WSR 09-23-085

PERMANENT RULES

DEPARTMENT OF HEALTH


[ Filed November 16, 2009, 5:21 p.m. , effective December 17, 2009 ]


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

     Purpose: Repealing WAC 246-976-485 through 246-976-887, designation of trauma care facilities. Adding new sections WAC 246-976-580, 246-976-700, and 246-976-800. These sections establish the department's responsibilities for statewide trauma service designation and establish rehabilitation standards for adults and pediatric services and trauma rehabilitation services.

     Citation of Existing Rules Affected by this Order: Repealing WAC 246-976-485 through 246-976-887.

     Statutory Authority for Adoption: RCW 70.168.050, 70.168.060, and 70.168.070.

      Adopted under notice filed as WSR 09-18-121 on September 2, 2009.

     Changes Other than Editing from Proposed to Adopted Version: Only minor edits were made to clarify the intent of the rules. The department of health (department) amended proposed trauma services designation rules following the CR-102 public hearing in response to requests for clarification from stakeholders. Clarifying language changes were made as follows:

     New section WAC 246-976-580:

     ▪     Language revised to consistently refer to the term "trauma rehabilitation services."

     ▪     Subsection (1)(d), inserting "service" in the phrase, "pediatric trauma service designation."

     ▪     Subsection (2)(b), inserting clarifying language to better explain application process.

     ▪     Subsection (2)(d), inserting terms "health care" and "trauma service" for clarification.

     ▪     Subsection (2)(e), inserting term "trauma service" for clarification.

     ▪     Subsection (3), inserting the term "at least" for clarification of minimal requirements.

     ▪     Subsection (3)(a)(i), adding clarifying language regarding compliance standards.

     ▪     Subsection (3)(iii) and (iv), adding terms "if applicable" for clarification.

     ▪     Subsection (4)(d)(v), revising for purposes of plain talk principles.

     ▪     Subsection (8)(a), clarifying rules reference to health care facilities.

     ▪     Subsection (9), replacing language with "or" versus "and/or."

     ▪     Subsection (10)(a), revising for purposes of plain talk principles.

     ▪     Subsection (10)(c), revising for purposes of plain talk principles.

     ▪     Subsection (11), revising for purposes of plain talk principles.

     New section WAC 246-976-700:

     ▪     Subsection (4)(o), adding term "trauma services" for clarification.

     ▪     Subsection (19)(a)(iii) and (iv), adding clarifying language to be more explicit of the department's intent for surgeon's arrival upon notification of patient's arrival.

     ▪     Subsection (19)(a)(v), clarifying language regarding qualifications and surgeon arrival time.

     ▪     Subsection (19)(a)(vi), clarifying language regarding surgeon arrival time.

     ▪     Subsection (19)(a)(vii), clarifying language regarding training requirements.

     ▪     Subsection (20)(a)(ii), clarifying neurosurgery services requirement.

     ▪     Subsection (20)(e), clarifying orthopedic surgery services requirement.

     ▪     Subsection (27)(a)(ii), adding Xs to indicate required level facility participation.

     ▪     Subsection (35), adding language "Provisions to allow for..." to make a complete sentence.

     New section WAC 246-976-800:

     ▪     Subsection (5), adding hyphen.

     ▪     Subsection (27), replacing language with "and" versus "and/or."

     A final cost-benefit analysis is available by contacting Kathy Schmitt, P.O. Box 47853, Olympia, WA 98504-7853, phone (360) 236-2969, fax (360) 236-2830, e-mail kathy.schmitt@doh.wa.gov.

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

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 3, Amended 0, Repealed 18.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 3, Amended 0, Repealed 18.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 3, Amended 0, Repealed 18.

     Date Adopted: November 12, 2009.

Mary C. Selecky

Secretary

OTS-2588.5


NEW SECTION
WAC 246-976-580   Trauma designation process.   The department designates health care facilities to provide adult and pediatric acute care trauma services ("trauma services") and adult and pediatric trauma rehabilitation services ("trauma rehabilitation services") as part of the statewide emergency medical services and trauma care (EMS/TC) system. This section describes the designation process.

     (1) The department must:

     (a) Provide written notification to all licensed hospitals and to other health care facilities that a new designation period is beginning. The written notification and the EMS/TC regional plans are posted on the department's web site;

     (b) Provide a trauma designation application schedule outlining the steps and timeline requirements for a facility to apply for trauma service designation. The schedule must provide each facility at least ninety days to complete an application for trauma designation. The application schedule is posted on the department's web site;

     (c) Provide an application for each level, type and combination of designation. Designation applications are released region by region, according to the established schedule;

     (d) Conduct a site review for any hospital applying for level I, II, or III adult and/or pediatric trauma service designation to determine compliance with required standards;

     (e) Initiate a three-year contract with successful applicants to authorize participation in the trauma system.

     (2) To apply for trauma service designation the health care facility must do the following according to the application schedule:

     (a) Request an application;

     (b) Submit a letter of intent to apply for trauma service designation indicating what level they are applying for;

     (c) Submit a completed application(s);

     (d) For health care facilities applying for level I, II, III adult and/or pediatric trauma service designation, the facility must complete a site review arranged and conducted by the department according to the following process:

     (i) The department will contract with trauma surgeons and trauma nurses to conduct the site review. The review team members must:

     (A) Work outside the state, for level I and II site reviews;

     (B) Work outside the applicant's EMS&TC region, for level III site reviews;

     (C) Maintain the confidentiality of all documents examined, in accordance with RCW 70.41.200 and 70.168.070. This includes, but is not limited to, all trauma patient data, staff discussions, patient, provider, and facility care outcomes, and any reports resulting from the site review;

     (D) Present their preliminary findings to the health care facility at the end of the site review visit;

     (ii) The department will provide the applicant the names of review team members prior to the site review. Any objections must be sent to the department within ten days of receiving the department's notification of review team members;

     (iii) A site review fee, as established in WAC 246-976-990, is charged and must be paid by the health care facility prior to the site review. A standard fee schedule is posted on the department's web site. For facilities applying for more than one type of designation or for joint designation, fee rates can be obtained by contacting the department;

     (iv) The applicant must provide the department and the site review team full access to the facility, facility staff, and all records and documents concerning trauma care including trauma patient data, education, training and credentialing documentation, standards of care, policies, procedures, protocols, call schedules, medical records, quality improvement materials, receiving facility patient feedback, and other relevant documents;

     (e) For health care facilities applying for level IV or V trauma service designation, level I, II, or III trauma rehabilitation service designation or level I pediatric trauma rehabilitation service designation, the department may, at its discretion, conduct a site review as part of the application process to determine compliance with required standards. If a site review is conducted, the process will be the same as identified in (d) of this subsection, except a site review fee will not be charged.

