initial evaluation, resuscitation and treatment.

(i) The team shall be organized and directed by a pediatric surgeon or general surgeon with special competence in care of the injured child, and who assumes responsibility for coordination of overall care of the pediatric trauma patient.

(ii) The team shall work in conjunction with a pediatric intensivist or pediatric emergency physician.

(iii) All members of the team, except the surgeon and the anesthesiologist, shall be available within five minutes of notification of team activation.

(iv) The team shall include:

(A) An emergency physician with special competence in pediatric care, who is:

(I) Responsible for activating the trauma team, using an approved method as defined in WAC 246-976-870; and

(II) Responsible for providing team leadership and care for the pediatric trauma patient until the arrival of the general surgeon in the resuscitation area.

(B) A pediatric surgeon, or general surgeon with special competence in pediatric trauma surgery, on-call and available within twenty minutes of notification of team activation, who shall assume responsibility for patient care upon arrival in the resuscitation area;

(v) The trauma care service shall identify all other members of the team.

(f) Specific delineation of pediatric trauma surgery privileges by the medical staff.

(2) An emergency department with written standards of care to ensure immediate and appropriate care for pediatric trauma patients.

(3) A surgery department, including:

(a) General surgery, with special competence in care of the pediatric trauma patient;

(b) A neurosurgical service. Coverage shall be available within five minutes of notification of team activation. In-house coverage shall be provided by:

(i) A neurosurgeon; or

(ii) A surgeon or other physician who has been judged competent by the neurosurgical consultants on staff to initiate measures to stabilize the patient, and to initiate diagnostic procedures, with a neurosurgeon on-call and available within thirty minutes of notification of team activation;

(c) The following surgical services on-call and available within thirty minutes of request by the trauma team leader:

(i) Gynecologic surgery;

(ii) Hand surgery;

(iii) Obstetric surgery;

(iv) Ophthalmic surgery;

(v) Oral/maxillofacial or otorhinolaryngologic surgery;

(vi) Orthopaedic surgery;

(vii) Pediatric surgery;

(viii) Plastic surgery;

(ix) Thoracic surgery;

(x) Urologic surgery; and

(xi) Vascular surgery.

(4) Nonsurgical specialties with special competence in pediatric care, including:

(a) Anesthesiology, with an anesthesiologist who ((is)):

(i) Is ACLS trained, except this requirement shall not apply to a physician board-certified in anesthesiology;

(ii) ((PALS or approved equivalent trained; and)) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-887; and

(iii) Is on-call and available within twenty minutes of notification of team activation;

(b) A radiologist on-call and available for patient service within twenty minutes of notification of team activation;

(c) The following services on-call and available for pediatric patient consultation or management:

(i) Cardiology;

(ii) Gastroenterology;

(iii) General pediatrics;

(iv) Hematology;

(v) Infectious disease specialists;

(vi) Nephrology;

(vii) Neurology;

(viii) Pathology;

(ix) Pediatric critical care; and

(x) Pulmonology;

(5) Written policy and procedures for access to ancillary services specific for pediatric patients, including:

(a) Chemical dependency services;

(b) Child and adult protection services;

(c) Clergy or pastoral care;

(d) Nutritionist services;

(e) Occupational therapy services;

(f) Pediatric therapeutic recreation;

(g) Pharmacy;

(h) Physical therapy services;

(i) Rehabilitation services;

(j) Social services; and

(k) Speech therapy services.

(6) A written policy and procedures to divert patients to other designated trauma care services. The policy shall be based on criteria which reflect the service's ability to resuscitate and stabilize each patient at a particular time.

(7) A trauma registry as required in WAC 246-976-430.

(8) A quality assurance program in accordance with WAC 246-976-881; and cooperate with regional trauma care quality assurance programs throughout the state established pursuant to WAC 246-976-910.

(9) Interfacility transfer guidelines and agreements consistent with WAC 246-976-890.

[Statutory Authority: Chapter 70.168 RCW. 98-19-107, 246-976-770, filed 9/23/98, effective 10/24/98; 98-04-038, 246-976-770, filed 1/29/98, effective 3/1/98; 93-20-063, 246-976-770, filed 10/1/93, effective 11/1/93. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-770, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending WSR 98-19-107, filed 9/23/98, effective 10/24/98)

WAC 246-976-780   Designation standards for facilities providing level II pediatric trauma care service -- Basic resources and capabilities.   A facility with a designated level II pediatric trauma care service shall have:

(1) An emergency department, with:

(a) A physician director who ((is)):

(i) Is board-certified in emergency medicine or pediatric emergency medicine;

(ii) Is ATLS trained, except this requirement shall not apply to a physician board-certified in emergency medicine; and

(iii) ((PALS or approved equivalent trained)) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-887, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine.

