6 CCR 1015-4-303 - Trauma Facility Designation Criteria - Level I and II Facilities
1. Prehospital Trauma Care Integration
A. The facility shall participate in the
development and improvement of prehospital care protocols and patient safety
programs.
B. The Trauma Medical
Director shall be involved in the development of the trauma facility's divert
protocol as it affects the trauma service.
C. A trauma surgeon shall be involved in any
decision regarding divert as it affects the care of the trauma
patient.
D. A liaison from the
emergency department shall participate in prehospital peer review/performance
improvement.
2.
Interfacility Consultation, Transfer Requirements, and Emergent Surgery
A. The facility shall provide on-going
consultation, education, and technical support to referring facilities,
individuals, or RETACS.
B.
Provisions for direct physician-to-physician contact shall be included in the
process of transferring a patient between facilities.
C. The decision to transfer a patient shall
be based on the clinical needs of the patient. Physicians shall be allowed to
transfer when in the best interest of the patient and shall not be encumbered
by restrictions to keep patients within a particular healthcare organization or
based on the patient's ability to pay.
D. If the facility does not have a burn
service, a reimplantation service, a pediatric trauma service, or an acute
rehabilitation service, the facility shall have written transfer guidelines for
patients in these categories.
E.
All Level I and II trauma centers may perform emergent surgery if appropriate
resources are available. If after the emergent surgery is performed, the
facility does not have the post-operative resources to care for the patient and
for potential complications, the facility shall transfer to a trauma center
with the necessary resources to meet the patient's needs.
F. Mandatory Transfers
(1) Patients of any age with a traumatic
injury requiring resources beyond those available in the facility's scope of
care, see 6 CCR 1015-4, Chapter Three, 303.4.B(1), shall be
transferred.
(2) Levels I and II
trauma centers that only admit children have a single extremity orthopedic
fracture or minor head trauma, as determined by best practice guidelines, shall
transfer any other pediatric patients, after emergency surgery, as necessary.
(a) Transfer shall be to a Regional Pediatric
Trauma Center or to a Level I or II trauma center that admits pediatric trauma
patients.
(b) The receiving trauma
center must meet the requirements set forth in 6 CCR 1015-4, Chapter Three,
Section 303.9.D and have a pediatric intensive care area staffed by a board
certified or board eligible pediatric intensivist available for consultation or
have a transfer protocol and transfer agreements for pediatric patients
requiring intensive care.
(c) The
receiving trauma center must have a neurosurgeon on call with qualifications
necessary to manage pediatric neurotrauma.
3. Performance Improvement Process
A. General Provisions
(1) The facility shall demonstrate a clearly
defined trauma performance improvement program that shall be coordinated with
the hospital-wide program.
(2) The
facility shall be able to demonstrate that the trauma patient population can be
identified for separate review regardless of the institutional performance
improvement processes.
(3)
Performance improvement shall be supported by a reliable method of data
collection that consistently obtains valid and objective information necessary
to identify opportunities for improvement. The process of analysis shall
include multidisciplinary review and shall occur at regular intervals to meet
the needs of the program. The results of analysis shall define corrective
strategies and shall be documented.
(4) The facility shall demonstrate that the
trauma registry is used to support the performance improvement
program.
(5) The performance
improvement program shall have defined audit filters based upon a regular
review of registry and/or clinical data.
(6) There shall be appropriate, objectively
defined standards to determine the quality of care.
(7) If more than 10 percent of injured
patients with an Injury Severity Score greater than or equal to nine (excluding
isolated hip fractures) are admitted to non-surgical services, the trauma
facility shall demonstrate the appropriateness of that practice through the
performance improvement program.
(8) Identified problem trends shall undergo
peer review by the Peer Review/Performance Improvement Committee.
(9) The facility shall review any diversion
or double transfer (from another facility and then transferred for additional
acute trauma care) of trauma patients.
(10) The facility shall demonstrate that its
graded activation criteria are regularly evaluated by the performance
improvement program.
(11) Physician
availability to the trauma patient in the ICU shall be monitored by the peer
review/performance improvement program.
B. Multidisciplinary Trauma Committee
(1) The facility shall have a
multidisciplinary committee to address trauma program operational
issues.
(2) A multidisciplinary
trauma committee shall continuously evaluate the trauma program's processes and
outcomes.