     (3) The department will designate the health care facilities it considers most qualified to provide trauma care services including when there is competition for trauma service designation within a region. There is competition for designation within a region when the number of applications for a level and type of designation is more than the maximum number of trauma services identified in the approved EMS/TC regional plan. The department will evaluate at least the following in making its decisions:

     (a) The quality of the health care facility's performance, based on:

     (i) The submitted application, attachments and any other information the department requests from the facility to verify compliance, or the ability to comply with trauma standards;

     (ii) Recommendations from the site review team;

     (iii) Trauma patient outcomes during the previous designation period, if applicable;

     (iv) Compliance with the contract during the previous designation period, if applicable;

     (b) The health care facility's conformity with the EMS/TC regional and state plans, based on:

     (i) The impact of the facility's designation on the effectiveness of the trauma system;

     (ii) Patient volumes for the area;

     (iii) The number, level, and distribution of trauma services identified in the state and approved regional plans;

     (iv) The facility's ability to comply with state and regional EMS/TC plan goals.

     (4) After trauma service designation decisions are made in a region, the department will:

     (a) Notify each applicant in writing of the department's designation decision;

     (b) Send each applicant a written report summarizing the department's findings, recommendations and additional requirements to maintain designation. If a site review was conducted as part of the application process, the review team findings and recommendations are also included in the written report. Reports are sent:

     (i) Within sixty days of announcing designation decisions for level IV and V trauma services and trauma rehabilitation services;

     (ii) Within one hundred twenty days of the site review for level I, II and III adult and pediatric trauma services and any other facility that received a site review as part of the application process;

     (c) Notify the EMS/TC regional council of designation decisions within the region and all subsequent changes in designation status;

     (d) Initiate a trauma designation contract with successful applicants. The contract will include:

     (i) Authority from the department to participate in the state trauma system, receive trauma patients from EMS agencies, and provide trauma care services for a three-year period;

     (ii) The contractual and financial requirements and responsibilities of the department and the trauma service;

     (iii) A provision to allow the department to monitor compliance with trauma service standards;

     (iv) A provision to allow the department to have full access to trauma patient data; the facility, equipment, staff and their credentials, education, and training documentation, and all trauma care documents such as: Standards of care, policies, procedures, protocols, call schedules, medical records, quality improvement documents, receiving facility patient feedback, and other relevant documents;

     (v) The requirement to maintain confidentiality of information relating to individual patient's, provider's and facility's care outcomes under RCW 70.41.200 and 70.168.070;

     (e) Notify the designated trauma service and other interested parties in the region of the next trauma designation application process at least one hundred fifty days before the contract expires.

     (5) Designated trauma services may ask the department to conduct a site review for technical assistance at any time during the designation period. The department has the right to require reimbursement for the costs of conducting the site review.

     (6) The department will not approve an application for trauma service designation if the applicant:

     (a) Is not the most qualified, when there is competition for designation; or

     (b) Does not meet the trauma care standards for the level applied for; or

     (c) Does not meet the requirements of the approved EMS/TC regional plan; or

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

     (e) Refuses to permit the department to examine any part of the facility that relates to the delivery of trauma care services, including, but not limited to, records, documentation, or files.

     (7) If the department denies an application, the department will send the facility a written notice to explain the reasons for denial and to explain the facility's right to appeal the department's decision in accordance with chapters 34.05 RCW and 246-10 WAC.

     (8) To ensure adequate trauma care in the state, the department may:

     (a) Provisionally designate health care facilities that are not able to meet all the requirements of this chapter. The provisional designation will not be for more than two years. A department-approved plan of correction must be prepared specifying steps necessary to bring the facility into compliance and an expected date of compliance. The department may conduct a site review to verify compliance with required standards. If a site review is conducted the department has the right to require reimbursement for the cost of conducting the site review;

     (b) Consider additional applications at any time, regardless of the established schedule, if necessary to attain the numbers and levels of trauma services identified in the approved EMS/TC regional and state plan;

     (c) Consider applications from hospitals located and licensed in adjacent states. The department will evaluate an out-of-state application in the same manner as all other applications. However, if the out-of-state applicant is designated as a trauma service in an adjacent state with an established trauma system whose standards meet or exceed Washington's standards and there is no competition for designation at that level, then the department may use the administrative findings, conclusions, and decisions of the adjacent state's designation evaluation to make the decision to designate. Additional information may be requested by the department to make a final decision.

     (9) The department may suspend or revoke a trauma designation if the facility or any owner, officer, director, or managing employee:

     (a) Is substantially out of compliance with trauma care standards WAC 246-976-700 through 246-976-800 or chapter 70.168 RCW and has refused or is unwilling to comply after a reasonable period of time;

     (b) Makes a false statement of a material fact in the designation application, or in any document required or requested by the department, or in a matter under investigation;

     (c) Prevents, interferes with, or attempts to impede in any way, the work of a department representative in the lawful enforcement of chapter 246-976 WAC, 34.05 RCW, 246-10 WAC, or 70.168 RCW;

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

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

     (10) The Administrative Procedure Act, chapter 34.05 RCW, and chapter 246-10 WAC govern the suspension and revocation process. The department will use the following process to suspend or revoke a facility's trauma designation:

     (a) The department will send the facility a written notice to explain the reasons it intends to suspend or revoke the designation and to explain the facility's right to a hearing to contest the department's intended action under WAC 246-10-201 through 246-10-205;

     (b) The notice will be sent at least twenty-eight days before the department takes action, unless it is a summary suspension, as provided for in the Administrative Procedure Act and WAC 246-10-301 through 246-10-306;

     (c) If a facility requests a hearing within twenty-eight days of the date the notice was mailed, a hearing before a health law judge will be scheduled. If the department does not receive the facility's request for a hearing within twenty-eight days of the date the notice was mailed, the facility will be considered in default under WAC 246-10-204;

     (d) For nonsummary suspensions, in addition to its request for a hearing, the facility may submit a plan within twenty-eight days of receiving the notice of the department's intent to suspend, describing how it will correct deficiencies:

     (i) The department will approve or disapprove the plan within thirty days of receipt;

     (ii) If the department approves the plan, the facility must begin to implement it within thirty days;

     (iii) The facility must notify the department when the problems are corrected;

     (iv) If, prior to sixty days before the scheduled hearing, the facility is able to successfully demonstrate to the department that it is meeting the requirements of chapters 246-976 WAC and 70.168 RCW, which may require a site review at the facility's expense, the department will withdraw its notice of intent to suspend designation;

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

     (11) A facility may seek judicial review of the department's final decision under the Administrative Procedure Act, RCW 34.05.510 through 34.05.598.

     (12) A newly designated or upgraded trauma service must meet education requirements for all applicable personnel according to the following schedule:

     (a) At the time of the new designation, twenty-five percent of all personnel must meet the education and training requirements in WAC 246-976-700 through 246-976-800;

     (b) At the end of the first year of designation, fifty percent of all personnel must meet the education and training requirements in WAC 246-976-700 through 246-976-800;

     (c) At the end of the second year of designation, seventy-five percent of all personnel must meet the education and training requirements defined in WAC 246-976-700 through 246-976-800;

     (d) At the end of the third year of designation, and all subsequent designation periods, ninety percent of all personnel must meet the education and training requirements defined in WAC 246-976-700 through 246-976-800.