(b) Physicians who:

(i) Are board-certified in emergency medicine, or pediatric emergency medicine, or board-certified in a specialty practicing emergency medicine as their primary practice with special competence in the care of pediatric trauma patients;

(ii) Are available within five minutes of patient's arrival in the emergency department;

(iii) Are ATLS and ACLS trained, except this requirement shall not apply to a physician board-certified in emergency medicine;

(iv) ((Are PALS or approved equivalent trained)) Have completed the PER as defined in WAC 246-976-887, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine; and

(v) Are designated as members of the trauma team;

(c) Registered nurses who:

(i) ((Are PALS or approved equivalent trained;)) Have completed the PER as defined in WAC 246-976-887;

(ii) Have successfully completed a trauma life support course as defined in WAC 246-976-885;

(iii) Are in the emergency department and available within five minutes of patient's arrival in the emergency department;

(d) An area designated for pediatric resuscitation, with equipment for resuscitation and life support of pediatric patients, including equipment as described in WAC 246-976-620;

(e) Routine radiological capabilities by a technician available within five minutes of notification of team activation;

(2) A surgery department, including:

(a) An attending pediatric surgeon, or general surgeon with special competence in pediatric care, who is on-call and available within twenty minutes of notification of team activation. The attending surgeon shall:

(i) Provide trauma team leadership upon arrival in the resuscitation area;

(ii) Be board-certified;

(iii) Have trauma surgery privileges as delineated by the medical staff;

(b) All general surgeons who are responsible for care and treatment of trauma patients shall ((be trained in)):

(i) Be trained in ATLS, except this requirement shall not apply to a physician board-certified in surgery;

(ii) ((PALS or approved equivalent.)) Have completed the PER as defined in WAC 246-976-887.

(3) An operating room available within five minutes of notification of team activation, with:

(a) A registered nurse or designee of the operating room staff who is available within five minutes of notification of team activation to open the operating room, and to coordinate responsibilities to ensure the operating room is ready for surgery upon arrival of the patient, the surgeon, and the anesthesiologist;

(b) Other essential personnel on-call and available within twenty minutes of notification of team activation;

(c) A written policy providing for mobilization of additional surgical teams for pediatric trauma patients;

(d) Instruments and equipment appropriate for pediatric surgery, including equipment as described in WAC 246-976-620;

(4) A post-anesthetic recovery unit, with:

(a) Essential personnel, including at least one registered nurse on-call and available twenty-four hours a day; and

(b) Nurses ACLS trained;

(c) Nurses ((PALS or approved equivalent trained)) who have completed the PER as defined in WAC 246-976-887;

(d) Appropriate monitoring and resuscitation equipment.

(5) A pediatric critical care service, with:

(a) A pediatric critical care unit, including patient isolation capacity;

(b) A medical director or codirector who is board-certified in pediatrics with sub-board certification in critical care, with responsibility for coordinating with the attending staff for the care of pediatric trauma patients, including:

(i) Development and implementation of policies;

(ii) Coordination of medical care;

(iii) Determination of patient isolation;

(iv) Authority for patient placement decisions;

(v) Equipment;

(vi) Coordination of staff education;

(vii) Coordination of statistics; and

(viii) Identification of criteria for reviewing quality of care on all pediatric critical care unit trauma patients, in conjunction with the trauma service medical director;

(c) A physician with special competence in pediatric critical care available within five minutes of notification;

(d) A physician-directed code team;

(e) Pediatric critical care nursing, with registered nurses who have:

(i) Special competence in pediatric trauma care; and

(ii) ((Successfully completed PALS or approved equivalent training;)) Completed the PER as defined in WAC 246-976-887;

(f) Equipment as described in WAC 246-976-620 and 246-976-825.