(3) The committee shall
include, at a minimum, the Trauma Medical Director or designee and all core
surgeons as well as liaisons from orthopedic surgery, neurosurgery, emergency
medicine, radiology, and anesthesia. Each of these liaisons shall attend at
least 50 percent of the meetings.
(4) The exact format of the committee may be
hospital specific, but shall be multidisciplinary and consist of hospital and
medical staff members who work to identify and correct trauma program system
issues.
(5) The committee minutes
shall reflect the review of operational issues and, when appropriate, the
analysis and proposed corrective actions. The process shall identify problems
and shall demonstrate problem resolution.
(6) The committee shall monitor compliance
with all required time frames for availability of trauma personnel including,
but not limited to, response times for general surgery, orthopedics,
neurosurgery, anesthesiology, radiology, and radiology, MRI, or CT
techs.
(7) The availability of
anesthesia services and the absence of delays in airway control or operations
shall be monitored.
(8)
Radiologists shall be involved in protocol development and trend analysis that
relate to diagnostic imaging.
(9)
The multidisciplinary committee shall review and address issues related to the
availability of necessary personnel and equipment to monitor and resuscitate
patients in the PACU.
C.
Peer Review/Performance Improvement Committee
(1) The facility shall have a Peer
Review/Performance Improvement Committee chaired by the Trauma Medical Director
or physician designee.
(2) The
committee shall include, at a minimum, the core group of general surgeons and a
physician liaison from orthopedic surgery, neurosurgery, emergency medicine,
radiology, and anesthesia. Each liaison shall attend at least 50 percent of the
meetings.
(3) Each liaison shall be
available to the Trauma Medical Director for committee issues that arise in his
or her department.
(4) The Peer
Review/Performance Improvement Committee shall document evidence of committee
attendance and participation.
(5)
The committee shall review the overall quality of care for the trauma service,
selected deaths, complications, and sentinel events with the objective of
identifying issues and appropriate responses.
(6) Trauma patient care may be evaluated
initially by individual specialties within their usual Departmental review
structures; however, identified problem trends shall undergo review within the
Peer Review/Performance Improvement Committee.
(7) The facility shall also, in this
committee or in another appropriate forum, provide for morbidity and mortality
review of trauma cases. All trauma deaths shall be systematically reviewed and
categorized as preventable, non-preventable, or potentially preventable or
equivalent taxonomy.
(8) When a
consistent problem or inappropriate variation is identified, corrective actions
shall be taken and documented.
(9)
The Trauma Medical Director shall ensure dissemination of committee information
to all non-core general surgeons with documentation.
(10) The Peer Review/Performance Improvement
Committee shall review and monitor the organ donation rate.
(11) The committee shall demonstrate that the
program complies with required surgical response times at least 80 percent of
the time.
(12) The peer
review/performance improvement program shall monitor changes in interpretation
of diagnostic information.
4. Facility Organization and the Trauma
Program
A. Facility Governing Body and Medical
Staff Commitment
(1) The facility shall
demonstrate the commitment of the facility's governing body and medical staff
through a written document. The document shall be reaffirmed every three years
and be current at the time of the site review.
(2) The administrative structure of the
hospital/trauma facility shall include, at a minimum, an administrator, a
Trauma Medical Director, and a trauma program manager.
B. Trauma Program
(1) Scope of care: All designated Level I and
II trauma centers shall define their scope of care based on the resources that
are available at the facility for adult and pediatric patients.
(2) The trauma program members or a
representative of the program shall participate in state and regional trauma
system planning, development, and operation.
(3) The trauma program shall have authority
to address issues that involve multiple disciplines. The Trauma Medical
Director shall have the authority and administrative support to lead the
program.
C. Trauma
Medical Director
(1) The Trauma Medical
Director shall be a board certified (not board eligible) surgeon, as those
boards are defined under the "Clinical Requirements for General Surgery" as
described in Section 303.5.C or shall be a Fellow of the American College of
Surgeons with special interest in trauma care, shall take trauma call, and
shall remain current in ATLS.
(2)
The Trauma Medical Director shall demonstrate membership and active
participation in state and either regional or national trauma
organizations.
(3) The Trauma
Medical Director shall have the authority to correct deficiencies in trauma
care and exclude from taking trauma call all trauma team members who do not
meet required criteria. Through the performance improvement program and
hospital policy, the Trauma Medical Director shall have the responsibility and
authority to determine each general surgeon's ability to participate on the
trauma panel based on an annual review.
