Purpose: To establish a process and minimum standards for designation of trauma care services.

Statutory Authority for Adoption: RCW 70.168.050(2).

Statute Being Implemented: Chapter 70.168 RCW.

Summary: Makes corrections to typographical errors in existing rules.

Reasons Supporting Proposal: Housekeeping changes will improve clarity of the rules.

Name of Agency Personnel Responsible for Drafting: Shane Sanderson, 2725 Harrison Avenue N.W., Olympia, WA, (360) 705-6727; Implementation and Enforcement: Scott Hogan, 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 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. They 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. The proposed changes are for housekeeping purposes only and makes no substantive changes to the existing rules.

Proposal does not change existing rules.

NOTICE

THIS RULE IS BEING PROPOSED TO BE ADOPTED USING AN EXPEDITED RULE-MAKING PROCESS THAT WILL ELIMINATE THE NEED FOR THE AGENCY TO HOLD PUBLIC HEARINGS, PREPARE A SMALL BUSINESS ECONOMIC IMPACT STATEMENT, OR PROVIDE RESPONSES TO THE CRITERIA FOR A SIGNIFICANT LEGISLATIVE RULE. IF YOU OBJECT TO THIS RULE BEING ADOPTED USING THE EXPEDITED RULE-MAKING PROCESS, YOU MUST EXPRESS YOUR OBJECTIONS IN WRITING AND THEY MUST BE SENT TO Janet Griffith, Director, Department of Health, P.O. Box 47853, Olympia, WA 98504-7853, AND RECEIVED BY August 29, 1998.

June 30, 1998

Patty Hayes

for Kris Van Gorkom

Deputy Secretary

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

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

(1) An emergency department, with:

(a) A physician director who is:

(i) 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) Physicians who:

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

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

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

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

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

(c) Registered nurses who:

(i) Are ACLS trained;

(ii) Are PALS or approved equivalent trained;

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

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

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

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

(2) A surgery department, including:

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

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

(ii) Be board-certified;

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

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

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

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

(ii) PALS or approved equivalent.

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

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

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

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

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

(4) A post anesthetic recovery unit with:

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

(b) Nurses ACLS trained;

(c) Nurses PALS or approved equivalent trained; and

(d) Appropriate monitoring and resuscitation equipment.

(5) A critical care service, with:

(a) A medical director who is:

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

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

(A) Development and implementation of policies;

(B) Coordination of medical care;

(C) Determination of patient isolation;

(D) Authority for patient placement decisions;

(E) Equipment;

(F) Coordination of staff education;

(G) Coordination of statistics;

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

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

(c) A physician directed code team;

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

(i) Are ACLS trained;

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

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

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

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

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

(8) Clinical laboratory services, including:

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

(b) Coagulation studies;

(c) Blood gases and pH determination;

(d) Serum and urine osmolality;

(e) Microbiology;

(f) Serum alcohol and toxicology determination;

(g) Drug screening; and

(h) Microtechnique.

(9) Blood and blood component services, including:

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

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

(c) Blood typing and cross-matching;

(d) Policies and procedures for massive transfusion;

(e) Autotransfusion; and

(f) Blood storage capability.

(10) Radiological services, including:

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

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

(i) Computerized tomography;

(ii) Angiography of all types; and

(iii) Sonography.

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

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

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

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

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

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

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

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

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

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

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

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

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

(1) An emergency department with:

(a) A physician director who is:

(i) 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) Physicians who:

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

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

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

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

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

(c) Registered nurses who:

(i) Are ACLS trained;

(ii) Are PALS or approved equivalent trained;

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

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

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

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

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

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

(b) Has general surgery privileges;

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

(d) Has PALS or approved equivalent training.

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

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

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

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

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

(((5))) (4) A post anesthetic recovery unit with:

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

(b) Nurses ACLS trained;

(c) Nurses PALS or approved equivalent trained; and

(d) Appropriate monitoring and resuscitation equipment.