(6) Respiratory therapy available within five minutes of notification;

(7) A clinical laboratory technologist available within five minutes of notification;

(8) Clinical laboratory services, including:

(a) Standard analyses of blood, urine, and other body fluids;

(b) Coagulation studies;

(c) Blood gases and pH determination;

(d) Serum and urine osmolality;

(e) Microbiology;

(f) Serum alcohol and toxicology determination;

(g) Drug screening; and

(h) Microtechnique;

(9) Blood and blood-component services, including:

(a) Blood and blood components available from in-house or through community services, to meet patient needs;

(b) Noncrossmatched blood available on patient arrival in the emergency department;

(c) Blood typing and cross-matching;

(d) Policies and procedures for massive transfusion;

(e) Autotransfusions; and

(f) Blood storage capability;

(10) Radiological services, including:

(a) A technician available within five minutes of notification, able to perform routine radiologic procedures;

(b) A technician on-call and available within twenty minutes of notification, able to perform the following:

(i) Angiography of all types;

(ii) Computerized tomography;

(iii) Sonography;

(11) Acute dialysis capability, or written transfer agreements.

(12)(a) A physician-directed burn unit staffed by nursing personnel trained in burn care; and equipped to care for extensively burned pediatric patients; or

(b) Written transfer guidelines and transfer agreements for burn care, in accordance with the guidelines of the American Burn Association.

(13)(a) The ability to manage acute head and/or spinal cord injuries; or

(b) Written transfer guidelines and agreements for head and spinal cord injuries.

(c) Early transfer to an appropriate designated trauma rehabilitation service shall be considered;

(14) A trauma rehabilitation coordinator to facilitate the trauma patient's access to pediatric rehabilitation services;

(15)(a) A designated pediatric trauma rehabilitation service; or

(b) Written agreements to transfer patients to a designated pediatric trauma rehabilitation service when medically feasible.

(16) 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.

[Statutory Authority: Chapter 70.168 RCW. 98-19-107, 246-976-780, filed 9/23/98, effective 10/24/98; 98-04-038, 246-976-780, filed 1/29/98, effective 3/1/98; 93-20-063, 246-976-780, filed 10/1/93, effective 11/1/93. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-780, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending WSR 98-19-107, filed 9/23/98, effective 10/24/98)

WAC 246-976-810   Designation standards for facilities providing level III pediatric trauma care service -- Administration and organization.   A facility with a designated level III pediatric trauma care service shall have:

(1)(a) Organization and direction by a general surgeon or other physician with special competence in care of the injured child. The service may have as codirector another physician with special competence in care of the injured child;

(b) Ongoing coordination of the trauma care service by a registered nurse with special competence in care of the injured child;

(c) A multidisciplinary trauma committee chaired by the trauma service director, with input to hospital management, including:

(i) An emergency physician with special competence in pediatric trauma care;

(ii) An emergency department registered nurse;

(iii) A general surgeon with special competence in pediatric trauma care;

(iv) An orthopaedic surgeon;

(v) An anesthesiologist;

(vi) The pediatric trauma care service nurse coordinator;

(vii) A pediatric critical care registered nurse;

(viii) A pediatrician with special competence in critical care; and

(ix) The trauma rehabilitation coordinator;

(d) The multidisciplinary trauma committee shall adopt an approved method to determine activation of the trauma team, as described in WAC 246-976-870;

(e) A trauma team to provide initial evaluation, resuscitation and treatment.

(i) The team shall be organized and directed by a general surgeon with special competence in care of the injured child; and who assumes responsibility for coordination of overall care of the pediatric trauma patient;

(ii) All members of the team, except the surgeon and the anesthesiologist or CRNA (if a member of the team), shall be available within five minutes of notification of team activation;

(iii) The team shall include:

(A) An emergency physician with special competence in pediatric trauma care, who is:

(I) Responsible for activating the trauma team, using an approved method as defined in WAC 246-976-870; and

(II) Responsible for providing team leadership and care for the pediatric trauma patient until the arrival of the general surgeon in the resuscitation area;

(B) A pediatric surgeon, or general surgeon with special competence in pediatric trauma surgery, on-call and available within thirty minutes of notification of team activation, who shall assume responsibility for patient care upon arrival in the resuscitation area;

(iv) The trauma care service shall identify all other members of the team.

(f) Specific delineation of pediatric trauma surgery privileges by the medical staff.

(2) An emergency department with written standards of care to ensure immediate and appropriate care for pediatric trauma patients.