D. Trauma Resuscitation Team
(1) The facility shall define criteria for
trauma resuscitation team activation.
(2) The criteria for a graded activation
shall be clearly defined and continuously evaluated by the performance
improvement program.
E.
Trauma Service
(1) A trauma service admission
is a patient who is admitted to or evaluated by an identifiable surgical
service staffed by credentialed trauma providers.
(2) The facility shall demonstrate or provide
documentation that the trauma service has sufficient infrastructure and support
to ensure the adequate provision of care.
(3) The trauma service shall maintain
oversight of the admitted patient until trauma care is no longer
necessary.
(4) Level I only: An
adult trauma facility shall demonstrate an annual volume of at least 320 trauma
patients with an Injury Severity Score (ISS) of 16 or greater.
F. Trauma Program Manager
The trauma program manager shall, at a minimum, be a registered nurse and demonstrate the following qualifications:
(1) Administrative ability,
(2) Evidence of educational preparation,
and
(3) Documented clinical
experience.
5. Clinical Requirements for General Surgery
A. Role/Availability
(1) The on-call attending trauma surgeon
shall be in the emergency department on patient arrival, as set forth below,
for the highest level of activation, with adequate notification from the field.
The maximum response time is 15 minutes, tracked from patient arrival, 80
percent of the time. The Multidisciplinary Trauma Committee shall monitor
compliance of the attending surgeon's arrival times.
(2) A resident in postgraduate year four or
five may begin resuscitation while awaiting arrival of the attending surgeon
based on facility-defined criteria.
B. Equipment/Resources
The facility shall provide all of the necessary resources, including instruments, equipment, and personnel, for current surgical trauma care.
C.
Qualifications/Board Certification
(1) Except
as provided below in subparagraph 2, all general surgeons on the trauma panel
shall be fully credentialed in critical care and board certified in surgery by
the American Board of Surgery (ABS), the Bureau of Osteopathic Specialists and
Boards of Certification, or the Royal College of Physicians and Surgeons of
Canada; or shall be board eligible, working toward certification, and less than
five years out of residency.
(2) A
foreign-trained, non-ABS boarded surgeon shall have the foreign equivalent of
ABS certification in general surgery, clinical expertise in trauma care, an
unrestricted Colorado license, and unrestricted credentials in surgery and
critical care at the facility.
D. Clinical Commitment/Involvement
(1) All general surgeons on the trauma panel
shall have general surgical privileges.
(2) The general surgeon on call shall be
dedicated to one trauma facility when taking trauma call.
(3) A published general surgery back-up call
schedule shall be available. The backup surgeon shall be present within 30
minutes of being requested to respond.
(4) An attending surgeon shall be present at
all trauma operations. The surgeon's presence shall be documented.
(5) The performance of all surgeons on the
trauma panel shall be reviewed annually by the Trauma Medical
Director.
E.
Education/Continuing Education: All general surgeons on the trauma panel shall
remain current in ATLS.
F.
Participation in Statewide Trauma System
Each Level I and II trauma facility shall provide a qualified surgeon as a state reviewer a minimum of one day per year, if requested by the Department.
6. Requirements for Emergency Medicine and
the Emergency Department
A. Role/Availability
(1) The facility shall have a designated
emergency department physician director supported by additional physicians to
ensure immediate care for injured patients.
(2) A physician shall be present in the
emergency department at all times.
(3) In facilities with emergency medicine
residents, an in-house attending emergency physician shall provide supervision
of the residents 24 hours per day.
(4) The facility shall designate an emergency
physician to serve as the emergency medicine liaison to the trauma
service.
B.
Equipment/Resources
The trauma facility shall provide all of the necessary resources, including instruments, equipment, and personnel, for current emergency trauma care.
C.
Qualifications/Board Certification
(1) All
emergency physicians on the trauma panel shall have successfully completed ATLS
at least once.
(2) Physicians
providing initial resuscitation in the emergency department shall be:
(a) Board certified in emergency medicine,
or
(b) Have current ATLS.
(3) Board certification shall be
issued by a certifying entity that is nationally recognized in the United
States.
D. Clinical
Commitment/Involvement
(1) The roles and
responsibilities of the emergency physician shall be defined, agreed on, and
approved by the Trauma Medical Director.