     (13) All currently designated trauma services must have a written education plan with a process for tracking and assuring that new physicians and staff meet all trauma education requirements within the first eighteen months of employment.

[]


NEW SECTION
WAC 246-976-700   Trauma service standards.  

WAC 246-976-700 Trauma Service Standards Adult Levels Pediatric Levels
A facility with a designated trauma service must have: I II III IV V I P II P III P
(1) A written trauma scope of service outlining the trauma care resources and capabilities available twenty-four hours every day for: X X X X X X X X
(a) Adult and pediatric trauma patient care; X X X X X
(b) Pediatric trauma patient care. X X X
(2) A trauma medical director responsible for the organization and direction of the trauma service, who: X X X X X
(a) Is a board-certified general surgeon; X X
(b) Is a board-certified general surgeon, or a general surgeon advanced cardiac life support (ACLS) trained with current certification in advanced trauma life support (ATLS); X
(c) Is a board-certified general surgeon or emergency physician, or a general surgeon ACLS trained with current certification in ATLS or a physician ACLS trained with current certification in ATLS; X
(d) Is a board-certified general surgeon or emergency physician, or a physician ACLS trained with current certification in ATLS, or a physician assistant or advanced registered nurse practitioner ACLS trained and who audits ATLS every four years; X
(e) Is a board-certified pediatric surgeon, or a board-certified general surgeon, with special competence in the care of pediatric patients; X X
(f) Is a board-certified general surgeon, with special competence in the care of pediatric patients, or a general surgeon ACLS trained, with current certification in ATLS and with special competence in the care of pediatric patients; X
(g) Meets the pediatric education requirement (PER) as defined in subsection (27) of this section. X X X X X X X X
(3) A trauma program manager or trauma service coordinator responsible for the overall operation of trauma service, who: X X X X X X X X
(a) Is a registered nurse; X X X X X X X X
(b) Has taken ACLS; X X X X X X X X
(c) Has successfully completed a trauma nursing core course (TNCC) or a department approved equivalent course, and thereafter completes twelve hours of trauma-related education every three-year designation period. The trauma education must include, but is not limited to, the following topics: X X X X X X X X
(i) Mechanism of injury; X X X X X X X X
(ii) Shock and fluid resuscitation; X X X X X X X X
(iii) Initial assessment; X X X X X X X X
(iv) Stabilization and transport; X X X X X X X X
(d) Has taken pediatric advanced life support (PALS) or emergency nursing pediatric course (ENPC), and thereafter meets the PER contact hours as defined in subsection (27) of this section; X X X X X
(e) Has current PALS or ENPC certification; X X X
(f) Has attended a trauma program manager orientation course provided by the department or a department approved equivalent, within the first eighteen months in the role. X X X X X X X X
(4) A multidisciplinary trauma quality improvement program that must: X X X X X X X X
(a) Be lead by the multidisciplinary trauma service committee with the trauma medical director as chair of the committee; X X X X X X X X
(b) Demonstrate a continuous quality improvement process; X X X X X X X X
(c) Have membership representation and participation that reflects the facility's trauma scope of service; X X X X X X X X
(d) Have an organizational structure that facilitates the process of quality improvement, with a reporting relationship to the hospital's administrative team and medical executive committee; X X X X X X X X
(e) Have authority to establish trauma care standards and implement patient care policies, procedures, guidelines, and protocols throughout the hospital; X X X X X X X X
(f) Have a process to monitor and track compliance with the trauma care standards using audit filters and benchmarks; X X X X X X X X
(g) Have a process to evaluate the care provided to trauma patients and to resolve identified prehospital, physician, nursing, or system issues; X X X X X X X X
(h) Have a process for correcting problems or deficiencies; X X X X X X X X
(i) Have a process to analyze, evaluate, and measure the effect of corrective actions to determine whether issue resolution was achieved; X X X X X X X X
(j) Have a process to continuously evaluate compliance with full and modified (if used) trauma team activation criteria; X X X X X X X X
(k) Have assurance from other hospital quality improvement committees, including peer review if conducted separately from the trauma committee, that resolution was achieved on trauma-related issues; X X X X X X X X
(l) Have a process to ensure the confidentiality of patient and provider information, in accordance with RCW 70.41.200 and 70.168.090; X X X X X X X X
(m) Have a process to communicate with, and provide feedback to, referring trauma services and trauma care providers; X X X X X X X X
(n) Have a current trauma quality improvement plan that outlines the trauma service's quality improvement process, as defined in this subsection; X X X X X X X X
(o) For level III, IV, V trauma services or level III pediatric trauma services with a total annual trauma volume of less than one hundred patients, the trauma service may integrate trauma quality improvement into the hospital's quality improvement program; however, trauma care must be formally addressed in accordance with the quality improvement requirements in this subsection. In that case, the trauma medical director is not required to serve as chair. X X X X
(5) Written trauma service standards of care to ensure appropriate care throughout the facility for: X X X X X X X X
(a) Adult and pediatric trauma patients; X X X X X
(b) Pediatric trauma patients. X X X
(6) Participation in the regional quality improvement program as defined in WAC 246-976-910. X X X X X X X X
(7) Participation in the Washington state trauma registry as defined in WAC 246-976-430. X X X X X X X X
(8) Written transfer-in guidelines consistent with the facility's designation level and trauma scope of service. The guidelines must identify the type, severity and complexity of injuries the facility can safely accept, admit, and provide with definitive care. X X X X X X X X
(9) Written transfer-out guidelines consistent with the facility's designation level and trauma scope of service. The guidelines must identify the type, severity and complexity of injuries that exceed the resources and capabilities of the trauma service. X X X X X X X X
(10) Written interfacility transfer agreements with all trauma services that receive the facility's trauma patients. Agreements must have a process to identify medical control during the interfacility transfer, and address the responsibilities of the trauma service, the receiving hospital, and the verified prehospital transport agency. All trauma patients must be transported by a trauma verified prehospital transport agency. X X X X X X X X
(11) An air medical transport plan addressing the receipt or transfer of trauma patients with a heli-stop, landing zone, or airport located close enough to permit the facility to receive or transfer trauma patients by fixed-wing or rotary-wing aircraft. X X X X X X X X
(12) A written diversion protocol for the emergency department to divert trauma patients from the field to another trauma service when resources are temporarily unavailable. The process must include: X X X X X X X X
(a)Trauma service and patient criteria used to decide when diversion is necessary;
(b) How the divert status will be communicated to the nearby trauma services and prehospital agencies;
(c) How the diversion will be coordinated with the appropriate prehospital agency;
(d) A method of documenting/tracking when the trauma service is on trauma divert, including the date, time, duration, reason, and decision maker.
(13) A trauma team activation protocol consistent with the facility's trauma scope of service. The protocol must: X X X X X X X X
(a) Define the physiologic, anatomic, and mechanism of injury criteria used to activate the full and modified (if used) trauma teams; X X X X X X X X
(b) Identify members of the full and modified (if used) trauma teams consistent with the provider requirements of this chapter; X X X X X X X X
(c) Define the process to activate the trauma team. The process must: X X X X X X X X
(i) Consistently apply the trauma service's established criteria; X X X X X X X X
(ii) Use information obtained from prehospital providers or an emergency department assessment for patients not delivered by a prehospital agency; X X X X X X X X
(iii) Be applied regardless of time post injury or previous care, whether delivered by prehospital or other means and whether transported from the scene or transferred from another facility; X X X X X X X X
(iv) Include a method to upgrade a modified activation to a full activation when newly acquired information warrants additional capabilities and resources; X X X X X X X X
(v) For full trauma team activations, include the mandatory presence of a general surgeon. The general surgeon assumes leadership and overall care - using professional judgment regarding the need for surgery and/or transfer; X X X X X X
(vi) For full trauma team activations, include the mandatory presence of a general surgeon if general surgery services are included in the facility's trauma scope of service. The general surgeon assumes leadership and overall care - using professional judgment regarding the need for surgery and/or transfer; X
(vii) For trauma team activations in pediatric designated trauma services (within five minutes for level I, twenty minutes for level II or thirty minutes for level III), one of the following pediatric physician specialists must respond:

     • A pediatric surgeon;

     • A pediatric emergency medicine physician;

     • A pediatric intensivist;

     • A pediatrician;

     • A postgraduate year two or higher pediatric resident.

 X X X
(14) Emergency care services available twenty-four hours every day, with: X X X X X X X X
(a) An emergency department (except for level V clinics); X X X X X X X X
(b) The ability to resuscitate and stabilize adult and pediatric trauma patients in a designated resuscitation area; X X X X X
(c) The ability to resuscitate and stabilize pediatric trauma patients in a designated resuscitation area; X X X
(d) A medical director, who: X X X X X X
(i) Is board-certified in emergency medicine or board-certified in general surgery or is board-certified in another relevant specialty practicing emergency medicine as their primary practice; X X X
(ii) Is board-certified in pediatric emergency medicine, or board-certified in emergency medicine with special competence in the care of pediatric patients or board-certified in general surgery with special competence in the care of pediatric patients, or board-certified in a relevant specialty practicing emergency medicine as their primary practice with special competence in the care of pediatric patients; X X X
(e) Emergency physicians who: X X X X X X X X
(i) Are board-certified in emergency medicine or board-certified in a relevant specialty practicing emergency medicine as their primary practice. This requirement can be met by a postgraduate year two or higher emergency medicine or general surgery resident working under the direct supervision of the attending emergency physician. The resident must be available within five minutes of notification of the patient's arrival to provide leadership and care until arrival of the general surgeon; X X
(ii) Are board-certified in pediatric emergency medicine, or board-certified in emergency medicine with special competence in the care of pediatric patients, or board-certified in a relevant specialty practicing emergency medicine as their primary practice with special competence in the care of pediatric patients. This requirement can be met by a postgraduate year two or higher emergency medicine or general surgery resident with special competence in the care of pediatric trauma patients and working under the direct supervision of the attending emergency physician. The resident must be available within five minutes of notification of the patient's arrival, to provide leadership and care until arrival of the general surgeon; X X
(iii) Are board-certified in emergency medicine or another relevant specialty practicing emergency medicine as their primary practice, or physicians practicing emergency medicine as their primary practice with current certification in ACLS and ATLS; X
(iv) Are board-certified pediatric emergency medicine, or board-certified in emergency medicine or surgery, with special competence in the care of pediatric patients, or board-certified in a relevant specialty practicing emergency medicine as their primary practice, with special competence in the care of pediatric patients, or physicians with current certification in ATLS, practicing emergency medicine as their primary practice, with special competence in the care of pediatric patients; X
(v) Are board-certified in emergency medicine or another relevant specialty and practicing emergency medicine as their primary practice, or physicians with current certification in ACLS and ATLS. A physician assistant or advanced registered nurse practitioner current in ACLS and who audits ATLS every four years may initiate evaluation and treatment upon the patient's arrival in the emergency department until the arrival of the physician; X
(vi) Are board-certified or qualified in emergency medicine, surgery, or other relevant specialty and practicing emergency medicine as their primary practice, or physicians with current certification in ACLS and ATLS or physician assistants (PAs), or advanced registered nurse practitioners (ARNPs) with current certification in ACLS and who audit ATLS every four years; X
(vii) Are available within five minutes of notification of the patient's arrival in the emergency department; X X X X X X
(viii) Are on-call and available within twenty minutes of notification of the patient's arrival in the emergency department; X X
(ix) Are currently certified in ACLS and ATLS. This requirement applies to all emergency physicians and residents who care for trauma patients in the emergency department except this requirement does not apply to physicians who are board-certified in emergency medicine or board-certified in another relevant specialty and practicing emergency medicine as their primary practice; X X X X X
(x) Are currently certified in ATLS. This requirement applies to all emergency physicians and residents who care for pediatric patients in the emergency department except this requirement does not apply to physicians who are board-certified in pediatric emergency medicine or board-certified in emergency medicine or board-certified in another relevant specialty and practicing emergency medicine as their primary practice; X X X
(xi) Meet the PER as defined in subsection (27) of this section; X X X X X X X X
(f) Emergency care registered nurses (RNs), who: X X X X X X X X
(i) Are in the emergency department and available within five minutes of notification of patient's arrival; X X X X X X
(ii) Are in-house, and available within five minutes of notification of the patient's arrival (except for level V clinics); X X
(iii) Have current certification in ACLS; X X X X X
(iv) Have successfully completed a trauma nurse core course (TNCC) or department approved equivalent course; X X X X X X X X
(v) Have completed twelve hours of trauma related education every designation period. The trauma education must include, but is not limited to, the following topics:

     • Mechanism of injury;

     • Shock and fluid resuscitation;

     • Initial assessment;

     • Stabilization and transport;

 X X X X X X X
(vi) Meet the PER as defined in subsection (27) of this section. X X X X X X X X
(g) Standard emergency equipment for the resuscitation and life support of adult and pediatric trauma patients, including: X X X X X X X X
(i) Immobilization devices: X X X X X X X X
▪ Back board; X X X X X X X X
▪ Cervical injury; X X X X X X X X
▪ Long-bone; X X X X X X X X
(ii) Infusion control device: X X X X X X X X
▪ Rapid infusion capability; X X X X X X
(iii) Intraosseous needles; X X X X X X X X
(iv) Sterile surgical sets: X X X X X X X X
▪ Chest tubes with closed drainage devices; X X X X X X X X
▪ Emergency transcutaneous airway; X X X X X X X X
▪ Peritoneal lavage; X X X X X X X
▪ Thoracotomy; X X X X X X
(v) Thermal control equipment: X X X X X X X X
▪ Blood and fluid warming; X X X X X X X X
▪ Devices for assuring warmth during transport; X X X X X X X X
▪ Expanded scale thermometer capable of detecting hypothermia; X X X X X X X X
▪ Patient warming and cooling; X X X X X X X X
(vi) Other equipment: X X X X X X X X
▪ Medication chart, tape or other system to assure ready access to information on proper doses-per-kilogram for resuscitation drugs and equipment sizes for pediatric patients; X X X X X X X X
▪ Pediatric emergency airway equipment readily available or transported in-house with the pediatric patient for evaluation, treatment or diagnostics, including:

     • Bag-valve masks;

     • Face masks;

     • Oral/nasal airways.