(3) A surgery department, including:

(a) General surgery, with special competence in care of the pediatric trauma patient;

(b)(i) Written transfer guidelines and agreements for head and spinal cord injuries; or

(ii) Neurosurgery, with a neurosurgeon on-call and available within thirty minutes of notification of team activation;

(c)(i) Written transfer guidelines and procedures for patients requiring orthopaedic surgery; or

(ii) Orthopaedic surgery, with an orthopaedic surgeon on-call and available within thirty minutes of request by the trauma team leader;

(4) Nonsurgical specialties, including:

(a) Anesthesiology, with an anesthesiologist or certified registered nurse anesthetist, who ((is)):

(i) Is ACLS trained, except this requirement shall not apply to a physician board-certified in anesthesiology;

(ii) ((PALS or approved equivalent trained; and)) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-887; and

(iii) On-call and available within thirty minutes of notification of team activation;

(b) A radiologist on-call and available for patient service within thirty minutes of notification of team activation;

(c) General pediatrics, with board-certified pediatricians on-call and available for pediatric patient consultation or management;

(5) Written policy and procedures for access to ancillary services specific for pediatric patients, including:

(a) Chemical dependency services;

(b) Child and adult protection services;

(c) Clergy or pastoral care;

(d) Nutritionist services;

(e) Pediatric therapeutic recreation;

(f) Pharmacy;

(g) Physical therapy services;

(h) Rehabilitation services;

(i) Social services;

(6) A written policy and procedures to divert patients to other designated trauma care services. The policy shall be based on criteria which reflect the service's ability to resuscitate and stabilize each patient at a particular time;

(7) A trauma registry as required by WAC 246-976-430;

(8) A quality assurance program in accordance with WAC 246-976-881; and cooperate with regional trauma care quality assurance programs throughout the state established pursuant to WAC 246-976-910;

(9) Interfacility transfer guidelines and agreements consistent with WAC 246-976-890.

[Statutory Authority: Chapter 70.168 RCW. 98-19-107, 246-976-810, filed 9/23/98, effective 10/24/98; 98-04-038, 246-976-810, filed 1/29/98, effective 3/1/98; 93-20-063, 246-976-810, filed 10/1/93, effective 11/1/93. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-810, filed 12/23/92, effective 1/23/93.]


AMENDATORY SECTION(Amending WSR 98-19-107, filed 9/23/98, effective 10/24/98)

WAC 246-976-820   Designation standards for facilities providing level III pediatric trauma care service -- Basic resources and capabilities.   A facility with a designated level III pediatric trauma care service shall have:

(1) An emergency department with:

(a) A physician director who ((is)):

(i) Is board-certified in emergency medicine or pediatric emergency medicine;

(ii) Is ATLS and ACLS trained, except this requirement shall not apply to a physician board-certified in emergency medicine; and

(iii) ((PALS or approved equivalent trained)) Has completed the pediatric education requirement (PER) as defined in WAC 246-976-887, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine;

(b) Physicians who:

(i) Have special competence in the resuscitation and care of pediatric trauma patients;

(ii) Are available within five minutes of patient's arrival in the emergency department;

(iii) Are ATLS and ACLS trained, except this requirement shall not apply to a physician board-certified in emergency medicine;

(iv) ((Are PALS or approved equivalent trained)) Have completed the PER as defined in WAC 246-976-887, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine; and

(v) Are designated as members of the trauma team;

(c) Registered nurses who:

(i) ((Are PALS or approved equivalent trained;)) Have completed the PER as defined in WAC 246-976-887;

(ii) Have successfully completed a trauma life support course as defined in WAC 246-976-885;

(iii) Are in the emergency department and available within five minutes of patient's arrival in the emergency department;

(d) An area designated for pediatric resuscitation, with equipment for resuscitation and life support of pediatric patients, including equipment as described in WAC 246-976-620;

(e) Routine radiological capabilities, by a technician available within twenty minutes of notification of team activation.

(2) A surgery department, including an attending surgeon who is:

On-call and available within thirty minutes of notification of team activation; and

(a) Has general surgery privileges, with special competence in pediatric care;

(b) ((Has PALS or approved equivalent training;)) Has completed the PER as defined in WAC 246-976-887;

(c) Has ATLS, except this requirement shall not apply to a physician board-certified in surgery.