(2) Emergency physicians on the call panel
shall be regularly involved in the care of the injured patient.
(3) The performance of all emergency
physicians on the trauma panel shall be reviewed annually by the emergency
medicine liaison or designated representative.
E. Nursing Services
(1) A qualified nurse shall be available 24
hours per day to provide care for patients during the emergency department
phase of care. Nursing personnel with special capability in trauma care shall
provide continual monitoring of the trauma patient from hospital arrival to
disposition in Intensive Care Unit (ICU), Operating Room (OR), or Patient Care
Unit (PCU).
(2) The nurse/patient
ratio shall be appropriate for the acuity of the trauma patients in the
emergency department.
7. Clinical Requirements for Neurosurgery
A. Role/Availability
(1) The facility shall designate a
neurosurgeon to serve as the neurosurgical liaison to the trauma
service.
(2) The facility shall
define criteria for neurosurgical attending response.
(3) Neurosurgical care must be continuously
available for all traumatic brain injury and spinal cord injury patients and
must be present within 30 minutes, based on the facility's neurosurgical
response criteria.
(4) Compliance
with the 30 minute response time to neurosurgical presence shall be monitored
by the trauma program and presented to the multidisciplinary trauma
committee.
(5) Level I
availability:
The facility shall provide a neurosurgical on-call schedule, dedicated only to that facility, available 24 hours per day, and either a posted backup call schedule or a contingency plan that includes bypass and transfer guidelines with another designated Level I, or in the event that no other Level I is available, then to a Level II facility with the necessary resources to meet the patient's needs.
(6) Level II availability:
a. The facility shall provide a neurosurgical
on-call schedule, dedicated only to that facility, available 24 hours per day,
and either a posted backup call schedule or a contingency plan that includes
bypass and transfer guidelines with a designated Level I or II facility with
the necessary resources to meet the patient's needs; or
b. If neurosurgeons take call at more than
one facility (either trauma or non-trauma) at a time, written primary and
backup call schedules are required and a contingency plan that includes bypass
and transfer guidelines with a designated Level I or II facility.
B. Equipment/Resources
The facility shall provide all of the necessary resources, including instruments, equipment, and personnel for current neurotrauma care.
C. Qualifications
(1) Neurosurgeons must be:
a. Board certified in neurosurgery, or
b. Board eligible and less than
seven years from residency, or
c.
Have current ATLS, if no longer boarded or board eligible.
(2) All board certifications shall be issued
by a certifying entity that is nationally recognized in the United
States.
D. Clinical
Commitment/Involvement
(1) Neurosurgeons shall
be credentialed by the hospital with general neurosurgical
privileges.
(2) Qualified
neurosurgeons shall be regularly involved in the care of the head and spinal
cord injured patients.
(3) The
performance of all neurosurgeons on the trauma panel shall be reviewed annually
by the liaison or designated representative.
8. Clinical Requirements for Orthopedic
Surgery
A. Role/Availability/Specialists
(1) The facility shall designate an
orthopedic surgeon to serve as the orthopedic liaison to the trauma
program.
(2) The facility shall
define criteria for the orthopedic surgeon attending response.
(3) Orthopedic care must be continuously
available for patients and must be present within 30 minutes based on the
facility's orthopedic response criteria.
(4) Compliance with the 30 minute response
time to orthopedic presence shall be monitored by the trauma program and
presented to the multidisciplinary trauma committee.
(5) Level I availability:
The facility shall provide an orthopedic on-call schedule, dedicated only to that facility, available 24 hours per day and either a posted backup call schedule or a contingency plan that includes bypass and transfer guidelines with another designated Level I, or in the event that no other Level I is available, then to a Level II facility with the necessary resources to meet the patient's needs.
(6) Level II availability:
a. The facility shall provide an orthopedic
on-call schedule, dedicated only to that facility, available 24 hours per day
and either a posted backup call schedule or a contingency plan that includes
bypass and transfer guidelines with a designated Level I or II facility with
the necessary resources to meet the patient's needs; or
b. If orthopedic surgeons take call at more
than one facility (either trauma or non-trauma) at a time, written primary and
backup call schedules are required and a contingency plan that includes bypass
and transfer guidelines with a designated Level I or II facility.
(7) A fully credentialed spine
surgeon shall be promptly available, as defined by the facility, 24 hours per
day.