 X X X X X X X X
(15) Respiratory therapy services, with a respiratory care practitioner available within five minutes of notification of patient's arrival. X X X X X X
(16) Diagnostic imaging services (except for level V clinics), with: X X X X X X X X
(a) A radiologist in person or by teleradiology, who is: X X X X X X
(i) On-call and available within twenty minutes of the trauma team leader's request; X X X X
(ii) On-call and available within thirty minutes of the trauma team leader's request; X X
(b) Personnel able to perform routine radiological capabilities, who are: X X X X X X X X
(i) Available within five minutes of notification of the patient's arrival; X X X X
(ii) On-call and available within twenty minutes of notification of the patient's arrival; X X X X
(c) A technologist able to perform computerized tomography, who is: X X X X X X
(i) Available within five minutes of the trauma team leader's request; X X
(ii) On-call and available within twenty minutes of the trauma team leader's request; X X X X
(d) Angiography with a technologist on-call and available within thirty minutes of the trauma team leader's request; X X X X
(e) Magnetic resonance imaging, with a technologist on-call and available within sixty minutes of the trauma team leader's request; X X X X
(f) Sonography with a technologist on-call and available within thirty minutes of the trauma team leader's request; X X X X
(g) Interventional radiology services on-call and available within thirty minutes of the trauma team leader's request. X X X X
(17) Clinical laboratory services (except for level V clinics), with: X X X X X X X X
(a) Lab services available within five minutes of notification of the patient's arrival; X X X X X X
(b) Lab services on-call and available within twenty minutes of notification of the patient's arrival; X X
(c) Blood gases and pH determination; X X X X X X X
(d) Coagulation studies; X X X X X X X X
(e) Drug or toxicology measurements; X X X X X X X X
(f) Microbiology; X X X X X X X X
(g) Serum alcohol determination; X X X X X X X X
(h) Serum and urine osmolality; X X X X
(i) Standard analysis of blood, urine, and other body fluids. X X X X X X X X
(18) Blood and blood-component services (except for level V clinics), with: X X X X X X X X
(a) Ability to obtain blood typing and crossmatching; X X X X X X X X
(b) Autotransfusion; X X X X X X
(c) Blood and blood components available from in-house or through community services, to meet patient needs; X X X X X X X X
(d) Blood storage capability; X X X X X X X
(e) Noncrossmatched blood available on patient arrival in the emergency department; X X X X X X X X
(f) Policies and procedures for massive transfusion. X X X X X X X
(19) General surgery services, with: X X X X X X
(a) Surgeons who: X X X X X X
(i) Are board-certified in general surgery and available within five minutes of notification of the patient's arrival when the full trauma team is activated. This requirement can be met by a postgraduate year four or higher surgery resident. The resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until arrival of the general surgeon. In this case the general surgeon must be available within twenty minutes of notification of patient's arrival; X
(ii) Are board-certified in pediatric surgery or board-certified in general surgery with special competence in the care of pediatric patients and are available within five minutes of notification of the patient's arrival when the full trauma team is activated. This requirement can be met by a post graduate year four or higher pediatric surgery resident or a general surgery resident with special competence in the care of pediatric patients. The resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until arrival of the pediatric or general surgeon. In this case the pediatric or general surgeon must be available within twenty minutes of notification of patient's arrival; X
(iii) Are board-certified in general surgery. For full trauma team activations, the surgeon must be in the emergency department upon patient arrival when prehospital estimated time of arrival (ETA) is twenty minutes or more. Otherwise the surgeon must be in the emergency department within twenty minutes of notification of patient's arrival. This requirement can be met by a postgraduate year four or higher surgery resident. The resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until arrival of the general surgeon; X
(iv) Are board-certified in pediatric surgery or board-certified in general surgery with special competence in the care of pediatric patients. For full trauma team activations, the surgeon must be in the emergency department upon patient arrival when prehospital estimated time of arrival (ETA) is twenty minutes or more. Otherwise the surgeon must be in the emergency department within twenty minutes of notification of patient's arrival. This requirement can be met by a postgraduate year four or higher pediatric surgery resident or a general surgical resident with special competence in the care of pediatric patients. The resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until arrival of the pediatric or general surgeon; X
(v) Are board-certified or trained in ACLS and currently certified in ATLS. For full trauma team activations, the surgeon must be in the emergency department upon patient arrival when prehospital estimated time of arrival (ETA) is thirty minutes or more. Otherwise the surgeon must be in the emergency department within thirty minutes of notification of patient's arrival; X
(vi) Are board-certified or board-qualified, with special competence in the care of pediatric patients. For full trauma team activations, the surgeon must be in the emergency department upon patient arrival when prehospital estimated time of arrival (ETA) is thirty minutes or more. Otherwise the surgeon must be in the emergency department within thirty minutes of notification of patient's arrival; X
(vii) Are trained in ACLS and currently certified in ATLS. This requirement applies to all surgeons and residents caring for trauma patients except this requirement does not apply to surgeons who are board certified in general surgery; X X X
(viii) Are currently certified in ATLS. This requirement applies to all surgeons and residents caring for pediatric trauma patients except this requirement does not apply to surgeons who are board certified in pediatric or general surgery; X X X
(ix) Meet the PER as defined in subsection (27) of this section; X X X X X X
(b) A written plan for general surgery coverage, if the general surgeon on call for trauma is otherwise clinically engaged. The plan must take into consideration the trauma service's total patient volume, patient acuity, geographic proximity to other trauma services, depth of trauma care resources, and the trauma scope of service. The plan must be monitored through the trauma service's trauma quality improvement program; X X X X X X
(c) For level IV, general surgery services that meet all level III general surgery service standards if the facility's trauma scope of service includes general surgery services twenty-four hours every day, or transfer trauma patients who need general surgery services to a designated trauma service with general surgery services available. X
(20) Neurosurgery services with neurosurgeons, who are: X X X X
(a) Board-certified, and: X X
(i) Available within five minutes of the trauma team leader's request;
(ii) This requirement can be met by a postgraduate year four or higher neurosurgery resident. The resident may initiate evaluation and treatment upon the patient's arrival in the emergency department until arrival of the neurosurgeon. In this case the neurosurgeon must be available within thirty minutes of the trauma team leader's request;
(b) Board-certified or board-qualified and on-call and available within thirty minutes of the trauma team leader's request; X X
(c) For level III and IV, board-certified or board-qualified and on-call and available within thirty minutes of the trauma team leader's request if the facility's trauma scope of service includes neurosurgery services twenty-four hours every day or transfer trauma patients who need neurosurgery services to a designated trauma service with neurosurgery services available. X X X
(21) Surgical services on-call and available within thirty minutes of the trauma team leader's request for: X X X X X X
(a) Cardiac surgery; X X
