WSR 98-04-038

PERMANENT RULES

DEPARTMENT OF HEALTH

[Filed January 29, 1998, 3:58 p.m.]

Date of Adoption: January 23, 1998.

Purpose: To define a process for trauma service designation and establish minimum standards for designated trauma care services to include Level I-V, Pediatric Level I-III, Rehabilitation Level I-III and Pediatric Rehabilitation Level I.

Citation of Existing Rules Affected by this Order: Repealing WAC 246-976-470, 246-976-475, 246-976-480, and 246-976-880; and amending WAC 246-976-485 through 246-976-890.

Statutory Authority for Adoption: Chapter 70.168 RCW.

Adopted under notice filed as WSR 97-24-102 on December 3, 1997.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, amended 0, repealed 0; Federal Rules or Standards: New 0, amended 0, repealed 0; or Recently Enacted State Statutes: New 0, amended 0, repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, amended 0, repealed 0.

Number of Sections Adopted on the Agency's own Initiative: New 7, amended 26, repealed 4.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 7, amended 26, repealed 4.

Number of Sections Adopted using Negotiated Rule Making: New 7, amended 26, repealed 4; Pilot Rule Making: New 0, amended 0, repealed 0; or Other Alternative Rule Making: New 0, amended 0, repealed 0.

Effective Date of Rule: Thirty-one days after filing.

January 27, 1998

Bruce Miyahara

Secretary

NEW SECTION

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

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

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

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

(d) The department's evaluation criteria; and

(e) The department's decision criteria.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(a) Evaluation of all applications submitted;

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

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

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

(e) Expected patient volume of the area;

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

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

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

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

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

(b) In regions where there is no competition, the department will send you the report within ninety days of the on-site review.

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

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

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

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

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

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

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

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

(11) The department may:

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

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

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

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

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

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

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

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

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

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

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

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

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

[]

NEW SECTION

WAC 246-976-490 Suspension or revocation of designation. The Administrative Procedure Act, chapter 34.05 RCW, and chapter 246-10 WAC govern the process of suspending or revoking trauma service designation.

(1) The department may suspend or revoke your trauma service designation if the designated facility and/or any owner, officer, director, or managing employee:

(a) Is substantially out of compliance with the requirements of this chapter and chapter 70.168 RCW, and has been unable or unwilling to comply as required by the department;

(b) Makes a false statement of a material fact in the application for designation, or in any record required by this chapter, or in a matter under investigation;

(c) Prevents, interferes with, or attempts to impede in any way, the work of a representative of the department in the lawful enforcement of this chapter or chapter 70.168 RCW;

(d) Uses false, fraudulent, or misleading advertising, or makes any public claims regarding the facility's ability to care for nontrauma patients based on its trauma care designation status;

(e) Misrepresents or is fraudulent in any aspect of conducting business.

(2) The department will use the following process to suspend trauma service designation:

(a) The department will notify you in writing if it intends to suspend your designation. It will send the notice at least twenty-eight days before it takes action, unless it is a summary suspension as provided for in the Administrative Procedure Act. The notice will include the reasons for the action, and describe your right to a hearing to contest the department's notice of intent to suspend your designation. If you request a hearing within twenty-eight days of the date the notice was mailed to you, a hearing before a health law judge will be scheduled. If you do not request a hearing within twenty-eight days of the date the notice was mailed to you, the suspension becomes final.

(b) You may submit a plan to the department within twenty-eight days after service of the department's notice of intent to suspend your designation, describing how you will correct deficiencies. The department will approve or disapprove your plan within thirty days of receiving your plan. If the department approves your plan, you must begin to implement it within thirty days. You must notify the department when the problems are corrected. When you have shown the department that you are meeting the requirements of chapter 70.168 RCW and this chapter, which may require a site review, the department will withdraw its notice of intent to suspend your designation or will otherwise reinstate designation if a final decision suspending designation has already occurred.

(c) The department will notify the regional EMS/TC council of the actions it has taken.

(3) The department will use the following process to revoke designation:

(a) The department will notify you in writing if it intends to revoke your designation. It will send the notice at least twenty-eight days before it takes action, unless it is a summary revocation as provided for in the Administrative Procedure Act. The notice will include the reasons for the action, and describe your right to a hearing to contest the department's notice of intent to revoke your designation. If you request a hearing, a hearing before a health law judge will be scheduled. If you do not request a hearing within twenty-eight days of the date the notice was mailed to you, the revocation becomes final.

(b) The department will notify the regional EMS/TC council of the actions it has taken.

(4) You may appeal final decisions to superior court under the Administrative Procedure Act, chapter 34.05 RCW.

[]

AMENDATORY SECTION (Amending Order 323, filed 12/23/92, effective 1/23/93 WAC 246-976-500 Designation standards for facilities providing level I trauma care ((hospital)) service--Administration and organization. A facility with a designated level I trauma care service shall have:

(1) ((For the purpose of administering trauma care, a designated level I hospital shall have a trauma service, including:))

(a) Organization and direction by a general surgeon ((who is expert in, and committed to,)) 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 ((ED)) emergency department registered nurse;

(iii) A ((trauma)) 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 ((intensive)) critical care ((unit)) service;

(ix) ((An intensive)) The trauma care service nurse coordinator;

(x) Critical care registered nurse; and

(((x))) (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 ((resuscitation)) team to provide initial evaluation, resuscitation and treatment.

(i) The team shall be organized and directed by a general surgeon ((who is expert in and committed to)) 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 year four resident;

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

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

(A) Responsible for activating the ((trauma resuscitation)) team, using an approved ((scoring system)) 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) ((Other members of the team shall be as specified in the hospital's application for designation;)) The trauma care service shall identify all other members of the team;

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

(2) ((A level I trauma care hospital shall have)) An ((ED)) emergency department with ((established)) written standards ((and procedures)) of care to ensure immediate and appropriate care for adult and pediatric trauma patients.

(3) A ((level I trauma care hospital shall have a)) surgery department, including:

(a) General surgery((, including an attending surgeon, in-house and available on patient's arrival in the ED, assuming five minute notification));

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

(i) ((In-house and available within five minutes. In-house coverage shall be provided by a board certified)) A neurosurgeon((, or by a surgeon who has been judged competent by the neurologic consultants on staff to initiate measures to stabilize the patient, and to initiate diagnostic procedures; and)); or

(ii) ((With a board-certified neurosurgeon on-call and available within thirty minutes;)) 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;

(((ii))) (iii) Hand surgery;

(((iii))) (iv) Microsurgery;

(((iv))) (v) Obstetric surgery;

(((v))) (vi) Ophthalmic surgery;

(vii) Oral/maxillofacial or otorhinolaryngologic surgery;

(viii) Orthopaedic surgery;

(((vi) Otorhinolaryngologic/maxillofacial surgery capable of managing upper airway trauma;

(vii))) (ix) Pediatric surgery;

(x) Plastic surgery;

(((viii))) (xi) Thoracic surgery; ((and

(ix))) (xii) Urologic surgery; and

(xiii) Vascular surgery.

(4) ((A level I trauma care hospital shall have)) 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) ((Is in-house and)) PALS or approved equivalent trained;

(iii) 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 ((within thirty minutes)) for patient consultation or management:

(i) Cardiology;

(ii) Gastroenterology;

(iii) Hematology;

(iv) Infectious disease specialists;

(v) Internal medicine;

(vi) Nephrology;

(vii) Neurology;

(viii) Pathology;

(((viii))) (ix) Pediatrics; and

(((ix))) (x) Pulmonology((; and

(d) Psychiatry)).

(5) ((A level I trauma care hospital shall have)) 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 ((ED)) emergency department and surgical interventions; and

(b) ((If it is not a level I pediatric hospital, includes written provision to transfer the patient to the appropriate level designated pediatric trauma facility after initial resuscitation and stabilization.)) 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.

(((6) A level I trauma care hospital shall have an approved)) (7) A written policy and procedures to divert patients to other designated ((facilities,)) trauma care services. The policy shall be based on ((it's)) criteria which reflect the service's ability to ((manage)) resuscitate and stabilize each patient at a particular time.

(((7) A level I trauma care hospital shall:)) (8) A trauma registry as required in WAC 246-976-430.

(((a) Have)) (9) A quality assurance program in accordance with WAC 246-976-880; and (((b))) 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: 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 93-20-063, filed 10/1/93, effective 11/1/93)

WAC 246-976-510 Designation standards for facilities providing level I trauma care ((hospitals)) service--Basic resources and capabilities. (((1))) A facility with a designated level I trauma care ((hospital)) service shall have ((an ED with)):

(1) An emergency department with:

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

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

(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) ((ACLS trained;)) Is PALS or approved equivalent trained, except that this requirement shall not apply to a physician board-certified in pediatric emergency medicine.