(8) Level I only: At least one
orthopedic traumatologist with a minimum of six to twelve months of fellowship
training (or equivalent) shall be a part of the trauma team.
B. Equipment/Resources
The facility shall provide all of the necessary resources including instruments, equipment, and personnel for current musculoskeletal trauma care.
C.
Qualifications
(1) Orthopedic surgeons must
be:
a. Board certified, or
b. Board eligible and less than seven years
from residency, or
c. Have current
ATLS, if no longer boarded or board eligible.
(2) All board certifications shall be issued
by a certifying entity that is nationally recognized in the United
States.
D. Clinical
Commitment/Involvement
(1) Orthopedic surgeons
shall be credentialed by the hospital with general orthopedic
privileges.
(2) Orthopedic surgeons
on the call panel shall be regularly involved in the care of the trauma
patient.
(3) The performance of all
orthopedic surgeons on the trauma panel shall be reviewed annually by the
liaison or designated representative.
9. Pediatric Trauma Care
A. Pediatric trauma care shall refer to care
delivered to children under age 15.
B. Level I and II adult trauma facilities can
and will receive pediatric trauma patients. All adult Level I and II facilities
shall:
(1) Provide evidence of safe pediatric
trauma care to include age-specific medical devices and equipment as
appropriate for the resuscitation and stabilization of the pediatric
patient.
(2) Assure that the
physician and nursing staff providing care to the pediatric patient
demonstrates competency in the care of the injured child appropriate to the
type of injured child.
(3)
Demonstrate oversight of the pediatric care provided through a
pediatric-specific peer review/performance improvement process.
C. Nonaccidental Trauma
(1) Pediatric patients with suspected or
evidence of nonaccidental trauma requiring social or clinical care beyond the
facility's resources shall be transferred to a Regional Pediatric Trauma Center
or to a Level I or II trauma center with the necessary resources that admits
pediatric trauma patients. The receiving trauma center must meet the
requirements set forth in 6 CCR 1015-4, Chapter Three, Section
303.9.D.
(2) All Level I-II
facilities admitting pediatric patients with nonaccidental traumatic injury
shall consult with a specialist in child maltreatment affiliated with a trauma
center for diagnostic and care consideration purposes.
D. A Level I or II adult trauma facility that
admits children having other than single extremity orthopedic fracture or minor
head trauma as determined by best practice guidelines shall meet the following
additional criteria:
(1) All physicians
providing care to pediatric trauma patients shall be credentialed for pediatric
trauma care by the hospital's credentialing body.
(2) The facility shall provide appropriate
pediatric medical equipment in the emergency department.
(3) The facility shall provide a pediatric
intensive care area staffed by a board certified or board eligible pediatric
intensivist available for consultation or have a transfer protocol and transfer
agreements for pediatric patients requiring intensive care.
(4) A neurosurgeon on call with
qualifications necessary to manage pediatric neurotrauma.
(5) The facility shall provide appropriate
pediatric resuscitation equipment in all pediatric care areas.
(6) The facility shall have a
pediatric-specific peer review/performance improvement process, which shall
include pediatric-specific process filters and outcome measures.
(7) The facility shall assure that the
nursing staff providing care to the pediatric patient has specialized training
in the care of the injured child.
10. Collaborative Clinical Services
A. Anesthesiology
(1) Role/Availability
a. The facility shall designate an
anesthesiologist to serve as the anesthesia liaison to the trauma
program.
b. Anesthesiology services
shall be promptly available as defined by the facility 24 hours per day for
emergency operations and airway problems in the injured patient. Compliance
with the facility-defined availability criteria shall be monitored by the
Multidisciplinary Trauma Committee.
c. When anesthesiology residents or certified
registered nurse anesthetists are used to fulfill availability requirements,
the staff anesthesiologist on call shall be notified and be present in the
operating department. The process shall be monitored through the performance
improvement process.
d. Level I
only: Anesthesiology coverage shall be in house.
(2) Qualifications
a. Levels I-II anesthesiologists and nurse
anesthetists must be:
i. Board certified, or
ii. Board eligible and less than
seven years from residency, or
iii.
Have current ATLS, if no longer boarded or board eligible.
b. All board certifications shall be issued
by a certifying entity that is nationally recognized in the United
States.
c. The performance of all
anesthesiologists on the trauma panel shall be reviewed annually by the
anesthesiology liaison or designated representative.
