WSR 97-24-102
PROPOSED RULES
DEPARTMENT OF HEALTH
[Filed December 3, 1997, 10:40 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 96-17-063.
Title of Rule: WAC 246-976-470 through 246-976-890, Emergency medical services and trauma care system--Designation of trauma care facilities.
Purpose: To 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.
Other Identifying Information: In accordance with chapter 183, Laws of 1988 the department is required to utilize the report generated by the Washington Trauma Advisory Committee to develop those standards.
Statutory Authority for Adoption: Chapter 70.168 RCW.
Statute Being Implemented: RCW 70.168.060.
Summary: This rule establishes the process and standards for the designation of trauma care services, makes technical and organizational corrections, eliminates inconsistencies, and revises equipment, education and 'response time' requirements.
Reasons Supporting Proposal: These rules set standards that provide for a consistent, coordinated and preplanned response by hospitals, and other health care facilities to the needs of the injured patient.
Name of Agency Personnel Responsible for Drafting: Shane Sanderson and Tami Schweppe, 2725 Harrison Avenue N.W., Olympia, WA, (360) 705-6727; Implementation and Enforcement: Gail Finley Rarey, 2725 Harrison Avenue N.W., Olympia, WA, (360) 705-6730.
Name of Proponent: Department of Health, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: These rules provide for a consistent, coordinated and preplanned response by hospitals and other health care facilities in order to meet the needs of the injured patient. RCW 70.168.060, in addition to requiring the department to establish these rules, also required the department to utilize the report generated by the Washington Trauma Advisory Committee as authorized by chapter 183, Laws of 1988 to develop those rules. Prior to this no standards for designated trauma care services were defined in statute. These rules are the only way to establish standards for the delivery of trauma care services in the hospital or health care setting to ensure compliance and consistency in the delivery of care.
Proposal Changes the Following Existing Rules: The WAC revisions proposed for various levels of designation are to resolve several issues: (1) Correct some inconsistencies between levels, ensuring that lower levels of designation do not have stricter standards than higher levels, and to make general and pediatric facilities the same where appropriate; (2) revise equipment and education requirements; (3) revise 'response times' for providers in all levels of care; and (4) improve housekeeping problems - structure, grammar, organization and remove duplication or unnecessary repetition of the WAC.
No small business economic impact statement has been prepared under chapter 19.85 RCW. According to RCW 19.85.020, "small business" means any business entity, including a sole proprietorship, corporation, partnership, or other legal businesses, that has the purpose of making a profit, and has fifty or fewer employees. All hospitals that these rules pertain to have fifty or more employees.
RCW 34.05.328 applies to this rule adoption. These rules are legislatively significant because (1) they subject program ineligibility for not complying with the rule (i.e. hospitals may not receive major trauma patients unless designated as a trauma care service) and (2) the rule establishes qualifications or processes for program eligibility.
Hearing Location: 1101 Eastside Street, Room 16, Olympia, WA, on January 6, 1998, at 9:00 a.m.
Assistance for Persons with Disabilities: Contact Tami Schweppe by December 29, 1997, TDD (800) 833-6388, or (360) 705-6748.
Submit Written Comments to: Janet Griffith, Director, P.O. Box 47853, Olympia, WA 98504-7853, FAX (360) 705-6706, by December 29, 1997.
Date of Intended Adoption: January 6, 1998.
December 2, 1997
Bruce Miyahara
Secretary
NEW SECTION
WAC 246-976-485 Designation of facilities to provide trauma care services. (1) For all levels of designated trauma care services, the department shall develop and utilize a competitive procurement process. This process shall include at a minimum:
(a) Identification of standards for all levels of trauma care services;
(b) Administrative requirements for the process;
(c) Delineation of materials required to demonstrate compliance with standards;
(d) Timeline requirements, which shall allow applicants no less than ninety days to complete an application packet;
(e) Fee schedules;
(f) Evaluation criteria; and
(g) Decision-making criteria.