(b) ((Emergency)) Physicians who ((are)):

(i) Are board-certified ((or eligible)) in emergency medicine, or board-certified in a specialty and practicing emergency medicine as their primary practice with special ((competency)) competence in care of trauma patients; (this requirement may be met by a surgical resident post graduate year two who is ATLS, ACLS, and PALS or approved equivalent trained, working under the direct supervision of the ((physician director of the emergency department)) attending emergency physician, until the arrival of the ((attending)) surgeon((. The attending surgeon shall be in-house and available upon the patients arrival in the ED, assuming five minute notification)) to assume leadership of the trauma team);

(ii) ((In-house and)) Are available within five minutes ((to patient on arrival to ED)) of patient's arrival in the emergency department;

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

(iv) ((ACLS trained;

(v))) Are PALS or approved equivalent trained, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine; and

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

(c) ((ED)) Registered nurses who:

(i) Are ACLS trained;

(ii) Are PALS or approved equivalent trained;

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

(iv) Are in the ((ED)) emergency department and available ((to the patient)) within five minutes of patient's arrival in the emergency department; ((with at least two RNs on duty per shift;))

(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;

(((i) Airway control and ventilation equipment including:

(A) Airways;

(B) Laryngoscopes, including curved and straight;

(C) Endotracheal tubes of all sizes;

(D) Bag-mask resuscitator, with full range of sizes, neonatal to adult;

(E) Sources of oxygen; and

(F) Mechanical ventilation;

(ii) Suction devices, including:

(A) Back-up suction source;

(B) Pediatric and adult suction catheters; and

(C) Tonsil suction tip;

(iii) Electrocardiograph;

(iv) Cardiac monitor;

(v) Defibrillator, including pediatric paddles;

(vi) All standard apparatus to establish central venous pressure monitoring;

(vii) All standard intravenous fluids and administering devices for adult and pediatric patients, including intravenous and intraosseous needles;

(viii) Sterile surgical sets for procedures standard for ED such as thoracostomy and cut down, including adult and pediatric sets;

(ix) Gastric lavage equipment;

(x) Drugs and supplies necessary for emergency care, including pediatric emergency care;

(xi) Capability for rapid infusion of fluids;

(xii) Capability for rapid fluid recovery and transfusion;

(xiii) X-ray capability with twenty-four hour coverage by in-house technician;

(xiv) Thermal control equipment for:

(A) Patient;

(B) Blood;

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

(xvi) Pneumatic anti-shock garments, all sizes; except, pediatric are sizes optional depending on local protocol;

(xvii) Cervical injury immobilization device;

(xviii) Long-bone stabilization device;

(xix) Backboard;

(xx) Equipment specific to pediatric trauma care, including:

(A) Traction splint;

(B) Blood pressure cuffs in infant, child sizes;

(C) Foley catheters;

(D) Rigid cervical collars;

(E) Doppler;

(F) Infant scale for accurate weight measurement under twenty-five pounds;

(G) Temperature controlled heating units, with/without open crib;

(H) Heating/cooling blankets;

(I) Heat lamp;

(J) Hypothermia thermometers;

(K) Expanded scale electronic thermometers;

(L) Device for assuring maintenance of infant warmth during evaluation and transport;

(M) Nasogastric/feeding tubes;

(N) Noninvasive BP monitor; and

(O) Pulse oximetry.))

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

(2) A ((level I trauma care hospital shall have a general)) surgery department including:

(a) An attending general surgeon ((who is in-house and)) available ((upon the patient's arrival in the ED, assuming)) 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; ((or have graduated from a residency program accredited by the accreditation council of graduate medical education, but who is less than five years out of training;

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

(b) A post-graduate year four or above surgical resident may initiate evaluation and treatment upon the patient's arrival in the ((ED)) emergency department until the arrival of the attending surgeon. In this case the attending surgeon shall be available within twenty minutes ((upon)) of notification of team activation. ((The resident shall have ATLS and PALS or approved equivalent training.))

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

(((d) All trauma surgeons trained in)) (i) ATLS and ACLS, except ((that)) this requirement shall not apply to a physician board-certified ((surgeons)) in surgery; and

(((e) All trauma surgeons trained in)) (ii) PALS or approved equivalent.

(3) ((A level I trauma care hospital shall have)) An operating ((suite)) room available within five minutes of notification of team activation, with:

(a) ((An operating room adequately staffed and available within five minutes after notification;)) 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) ((Essential personnel, including at least one OR nurse, in-house and available twenty-four hours a day;

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

(((d) Equipment or capabilities including:

(i) Cardiopulmonary bypass capability;

(ii) Operating microscope;

(iii) Thermal control equipment for patients;

(iv) Thermal control equipment for blood;

(v) Rapid infusion capability;

(vi) Rapid fluid recovery capability;

(vii) X-ray capability;

(viii) Bronchoscope in operating room;

(ix) Endoscopes available from elsewhere in the facility;

(x) Craniotome;

(xi) Monitoring equipment; and

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

(4) A ((level I trauma care hospital shall have a)) post anesthetic recovery unit with:

(a) Essential personnel, including at least one registered nurse ((with critical post anesthetic nurse training, in-house and)) available twenty-four hours a day;

(b) ((All)) Nurses ACLS trained; ((and))

(c) Nurses PALS or approved equivalent trained; and

(d) Appropriate monitoring and resuscitation equipment.

(5) A ((level I trauma care hospital shall have an intensive)) critical care ((unit)) service with:

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

(i) Board-certified ((or eligible)) in ((critical care, pulmonary medicine, cardiology, or)) 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; ((and))

(iii) ((ATLS trained.)) 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 ((on duty in the ICU twenty-four hours a day, or who is in-house and)) with special competence in critical care available in the critical care unit within five minutes of notification;

(c) A physician directed code team;

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

(i) Are ACLS trained; and

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

(e) ((Immediate access to clinical laboratory services;)) 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 ((appropriate for adult and pediatric patients, including:

(i) Airway control and ventilation devices;

(ii) Oxygen source with concentration controls;

(iii) Cardiac emergency cart;

(iv) Temporary transvenous pacemaker;

(v) Electrocardiograph-cardiac monitor-defibrillator;

(vi) Cardiac output monitoring;

(vii) Electronic pressure monitoring;

(viii) Mechanical ventilator-respirators;

(ix) Patient weighing devices;

(x) Pulmonary function measuring devices;

(xi) Temperature control devices;

(xii) Drugs, intravenous fluids, and supplies; and

(xiii) Intracranial pressure monitoring devices)) as described in WAC 246-976-620.

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

(7) A ((level I trauma care hospital shall have a)) clinical laboratory technologist available within five minutes((, including:)) 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)) pH determination;

(d) Serum and urine osmolality;

(e) Microbiology;

(f) Serum alcohol and toxicology determination;

(g) Drug screening; and

(h) Microtechnique.

(((7) A level I trauma care hospital shall have transfusion)) (9) Blood and blood component services, including:

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

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

(c) Blood typing and cross-matching;

(d) Policies and procedures for massive transfusion ((protocols in place));

(((d) Ability to perform massive transfusions and)) (e) Autotransfusion; and

(((e))) (f) Blood storage capability.

(((8) A level I trauma care hospital shall have)) (10) Radiological services, including:

(a) ((The following services in-house and)) A technician available within five minutes of notification, able to perform the following:

(i) Computerized tomography; and

(ii) ((X-ray capability;)) Routine radiological capabilities;

(b) ((The following services)) 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.

(((9) A level I trauma care hospital shall have acute hemodialysis)) (11) Acute dialysis capability, or ((a)) written transfer agreements.

(((10) A level I trauma care hospital shall have:)) (12)(a) A physician-directed burn unit ((which is)) 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 ((with a burn center or hospital with burn unit)) for burn care.

(((11) A level I trauma care hospital shall be able)) (13) The ability to manage acute head and/or spinal cord ((injury; or have written transfer agreements with a facility with such capabilities)) injuries. Early transfer to an appropriate designated trauma rehabilitation ((facility)) service shall be considered.

(((12) A level I trauma care hospital shall have)) (14) A trauma rehabilitation coordinator to facilitate the trauma patient's access to rehabilitation services.

(((13) A level I trauma care hospital shall have:)) (15)(a) A ((physician-directed)) designated trauma rehabilitation ((medicine)) service ((which is staffed by personnel trained in rehabilitation care; and is equipped to care for the trauma patient)); or

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

(((14))) (16) A ((level I trauma care hospital shall have a heliport or)) heli-stop, landing zone, or airport located close enough to permit the facility to receive or transfer patients by ((air)) fixed-wing or rotary-wing aircraft.

[Statutory Authority: Chapter 70.168 RCW. 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 93-20-063, filed 10/1/93, effective 11/1/93)

WAC 246-976-520 Designation standards for facilities providing level I trauma care ((hospitals)) service--Outreach, ((training, and public education)) public education, trauma care education, and research. A facility with a designated level I trauma care ((hospital)) service shall have:

(1) An outreach program with telephone and on-site consultations with physicians of the community and outlying areas regarding trauma care;

(2) A public education program addressing injury prevention;

(3) Training, including:

(a) A formal program of continuing trauma care education for:

(i) Staff physicians;

(ii) Nurses;

(iii) Allied health care professionals;

(iv) Community physicians; and

(v) Prehospital personnel;

(b) ((A)) Residency programs accredited by the accreditation council of graduate medical education, with a commitment to training physicians in trauma management;

(c) In-house initial and maintenance training of invasive manipulative skills for prehospital personnel;

(((3) A public education program addressing:

(a) Injury prevention:

(i) In the home;

(ii) In industry and the work place;

(iii) On the highways;

(iv) On athletic fields; and

(v) For recreational or sports related activities;

(b) First aid or CPR;

(c) Problems confronting the public, the medical profession, and hospitals regarding optimal care for the injured.))

(4) A trauma research program.

[Statutory Authority: Chapter 70.168 RCW. 93-20-063, 246-976-520, 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), 246-976-520, filed 12/23/92, effective 1/23/93.]

AMENDATORY SECTION (Amending Order 323, filed 12/23/92, effective 1/23/93 WAC 246-976-550 Designation standards for facilities providing level II trauma care ((hospitals)) service--Administration and organization. (((1) For the purpose of administering trauma care, a designated level II hospital shall have a trauma service, including:)) A facility with a designated level II trauma care service shall have:

(1)(a) Organization and direction by a general surgeon ((who is expert in, and committed to,)) 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 ((ED)) emergency department registered nurse;

(iii) A ((trauma)) 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 ((intensive care unit)) the critical care service; ((and))

(ix) ((An intensive)) 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;

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

(i) The team shall be organized and directed by a general surgeon ((who is expert in and committed to)) 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 ((in-house and)) available within five minutes of notification of team activation;

(iii) ((The surgeon shall be available upon the patient's arrival in the ED, assuming twenty minute notification; and shall assume responsibility for patient care upon the surgeon's arrival in the resuscitation area;

(iv))) The team shall include ((an emergency physician)):

(A) An emergency physician who is:

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

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

(((v) Other members of the team shall be as specified in the hospital's application for designation;

(e))) (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) ((A level II trauma care hospital shall have an ED)) An emergency department with ((established)) written standards ((and procedures)) of care to ensure immediate and appropriate care for adult and pediatric trauma patients.