(((6))) (5) A critical care service, with:

(a) A medical director who is:

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

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

(A) Development and implementation of policies;

(B) Coordination of medical care;

(C) Determination of patient isolation;

(D) Authority for patient placement decisions;

(E) Equipment;

(F) Coordination of staff education;

(G) Coordination of statistics;

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

(b) A physician-directed code team;

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

(i) Are ACLS trained; and

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

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

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

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

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

(((9))) (8) Clinical laboratory services, including:

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

(b) Coagulation studies;

(c) Blood gases and pH determination;

(d) Microbiology;

(e) Serum alcohol and toxicology determination; and

(f) Microtechnique.

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

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

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

(c) Blood typing and cross-matching;

(d) Policies and procedures for massive transfusion;

(e) Autotransfusion; and

(f) Blood storage capability.

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

(a) Routine radiological procedures; and

(b) Computerized tomography.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(1) An emergency department with:

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

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

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

(i) Is ACLS trained;

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

(iii) Is PALS or approved equivalent trained;

(c) Basic emergency services including:

(i) Assessment of the patient's condition;

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

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

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

(i) Airway control and ventilation equipment including:

(A) Airways, neonatal to adult;

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

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

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

(E) Sources of oxygen;

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

(G) Suction devices;

(ii) Cardiac monitoring devices, including:

(A) Electrocardiograph;

(B) Cardiac monitor;

(C) Defibrillator with pediatric paddles;

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

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

(B) Intraosseous needles;

(C) Infusion control device;

(iv) Gastric lavage equipment;

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

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

(vii) Immobilization devices, including:

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

(B) Long-bone stabilization device; and

(C) Backboard;

(viii) Ability to provide thermal control equipment for:

(A) Patient warming and cooling;

(B) Blood warming and cooling;

(ix) Other equipment:

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

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

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

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

(a) Staff, including:

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

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

(B) Is PALS or approved equivalent trained;

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

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

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

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

(B) Has PALS or approved equivalent training; and

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

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

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

(d) The operating room shall have available:

(i) Ability to provide thermal control equipment for:

(A) Patient warming;

(B) Blood and fluid warming;

(ii) Radiological capabilities;

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

(iv) Monitoring equipment;

(((3))) (e) Post anesthetic recovery services, with:

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

(((b))) (ii) Nurses ACLS trained;

(((c))) (iii) Appropriate monitoring and resuscitation equipment;

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

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

(((5))) (4) Clinical laboratory services available, for:

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

(b) Blood gases and pH determination;

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

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

(b) Policies and procedures for massive transfusions; and

(c) Blood storage capability;

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(i) A pediatric emergency physician;

(ii) An emergency department registered nurse;

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

(iv) A neurosurgeon;

(v) An orthopaedic surgeon;

(vi) An anesthesiologist;

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

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

(ix) The pediatric trauma care service nurse coordinator;

(x) A pediatric critical care registered nurse;

(xi) A pediatric intensivist; and

(xii) The trauma rehabilitation coordinator;

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

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

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

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

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

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

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

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

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

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

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

(3) A surgery department, including:

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

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

(i) A neurosurgeon; or

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

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

(i) Cardiac surgery;

(ii) Gynecologic surgery;

(iii) Hand surgery;

(iv) Microsurgery;

(v) Obstetric surgery;

(vi) Ophthalmic surgery;

(vii) Oral/maxillofacial or otorhinolaryngologic surgery;

(viii) Orthopaedic surgery;

(ix) Pediatric surgery;

(x) Plastic surgery;

(xi) Thoracic surgery;

(xii) Urologic surgery; and

(xiii) Vascular surgery.

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

(a) Anesthesiology, with an anesthesiologist who is:

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

(ii) PALS or approved equivalent trained; and

(iii) Available within five minutes of team activation;

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

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

(i) Cardiology;

(ii) Gastroenterology;

(iii) General pediatrics;

(iv) Hematology;

(v) Infectious disease specialists;

(vi) Nephrology;

(vii) Pediatric neurology;

(viii) Pathology;

(ix) Pediatric critical care;

(x) Pulmonology; and

(xi) Psychiatry;

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

(a) Chemical dependency services;

(b) Child and adult protection services;

(c) Clergy or pastoral care;

(d) Nutritionist services;

(e) Occupational therapy services;

(f) Pediatric therapeutic recreation;

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

(h) Physical therapy services;

(i) Psychological services;