(2) The applicant for designation as a trauma care service shall:
(a) Submit written notice to the department of their intent to apply for a specific level of designation, according to a published schedule;
(b) Submit a completed application packet to the department according to a published schedule;
(i) A facility shall submit a separate application for each level and/or category of trauma service designation being applied for;
(ii) Multiple facilities applying for joint designation shall submit a single application for each level and/or category of trauma service designation being applied for;
(c) Submit fees as required by WAC 246-976-990, no later than thirty days prior to the scheduled on-site review;
(d) Provide the department's on-site review team access to the facility, medical and facility staff, and hospital records related to trauma care, including but not limited to standards of care, policy and procedures, patient care records, trauma quality assurance/improvement materials, and other relevant documents.
(3) The department shall conduct an on-site review of an applicant's facility prior to designation as level I, II or III trauma care service, or level I, II or III pediatric trauma care service.
(a) The department shall:
(i) Select and contract with multidisciplinary review teams appropriate to the level of designation required.
(A) Review team members for level I and II trauma care services and pediatric trauma care services cannot live or work in the same state as the applicant.
(B) Review team members for level III trauma care services and pediatric trauma care services cannot live or work in the same region as the applicant.
(ii) Provide the names of members of the on-site review team to the applicant.
(iii) Require the on-site review team to evaluate the appropriateness and capabilities of the applicant to provide trauma care services in accordance with this chapter for the level of designation sought, by inspecting the facility, examining hospital records, such as patient care records and trauma quality assurance/improvement materials, and interviewing appropriate individuals.
(iv) Require the on-site review team to provide an oral report of preliminary findings prior to leaving the facility being reviewed and provide written recommendations to the department.
(v) Require and 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.
(b) The applicant may submit to the department written objections or concerns of conflict of interest regarding any member of the on-site review team within ten days of notification by the department.
(4) The department may conduct an on-site review of an applicant's facility:
(a) Prior to designation as level IV or V trauma care services, levels I, II, or III trauma rehabilitation services, or level I pediatric trauma rehabilitation services;
(b) After designation of a facility, upon the facility's request. If an on-site survey is requested, the department may request reimbursement of its costs for conducting the survey.
(5) For all levels of trauma care services the department shall:
(a) Designate the health care facilities it deems most qualified to provide trauma care services, based on relevant factors including, but not limited to:
(i) Evaluation of the application submitted;
(ii) Recommendations from the on-site review team;
(iii) Trauma patient outcomes during the previous designation period;
(iv) The impact of designation on the effectiveness of the trauma care system;
(v) Expected patient volume of the area;
(vi) The number, levels, and distribution of designated health care facilities established in the state and regional EMS/TC plans;
(vii) Ability of each applicant to comply with goals of the state and regional EMS/TC plans; and
(viii) Compliance with contractual obligations to the department during the previous designation period.
(b) Notify the applicant in writing of designation decision.
(c) Provide the applicant a written report summarizing the department's review of the application, on-site review findings if applicable, and any department decisions:
(i) Within ninety days of the department's announcement of its designation decisions, in any region where there is competition for designation. Competition for designation exists in any region where the maximum number of designated trauma care services identified in the state plan is less than the number of applicants for designation for each level and type of service; or
(ii) Within ninety days of the on-site review, in any region where there is not competition for designation.
(d) Notify regional EMS/TC councils of the name, location, and level of services that have been designated in their regions.
(6) The department shall deny the application of a facility for designation if it finds, in the course of the designation process, that the facility:
(a) Is not the most qualified applicant, when the number of applicants exceeds the number of trauma care services identified in the state plan;
(b) Is unable to meet the requirements of this chapter for the level of designation sought;
(c) Is unable to meet or comply with the requirements of the approved regional plan;
(d) Makes a false statement of a material fact in its application for designation; or
(e) Refuses to allow representatives of the department to inspect any part of the facility related to the delivery of trauma care services, including records, documentation, or files.
(7) If an application for trauma care service designation is denied:
(a) The department shall notify the facility in writing of denial of designation. Such notice shall include:
(i) The reasons for the action; and
(ii) The rights of the facility, which include a right to hearing.
(b) The facility may appeal decisions of denial of designation in accordance with the provisions of chapter 34.05 RCW and chapter 246-10 WAC. Appeals should be addressed to the adjudicative clerk's office at the address indicated on the notice of decision.