(3) A ((level II trauma care hospital shall have a)) surgery department, including:

(a) General surgery((, including a trauma surgeon));

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

(i) ((In-house and available within five minutes. In-house coverage shall be provided by a neurosurgeon, surgeon, or other physician who has been judged competent by the neurologic consultants on staff to initiate measures to stabilize the patient, and to initiate diagnostic procedures; and)) 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;

(((iii))) (iv) Ophthalmic surgery;

(v) Oral/maxillofacial or otorhinolaryngologic surgery;

(vi) Orthopaedic surgery;

(((iv))) (vii) Plastic surgery;

(((v) Otorhinolaryngologic/maxillofacial surgery capable of managing upper airway trauma; and

(vi))) (viii) Thoracic surgery;

(ix) Urologic surgery; and

(x) Vascular surgery.

(4) ((A level II trauma care hospital shall have)) 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; ((and))

(ii) ((Is)) PALS or approved equivalent trained; and

(iii) On-call and available ((on patient's arrival in ED, assuming a twenty minute notification)) 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 ((within thirty minutes)) for patient consultation or management:

(i) Cardiology;

(ii) Gastroenterology;

(iii) Hematology;

(((iii))) (iv) Infectious disease specialists;

(v) Internal medicine;

(((iv))) (vi) Nephrology;

(vii) Neurology;

(viii) Pathology; ((and

(v))) (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 ((level II trauma care hospital shall have a)) pediatric trauma policy that:

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

(b) ((If it is not a level II pediatric trauma hospital, includes written provision to transfer the patient to the appropriate level designated pediatric trauma facility after initial resuscitation and stabilization.)) 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.

(((6))) (7) A ((level II trauma care hospital shall have an approved)) written policy and procedures to divert patients to other designated ((facilities,)) trauma care services. The policy shall be based on ((it's)) criteria which reflect the service's ability to ((manage)) resuscitate and stabilize each patient at a particular time.

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

(9) A ((level II trauma care hospital shall have 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: 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 93-20-063, filed 10/1/93, effective 11/1/93)

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

(1) ((A level II trauma care hospital shall have an ED)) An emergency department, with:

(a) A physician director who is ((board certified or eligible in emergency medicine;)):

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

(ii) 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, except that this requirement shall not apply to a physician board-certified in pediatric emergency medicine.

(b) ((Emergency)) Physicians who ((are)):

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

(ii) ((In-house and)) Are available within five minutes ((to patient on arrival to ED)) of patient's arrival in the emergency department;

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

(iv) ((ACLS trained;

(v))) Are PALS or approved equivalent trained, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine; and

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

(c) ((ED)) Registered nurses who:

(i) Are ACLS trained;

(ii) Are PALS or approved equivalent trained;

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

(iv) Are in the ((ED)) emergency department and available ((to the patient)) within five minutes of patient's arrival in the emergency department; ((with at least two RN's on duty per shift;))

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

(((i) Airway control and ventilation equipment including:

(A) Airways;

(B) Laryngoscopes, including curved and straight;

(C) Endotracheal tubes of all sizes;

(D) Bag-mask resuscitator, with full range of sizes, neonatal to adult;

(E) Sources of oxygen; and

(F) Mechanical ventilation;

(ii) Suction devices, including:

(A) Back-up suction source;

(B) Pediatric and adult suction catheters; and

(C) Tonsil suction tip;

(iii) Electrocardiograph;

(iv) Cardiac monitor;

(v) Defibrillator, including pediatric paddles;

(vi) All standard apparatus to establish central venous pressure monitoring;

(vii) All standard intravenous fluids and administering devices for adult and pediatric patients, including intravenous catheters and intraosseous needles;

(viii) Sterile surgical sets for procedures standard for ED such as thoracostomy and cut down, including adult and pediatric sets;

(ix) Gastric lavage equipment;

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

(xi) Capability for rapid infusion of fluids;

(xii) Capability for rapid fluid recovery and transfusion;

(xiii) X-ray capability with twenty-four hour coverage by in-house technician;

(xiv) Thermal control equipment for:

(A) Patient; and

(B) Blood;

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

(xvi) Pneumatic anti-shock garments, all sizes; except, pediatric sizes are optional, depending on local protocol;

(xvii) Cervical injury immobilization device;

(xviii) Long-bone stabilization device;

(xix) Backboard;

(xx) Equipment specific to pediatric care, including:

(A) Traction splint;

(B) Blood pressure cuffs in infant, child, and toddler sizes;

(C) Foley catheters;

(D) Rigid cervical collars;

(E) Doppler;

(F) Infant scale for accurate weight measurement under twenty-five pounds;

(G) Temperature controlled heating units with/without open crib;

(H) Heating/cooling blankets;

(I) Heat lamp;

(J) Hypothermia thermometers;

(K) Expanded scale electronic thermometers;

(L) Device for assuring maintenance of infant warmth during transport;

(M) Nasogastric/feeding tubes;

(N) Noninvasive BP monitor; and

(O) Pulse oximetry.))

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

(2) A ((level II trauma care hospital shall have a general)) surgery department, including:

(a) An attending general surgeon ((who is)) on-call and available ((upon the patient's arrival in the ED, assuming twenty minute notification)) 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; ((or have graduated from a residency program accredited by the accreditation council of graduate medical education, but who is less than five years out of training;

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

(b) A post-graduate year four or above surgical resident may initiate evaluation and treatment upon the patient's arrival in the ((ED)) 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 and PALS or approved equivalent training;

(c) All ((trauma)) general surgeons who are responsible for care and treatment of trauma patients shall be trained in ((ATLS except that this requirement shall not apply to board certified surgeons; and)):

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

(((d) All trauma surgeons trained in ACLs and)) (ii) PALS or approved equivalent.

(3) ((A level II trauma care hospital shall have)) An operating ((suite)) room available within five minutes of notification of team activation, with:

(a) ((An operating room adequately staffed with one operating room nurse or other member of the operating room staff who is in-house and available within five minutes and is qualified to open a room, dispense necessary drugs, and is otherwise qualified to prepare the operating suite for immediate patient care. The remainder of the staff shall be in-house or on-call and available within twenty minutes;)) 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) ((Essential personnel, including at least one OR nurse, available twenty-four hours a day;)) Other essential personnel on-call and available within twenty minutes of notification of team activation;

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

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

(((i) Operating microscope;

(ii) Thermal control equipment for patients;

(iii) Thermal control equipment for blood;

(iv) Rapid infusion capability;

(v) Rapid fluid recovery capability;

(vi) X-ray capability;

(vii) Bronchoscope in operating room;

(viii) Endoscopes available from elsewhere in the facility;

(ix) Craniotome;

(x) Monitoring equipment; and

(xi) Instruments and equipment appropriate to pediatric trauma care.))

(4) A ((level II trauma care hospital shall have a)) post anesthetic recovery unit with:

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

(b) ((All)) Nurses ACLS trained;

(c) Nurses PALS or approved equivalent trained; and

(d) Appropriate monitoring and resuscitation equipment.

(5) A ((level II trauma care hospital shall have an intensive care unit)) critical care service, with:

(a) A medical director who is:

(i) Board-certified((, board eligible, or who has expertise in critical care, pulmonary medicine, cardiology,)) in surgery, internal medicine, or anesthesiology, with special competence in critical care; and

(ii) ((ACLS trained;)) 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 ((on duty in the ICU twenty-four hours a day, or who is in-house and)) available in the critical care unit within five minutes of notification;

(c) A physician directed code team;

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

(i) Are ACLS trained;

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

(e) ((Immediate access to clinical laboratory services;)) 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 ((appropriate for adult and pediatric patients, including:

(i) Airway control and ventilation devices;

(ii) Oxygen source with concentration controls;

(iii) Cardiac emergency cart;

(iv) Temporary transvenous pacemaker;

(v) Electrocardiograph-cardiac monitor-defibrillator;

(vi) Cardiac output monitoring;

(vii) Electronic pressure monitoring;

(viii) Mechanical ventilator-respirators;

(ix) Patient weighing devices;

(x) Pulmonary function measuring devices;

(xi) Temperature control devices;

(xii) Drugs, intravenous fluids, and supplies; and

(xiii) Intracranial pressure monitoring devices)) as described in WAC 246-976-620.

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

(7) A ((level II trauma care hospital shall have)) clinical laboratory ((services)) 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.

(((7) A level II trauma care hospital shall have transfusion)) (9) Blood and blood component services, including:

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

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

(c) Blood typing and cross-matching;

(d) Policies and procedures for massive transfusion ((protocols in place));

(((d) Ability to perform massive transfusions and)) (e) Autotransfusion; and

(((e))) (f) Blood storage capability.

(((8) A level II trauma care hospital shall have)) (10) Radiological services, including:

(a) ((X-ray capabilities in-house and)) A technician available within five minutes of notification, able to perform routine radiological procedures;

(b) ((The following services)) 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.

(((9) A level II trauma care hospital shall have acute hemodialysis)) (11) Acute dialysis capability, or ((a)) written transfer agreements.

(((10) A level II trauma care hospital shall have:)) (12)(a) A physician-directed burn unit ((which is)) staffed by nursing personnel trained in burn care; and ((is)) equipped to care for ((the)) extensively burned patients; or

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

(((11) A level II trauma care hospital shall be able)) (13)(a) The ability to manage acute head and/or spinal cord injuries((,)) or;

(b) Have written transfer guidelines and agreements ((with facility with such capabilities.)) for head and spinal cord injuries;

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

(((12))) (14) A ((level II trauma care hospital shall have a)) trauma rehabilitation coordinator to facilitate the trauma patient's access to rehabilitation services.