(j) Rehabilitation services;

(k) Social services;

(l) Speech therapy services;

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

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

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

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

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

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

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

(1) An emergency department with:

(a) A physician director who:

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

(ii) Has documented experience as director of an emergency department which has been previously recognized as a level I trauma center either by a regional entity or as verified by the Committee on Trauma of the American College of Surgeons;

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

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

(b) Emergency physicians who:

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

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

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

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

(v) Are designated members of the trauma team;

(c) Registered nurses who:

(i) Are PALS or approved equivalent trained;

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

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

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

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

(2) A surgery department including:

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

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

(ii) Be board-certified;

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

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

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

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

(ii) PALS or approved equivalent;

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

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

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

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

(4) A post-anesthetic recovery unit with:

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

(b) Nurses ACLS trained;

(c) Nurses PALS or approved equivalent trained;

(d) Appropriate monitoring and resuscitation equipment.

(5) A pediatric critical care service, with:

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

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

(i) Development and implementation of policies;

(ii) Coordination of medical care;

(iii) Determination of patient isolation;

(iv) Authority for patient placement decisions;

(v) Equipment;

(vi) Coordination of staff education;

(vii) Coordination of statistics; and

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

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

(d) A physician-directed code team;

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

(i) Special competence in pediatric trauma care; and

(ii) Successfully completed PALS or approved equivalent training;

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

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

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

(8) Clinical laboratory services, including:

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

(b) Coagulation studies;

(c) Blood gases and pH determination;

(d) Serum and urine osmolality;

(e) Microbiology;

(f) Serum alcohol and toxicology determination;

(g) Drug screening; and

(h) Microtechnique.

(9) Blood and blood component services, including:

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

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

(c) Blood typing and cross-matching;

(d) Policies and procedures for massive transfusion;

(e) Autotransfusions; and

(f) Blood storage capability;

(10) A radiological service, including:

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

(i) Routine radiological procedures; and

(ii) Computerized tomography;

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

(i) Angiography of all types;

(ii) Sonography;

(iii) Nuclear scanning;

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

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

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

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

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

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

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

(16) Heli-stop, landing zone or airport located close enough to permit the facility to receive or transfer patients by fixed-wing or rotary-wing aircraft.

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

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

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

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

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

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

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

(ii) An emergency department registered nurse;

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

(iv) A neurosurgeon;

(v) An orthopaedic surgeon;

(vi) An anesthesiologist;

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

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

(ix) The pediatric trauma care service nurse coordinator;

(x) A pediatric critical care registered nurse;

(xi) Pediatric intensivist; and

(xii) The trauma rehabilitation coordinator;

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

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

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

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

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

(iv) The team shall include:

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

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

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

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

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

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

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

(3) A surgery department, including:

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

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

(i) A neurosurgeon; or

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

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

(i) Gynecologic surgery;

(ii) Hand surgery;

(iii) Obstetric surgery;

(iv) Ophthalmic surgery;

(v) Oral/maxillofacial or otorhinolaryngologic surgery;

(vi) Orthopaedic surgery;

(vii) Pediatric surgery;

(viii) Plastic surgery;

(ix) Thoracic surgery;

(x) Urologic surgery; and

(xi) Vascular surgery.

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

(a) Anesthesiology, with an anesthesiologist who is:

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

(ii) PALS or approved equivalent trained; and

(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 services on-call and available for pediatric patient consultation or management:

(i) Cardiology;

(ii) Gastroenterology;

(iii) General pediatrics;

(iv) Hematology;

(v) Infectious disease specialists;

(vi) Nephrology;

(vii) Neurology;

(viii) Pathology;

(ix) Pediatric critical care; and

(x) Pulmonology;

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

(a) Chemical dependency services;

(b) Child and adult protection services;

(c) Clergy or pastoral care;

(d) Nutritionist services;

(e) Occupational therapy services;

(f) Pediatric therapeutic recreation;

(g) Pharmacy;

(h) Physical therapy services;

(i) Rehabilitation services;

(j) Social services; and

(k) Speech therapy services.