B. Operating Room
(1) General Requirements
a. A dedicated operating room team shall
always be available.
b. If the
primary operating room team is occupied, there shall be a mechanism in place to
staff a second operating room.
c.
There shall be a facility-defined access policy for urgent trauma cases of all
specialties.
(2)
Equipment Requirements
a. The facility shall
have rapid infusers, thermal control equipment for patients and fluids,
intraoperative radiological capabilities, equipment for fracture fixation,
equipment for endoscopic evaluation (bronchoscopy and gastrointestinal
endoscopy), and other equipment to provide operative care consistent with
current practice.
b. The facility
shall have the necessary equipment to perform a craniotomy.
c. Level I only: The facility shall have
cardiopulmonary bypass equipment and an operating microscope available 24 hours
per day.
C.
Postanesthesia Care Unit (PACU)
(1) Qualified
nurses shall be available 24 hours per day to provide care for the trauma
patient, if needed, in the recovery phase.
(2) If the availability of PACU nurses is met
with an on-call team from outside the hospital, the availability of the PACU
nurses and absence of delays shall be monitored by the peer review/performance
improvement program.
(3) The PACU
shall provide all of the necessary resources including instruments, equipment,
and personnel to monitor and resuscitate patients consistent with the
facility-defined process of care.
(4) Recovery of the trauma patient in a
critical care (intensive care) unit is also acceptable.
D. Radiology
(1) Role/Availability
a. Qualified radiologists shall be promptly
available as defined by the facility for the interpretation of imaging studies
and shall respond in person when requested.
b. The facility shall designate a radiologist
to serve as the radiology liaison to the trauma program.
c. Interventional Radiology Requirements:
i. Level I: Personnel qualified in advanced
neuro, endovascular, and interventional procedures shall be promptly available
as defined by the facility 24 hours per day and available in less than 30
minutes when requested by a trauma surgeon.
ii. Level II: Personnel qualified in
interventional procedures shall be promptly available as defined by the
facility 24 hours per day when requested by a trauma surgeon.
(2) Clinical
Commitment/Involvement
a. Diagnostic
information shall be communicated in written form in a timely manner as defined
by the facility.
b. Critical
information that is deemed to immediately affect patient care shall be promptly
communicated to the trauma team.
c.
The final report shall accurately reflect the chronology and content of
communications with the trauma team, including changes between the preliminary
and final interpretation.
(3) Radiology Support Services
a. The facility shall have policies designed
to ensure that trauma patients who may require resuscitation and monitoring are
accompanied by appropriately trained providers during transport to and while in
the radiology department.
b.
Conventional radiography and computed tomography (CT) shall be promptly
available as defined by the facility 24 hours per day and available in less
than 30 minutes when requested by a trauma surgeon.
c. An in-house radiographer and in-house CT
technologist shall be promptly available as defined by the facility 24 hours
per day and available in less than 30 minutes when requested by a trauma
surgeon.
d. Conventional catheter
angiography and sonography shall be promptly available as defined by the
facility 24 hours per day and available in less than 30 minutes when requested
by a trauma surgeon.
e. Magnetic
resonance imaging capability shall be promptly available as defined by the
facility 24 hours per day and available in less than 30 minutes when requested
by a trauma surgeon.
f. The peer
review/performance improvement program shall review and address any variance
from facility-defined response times.
E. Critical Care
(1) Organization of the Intensive Care Unit
(ICU)
a. ICU service leadership:
i. Level I: This service shall be led by a
qualified surgeon who is board certified in critical care by the American Board
of Surgery. The surgical director shall have obtained critical care training
during residency or fellowship and shall have expertise in the perioperative
and post injury care of injured patients.
ii. Level II: This service shall be directed
or co-directed by a qualified surgeon with expertise in the care of injured
patients.
b. This
service may be staffed by critical care trained physicians from different
specialties.
c. Physician coverage
of critically ill trauma patients shall be promptly available as defined by the
facility 24 hours per day. These physicians shall be capable of rapid response
to deal with urgent problems as they arise. Availability shall be monitored by
the peer review/performance improvement program.
d. All trauma surgeons shall be fully
credentialed by the facility to provide all intensivist services in the ICU.
There shall be full hospital privileges for critical care.
e. The trauma surgeon shall retain oversight
of the patient while in the ICU.
f.