(((13) A level II trauma care hospital shall have:)) (15)(a) A ((physician-directed)) designated trauma rehabilitation ((medicine)) service ((which is staffed by personnel trained in rehabilitation care, and is equipped to care for the trauma patient)); or

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

(((14))) (16) A ((level II trauma care hospital shall have a heliport or)) heli-stop, landing zone, or airport located close enough to permit the facility to receive or transfer patients by ((air)) fixed-wing or rotary-wing aircraft.

[Statutory Authority: Chapter 70.168 RCW. 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 Order 323, filed 12/23/92, effective 1/23/93 WAC 246-976-570 Designation standards for facilities providing level II trauma care ((hospitals)) service--Outreach, public education and ((training)) trauma care education. A facility with a designated level II trauma care ((hospitals)) service shall have:

(1) ((Have)) An outreach program with telephone and on-site consultations with physicians of the community and outlying areas regarding trauma care;

(2) ((Have)) A public education program addressing injury prevention;

(3) A formal program of continuing trauma care education for:

(a) Staff physicians;

(b) Nurses;

(((b))) (c) Allied health care professionals;

(d) Community physicians; and

(((c))) (e) Prehospital personnel;

(((3))) (4) Make the facility available for initial and maintenance training of invasive manipulative skills for prehospital personnel.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-570, filed 12/23/92, effective 1/23/93.]

AMENDATORY SECTION (Amending WSR 93-20-063, filed 10/1/93, effective 11/1/93)

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

(1) ((For the purpose of administering trauma care, a designated level III hospital shall have a trauma service, including:)) (a) Organization and direction by a general surgeon or other physician ((who is expert in, and committed to,)) 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 ((ED)) emergency department registered nurse;

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

(iv) An orthopaedic surgeon;

(v) A pediatrician;

(vi) An anesthesiologist;

(((vi) A pediatrician;))

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

(viii) ((An intensive)) 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 ((resuscitation)) team to provide initial evaluation, resuscitation and treatment((:)).

(i) The team shall be organized and directed by a general surgeon ((who is expert in, and committed to,)) with special competence in care of the injured, and who assumes responsibility for coordination of overall care of the trauma patient((. The attending surgeon shall be on-call and available within thirty minutes of being called));

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

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

(A) An emergency physician who is:

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

(((B))) (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) ((Other members of the team shall be as specified in the hospital's application for designation.)) The trauma care service shall identify all other members of the team.

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

(2) ((A level III trauma care hospital shall have an ED)) An emergency department with ((established)) written standards ((and procedures)) of care to ensure immediate and appropriate care for adult and pediatric trauma patients.

(3) A ((level III trauma care hospital shall have a)) surgery department ((with)), including:

((An attending surgeon who is on-call and available within thirty minutes, and:

(a) Has general surgery privileges;

(b) Has ATLS training.)) (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) ((A level III trauma care hospital shall have)) Nonsurgical specialties, including:

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

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

(ii) PALS or approved equivalent trained;

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

(((ii) ACLS trained; and))

(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 ((within thirty minutes)) for patient consultation or management:

(i) Internal medicine; and

(ii) ((A radiologist.)) 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 ((level III trauma hospital shall have a)) pediatric trauma policy that:

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

(b) ((If it is not a level III pediatric hospital, includes written provision to transfer patients to the appropriate level designated pediatric trauma facility after initial resuscitation and stabilization.)) 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.

(((6))) (7) A ((level III trauma hospital shall have an approved)) written policy and procedure to divert patients to other designated ((facilities,)) trauma care services. The policy shall be based on ((it's)) criteria which reflect the service's ability to ((manage)) resuscitate and stabilize each patient at a particular time.

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

(9) A ((level III trauma care hospital shall have 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. 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 93-20-063, filed 10/1/93, effective 11/1/93)

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

(1) ((A level III trauma care hospital shall have an ED)) An emergency department with:

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

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

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

(iii) PALS or approved equivalent training, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine.

(b) ((A physician in-house and available within five minutes of patient's arrival in the ED, who is)) Physicians who:

(i) ((Experienced)) 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;

(((iii))) (iv) Are PALS or approved equivalent trained, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine; and

(((iv) ACLS trained; and))

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

(c) ((ED)) Registered nurses who:

(i) Are ACLS trained;

(ii) Are PALS or approved equivalent trained;

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

(iv) Are in the ((ED)) emergency department and available ((to the patient)) 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.

(((i) Airway control and ventilation equipment including:

(A) Airways;

(B) Laryngoscopes, including curved and straight;

(C) Endotracheal tubes of all sizes;

(D) Bag-mask resuscitator, with full range of sizes, neonatal to adult;

(E) Sources of oxygen; and

(F) Mechanical ventilation available to the patient within five minutes;

(ii) Suction devices, including:

(A) Back-up suction source;

(B) Pediatric and adult suction catheters; and

(C) Tonsil suction tip;

(iii) Electrocardiograph;

(iv) Cardiac monitor;

(v) Defibrillator, including pediatric paddles;

(vi) All standard apparatus to establish central venous pressure monitoring;

(vii) All standard intravenous fluids and administering devices appropriate for adult and pediatric patients, including intravenous catheters and intraosseous needles;

(viii) Sterile surgical sets for procedures standard for ED such as thoracostomy and cut down, including both adult and pediatric sets;

(ix) Gastric lavage equipment;

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

(xi) Capability for rapid infusion of fluids;

(xii) X-ray capabilities, with a technician on-call and available within twenty minutes;

(xiii) Thermal control equipment for:

(A) Patient; and

(B) Blood;

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

(xv) Pneumatic anti-shock garments, all sizes; except, pediatric sizes are optional, depending on local protocol;

(xvi) Cervical injury immobilization device;

(xvii) Long-bone stabilization device;

(xviii) Backboard;

(xix) Equipment specific to pediatric care, including:

(A) Traction splint;

(B) Blood pressure cuffs in infant, child sizes;

(C) Foley catheter;

(D) Rigid cervical collars;

(E) Doppler;

(F) Infant scale for accurate weight measurement under twenty-five pounds;

(G) Temperature-controlled heating units with/without open crib available within five minutes;

(H) Heating/cooling blankets;

(I) Heat lamp;

(J) Hypothermia thermometers;

(K) Expanded scale electronic thermometers;

(L) Device for assuring maintenance of infant warmth during evaluation and transport;

(M) Nasogastric/feeding tubes;

(N) Noninvasive BP monitor; and

(O) Pulse oximetry.))

(2) ((A level III trauma care hospital shall have)) Routine radiological capabilities by a technician available within twenty minutes of notification of team activation.

(3) 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.

(4) An operating ((suite adequately staffed with one operating room nurse or operating-room-qualified designee who is in-house and available to the operating suite within five minutes and the remainder of the staff on-call and available within thirty minutes.)) room available within five minutes of notification of team activation, with:

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

(((b) A documented method for prompt mobilization of consecutive surgical teams for trauma patients)) (c) A written policy providing for mobilization of additional surgical teams for trauma patients; and

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

(((i) Thermal control equipment for patients;

(ii) Thermal control equipment for blood;

(iii) X-ray capability;

(iv) Bronchoscope in operating room;

(v) Endoscopes available from elsewhere in the facility;

(vi) Monitoring equipment; and

(vii) Instruments and equipment appropriate to pediatric trauma care.

(3))) (5) A ((level III trauma care hospital shall have a)) post anesthetic recovery unit with:

(a) Essential personnel((, including registered nurses with ACLS training,)) on-call and available twenty-four hours a day;

(b) Nurses ACLS trained;

(c) Nurses PALS or approved equivalent trained; and

(d) Appropriate monitoring and resuscitation equipment.

(((4))) (6) A ((level III trauma care hospital shall have an intensive care unit)) critical care service, with:

(a) A medical director who is ((ACLS trained;)):

(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) ((ICU)) 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) ((Immediate access to clinical laboratory services;)) 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 ((appropriate for adult and pediatric patients, including:)) as described in WAC 246-976-620.

(((i) Airway control and ventilation devices;

(ii) Oxygen source with concentration controls;

(iii) Cardiac emergency cart;

(iv) Artificial pacing capabilities;

(v) Electrocardiograph-defibrillator;

(vi) Electronic pressure monitoring;

(vii) Mechanical ventilator-respirators available within five minutes;

(viii) Patient weighing devices;

(ix) Pulmonary function measuring devices;

(x) Temperature control devices; and

(xi) Drugs, intravenous fluids, and supplies.))

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

(((5))) (8) A ((level III trauma care hospital shall have)) clinical laboratory ((services)) technologist available within twenty minutes of notification.

(9) 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.

(((6) A level III trauma care hospital shall have transfusion)) (10) Blood and blood component services, including:

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

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

(c) Blood typing and cross-matching;

(d) Policies and procedures for massive transfusion ((protocols in place));

(((d) Ability to perform massive transfusions and)) (e) Autotransfusion; and

(((e))) (f) Blood storage capability.

(11) 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.

(((7) A level III trauma care hospital shall have acute hemodialysis)) (12) Acute dialysis capability, or written transfer agreements.

(((8) A level III trauma care hospital shall have:)) (13) 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.

(((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 agreements with burn centers or hospitals with burn units.

(9) A level III trauma care hospital shall be able to manage acute head and/or spinal cord injuries, or have written transfer agreements with facilities with such capabilities. Early transfer to an appropriate designated rehabilitation facility shall be considered.

(10))) (14) 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.

(15) A ((level III trauma care facility shall have a)) trauma rehabilitation coordinator to facilitate the trauma patient's access to rehabilitation services.