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

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

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

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

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

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

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

(1) An emergency department, with:

(a) A physician director who is:

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

(b) Physicians who:

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

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

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

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

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

(c) Registered nurses who:

(i) Are PALS or approved equivalent trained;

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

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

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

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

(2) A surgery department, including:

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

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

(ii) Be board-certified;

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

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

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

(ii) PALS or approved equivalent.

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

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

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

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

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

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

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

(b) Nurses ACLS trained;

(c) Nurses PALS or approved equivalent trained;

(d) Appropriate monitoring and resuscitation equipment.

(5) A pediatric critical care service, with:

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

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

(i) Development and implementation of policies;

(ii) Coordination of medical care;

(iii) Determination of patient isolation;

(iv) Authority for patient placement decisions;

(v) Equipment;

(vi) Coordination of staff education;

(vii) Coordination of statistics; and

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

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

(d) A physician-directed code team;

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

(i) Special competence in pediatric trauma care; and

(ii) Successfully completed PALS or approved equivalent training;

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

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

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

(8) Clinical laboratory services, including:

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

(b) Coagulation studies;

(c) Blood gases and pH determination;

(d) Serum and urine osmolality;

(e) Microbiology;

(f) Serum alcohol and toxicology determination;

(g) Drug screening; and

(h) Microtechnique;

(9) Blood and blood component services, including:

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

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

(c) Blood typing and cross-matching;

(d) Policies and procedures for massive transfusion;

(e) Autotransfusions; and

(f) Blood storage capability;

(10) Radiological services, including:

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

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

(i) Angiography of all types;

(ii) Computerized tomography;

(iii) Sonography;

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(ii) An emergency department registered nurse;

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

(iv) An orthopaedic surgeon;

(v) An anesthesiologist;

(vi) The pediatric trauma care service nurse coordinator;

(vii) A pediatric critical care registered nurse;

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

(ix) The trauma rehabilitation coordinator;

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

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

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

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

(iii) The team shall include:

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

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

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

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

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

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

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

(3) A surgery department, including:

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

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

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

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

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

(4) Nonsurgical specialties, including:

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

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

(ii) PALS or approved equivalent trained; and

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

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

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

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

(a) Chemical dependency services;

(b) Child and adult protection services;

(c) Clergy or pastoral care;

(d) Nutritionist services;

(e) Pediatric therapeutic recreation;

(f) Pharmacy;

(g) Physical therapy services;

(h) Rehabilitation services;

(i) Social services;

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

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

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

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

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

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

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

(1) An emergency department with:

(a) A physician director who is:

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

(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 this requirement shall not apply to a physician board-certified in pediatric emergency medicine;

(b) Physicians who:

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

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

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

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

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

(c) Registered nurses who:

(i) Are PALS or approved equivalent trained;

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

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

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

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

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

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

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

(b) Has PALS or approved equivalent training;

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

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

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

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

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

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

(4) A post-anesthetic recovery unit with:

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

(b) Nurses ACLS trained;

(c) Nurses PALS or approved equivalent trained;

(d) Appropriate monitoring and resuscitation equipment;

(5) Availability of pediatric critical care, with:

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

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

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

(d) A physician-directed code team;

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

(i) Special competence in pediatric trauma care; and

(ii) Completed PALS or approved equivalent training;

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

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

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

(8) Clinical laboratory services, including:

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

(b) Coagulation studies;

(c) Blood gases and pH determination;

(d) Microbiology;

(e) Serum alcohol and toxicology determination; and

(f) Microtechnique.

(9) Blood and blood component services, including:

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

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

(c) Blood typing and cross-matching;

(d) Policies and procedures for massive transfusion;

(e) Autotransfusions; and

(f) Blood storage capability;

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

(a) Routine radiological studies;

(b) Computerized tomography;

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

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

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

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

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

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

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

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

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

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

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

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

WAC 246-976-860  Designation standards for facilities providing level I pediatric trauma rehabilitation service. (1) Level I pediatric rehabilitation services shall:

(a) Treat inpatients and outpatients, regardless of disability or level of severity or complexity, who are:

(i) Under fifteen years old; or

(ii) For adolescent trauma patients, determine whether educational goals, premorbid learning or developmental status, social or family needs, or other factors indicate treatment in an adult or pediatric setting.

