6 CCR 1015-4-305 - Scope of Care for Designated Trauma Centers Level III-V
1. General Requirements
A. All designated Level III-V trauma centers
shall define their Scope of Care (SOC) based on the resources that are
available at the facility.
B. A
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.
2. Emergent Surgery
at Level III and IV Trauma Centers
A. All
Level III and IV 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.
B. If the surgeon on call at a Level III or
IV trauma center is encumbered in the operating room, the attending emergency
department physician shall consult the surgeon to determine the plan of care,
including the potential to consult with or transfer to a higher level trauma
center.
C. For patients at Level IV
trauma centers that require emergent surgery, the emergency physician shall
consult the trauma surgeon on call. If the time to surgeon and operating room
availability exceeds the transfer time to a trauma center with the necessary
resources, the patient shall be transferred.
3. Mandatory Transfer and Consultation, Level
III-V Trauma Centers
A. General Requirements
for Transfer
(1) Every trauma center shall
establish a policy and procedure for addressing when a patient or patient's
representative refuses transfer and for when weather, disaster, or other
extreme conditions prohibit the safe transfer of the patient.
(2) Nothing in these rules shall preclude any
facility with the appropriate resources from providing emergency surgery as
provided in Section 305.2.
(3)
Patients of any age with a traumatic injury requiring resources beyond those
available in the facility's scope of care shall be transferred.
(4) Pediatric patients requiring transfer but
not requiring emergent intervention shall be transferred to a Regional
Pediatric Trauma Center or to a Level I or II trauma center that admits
pediatric patients. The receiving trauma center must meet requirements set
forth in 6 CCR 1015-4, Chapter Three, Section 303.9.D.
B. Mandatory Consultation
(1) All Level III and IV trauma centers
treating patients with a traumatic injury requiring a massive transfusion shall
consult a trauma surgeon at a Level I or II key resource facility for
diagnostic and care consideration purposes, including consideration of
transfer.
(2) Level III trauma
centers with no neurosurgical/orthopedic spine coverage and all Level IV trauma
centers treating any patient with intracranial hemorrhage or evidence of
cerebral edema due to trauma shall consult a neurosurgeon at a higher level of
care for consideration of transfer. If the patient is admitted at the Level III
or IV trauma center, after consultation, a general surgeon on the trauma panel
shall admit and manage the patient through the course of high acuity
care.
(3) All Level III and IV
trauma centers shall consult a spinal specialist at a higher level of care to
determine the need for transfer for any spinal column fracture other than a
lumbar or thoracic transverse process fracture.
(4) All Level III-V 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 purposes.
C.
Mandatory Transfers for Patients of All Ages
(1) Level III-V trauma centers shall transfer
patients with the following traumatic injuries:
a. Hemodynamically unstable pelvic
fracture.
b. Pelvic fracture
requiring operative fixation.
c.
Fracture or dislocation with vascular injury requiring operative vascular
repair.
d. Aortic tears.
e. Abdominal or pelvic injury requiring
emergent surgery and packing with non-definitive closure.
f. Burns in accordance with 6 CCR 1015-4,
Chapter Three, Section 308.
(2) All Level III-V trauma centers shall
transfer patients if the facility does not have the resources and clinical
expertise to manage their medical co-morbidities, including, but not limited
to:
a. Severe chronic obstructive pulmonary
disease with home O2 requirement > 4L.
b. Pulmonary hypertension.
c. Critical aortic stenosis.
d. Coronary artery disease and/or recent
myocardial infarction within 6 months.
e. Renal disease requiring
dialysis.
f. End stage liver
disease.
g. Unmanageable
coagulopathy.
h. Body mass index
> 40.
i. Pregnancy > 20
weeks.
(3) Level III
trauma centers with no neurosurgical/orthopedic spine coverage and all Level IV
and V trauma centers receiving trauma patients shall transfer under the
following conditions:
a. Glasgow Motor Score
[SMALLER THAN EQUAL TOO] 4 due to trauma with a normal CT scan.
b. Any intracranial hemorrhage on
anti-coagulation or anti-platelet therapy.
c. Lateralizing or focal neurologic
deficit.
d. Any open, depressed, or
basilar skull fracture.
e. Any
unstable spinal column fracture.
f.
Spinal column fracture with any motor or sensory deficit.
g. No spinal column fracture but nerve root
injury with focal motor deficit or bilateral sensory deficit.
(4) All Level III trauma centers
with full or part-time neurosurgical/orthopedic spine coverage shall transfer
any patient with a Glasgow Coma Score < 9 due to trauma or any spinal cord
injury except those with a transient or unilateral sensory deficit.