(((11) A level III trauma care hospital shall have:)) (16)(a) A ((physician-directed)) designated trauma rehabilitation ((medicine)) service ((staffed by personnel trained in rehabilitation care; and equipped to care for the trauma patient)); or

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

(((12))) (17)(a) A ((level III trauma care hospital shall have a heliport or)) heli-stop, landing zone, or airport located ((near)) close enough to permit the facility to receive or transport patients by ((air)) 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. 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.]

NEW SECTION

WAC 246-976-615 Designation standards for facilities providing level III trauma care service--Trauma care education. A facility with a designated level III trauma care service shall:

(1) Have a public education program addressing injury prevention;

(2) Make the facility available for initial and maintenance training of invasive manipulative skills for prehospital personnel.

[]

NEW SECTION

WAC 246-976-620 Equipment requirements for levels I - III and levels I - III pediatric trauma care services. A facility providing level I - III or level I - III pediatric trauma care services shall have the following equipment:

(1) In the emergency department:

(a) Airway control and ventilation equipment, including:

(i) Airways, neonate to adult;

(ii) Laryngoscopes, including curved and straight blades, size 0-4;

(iii) Endotracheal tubes size 2.5 to 8.0 with stylets available;

(iv) Bag-valve-mask resuscitator, neonate, child and adult;

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

(vi) CO₂ measurement;

(vii) Sources of oxygen;

(viii) Ability to provide mechanical ventilation;

(b) Suction devices, including:

(i) Back up suction source;

(ii) Pediatric and adult suction catheters, size 5.0 to 14 fr; and

(iii) Tonsil tip suction;

(c) Cardiac monitoring devices, including:

(i) Cardiac monitor;

(ii) Defibrillator, including pediatric paddles;

(iii) Electrocardiograph;

(iv) Portable transport monitor with ECG;

(v) Blood pressure cuffs, neonate, infant, child, adult;

(vi) Noninvasive blood pressure monitor; and

(vii) Doppler device;

(d) Intravenous supplies, including:

(i) Standard apparatus to establish central venous pressure monitoring;

(ii) Standard intravenous fluids and administration devices, including:

(A) Intravenous catheters: Size 24g to 14g;

(B) Intraosseous needles;

(C) Umbilical catheters: Size 5.0 - 8.0;

(D) Infusion controllers or pumps;

(iii) Pediatric and adult dosages/dilutions of medications;

(e) Sterile surgical sets appropriate for pediatric and adult patients, for standard emergency department procedures, including:

(i) Thoracotomy set;

(ii) Chest tubes, sizes 10-36 with sealing devices;

(iii) Emergency surgical airway set;

(iv) Peritoneal lavage set;

(v) Cutdown set;

(f) Gastric supplies, including:

(i) Gastric lavage equipment;

(ii) Nasogastric tubes, size 10 fr to 18 fr;

(g) Ability to provide thermal control equipment, including:

(i) Patient warming/cooling device;

(ii) Blood and fluid warming device;

(iii) Expanded scale thermometer capable of detecting hypothermia;

(iv) Device for assuring maintenance of infant warmth during evaluation and transport;

(h) Immobilization equipment, including:

(i) Traction splint;

(ii) Rigid cervical collars;

(iii) Cervical injury immobilization device;

(iv) Long-bone stabilization device; and

(v) Backboard;

(i) Other equipment, including:

(i) Urinary bladder catheters;

(ii) Infant scale for accurate weight measurement under twenty-five pounds;

(iii) 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; and

(iv) Two-way radio linked with EMS vehicles from trauma facility;

(2) In the surgery department, instruments and equipment or capabilities appropriate for pediatric and adult surgery (in levels I - III) or pediatric surgery (in pediatric levels I - III), including:

(a) Cardiopulmonary bypass (level I and pediatric level I only);

(b) Ability to provide thermal control equipment for:

(i) Patient warming/cooling;

(ii) Blood and fluid warming;

(c) Rapid infusion capability;

(d)(i) For level I and II and level I and II pediatric trauma care services, intraoperative autologous blood recovery and transfusion;

(ii) For level III and level III pediatric trauma care services, autologous blood recovery and transfusion;

(e) Ability to provide bronchoscopic capability in the operating room;

(f) Ability to provide endoscopes;

(g) Craniotomy set; except this is not required for level III or level III pediatric trauma care services; and

(h) Monitoring equipment;

(3) In the critical care unit for levels I - III, equipment appropriate for adult patients, including:

(a) Airway control and ventilation devices;

(b) Oxygen source with concentration controls;

(c) Cardiac emergency cart;

(d) Cardiac pacing capabilities;

(e) Electrocardiograph-cardiac monitor-defibrillator;

(f) Cardiac output monitoring;

(g) Electronic pressure monitoring;

(h) Ability to provide mechanical ventilator;

(i) Ability to provide patient weighing devices;

(j) Ability to provide thermal control equipment for:

(i) Patient warming/cooling;

(ii) Blood and fluid warming;

(k) Intracranial pressure monitoring devices, except this is not required in level III or level III pediatric trauma care services;

(4) In the critical care unit for level I - III pediatrics:

(a) Airway control and ventilation equipment, including:

(i) Oral and nasopharyngeal airways, all sizes neonate to adult (NOTE: Neonate and infants can use ETT for NP airway);

(ii) Laryngoscopes with curved and straight blades, size 0-4;

(iii) Endotracheal tubes size 2.5 to 8.0, with stylets available;

(iv) Bag-valve-mask resuscitators: Neonate, child, adult;

(v) Mechanical ventilator appropriate for entire pediatric spectrum;

(vi) Noninvasive oximetry and capnometry;

(b) Suction devices, including:

(i) Suction machine;

(ii) Suction catheters size 5.0 to 14 fr;

(iii) Tonsil tip suction;

(c) Cardiac monitoring devices, including:

(i) Cardiac monitor with capability to continuously monitor: Heart rate, respiration, temperature, and at least two pressure monitoring modules;

(ii) Hard copy monitor recording capabilities;

(iii) Defibrillator with pediatric paddles;

(iv) Electrocardiograph; and

(v) Portable transport monitor with ECG and pressure monitoring capability;

(d) Intravenous supplies, including:

(i) Standard apparatus to establish central venous pressure monitoring;

(ii) Standard IV fluids and administration devices appropriate for pediatric patients including:

(A) IV catheters: Size 24g to 16g;

(B) Intraosseous needles;

(C) Infusion sets and pumps with micro-infusion capabilities;

(D) Infusion controllers;

(iii) Pediatric dosages/dilutions of medications;

(e) Sterile surgical sets appropriate for pediatric patients, including:

(i) Thoracotomy set;

(ii) Chest tubes; (sizes 10 to 36);

(iii) Emergency surgical airway sets;

(iv) Peritoneal lavage set;

(v) Cutdown set;

(vi) Lumbar puncture set;

(f) Gastric supplies, including NG tubes: Size 10 fr to 16 fr;

(g) Ability to provide thermal control equipment, including:

(i) Temperature controlled heating units with or without open crib;

(ii) Heating/cooling blanket;

(iii) Heat lamp;

(iv) Blood and fluid warming device;

(v) Expanded scale thermometer capable of detecting hypothermia;

(vi) Device for assuring maintenance of infant warmth during transport;

(h) Equipment specific to pediatric trauma care including:

(i) Urinary bladder catheters;

(ii) Otoscope/ophthalmoscope;

(iii) Refractometer;

(iv) Blood pressure cuffs: Neonate, infant, child, adult;

(v) Doppler device;

(vi) Noninvasive blood pressure machine;

(vii) Ability to provide patient weighing devices including an infant scale for accurate weight measurement under twenty-five pounds;

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

[]

AMENDATORY SECTION (Amending Order 323, filed 12/23/92, effective 1/23/93 WAC 246-976-640 Designation standards for facilities providing level IV trauma care ((facilities)) services--Administration and organization. ((For the purpose of administering trauma care,)) A facility with a designated level IV ((hospital)) trauma care service shall:

(1) Define a system for providing emergency care twenty-four hours every day, which shall include ongoing coordination by a registered nurse; ((and))

(2) Establish emergency care services consistent with community needs, the approved regional plan, and within the facility's capabilities((; and)). The service shall have a policy that identifies and establishes its scope of trauma care for both adult and pediatric patients, including but not limited to:

(a) Initial resuscitation and stabilization;

(b) Admission criteria;

(c) Surgical capabilities;

(d) Critical care capabilities;

(e) Rehabilitation capabilities;

(3) ((A written plan for diversion and transfer of)) Have a method of activating trauma-response personnel consistent with the scope of trauma care and in keeping with the goals of WAC 246-976-870;

(4) Have a written policy and procedures to divert trauma patients to other designated trauma care services. The policy shall be based on criteria which reflect the ability of the service to accept, resuscitate and stabilize each patient at a particular time, and shall include notification of prehospital providers of the facility's diversion status; ((and

(4))) (5) Have interfacility transfer guidelines and agreements consistent with WAC 246-976-890;

(6) Participate in the state trauma registry as required in WAC 246-976-430, with a person identified as responsible for coordination of trauma registry activities;

(7) Have a quality assurance program in accordance with WAC ((246-976-880)) 246-976-881; and

(8) Participated in the regional trauma quality assurance program as required in WAC 246-976-910.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-640, filed 12/23/92, effective 1/23/93.]