(b) Microsurgery; X X
(c) Obstetric surgery or for level III trauma services, a plan to manage the pregnant trauma patient; X X X X X X
(d) Orthopedic surgery; X X X X X X
(e) For level IV, orthopedic surgery services on-call and available within thirty minutes of the trauma team leader's request if the facility's trauma scope of service includes orthopedic surgery services twenty-four hours every day, or transfer trauma patients who need orthopedic surgery services to a designated trauma service with orthopedic surgery services available; X
(f) Thoracic surgery; X X X X
(g) Urologic surgery; X X X X
(h) Vascular surgery. X X X X
(22) Surgical services on-call for patient consultation or management at the trauma team leader's request for: X X X X
(a) Cranial facial surgery; X X X X
(b) Gynecologic surgery; X X X X
(c) Ophthalmic surgery; X X X X
(d) Plastic surgery. X X X X
(23) Anesthesiology services, with board-certified anesthesiologists or certified registered nurse anesthetists (CRNAs), who: X X X X X X
(a) Are available within five minutes of the trauma team leader's request; X X
(b) Are on-call and available within twenty minutes of the trauma team leader's request; X X
(c) Are on-call and available within thirty minutes of the trauma team leader's request; X X
(d) Are ACLS trained except this requirement does not apply to physicians board-certified in anesthesiology; X X X X X X
(e) Meet the PER as defined in subsection (27) of this section. X X X X X X
(f) For level IV, meet all level III anesthesiology service standards, if the facility's trauma scope of service includes surgery services twenty-four hours every day or transfer trauma patients who need surgery services to a designated trauma service with surgery services available. X
(24) Operating room services, with: X X X X X X
(a) Hospital staff responsible for opening and preparing the operating room available within five minutes of notification; X X X X X X
(b) Operating room staff on-call and available within twenty minutes of notification; X X X X
(c) Operating room staff on-call and available within thirty minutes of notification; X X
(d) A written plan to mobilize additional surgical team members for trauma patient surgery; X X X X X X
(e) Standard surgery instruments and equipment needed to perform operations on adult and pediatric patients, including: X X X X X X
(i) Autologous blood recovery and transfusion; X X X X X X
(ii) Bronchoscopic capability; X X X X X X
(iii) Cardiopulmonary bypass; X X X X
(iv) Craniotomy set; X X X X
(v) Endoscopes; X X X X X X
(vi) Rapid infusion capability; X X X X X X
(vii) Thermal control equipment: X X X X X X
▪ Blood and fluid warming; X X X X X X
▪ Patient warming and cooling; X X X X X X
(f) For level IV, operating room services that meet all level III operating room service standards if the facility's trauma scope of care includes surgery services twenty-four hours every day or transfer trauma patients who need surgery services to a designated trauma service with surgery services available. X
(25) Post anesthesia care services with: X X X X X X
(a) At least one registered nurse available twenty-four hours every day; X X
(b) At least one registered nurse on-call and available twenty-four hours every day; X X X X
(c) Registered nurses who are ACLS trained; X X X X X X
(d) For level IV, post anesthesia care services that meet all level III post anesthesia care service standards if the facility's trauma scope of care includes general surgery services twenty-four hours every day or transfer trauma patients who need surgery services to a designated trauma service with surgery services available. X
(26) Critical care services, with: X X X X X
(a) A critical care medical director, who is: X X X X X
(i) Board-certified in: X
(A) Surgery and critical care; X
(B) Pediatric critical care; X
(ii) Board-certified in critical care or board-certified in surgery, internal medicine or anesthesiology with special competence in critical care; X X
(iii) Board-certified in critical care, with special competence in pediatric critical care or is board-certified in surgery, internal medicine or anesthesiology, with special competence in pediatric critical care; X
(iv) Responsible for coordinating with the attending physician for trauma patient care; X X X X X
(b) Critical care registered nurses, who: X X X X X
(i) Are ACLS trained; X X X
(ii) Have special competence in pediatric critical care; X X
(iii) Have completed a minimum of six contact hours of trauma specific education every three-year designation period; X X X X
(iv) Have completed a minimum of three contact hours of trauma specific education every three-year designation period; X
(c) A physician directed code team; X X X X X
(d) Pediatric patient isolation capacity; X X
(e) General surgery consults for critical care trauma patients or if intensivists are the primary admitting nonsurgical physician caring for trauma patients, the intensivists must complete a minimum of twelve hours of trauma critical care specific continuing medical education (CME) every three-year designation period; X X X X X X
(f) Standard critical care equipment for adult and pediatric trauma patients, including: X X X X X
(i) Cardiac devices: X X X X X
▪ Cardiac pacing capabilities; X X X X X
▪ Cardiac monitor with at least two pressure monitoring modules (cardiac output and hard copy recording), with the capability to continuously monitor heart rate, respiratory rate, and temperature; X X X X X
(ii) Intracranial pressure monitoring devices; X X X X
(iii) Intravenous supplies: X X X X X
▪ Infusion control device; X X X X X
▪ Rapid infusion capability; X X X X X
(iv) Sterile surgical sets: X X X X X
▪ Chest tubes; X X X X X
▪ Emergency surgical airway; X X X X X
▪ Peritoneal lavage; X X X X X
▪ Thoracotomy; X X X X X
(v) Thermal control equipment: X X X X X
▪ Blood and fluid warming; X X X X X
▪ Devices for assuring warmth during transport; X X X X X
▪ Expanded scale thermometer capable of detecting hypothermia; X X X X X
▪ Patient warming and cooling; X X X X X
(g) A written policy to transfer all pediatric trauma patients who need critical care services to a pediatric designated trauma service with critical care services available; X X X
(h) For level IV, critical care services that meet all level III critical care service standards, if the facility's trauma scope of service includes critical care services for trauma patients twenty-four hours every day or transfer trauma patients who need critical care services to a designated trauma service with critical care services available; X
(i) For level III pediatric trauma services, critical care services that meet all level II pediatric critical care service standards if the facility's trauma scope of care includes pediatric critical care services for trauma patients twenty-four hours every day or transfer pediatric trauma patients who need critical care services to a designated pediatric trauma service, with pediatric critical care services available. X
(27) Pediatric education requirement (PER): X X X X X X X X
(a) PER must be met by the following providers who are directly involved in the initial resuscitation and stabilization of pediatric trauma patients: X X X X X X X X
(i) Emergency department physicians; X X X X X X X X
(ii) Emergency department registered nurses; X X X X X X X X
(iii) Physician assistants or ARNPs who initiate evaluation and treatment prior to the arrival of the physician in the emergency department; X X
(iv) Emergency medicine or surgical residents who initiate care prior to the arrival of the emergency physician; X X X X
(v) General surgeons; X X X X X X
(vi) Surgical residents who initiate care prior to the arrival of the general surgeon; X X X X
(vii) Anesthesiologists and CRNAs; X X X X X X
(viii) General surgeons, anesthesiologists and CRNAs if the facility's trauma scope of service includes general surgery services twenty-four hours every day; X
(ix) Intensivists involved in the resuscitation, stabilization and in-patient care of pediatric trauma patients; X X X
(b) PER must be met by completing pediatric specific contact hours as defined below: X X X X X X X X
(i) Five contact hours per provider during each three-year designation period; X X X X X
(ii) Seven contact hours per provider during each three-year designation period; X X X
(iii) Contact hours should include, but are not limited to, the following topics:

     • Initial stabilization and transfer of pediatric trauma;

     • Assessment and management of pediatric airway and breathing;

     • Assessment and management of pediatric shock, including vascular access;

     • Assessment and management of pediatric head injuries;

     • Assessment and management of pediatric blunt abdominal trauma;

 X X X X X X X X
(iv) Contact hours may be accomplished through one or more, but not limited to, the following methods:

     • Review and discussion of individual pediatric trauma cases within the trauma quality improvement program;

     • Staff meetings;

     • Classes, formal or informal;

     • Web-based learning;

     • Certification in ATLS, PALS, APLS, ENPC, or other department approved equivalents;

     • Other methods of learning which appropriately communicates the required topics listed in this section.

 X X X X X X X X
(28) Acute dialysis services, or must transfer trauma patients needing dialysis. X X X X X X X X
(29) A burn center, in accordance with the American Burn Association, to care for burn patients, or must transfer burn patients to a burn center, in accordance with the American Burn Association transfer guidelines. X X X X X X X X
(30) Services on-call for consultation or patient management: X X X X X X
(a) Cardiology; X X X X
(b) Gastroenterology; X X X X
(c) Hematology; X X X X
(d) Infectious disease specialists; X X X X
(e) Internal medicine; X X X
(f) Nephrology; X X X X
(g) Neurology; X X X X
(h) Pediatric neurology; X X
(i) Pathology; X X X X X X
(j) Pediatrician; X X X X X
(k) Pulmonology; X X X X
(l) Psychiatry or a plan for management of the psychiatric trauma patient. X X X X
(31) Ancillary services available for trauma patient care: X X X X X X X X
(a) Adult protective services; X X X X X
(b) Child protective services; X X X X X X X X
(c) Chemical dependency services; X X X X X X
(d) Nutritionist services; X X X X X X X
(e) Occupational therapy services; X X X X X X
(f) Pastoral or spiritual care; X X X X X X X X
(g) Pediatric therapeutic recreation/child life specialist; X X
(h) Pharmacy services, with an in-house pharmacist; X X
(i) Pharmacy services; X X X X X X
(j) Physical therapy services; X X X X X X X
(k) Psychological services; X X X X X X
(l) Social services; X X X X X X X
(m) Speech therapy services. X X X X X X
(32) A trauma care outreach program, including: X X X X
(a) Telephone consultations with physicians of the community and outlying areas;
(b) On-site consultations with physicians of the community and outlying areas.
(33) Injury prevention, including: X X X X X X X X
(a) A public injury prevention education program; X X X X X X
(b) Participation in community or regional injury prevention activities; X X X X X X X X
(c) A written plan for drug and alcohol screening and brief intervention and referral. X X X X X X X X
(34) A formal trauma education training program, for: X X X X
(a) Allied health care professional; X X X X
(b) Community physicians; X X X X
(c) Nurses; X X X X
(d) Prehospital personnel; X X X X
(e) Staff physicians. X X X X
(35) Provisions to allow for initial and maintenance training of invasive manipulative skills for prehospital personnel. X X X X X X X
(36) Residency programs: X X
(a) Accredited by the Accreditation Council of Graduate Medical Education;
(b) With a commitment to training physicians in trauma management.
(37) A trauma research program with research applicable to the adult and pediatric trauma patient population. X X
(38) For joint trauma service designation (when two or more hospitals apply to share a single trauma designation): X X X X X X
(a) A single, joint multidisciplinary trauma quality improvement program in accordance with the trauma quality improvement standards defined in subsection (4) of this section;
(b) A set of common policies and procedures adhered to by all hospitals and providers in the joint trauma service;
(c) A predetermined, published hospital rotation schedule for trauma care.

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NEW SECTION
WAC 246-976-800   Trauma rehabilitation service standards.  