Level I only: A facility-defined team shall provide daily multidisciplinary
rounds to patients in the ICU.
(2) Nursing Services
a. A qualified nurse shall be available 24
hours per day to provide care for patients during the ICU phase of
care.
b. The nurse/patient ratio
shall be appropriate for the acuity of the trauma patients in the
ICU.
c. The facility shall assure
that the nursing staff providing care to the pediatric patient has specialized
training in the care of the injured child.
(3) Equipment
a. The ICU shall have the necessary resources
including instruments and equipment to monitor and resuscitate patients
consistent with the facility-defined process of care.
b. Arterial pressure monitoring, pulmonary
artery catheterization, patient rewarming, intracranial pressure monitoring,
and other equipment to provide critical care consistent with current practice
shall also be available.
c.
Ventilator support shall be available for trauma patients 24 hours per
day.
F. Other
Surgical Specialties - The facility shall have a full spectrum of surgical
specialists on staff including, but not limited to, the following surgical
specialties:
(1) Thoracic, peripheral
vascular, obstetric, gynecological, otolaryngologic, urologic, ophthalmologic,
facial trauma, and plastic.
(2) In
addition, Level I only: cardiac, microvascular, and hand.
G. Medical Consultants
(1) The facility shall have the following
medical specialists and their respective support teams on staff: cardiology,
infectious disease, internal medicine, pulmonary medicine, and
nephrology.
(2) A respiratory
therapist shall be promptly available to care for trauma patients.
(3) Acute hemodialysis shall be promptly
available for the trauma patient.
(4) Services shall be available 24 hours per
day for the standard analyses of blood, urine, and other body fluids,
coagulation studies, blood gases, and microbiology, including microsampling
when appropriate.
(5) The blood
bank shall be capable of blood typing and cross-matching and shall have an
adequate supply of red blood cells, fresh frozen plasma, platelets,
cryoprecipitate, and appropriate coagulation factors to meet the needs of
injured patients.
11. Rehabilitation Requirements
A. Rehabilitation services shall be available
to the trauma patient:
(1) Within the
hospital's physical facilities, or
(2) At a freestanding rehabilitation
hospital. In this circumstance, the trauma facility shall have appropriate
transfer agreements.
B.
The following services shall be available during the trauma patient's ICU and
other acute phases of care:
(1) Physical,
occupational, and speech therapy, and
(2) Social services.
12. Trauma Registry
A. Trauma registry data shall be collected
and analyzed by every trauma facility. It shall contain detailed, reliable, and
readily accessible information that is necessary to operate a trauma
facility.
B. Trauma data shall be
submitted to the National Trauma Data Bank on an annual basis.
C. The facility shall demonstrate that the
trauma registry is used to support the performance improvement
program.
D. Trauma data shall be
submitted to the Colorado Trauma Registry within 60 days of the end of the
month during which the patient was discharged.
E. The trauma program shall have in place
appropriate measures to assure that trauma data remain confidential.
F. The facility shall monitor data
validity.
13. Outreach
and Education
A. Public Outreach and
Education: The facility shall engage in public education that includes
prevention activities, referral, and access to trauma facility
resources.
B. Professional Outreach
and Education: The facility shall engage in professional outreach and education
that include, at a minimum:
(1) Level I:
a. Providing or participating in one ATLS
course annually,
b. Providing a
continuous rotation in trauma surgery for senior residents that is part of a
program accredited by the Accreditation Council for Graduate Medical Education
in either general surgery, orthopedic surgery, neurosurgery, or family
medicine; or support of a critical care fellowship or an acute care surgery
fellowship consistent with the educational requirements of the American
Association for the Surgery of Trauma, and
c. Providing a mechanism to offer
trauma-related education to nurses involved in trauma care.
(2) Level II: Internal and
external trauma-related educational opportunities for physicians, nurses, and
allied health professionals.
14. Prevention
A. The facility shall participate in injury
prevention. The facility shall provide documentation of the presence of
prevention activities that center on priorities based on local data.
B. The facility shall demonstrate evidence of
a job description and salary support for an injury prevention coordinator who
is a separate person from, but collaborates with, the trauma program
manager.