AMENDATORY SECTION (Amending WSR 93-20-063, filed 10/1/93, effective 11/1/93)

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

(1) ((A level IV trauma care hospital shall have an ED)) An emergency department with:

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

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

(ii) ((ATLS trained; and)) Responsible for activating trauma-response personnel;

(iii) 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, except this requirement shall not apply to a physician board-certified in emergency medicine or pediatric emergency medicine;

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

(i) Is ACLS trained; ((and))

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

(iii) Is PALS or approved equivalent trained;

(c) Basic emergency services including:

(i) Assessment of the patient's condition((, in person by a registered nurse, physician, physician's assistant, physician extender, or advanced registered nurse practitioner));

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

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

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

(((C))) (D) Bag-valve-mask resuscitator ((with full range of mask sizes, neonatal to)) sizes neonatal, child and adult;

(((D))) (E) Sources of oxygen; ((and

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

(G) Suction devices;

(ii) Cardiac monitoring devices, including:

(A) Electrocardiograph;

(((iii))) (B) Cardiac monitor;

(((iv))) (C) Defibrillator with pediatric paddles;

(((v) All)) (iii) Standard intravenous fluids and administering devices, including ((intravenous catheters and intraosseous needles;)):

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

(B) Intraosseous needles;

(C) Infusion control device;

(((vi) Sterile surgical sets for procedures standard for ED;

(vii))) (iv) Gastric lavage equipment;

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

(((ix) X-ray capability, with technician on-call and available within twenty minutes;

(x))) (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 ((patient;)):

(A) Patient warming and cooling;

(B) Blood warming and cooling;

(ix) Other equipment:

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

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

(((xii) Pneumatic anti-shock garments; if use of this device is allowed in hospital protocols;

(xiii) Cervical injury immobilization device;

(xiv) Long-bone stabilization device; and

(xv) Backboard.))

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

(2) ((A level IV trauma care hospital shall have surgery capabilities, including)) 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) ((Adequate)) 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 ACLS trained; and)) 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

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

(ii) Anesthesiology, with an anesthesiologist or certified registered nurse anesthetist, who ((has ACLS training, and is on-call and available within thirty minutes;

(b) An operating suite with one RN or qualified designee who is in-house and available to the operating suite within five minutes and the remainder of the staff on-call and available within thirty minutes. The operating suite shall be equipped with)):

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

(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 ((patients;)):

(((ii) X-ray capability;)) (A) Patient warming;

(B) Blood and fluid warming;

(ii) Radiological capabilities;

(iii) Ability to provide endoscopes ((available from elsewhere in the facility)) appropriate to trauma resuscitation; and

(iv) Monitoring equipment((.));

(((3) A level IV trauma care hospital shall have a post anesthetic recovery unit with appropriate monitoring and resuscitation equipment.)) (3) Post anesthetic recovery services, with:

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

(b) Nurses ACLS trained;

(c) Appropriate monitoring and resuscitation equipment;

(4) ((A level IV trauma care hospital's shall have:

(a) An ICU)) (a) A critical care unit which meets requirements for a designated level III trauma ((hospital)) service as described in WAC 246-976-610((, except for availability of a mechanical ventilator-respirator and a temporary transvenous pacemaker)); or

(b) Written transfer guidelines and agreements with ((appropriate facilities to transfer)) designated trauma care services for patients requiring ((intensive)) critical care((.));

(5) ((A level IV trauma care hospital shall have)) Clinical laboratory services available, ((including)) for:

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

(b) Blood gases and pH determination((.));

(6) ((A level IV trauma care hospital shall have transfusion)) Blood and blood-component services, including:

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

(b) ((Ability to perform)) Policies and procedures for massive transfusions((, or written transfer agreements with facilities having such capability)); and

(c) Blood storage capability((.));

(7) ((A level IV trauma care hospital shall be able to perform acute hemodialysis)) Acute dialysis capabilities, or have written transfer guidelines and agreements ((with facilities having such capability.)) for dialysis service;

(8) ((A level IV trauma care hospital shall have:

(a) A physician-directed burn unit staffed by nursing personnel trained in burn care, and equipped to care for extensively burned patients; or)) Ability to resuscitate and stabilize burn patients; and have (((b))) Written transfer guidelines in accordance with the guidelines of the American Burn Association, and agreements ((with a burn center or hospital with burn unit.)) for burn care;

(9) ((A level IV trauma care hospital shall be able)) Ability to ((manage)) resuscitate and stabilize acute head and/or spinal cord injuries((, or have written transfer agreements with facilities that have such capabilities. Early transfer to an appropriate designated trauma rehabilitation facility shall be considered.)); 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;

(10) ((A level IV trauma care hospital shall have)) A qualified person assigned to coordinate trauma rehabilitation activities and referrals;

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

[Statutory Authority: Chapter 70.168 RCW. 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 93-20-063, filed 10/1/93, effective 11/1/93)

WAC 246-976-680 Designation standards for facilities providing level V trauma care ((facilities)) services--Administration and organization. ((For the purpose of administering trauma care, a designated level V trauma care facility shall)) A facility with a designated level V trauma care service shall:

(1) Have written ((policy)) policies and ((patient care)) procedures for providing emergency ((medical)) care, ((consistent with regional patient care procedures)) twenty-four hours every day for adult and pediatric trauma patients; and

(2) Establish emergency care services ((with a nature and scope)) consistent with community needs, the approved regional plan, and within the facilities capabilities. The service shall have a policy that identifies and establishes its scope of trauma care for both adult and pediatric trauma patients, including but not limited to:

(a) Initial resuscitation and stabilization;

(b) Admission criteria;

(3) Have a method of activating trauma-response personnel consistent with the scope of trauma care and in keeping with the goals of WAC 246-976-870;

(4) Participate in the state trauma registry as required in WAC 246-976-430 ((with a person identified as responsible for coordination of trauma registry activities.));

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

(6) Have interfacility transfer guidelines and agreements consistent with WAC 246-976-890;

(7) Have a quality assurance program in accordance with WAC 246-976-881;

(8) Participate in the regional trauma ((network)) quality assurance program as required in WAC 246-976-910.

[Statutory Authority: Chapter 70.168 RCW. 93-20-063, 246-976-680, 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), 246-976-680, filed 12/23/92, effective 1/23/93.]

AMENDATORY SECTION (Amending Order 323, filed 12/23/92, effective 1/23/93 WAC 246-976-690 Designation standards for facilities providing level V trauma care ((facilities)) service--Basic resources and capabilities. A facility with a designated level V trauma care ((facility)) service shall have:

(1) A physician, physician assistant registered in accordance with chapter 18.71 RCW, or advanced registered nurse practitioner, on-call and available within twenty minutes of notification, who has((:

(a))) ATLS training, ((or approved equivalent)) except the ATLS requirement shall not apply to a physician board-certified in emergency medicine or board-certified in surgery;

(((b) Experience in resuscitation and care of trauma patients.))

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

(a) Airway control and ventilation equipment, including:

(i) Airways, neonate to adult;

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

(((ii))) (iii) Endotracheal tubes ((of all sizes)) available, sizes 2.5 to 8.0, with stylets;

(((iii))) (iv) Bag-valve-mask resuscitator ((with full range of sizes, neonatal to adult)), sizes neonatal, child, and adult;

(((iv))) (v) Sources of oxygen; ((and

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

(vii) Suction devices;

(b) Cardiac monitoring devices, including:

(i) Electrocardiograph;

(((c))) (ii) Cardiac monitor;

(((d))) (iii) Defibrillator, with pediatric paddles;

(((e))) (c) All standard intravenous fluids and administering devices, including ((intravenous catheters;)):

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

(ii) Intraosseous needles;

(iii) Infusion control device;

(((f))) (d) Gastric lavage equipment;

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

(((h) Pneumatic anti-shock garment if use of this device is allowed under facility protocol;)) (f) 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;

(g) Immobilization devices, including:

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

(((j))) (ii) Long-bone stabilization device; and

(((k))) (iii) Backboard((.));

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

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-690, filed 12/23/92, effective 1/23/93.]

AMENDATORY SECTION (Amending WSR 93-20-063, filed 10/1/93, effective 11/1/93)

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

(1) ((For the purpose of administering trauma care, a designated level I pediatric hospital shall have a trauma service, including:)) (a) Organization and direction by a general surgeon ((who is expert in, and committed to,)) 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 ((ED)) emergency department registered nurse;

(iii) A ((trauma)) 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 ((intensive)) critical care service;

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

(ix) The pediatric trauma care service nurse coordinator;

(x) A pediatric ((intensive)) critical care registered nurse; ((and

(ix))) (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;

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

(i) The team shall be organized and directed by a pediatric surgeon ((who is expert in and committed to)) 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 ((in-house and)) available within five minutes of notification of team activation.

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

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

(A) Responsible for activating the trauma ((resuscitation)) team, using an approved ((scoring system)) 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 ((shall be as specified in the hospital's application for designation)).

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

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

(2) ((A level I pediatric trauma care hospital shall have an ED with established)) An emergency department with written standards ((and procedures)) of care to ensure immediate and appropriate care for pediatric trauma patients.

(3) ((A level I pediatric trauma care hospital shall have a)) A surgery department, including:

(a) General surgery ((in-house and available upon patient's arrival in the ED, assuming a five-minute notification)) with special competence in care of the pediatric trauma patient;

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

(i) ((In-house and available within five minutes. In-house coverage shall be provided by a board certified neurosurgeon or surgeon who has been judged competent by the neurosurgical consultants on staff to initiate measures directed toward stabilizing the pediatric patient and to initiate diagnostic procedures; and)) A neurosurgeon; or

(ii) ((With a neurosurgeon on-call and available within thirty minutes.)) 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) ((Microsurgery;

(iii))) Gynecologic surgery;

(((iv))) (iii) Hand surgery;

(((v))) (iv) Microsurgery;

(v) Obstetric surgery;

(vi) Ophthalmic surgery;

(((vi) Oral/dental surgery;))

(vii) Oral/maxillofacial or otorhinolaryngologic surgery;

(viii) Orthopaedic surgery;

(((viii) Otorhinolaryngologic surgery;))

(ix) Pediatric surgery;

(x) Plastic ((and maxillofacial)) surgery;

(((x))) (xi) Thoracic surgery; ((and

(xi))) (xii) Urologic surgery; and

(xiii) Vascular surgery.