(3) An operating room available within five minutes of notification of team activation, with:

(a) A registered nurse or designee of the operating room staff who is available within five minutes of notification of team activation to open the operating room, and to coordinate responsibilities to ensure the operating room is ready for surgery upon arrival of the patient, the surgeon, and the anesthesiologist;

(b) Other essential personnel on-call and available within thirty minutes of notification of team activation;

(c) A written policy providing for mobilization of additional surgical teams for pediatric trauma patients.

(d) Instruments and equipment appropriate for pediatric surgery, including equipment as described in WAC 246-976-620;

(4) A post-anesthetic recovery unit with:

(a) Essential personnel on-call and available twenty-four hours a day;

(b) Nurses ACLS trained;

(c) Nurses ((PALS or approved equivalent trained)) who have completed the PER as defined in WAC 246-976-887;

(d) Appropriate monitoring and resuscitation equipment;

(5) Availability of pediatric critical care, with:

(a) A written transfer agreement and guidelines for pediatric trauma patients requiring critical care services; or

(b) A pediatric critical care unit in accordance with standards as delineated for level II pediatric trauma service in WAC 246-976-780(5), except the medical director or codirector shall be board-certified in pediatrics or another relevant specialty with special competence in pediatric critical care;

(c) A physician with special competence in pediatric critical care, available within five minutes of notification;

(d) A physician-directed code team;

(e) Pediatric critical care nursing, with registered nurses who have:

(i) Special competence in pediatric trauma care; and

(ii) Completed ((PALS or approved equivalent training)) the PER as defined in WAC 246-976-887;

(f) Equipment as described in WAC 246-976-620 and WAC 246-976-825.

(6) Respiratory therapy on-call and available within five minutes of notification;

(7) A clinical laboratory technologist available within twenty minutes of notification;

(8) Clinical laboratory services, including:

(a) Standard analyses of blood, urine, and other body fluids;

(b) Coagulation studies;

(c) Blood gases and pH determination;

(d) Microbiology;

(e) Serum alcohol and toxicology determination; and

(f) Microtechnique.

(9) Blood and blood-component services, including:

(a) Blood and blood components available from in-house or through community services, to meet patient needs;

(b) Noncrossmatched blood available on patient arrival in the emergency department;

(c) Blood typing and cross-matching;

(d) Policies and procedures for massive transfusion;

(e) Autotransfusions; and

(f) Blood storage capability;

(10) Radiological services, including a technician on-call and available within twenty minutes of notification, able to perform:

(a) Routine radiological studies;

(b) Computerized tomography;

(11) Acute dialysis capability, or written transfer agreements;

(12) Written transfer guidelines in accordance with the guidelines of the American Burn Association, and transfer agreements for burn care;

(13)(a) Written transfer guidelines and agreements for patients with head or spinal cord injuries; or

(b) Have neurosurgery, with a neurosurgeon on-call and available within thirty minutes of request by the trauma team leader.

(c) Early transfer to an appropriate designated trauma rehabilitation service shall be considered;

(14) A trauma rehabilitation coordinator to facilitate the pediatric trauma patient's access to pediatric rehabilitation services;

(15)(a) A designated pediatric trauma rehabilitation service; or

(b) Written agreements to transfer patients to a designated pediatric trauma rehabilitation service when medically feasible.

(16)(a) 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; or

(b) Have a written policy and procedures addressing the receipt of patients by air, and transfer of patients to other designated trauma services by ground or air.

[Statutory Authority: Chapter 70.168 RCW. 98-19-107, 246-976-820, filed 9/23/98, effective 10/24/98; 98-04-038, 246-976-820, filed 1/29/98, effective 3/1/98; 93-20-063, 246-976-820, filed 10/1/93, effective 11/1/93. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-820, filed 12/23/92, effective 1/23/93.]


NEW SECTION
WAC 246-976-886   Pediatric education requirements (PER) for nonpediatric designated facilities.   (1) In designated levels I, II, III, and IV general trauma care services emergency physicians and emergency 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.

(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;

(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.

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NEW SECTION
WAC 246-976-887   Pediatric education requirements (PER) for pediatric designated facilities.   (1) In designated levels I, II, III pediatric trauma care services emergency physicians, emergency RNs, general surgeons, pediatric intensivists, anesthesiologists, CRNAs, ICU RNs and PACU RNs who are involved in the resuscitation, stabilization and in-patient care of pediatric trauma patients shall have PER, as provided in subsection (2) of this section, appropriate to their scope of trauma care.

(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;

(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.

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Washington State Code Reviser's Office