WAC 246-976-800 Trauma Rehabilitation Service Standards Levels
A designated trauma rehabilitation service must: I II III I Pediatric
(1) Be a licensed hospital as defined in chapter 246-320 WAC. X X
(2) Treat adult and adolescent trauma patients in inpatient and outpatient settings regardless of disability or level of severity or complexity. X
(3) Treat pediatric and adolescent trauma patients in inpatient and outpatient settings regardless of disability or level of severity or complexity. X
(4) Treat adult and adolescent trauma patients in inpatient and outpatient settings with disabilities or level of severity or complexity within the facility's capability and as specified in the facility's admission criteria. X
(5) For adolescent patients (approximately twelve to eighteen years of age), the service must consider whether physical development, educational goals, preinjury learning or developmental status, social or family needs, and other factors indicate treatment in an adult or pediatric rehabilitation service. X X X
(6) Have and retain full accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF) for inpatient medical rehabilitation programs. X X
(7) Have and retain full accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF) for pediatric inpatient medical rehabilitation programs. X
(8) House patients on a designated rehabilitation nursing unit. X X
(9) House patients in a designated pediatric rehabilitation area, providing an environment appropriate to the age and developmental status of the patient. X
(10) Provide a peer group for persons with similar disabilities. X X X
(11) Have a medical director who: X X X
(a) Is a physiatrist;
(b) Is responsible for the organization and direction of the trauma rehabilitation service; and
(c) Participates in the trauma rehabilitation service's quality improvement program.
(12) Have a physiatrist in-house or on-call twenty-four hours every day and responsible for the day-to-day clinical management and the treatment plan of trauma patients. X X X
(13) Provide rehabilitation nursing personnel twenty-four hours every day, with: X X X
(a) Management and supervision by a registered nurse; X X X
(b) The initial care plan and weekly update reviewed and approved by a certified rehabilitation registered nurse (CRRN); X X X
(c) An orientation and training program for all levels of rehabilitation nursing personnel; X X X
(d) A minimum of six clinical nursing care hours, per patient day, for each trauma patient; X X X
(e) At least one CRRN on duty, each day and evening shift, when a trauma patient is present; X X
(f) At least one CRRN on duty, one shift each day, when a trauma patient is present. X
(14) Provide the following trauma rehabilitation services with providers who are licensed, registered, certified, or degreed and are available to provide treatment as defined in the patient's rehabilitation plan: X X X
(a) Occupational therapy; X X X
(b) Physical therapy; X X X
(c) Speech/language pathology; X X X
(d) Social services; X X X
(e) Nutritional counseling; X X X
(f) Clinical psychological services, including testing and counseling; X X X
(g) Neuropsychological services. X X X
(15) Provide the following health personnel and consultative services in-house or on-call twenty-four hours every day: X X X
(a) A pharmacist with immediate access to pharmaceuticals and patient medical records and pharmacy data bases; X X X
(b) Respiratory care practitioners; X X X
(c) Pastoral or spiritual care; X X X
(d) A radiologist; X X X
(e) A pediatrician. X
(16) Provide the following services in-house or through affiliation or consultative arrangements with providers who are licensed, registered, certified, or degreed: X X X
(a) Anesthesiology (anesthesiologist or CRNA); X X X
(b) Audiology; X X X
(c) Communication augmentation; X X X
(d) Dentistry; X X X
(e) Diagnostic imaging, including: X X X
(i) Computerized tomography;
(ii) Magnetic resonance imaging;
(iii) Nuclear medicine; and
(iv) Radiology;
(f) Driver evaluation and training; X X
(g) Educational program appropriate to the disability and developmental level of the pediatric or adolescent patient, to include educational screening, instruction, and discharge planning coordinated with the receiving school district; X X X
(h) Electrophysiologic testing, including: X X X
(i) Electroencephalography;
(ii) Electromyography; and
(iii) Evoked potentials;
(i) Laboratory services; X X X
(j) Orthotics; X X X
(k) Prosthetics; X X X
(l) Pediatric therapeutic recreation specialist or child life specialist; X
(m) Rehabilitation engineering for device development and adaptations; X X X
(n) Substance abuse counseling; X X X
(o) Therapeutic recreation; X X X
(p) Vocational rehabilitation; X X
(q) Urodynamic testing. X X X
(17) Have providers with documented special competence in pediatric rehabilitation care. This requirement applies to all pediatric trauma rehabilitation providers. X
(18) Serve as a regional referral center for patients in their geographical area needing only level II or III rehabilitation care. X
(19) Have an outreach program regarding trauma rehabilitation care, consisting of telephone and on-site consultations with physicians and other health care professionals in the community and outlying areas. X X X
(20) Have a formal program of continuing trauma rehabilitation care education, both in-house and outreach, provided for nurses and allied health care professionals. X X X
(21) Have an ongoing structured program to conduct clinical studies, applied research, or analysis in rehabilitation of trauma patients, and report results within a peer review process. X X
(22) Have a quality improvement program that reflects and demonstrates a process for continuous quality improvement in the delivery of trauma rehabilitation care, with: X X X
(a) An organizational structure and plan that facilitates the process of quality improvement and identifies the authority to change policies, procedures, and protocols that address the care of the trauma patient;
(b) Representation and participation by the interdisciplinary trauma rehabilitation team;
(c) A process for communicating and coordinating with referring trauma care providers as needed;
(d) Development of outcome standards;
(e) A process for monitoring compliance with or adherence to the outcome standards;
(f) A process of internal peer review to evaluate specific cases or problems;
(g) A process for implementing corrective action to address problems or deficiencies;
(h) A process to analyze and evaluate the effect of corrective action; and
(i) A process to ensure that confidentiality of patient and provider information is maintained according to the standards of RCW 70.41.200 and 70.168.090.
(23) Participate in the regional trauma quality improvement program as defined in WAC 246-976-910. X X X X
(24) Participate in the Washington state trauma registry as defined in WAC 246-976-430. X X X X
(25) Provide a community based program of coordinated and integrated outpatient trauma rehabilitation services, evaluation, and treatment to persons with trauma-related functional limitations who do not need or no longer require comprehensive inpatient rehabilitation. Services may be provided in, but not limited to, the following settings: X
(a) Freestanding outpatient rehabilitation centers;
(b) Organized outpatient rehabilitation programs in acute hospital settings;
(c) Day hospital programs;
(d) Other community settings.
(26) Treat patients according to admission criteria based on diagnosis and severity. X
(27) Be directed by a physician with training and experience necessary to provide rehabilitative physician services, acquired through one of the following: X
(a) Formal residency in physical medicine and rehabilitation; or
(b) A fellowship in rehabilitation for a minimum of one year; or
(c) A minimum of two years' experience in providing rehabilitation services for patients typically seen in CARF-accredited inpatient rehabilitation programs.
(28) Provide the following trauma rehabilitation services with providers who are licensed, registered, or certified according to the frequency as defined in the rehabilitation plan: X
(a) Occupational therapy;
(b) Physical therapy;
(c) Social services;
(d) Speech/language pathology.
(29) Provide or assist the patient to obtain the following as defined in the rehabilitation plan: X
(a) Audiology;
(b) Dentistry;
(c) Driver evaluation and training;
(d) Education;
(e) Nursing;
(f) Nutrition counseling;
(g) Orthotics;
(h) Pastoral or spiritual care;
(i) Prosthetics;
(j) Psychology;
(k) Rehabilitation engineering for device development and adaptations;
(l) Respiratory therapy;
(m) Substance abuse counseling;
(n) Therapeutic recreation;
(o) Vocational rehabilitation.
(30) Have a quality improvement program that reflects and demonstrates a process for continuous quality improvement in the delivery of trauma care, with: X
(a) A process to identify and monitor trauma rehabilitation care and outcome standards and indicators;
(b) An interdisciplinary team, to include the trauma rehabilitation service physician director;
(c) A process to ensure confidentiality of patient and provider information in accordance with RCW 70.41.200 and 70.168.090.

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REPEALER

     The following sections of the Washington Administrative Code are repealed:
WAC 246-976-485 Designation of facilities to provide trauma care services.
WAC 246-976-490 Suspension or revocation of designation.
WAC 246-976-530 Trauma service designation -- Administration and organization.
WAC 246-976-535 Trauma service designation -- Basic resources and capabilities.
WAC 246-976-540 Trauma service designation -- Outreach, public education, provider education, and research.
WAC 246-976-620 Equipment standards for trauma service designation.
WAC 246-976-750 Pediatric trauma service designation -- Administration and organization.
WAC 246-976-755 Pediatric trauma service designation -- Basic resources and capabilities.
WAC 246-976-760 Pediatric trauma service designation -- Outreach, public education, provider education, and research.
WAC 246-976-830 Designation standards for facilities providing level I trauma rehabilitation service.
WAC 246-976-840 Designation standards for facilities providing level II trauma rehabilitation service.
WAC 246-976-850 Designation standards for level III trauma rehabilitation service.
WAC 246-976-860 Designation standards for facilities providing level I pediatric trauma rehabilitation service.
WAC 246-976-870 Trauma team activation.
WAC 246-976-881 Trauma quality improvement programs for designated trauma care services.
WAC 246-976-885 Educational requirements -- Designated trauma care service personnel.
WAC 246-976-886 Pediatric education requirements (PER) for nonpediatric designated facilities.
WAC 246-976-887 Pediatric education requirements (PER) for pediatric designated facilities.

© Washington State Code Reviser's Office