(4) ((A level I pediatric trauma care hospital shall have)) Nonsurgical specialties with special ((expertise)) competence in pediatric care, including:

(a) Anesthesiology, with an anesthesiologist who is:

(i) ((ATLS trained;

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

(((iii))) (ii) PALS or approved equivalent trained; and

(((iv) In-house and)) (iii) Available ((on patient's arrival in ED, assuming five-minute notification)) within five minutes of team activation;

(b) ((General pediatrics in-house and available on patient's arrival in ED, assuming five-minute notification, with pediatricians who are:

(i) Board certified; and

(ii) PALS or approved equivalent trained;

(iii) These requirements may be met by a PL 2;)) 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 ((within thirty minutes)) for pediatric patient consultation or management:

(i) Cardiology;

(ii) Gastroenterology;

(iii) General pediatrics;

(iv) Hematology((/pathology));

(((iv))) (v) Infectious disease((s)) specialists;

(((v))) (vi) Nephrology;

(((vi) Neuro-radiology;

(vii) Pediatric cardiology;

(viii) Pediatric hematology/oncology;

(ix))) (vii) Pediatric neurology;

(viii) Pathology;

(ix) Pediatric critical care;

(x) ((Pediatric)) Pulmonology; and

(((x))) (xi) Psychiatry; ((and

(xi) A radiologist.

(d) Pediatric neurology on-call and available within one hour.))

(5) ((A level I pediatric trauma care hospital shall have an approved)) 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 ((facilities,)) trauma care services. The policy shall be based on ((it's)) criteria which reflect the service's ability to ((manage)) resuscitate and stabilize each patient at a particular time.

(((6) A level I pediatric trauma care hospital shall:

(a) Have a quality assurance program in accordance with WAC 246-976-880; and

(b) Cooperate with regional trauma care quality assurance programs throughout the state established pursuant to WAC 246-976-910.)) (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. 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 93-20-063, filed 10/1/93, effective 11/1/93)

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

(1) ((A level I pediatric trauma care hospital shall have an ED)) An emergency department with:

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

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

(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

(((iii) ACLS trained; and))

(iv) Is PALS or approved equivalent trained, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine;

(b) Emergency physicians who ((are)):

(i) Are board-certified ((or eligible)) in emergency medicine, or pediatric emergency medicine, or in a specialty practicing emergency medicine as their primary practice with special competence in ((the)) care of ((the)) pediatric trauma patients; (this requirement may be met by a surgical resident post graduate year two who is ATLS, ACLS, and PALS or approved equivalent trained, working under the direct supervision of the ((physician director of the emergency department)) attending emergency department physician, until the arrival of the ((attending)) surgeon((. The attending surgeon shall be in-house and available upon the patient's arrival in the ED, assuming five minute notification)) to assume leadership of the trauma team);

(ii) ((In-house and)) Are available within five minutes of the patient's arrival in the ((ED)) emergency department;

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

(iv) ((ACLS trained;

(v))) Are PALS or approved equivalent ((pediatric ALS)) trained, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine; and

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

(c) ((ED)) Registered nurses who:

(i) Are ((ACLS)) PALS or approved equivalent trained;

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

(iii) ((Are PALS or approved equivalent trained;

(iv))) Are in the ((ED)) 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;

(((i) Airway control and ventilation equipment including:

(A) Airways;

(B) Laryngoscopes, including curved and straight;

(C) Endotracheal tubes of all sizes;

(D) Bag-valve-mask resuscitator with all mask sizes;

(E) Sources of oxygen;

(F) Child and neonatal BVM resuscitation device designed to deliver one hundred percent oxygen; and

(G) Mechanical ventilation;

(ii) Suction devices including:

(A) Back-up suction source;

(B) Pediatric suction catheters; and

(C) Tonsil suction tip;

(iii) Electrocardiograph-cardiac monitor-defibrillator appropriate to pediatric patients;

(iv) All standard apparatus to establish central venous pressure monitoring;

(v) All standard IV fluids and administering devices appropriate for pediatric patients, including:

(A) IV catheters;

(B) Intraosseous needles;

(C) Infusion sets;

(D) Infusion pumps including micro-infusion capabilities;

(E) Infusion controllers;

(F) Pediatric dosages/dilutions of medications; and

(G) IV fluid/blood warmer.

(vi) Sterile surgical sets appropriate for pediatric patients, for standard ED procedures including:

(A) Thoracostomy set;

(B) Chest tubes;

(C) Tracheostomy set;

(D) Spinal tap set;

(E) Peritoneal lavage set; and

(F) Cricothyrotomy set;

(vii) Gastric lavage equipment;

(viii) Drugs and supplies necessary for pediatric emergency care;

(ix) X-ray capability with twenty-four-hour coverage by in-house technicians;

(x) Respiratory therapy available within five minutes;

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

(xii) Pneumatic anti-shock garment, if included in local protocols for pediatric patients;

(xiii) Skeletal traction device for cervical injuries;

(xiv) Backboard;

(xv) Equipment specific to pediatric trauma care, including:

(A) Traction splint;

(B) Blood pressure cuffs in infant and child sizes;

(C) Foley catheters;

(D) Rigid cervical collars;

(E) Doppler;

(F) Infant scale for accurate weight measurement under twenty-five pounds;

(G) Temperature controlled heating units with/without open crib;

(H) Heating/cooling blankets;

(I) Heat lamp;

(J) Hypothermia thermometers;

(K) Expanded scale electronic thermometers;

(L) Device for assuring maintenance of infant warmth during evaluation and transport;

(M) Nasogastric/feeding tubes;

(N) Noninvasive BP monitor; and

(O) Pulse oximetry.

(2) A level I pediatric trauma care hospital shall have a general)) (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 ((expertise)) care who is ((in-house and)) available ((upon the patient's arrival in the ED, assuming)) 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; ((or have graduated from a residency program accredited by the accreditation council of graduate medical education, but who is less than five years out of training;

(ii) Have PALS or approved equivalent training;

(iii) Be ATLS trained;

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

(b) A post-graduate year four or above surgical resident may initiate evaluation and treatment upon the patient's arrival in the ((ED)) emergency department until the arrival of the attending surgeon. In this case, the attending surgeon shall be available within twenty minutes ((upon)) of notification of team activation. ((The resident shall have ATLS and PALS or approved equivalent training;))

(c) All ((trauma)) general surgeons and surgical residents who are responsible for care and treatment of trauma patients shall be trained in ((ATLS except that this requirement shall not apply to board certified surgeons.)):

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

(ii) PALS or approved equivalent;

(3) ((A level I pediatric trauma care hospital shall have)) An operating ((suite)) room available within five minutes of notification of team activation, with:

(a) ((An operating room adequately staffed and available within five minutes of notification;

(b) Essential personnel, including at least one OR nurse, in-house and available twenty-four hours a day;

(c))) 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 ((documented method)) written policy providing for ((prompt)) mobilization of ((consecutive)) additional surgical teams for pediatric trauma patients;

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

(((i) Cardiopulmonary bypass;

(ii) Operating microscope;

(iii) Thermal control equipment for patient;

(iv) Thermal control equipment for blood;

(v) X-ray capability;

(vi) Pediatric endoscopes/bronchoscopes;

(vii) Craniotomy set;

(viii) Monitoring equipment; and

(ix) Pediatric instruments and equipment.))

(4) A ((level I pediatric trauma care hospital shall have a)) post-anesthetic recovery ((room)) unit with:

(a) Essential personnel, including at least one registered nurse ((with critical post anesthetic nurse training, in-house and)) available twenty-four hours a day;

(b) ((All)) Nurses ACLS trained;

(c) ((All)) Nurses PALS or approved equivalent trained;

(d) Appropriate monitoring and resuscitation equipment.

(5) A ((level I pediatric trauma care hospital shall have a pediatric intensive care unit exclusively for children)) pediatric critical care service, with:

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

(b) A medical director or ((co-director)) codirector who is ((a board certified or eligible pediatric intensivist)) board-certified in pediatrics, with sub-board certification in critical care, with:

(((i) PALS or approved equivalent training;

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

(((A))) (i) Development and implementation of policies;

(((B) Supervision of resuscitation;

(C))) (ii) Coordination of medical care;

(((D))) (iii) Determination of patient isolation;

(((E) Ultimate)) (iv) Authority for ((triage)) patient placement decisions;

(((F) Maintenance of)) (v) Equipment;

(((G))) (vi) Coordination of staff education;

(((H) Maintenance)) (vii) Coordination of statistics; and

(((I))) (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;

(((b))) (c) A physician with ((expertise)) special competence in pediatric critical care ((in-house and)) available within five minutes of notification;

(((c) A nurse manager responsible for training and coordination of nurses, physicians, and community agencies or services;

(d) Nurses with PALS or approved equivalent training;

(e) Patient isolation capacity; and

(f))) (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;

(f) Equipment ((appropriate for pediatric patients, including:)) as described in WAC 246-976-620 and 246-976-825;

(((i) Airway control and ventilation including:

(A) Oral and nasopharyngeal airways, all sizes neonatal through adult;

(B) Child, infant and neonatal bag-mask resuscitators, able to deliver one hundred percent oxygen;

(C) Endotracheal tubes with stylet;

(D) Infant and child laryngoscopes, curved and straight;

(E) Suction catheters; and

(F) Tonsil suction tip;

(ii) Oxygen source with concentration controls;

(iii) Cardiac emergency cart;

(iv) Temporary transvenous pacemaker;

(v) Electrocardiograph-cardiac monitor-defibrillator;

(vi) Electronic pressure monitoring;

(vii) Automated blood pressure apparatus;

(viii) Mechanical ventilator-respirator appropriate for entire pediatrics spectrum including:

(A) Air/oxygen blenders; and

(B) Oxygen analyzers;

(ix) Patient weighing devices, including infant scale;

(x) Pulmonary function measuring devices;

(xi) Temperature control devices including:

(A) Temperature controlled heating units with/without open crib;

(B) Heating/cooling blankets; and

(C) Heat lamp;

(xii) Drugs, IV fluids, and supplies including:

(A) Intravenous and intraosseous needles and catheters;

(B) Pediatric infusion sets;

(C) Pediatric dosages/dilutions;

(D) Infusion pumps;

(E) Infusion controllers; and

(F) IV fluid warmer;

(xiii) Spotlight;

(xiv) Doppler ultrasound BP device;

(xv) Suction machine;

(xvi) Refractometer;

(xvii) Otoscope/ophthalmoscope;

(xviii) Thermometers;

(xix) Pressor infuser pumps;

(xx) Portable EEG;

(xxi) Bedside EKG;

(xxii) Bedside echocardiography;

(xxiii) Bedside ultrasound;

(xxiv) Nuclear scan;

(xxv) Noninvasive oximetry and capnometry;

(xxvi) Portable transport monitor;

(xxvii) Specialized pediatric sets for thoracostomy, tracheostomy, spinal tap, cricothyroidotomy, and peritoneal lavage;

(xxviii) Foley catheters;

(xxix) Chest tubes;

(xxx) Capability for continuous monitoring of:

(A) EKG, heart rate;

(B) Respiration;

(C) Temperature;

(D) Arterial pressure; and

(E) Central venous pressure;

(xxxi) High/low alarms for heart rate, respiratory rate, and all pressures;

(xxxii) Provision for life support and cardiopulmonary monitoring; and

(xxxiii) Hard copy monitor recording capability.