(b) Have and retain accreditation by the commission on accreditation of rehabilitation facilities (CARF) for hospital-based comprehensive inpatient rehabilitation category one, including the additional designated pediatric program standards required to provide pediatric rehabilitative services;

(i) Abeyance or deferral status do not qualify an applicant for designation;

(ii) If the applicant holds one-year accreditation, the application for trauma care service designation shall include a copy of the CARF survey report and recommendations;

(c) House patients in a designated pediatric rehabilitation area, providing a pediatric milieu;

(d) Provide a peer group for persons with similar disabilities;

(e) Be directed by a physiatrist who is in-house or on-call and responsible for rehabilitation concerns twenty-four hours every day;

(f) Have a diversion or transfer policy with protocols on an individual patient basis, based on the ability to manage that patient at that time;

(g) In addition to the CARF medical consultative service requirements, have the following medical services in-house or on-call twenty-four hours every day:

(i) Anesthesiology, with an anesthesiologist or certified registered nurse anesthetist (CRNA);

(ii) A pediatrician;

(iii) Radiology;

(h) Provide rehabilitation nursing personnel twenty-four hours every day, with:

(i) Management by a registered nurse;

(ii) At least one certified rehabilitation registered nurse (CRRN) on duty each day shift and evening shift when a trauma patient is present;

(iii) A minimum of six clinical nursing care hours per patient day for each trauma patient;

(iv) All nursing personnel trained and/or experienced in pediatric rehabilitation;

(v) The initial care plan and weekly update reviewed and approved by a CRRN; and

(vi) An orientation and training program for all levels of rehabilitation nursing personnel;

(i) Provide the following health personnel and services twenty-four hours every day:

(i) Access to pharmaceuticals, with pharmacist in house;

(ii) Personnel trained in intermittent urinary catheterization; and

(iii) Respiratory therapy;

(j) Provide the following trauma rehabilitation services with staff who are licensed, registered, or certified, who are trained and/or experienced in pediatric rehabilitation, and who are in-house or available for treatment every day when indicated in the rehabilitation plan:

(i) Occupational therapy;

(ii) Physical therapy;

(iii) Psychology, including:

(A) Neuropsychological services;

(B) Clinical psychological services, including testing and counseling; and

(C) Substance abuse counseling;

(iv) Social services;

(v) Speech/language pathology;

(k) Provide the following ((diagnostic)) services in-house or through affiliation or consultative arrangements with staff who are licensed, registered, certified, or degreed:

(i) Communication augmentation;

(ii) Educational component of the program appropriate to the disability and developmental level of the child, to include educational screening, instruction, and discharge planning coordinated with the receiving school district;

(iii) Orthotics;

(iv) Play space, with supervision by a pediatric therapeutic recreation specialist or child life specialist, to provide assessment and play activities;

(v) Prosthetics;

(vi) Rehabilitation engineering for device development and adaptations;

(vii) Therapeutic recreation;

(l) Provide the following diagnostic services in-house or through affiliation or consultative arrangements with staff who are licensed, registered, certified, or degreed:

(i) Electrophysiologic testing, to include:

(A) Electroencephalography;

(B) Electromyography;

(C) Evoked potentials;

(ii) Diagnostic imaging, including computerized tomography, magnetic resonance imaging, nuclear medicine, and radiology;

(iii) Laboratory services; and

(iv) Urodynamic testing;

(m) Have an outreach program regarding pediatric trauma rehabilitation care, consisting of telephone and on-site consultations with physicians and other health care professionals in the community and outlying areas;

(n) Have a formal program of continuing pediatric trauma rehabilitation care education, both in-house and outreach, provided for nurses and allied health care professionals;

(o) Have an ongoing structured program to conduct clinical studies, applied research or analysis in rehabilitation of pediatric trauma patients, and report results within a peer-review process.

(2) A level I pediatric rehabilitation service shall:

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

(b) Participate in trauma registry activities as required in WAC 246-976-430;

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

[Statutory Authority: Chapter 70.168 RCW. 98-04-038, § 246-976-860, filed 1/29/98, effective 3/1/98; 93-20-063, § 246-976-860, filed 10/1/93, effective 11/1/93.]