C. The trauma service
shall develop an injury prevention program that, at a minimum, incorporates the
following:
(1) Selecting a target injury
population,
(2) Gathering and
analyzing data,
(3) Developing
evidenced-based intervention strategies based on local data and best
practices,
(4) Formulating a
plan,
(5) Implementing the program,
and
(6) Evaluating and revising the
program as necessary.
D.
The facility shall demonstrate collaboration with or participation in national,
regional, or state injury prevention programs.
E. The facility shall have a mechanism to
identify patients who may have an alcohol addiction. The facility shall also
have the capability to provide an intervention for patients identified as
potentially having an alcohol addiction.
F. The facility shall collaborate and mentor
lower level trauma centers regarding injury prevention.
15. Level I only: Research and Scholarship
A. The facility shall meet one of the
following options:
(1) Twenty peer-reviewed
articles published in journals included in Index Medicus in a three-year
period. These articles shall result from work related to the trauma facility.
a. Of the 20 articles, there shall be at
least one authored or coauthored by members of the general surgery trauma team,
and
b. There shall be at least one
each from three of the following seven disciplines: neurosurgery, emergency
medicine, orthopedics, radiology, anesthesia, nursing, or rehabilitation;
or
(2) Ten peer-reviewed
articles published in journals included in Index Medicus in a three-year
period. These articles shall result from work related to the trauma facility.
a. Of the 10 articles, there shall be at
least one authored or coauthored by members of the general surgery team, and
b. There shall be at least one each
from three of the following seven disciplines: neurosurgery, emergency
medicine, orthopedics, radiology, anesthesia, nursing, or rehabilitation; and
c. Four of the following scholarly
activities shall be demonstrated:
i.
Leadership in major trauma organizations.
ii. Peer-reviewed funding for trauma
research.
iii. Evidence of
dissemination of knowledge to include review articles, book chapters, technical
documents, Web-based publications, editorial comments, training manuals, and
trauma-related course materials.
iv. Display of scholarly application of
knowledge as evidenced by case reports or reports of clinical series in
journals included in MEDLINE.
v.
Participation as a visiting professor or invited lecturer at national or
regional trauma conferences.
vi.
Support of resident participation in facility-focused scholarly activity,
including laboratory experiences, clinical trials, or resident trauma paper
competitions at the state, regional, or national level.
vii. Mentorship of residents and fellows, as
evidenced by the development of a trauma fellowship program or successful
matriculation of graduating residents into trauma fellowship
programs.
B. The facility shall demonstrate support for
the trauma research program by providing such items as basic laboratory space,
sophisticated research equipment, advanced information systems, biostatistical
support, salary support for basic and social scientists, or seed grants for
less experienced faculty.
16. Organ Procurement Activities
A. The facility shall have an established
relationship with a recognized organ procurement organization (OPO).
B. The facility shall have a written policy
for triggering notification of the regional OPO.
C. The facility shall have written protocols
defining clinical criteria and confirmatory tests for the diagnosis of brain
death.
17. Disaster
Planning and Management
A. The facility shall
meet the Emergency Management-related requirements of the U.S. Department of
Health and Human Services.
(1) These rules
incorporate by reference the 42 CFR §
482.15, "Condition
of Participation: Emergency Preparedness Federal Regulations" (eff. November
29, 2019).
(2) Such incorporation
does not include later amendments to or editions of the referenced material.
The Health Facilities and Emergency Medical Services Division of the Department
maintains copies of the complete text of the incorporated materials for public
inspection during regular business hours, and shall provide certified copies of
any non-copyrighted material to the public at cost upon request. Information
regarding how the incorporated materials may be obtained or examined is
available from the Division by contacting:
EMTS Branch Chief
Health Facilities and EMS Division
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver, CO 80246-1530
These materials are available and may be accessed at:
B. Level I only:
(1) A surgeon from the trauma panel shall
participate on the hospital's disaster committee.
(2) The facility shall have a disaster
preparedness plan in its policy and procedure manual or equivalent.
(3) Hospital drills that test the facility's
preparedness plan shall be conducted no less than every six months.
(4) The facility disaster preparedness plan
shall be integrated into local, regional, and state disaster preparedness
plans.
18.
RETAC Integration
The facility shall demonstrate integration and cooperation with its Regional Emergency Medical and Trauma Advisory Council (RETAC). Evidence of such integration may include, but is not limited to: attendance at periodic RETAC meetings, participation in RETAC injury prevention activities, participation in RETAC data and/or quality improvement projects, etc.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.