(6) A level I pediatric trauma care hospital shall designate a physician, who has an established relationship to the pediatric critical care team, to respond to pediatric airway emergencies. This requirement may be met by an emergency physician or an ICU physician.)) (6) Respiratory therapy available within five minutes of notification;

(7) A ((level I pediatric trauma care hospital shall have)) clinical laboratory ((services)) technologist available within five minutes of notification;

(8) Clinical laboratory services, including:

(a) ((Micro-technique capability;

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

(((c) Blood typing and cross-matching;

(d))) (b) Coagulation studies;

(((e) Comprehensive blood bank, or access to a community central blood bank, and adequate hospital storage facilities;

(f))) (c) Blood gases and pH determination;

(((g))) (d) Serum and urine osmolality;

(((h))) (e) Microbiology;

(((i))) (f) Serum alcohol and toxicology determination; ((and

(j))) (g) Drug screening; and

(h) Microtechnique.

(((8))) (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 ((level I pediatric trauma care hospital shall have)) radiological service((s)), ((staffed and equipped)) including:

(a) ((The following services in-house and)) A technician available within five minutes of notification, able to perform the following:

(i) Routine radiological procedures; and

(ii) Computerized tomography;

(b) ((The following services)) 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;

(((iv) Fluoroscopy;

(v) Contrast studies, including intravenous pyelograms, esophagrams, and barium enemas.

(9) A level I pediatric trauma care facility shall have acute hemodialysis)) (11) Acute dialysis capability, or ((a)) written transfer agreements.

(((10) A level I pediatric trauma care hospital shall have:))

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

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

(((11) A level I pediatric trauma care hospital shall be able)) (13) The ability to manage acute head and/or spinal cord injuries((, or have written transfer agreements with facility with such capabilities)). Early transfer to ((a designated)) an appropriate pediatric trauma rehabilitation ((facility)) service shall be considered.

(((12) A level I pediatric trauma care hospital shall have respiratory therapy in-house and available within five minutes to the patient in the ED or ICU, with a therapist who has special pediatric training and/or experience.

(13))) (14) A ((level I pediatric trauma care hospital shall have a)) trauma rehabilitation coordinator ((and:)) to facilitate the trauma patient's access to pediatric rehabilitation services.

(15)(a) A ((physician-directed)) designated pediatric trauma rehabilitation ((medicine)) service ((which is staffed by nursing personnel trained in rehabilitation care, and is equipped to care for the pediatric trauma patient)); or

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

(((14) A level I pediatric trauma care hospital shall have ancillary services including:

(a) Pharmacy, with pharmacist in-house;

(b) Pediatric therapeutic recreation;

(c) Clergy or pastoral care;

(d) Social work, with social workers on-call and available within thirty minutes, and with written policies and procedures, including comprehensive case-finding mechanisms;

(e) Child protection services;

(f) Nutritionist services;

(g) Physical therapy services;

(h) Occupational therapy and therapeutic recreation services.

(15) A level I pediatric trauma care hospital shall have a heliport or)) (16) Heli-stop, landing zone or airport located close enough to permit the facility to receive or transfer patients by ((air)) fixed-wing or rotary-wing aircraft.

[Statutory Authority: Chapter 70.168 RCW. 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 Order 323, filed 12/23/92, effective 1/23/93 WAC 246-976-740 Designation standards for facilities providing level I pediatric trauma care ((hospitals)) service--Outreach, ((training)) public education, trauma care education, and research((, and public education)). A facility with a designated level I pediatric trauma care ((hospital)) service shall have:

(1) An outreach program with telephone and on-site consultations with physicians in the community and outlying areas regarding pediatric trauma care;

(2) A public education program addressing injury prevention;

(3) Training, including:

(a) A formal program of continuing trauma care education for:

(i) Staff physicians;

(ii) Nurses;

(iii) Allied health care professionals;

(iv) Community physicians; and

(v) Prehospital personnel;

(b) ((A general surgery)) Residency programs accredited by the accreditation council of graduate medical education, with commitment to training physicians in pediatric trauma management;

(c) In-house initial and maintenance training of invasive manipulative skills for prehospital personnel;

(((3) A public education program addressing:

(a) Injury prevention;

(b) First aid;

(c) Problems confronting the public, medical profession, and hospitals regarding optimal care for the injured child;))

(4) A pediatric trauma research program.

[Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. 93-01-148 (Order 323), 246-976-740, filed 12/23/92, effective 1/23/93.]

AMENDATORY SECTION (Amending WSR 93-20-063, filed 10/1/93, effective 11/1/93)

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

(1) ((For the purpose of administering trauma care, a designated level II pediatric hospital shall have a trauma service, including:))

(a) Organization and direction by a general surgeon ((who is expert in, and committed to,)) 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 ((ED)) emergency department registered nurse;

(iii) A ((trauma)) 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 ((intensive)) critical care service;

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

(ix) The pediatric trauma care service nurse coordinator;

(x) A pediatric ((intensive)) critical care registered nurse; ((and

(ix))) (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 ((resuscitation)) team to provide initial evaluation, resuscitation and treatment.

(i) The team shall be organized and directed by a pediatric surgeon ((expert in, and committed to,)) 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 ((intensive care physician)) intensivist or pediatric emergency physician.

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

(iv) The team shall include ((an emergency physician)):

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

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

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

(III) 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) ((Other members of the team shall be as specified in the hospital's application for designation.)) The trauma care service shall identify all other members of the team.

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

(2) ((A level II pediatric trauma care hospital shall have an ED)) An emergency department with ((established)) written standards ((and procedures)) of care to ensure immediate and appropriate care for pediatric trauma patients.

(3) A ((level II pediatric trauma care hospital shall have a)) surgery department, including:

(a) General surgery, with ((an attending surgeon on-call and available on the patient's arrival in the ED, assuming a twenty-minute notification)) special competence in care of the pediatric trauma patient;

(b) ((Neurosurgery:

(i) In-house and available within five minutes. In-house coverage shall be provided by a neurosurgeon,)) 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 ((neurologic)) 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; ((and

(ii) With a neurosurgeon on-call and available within thirty minutes;))

(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;

(((ii) Orthopedic)) (v) Oral/maxillofacial or otorhinolaryngologic surgery;

(vi) Orthopaedic surgery;

(((iii) Otorhinolaryngologic surgery;

(iv))) (vii) Pediatric surgery;

(viii) Plastic ((and maxillofacial)) surgery;

(((v))) (ix) Thoracic surgery; ((and

(vi))) (x) Urologic surgery; and

(xi) Vascular surgery.

(4) ((A level II pediatric trauma care hospital shall have nonsurgical specialty capabilities with pediatric expertise)) 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

(((ii) Is)) (iii) 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 ((specialty)) services on-call and available ((within thirty minutes)) for pediatric patient consultation or management:

(i) Cardiology;

(ii) ((Pulmonology;

(iii))) Gastroenterology;

(iii) General pediatrics;

(iv) Hematology((/pathology));

(v) Infectious disease specialists;

(vi) Nephrology;

(vii) ((Neuro-radiology)) Neurology;

(viii) ((General pediatrics, with board-certified pediatricians who are PALS or approved equivalent trained; and)) Pathology;

(ix) ((A radiologist.)) 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.

(((5))) (6) A ((level II pediatric trauma care hospital shall have an approved)) written policy and procedures to divert patients to other designated ((facilities,)) trauma care services. The policy shall be based on ((it's)) criteria which reflect the service's ability to ((manage)) resuscitate and stabilize each patient at a particular time.

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

(8) A ((level II pediatric trauma care hospital shall have a)) quality assurance program in accordance with WAC ((246-976-880)) 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. 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 93-20-063, filed 10/1/93, effective 11/1/93)

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

(1) ((A level II pediatric trauma care hospital shall have an ED)) An emergency department, with:

(a) A physician director who is:

(i) Board-certified ((or eligible)) in emergency medicine or pediatric emergency medicine;

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

(iii) ((ACLS trained; and

(iv))) PALS or approved equivalent trained, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine.

(b) ((Emergency)) Physicians who ((are)):

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

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

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

(iv) ((ACLS trained;

(v))) Are PALS or approved equivalent trained, except this requirement shall not apply to a physician board-certified in pediatric emergency medicine; and

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

(c) ((ED)) Registered nurses who:

(i) Are ((ACLS)) PALS or approved equivalent trained;

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

(iii) ((Are PALS or approved equivalent trained;

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