(8) The department may:
(a) Consider and approve applications for designation for more than one level or category of trauma care service from a single facility at one time;
(b) Consider and approve applications from two or more facilities for joint designation to provide a single trauma care service. Applications for joint designation shall be evaluated following the same criteria as for a single-facility designation. The department shall conduct an on-site review before the end of the initial eighteen months of joint operation to confirm compliance with the provisions 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;
(c) Consider applications from facilities located and licensed in adjacent states in the same manner as applications received from facilities located and licensed in Washington;
(d) In any region where competition does not exist for a particular level and type of trauma care service, where designation for such is sought by a designated facility in an adjacent state that has an established trauma care system with standards which meet or exceed Washington standards, the department may consider the administrative findings, conclusions, and determination of the adjacent state in determining whether the applicant facility currently meets Washington standards. The department shall review the current standards of the adjacent state for the level and type of designation sought and may request additional information as necessary;
(e) In order to ensure adequate trauma care, grant provisional designation, for a period not exceeding two years, to facilities that are currently unable to fully meet the standards of this chapter.
(9) The department and the designated trauma care service shall enter into a contractual agreement. The contract shall include but not be limited to:
(a) The facility's authority to provide trauma care services for a three-year period;
(b) Identification of any contractual and financial requirements and responsibilities of both the facility and the department;
(c) The department's authority to monitor compliance with trauma care service standards during the contract period, including access to:
(i) Discharge summaries for trauma patients;
(ii) Patient care logs;
(iii) Trauma patient care records;
(iv) Hospital trauma care quality assurance/improvement materials, including minutes; and
(v) Other relevant documents;
(d) A requirement for confidentiality of information relating to individual patient's, provider's, and facility's care outcomes.
(10) The department shall initiate a new competitive procurement process for designation as described in this section, for all interested health care facilities, including those currently designated, no later than one hundred fifty days prior to the expiration of trauma care service designation in each region.
(11) The department may consider additional applications for trauma
service designation to ensure adequate coverage state-wide or by 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 designation of a health care facility if 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 refused 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 shall use the following process to suspend trauma service designation, consistent with the requirements of the Administrative Procedure Act:
(a) Except for summary action as provided for in the Administrative Procedure Act, the department shall notify the facility in writing of its intent to suspend designation at least twenty-eight days before it takes such action.
(b) The department shall notify a facility in writing of suspension of designation. Such notice shall include the reasons for the action, and the rights of the facility, which include a right to hearing.
(i) The facility may submit a plan for correction to the department within thirty days after notification. The plan shall include steps the facility is to take to correct deficiencies.
(ii) The department shall approve or disapprove the plan within thirty days of receipt.
(iii) Upon notification that the plan of correction is approved by the department, the facility shall implement that plan within thirty working days, and notify the department upon completion.
(c) The department shall notify the regional EMS/TC council of the action taken.
(d) Upon satisfactory evidence of compliance with chapter 70.168 RCW and this chapter, which may include an on-site review, the department shall reinstate designation status and notify the regional EMS/TC council of the action taken.
(e) The facility may appeal decisions of suspension of designation. Appeals should be addressed to the adjudicative clerk's office at the address indicated on the notice of decision.
(3) The department shall use the following process to revoke designation, consistent with the requirements of the Administrative Procedure Act:
(a) Except for summary action as provided for in the Administrative Procedure Act, the department shall notify the facility in writing of its intent to revoke designation at least twenty-eight days before it takes such action.
(b) The department shall notify a facility in writing of revocation of designation. Such notice shall include:
(i) The reasons for the action; and
(ii) Rights of the facility, which include a right to a hearing.
(c) The department shall notify the regional EMS/TC council of the action taken.
(d) The facility may appeal decisions of revocation of designation.
Appeals should be addressed to the adjudicative clerk's office at the
address indicated on the notice of decision.
[]
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 triage decisions;
(E) Equipment;
(F) Coordination of staff education;
(G) Coordination of statistics;
(H) 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 triage decisions;
(E) Equipment;
(F) Coordination of staff education;
(G) Coordination of statistics;
(H) 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 triage decisions;
(E) Equipment;
(F) Coordination of staff education;
(G) Coordination of statistics;
(H) 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/opthalmoscope;
(iii) Refractometer;
(iv) Blood pressure cuffs: Neonate, infant, child, adult;
(v) Doppler device;
(vi) Noninvasive blood pressure mach