(5) In addition, Level IV-V trauma centers
shall transfer trauma patients of any age with the following traumatic
injuries:
a. Bilateral femur
fractures.
b. Femoral shaft
fracture with any of the following:
i. Head
injury with any evidence or intracranial hemorrhage, depressed skull fracture,
or skull fracture with sinus involvement.
ii. Chest injury - Multiple rib fractures
(> 4 unilaterally or > 2 bilaterally) or hemothorax.
iii. Abdomen - Hollow organ or solid visceral
injury, intra- or retroperitoneal bleeding.
c. Flail chest.
d. Age greater than 65 years with multiple
rib fractures (> 4 unilaterally or > 2 bilaterally).
e. Persistent pneumothorax that is
unresponsive after adequately placed chest tube having a massive or prolonged
air leak.
f. Hemothorax treated
with an initial chest tube that does not achieve complete evacuation within
twenty four (24) hours.
g.
Mechanical ventilation anticipated to be greater than twenty four (24) hours,
if the facility does not have the necessary resources to provide ongoing
ventilator management.
h. Solid
visceral or hollow organ injury, if the facility does not have the necessary
resources to care for the patient.
i. Vascular injury requiring operative
vascular repair.
j. Crushed,
de-gloved, or mangled extremity.
k.
Suspected or evidence of nonaccidental trauma requiring social or clinical care
beyond the facility's resources.
D. Mandatory transfers for pediatric
patients: In addition to the injuries listed above, all Level III-V trauma
centers shall transfer patients ages 0-14 with:
(1) Intracranial hemorrhage, evidence of
cerebral edema due to trauma, Glasgow Motor Score [SMALLER THAN EQUAL TOO] 4
with a normal CT scan, or lateralizing or focal neurologic deficit.
(2) Intracranial, intrathoracic, or
intra-abdominal penetrating injuries or penetrating injuries with orthopedic or
neurovascular compromise.
(3)
Injuries resulting in the need for mechanical ventilation.
(4) Injuries resulting in the need for a
transfusion of packed red blood cells.
(5) Hemothorax.
(6) Pulmonary contusions resulting in
associated hypoxia.
(7) Multiple
rib fractures or flail chest.
(8)
Abdominal hollow organ or solid visceral injury, intra- or retroperitoneal
bleeding.
(9) Vascular injury
requiring operative vascular repair.
4. Level III and IV trauma centers providing
an expanded scope of care shall have:
A. A
written policy for the management of each expanded scope service line being
offered, for example, orthopedic surgery, plastic surgery, general surgery, or
neurosurgery.
B. For Level IV
facilities, if there is an emergency physician serving as the Trauma Medical
Director, there shall be a physician with surgical expertise to assist with
performance improvement.
C. A
written policy and plan for patient management when each service is not
available, to include:
(1) A defined service
that manages inpatient care for continuity.
(2) A written plan to ensure continuity of
care for all admitted patients.
(3)
Regular communication with transport providers and referring hospitals on
availability of the expanded scope service(s).
(4) A hospital-defined continuity of care
plan that includes time of availability and proof of communication between
services.
D. Formal
transfer guidelines for times when a facility does not have specialty
coverage.
E. Management guidelines
based on the defined expanded scope of care and nationally recognized best
practice standards.
F. An emergency
department with:
(1) A defined call response
time for each specialty consultation.
(2) A massive transfusion protocol.
G. An Operating Room with:
(1) Defined operating room availability,
within 30 minutes, if the facility is providing emergent surgery as part of an
expanded scope of care.
(2)
Anesthesia service and appropriate operating room staff shall match fully
functional operating room availability.
(3) Facilities shall match specialty provider
availability with operating room availability.
(4) Intra-operative equipment and radiology
capability commensurate with the expanded scope of care provided.
H. Inpatient services with medical
consultation with a physician appropriately credentialed by the facility to
treat medical co-morbidities.
I.
Education, including:
(1) Administrative
support for the trauma program and the Trauma Medical Director in providing
appropriate staff education commensurate with the expanded scope of care and
based on patient population served.
(2) The facility shall ensure that the
physician specialists direct and/or provide education to the team looking after
their patients, including:
a. Post-operative
care.
b. Recognition and care of
potential complications.
c.
Recognition and care of hemodynamic instability.
J. With respect to Levels III-IV
trauma centers that provide an expanded scope of care with part-time specialty
coverage:
(1) All Level III trauma centers
with part-time neurosurgical/orthopedic spine coverage shall:
a. Have a published call schedule.
b. Communicate with prehospital regarding
availability of neurosurgical/orthopedic spine coverage.
c. Meet the standards in 6 CCR 1015-4,
Chapter Three, 305.3.C.(3) when there is no neurosurgical/orthopedic spine
coverage.
(2) Level IV
facilities with part-time orthopedic coverage shall not operate on femoral
fractures unless there is general surgery availability.
(3) Cases shall be reviewed for projected
length of stay and monitored through the performance improvement process. If
the length of stay for any patient requiring an expanded scope service is
greater than the specialty coverage and general surgery availability, then the
patient shall be transferred.
Notes
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