6 CCR 1015-4-307 - Trauma Facility Designation Criteria - Level IV and V

Level IV trauma centers must be licensed as: a general hospital, FSED, a community clinic providing emergency services, or a Critical Access Hospital per 42 CFR 485.601, et seq., and be open 24 hours a day, 365 days a year with physician coverage for trauma patients arriving by ambulance.

Level V trauma centers must be licensed as: a general hospital, FSED, a community clinic providing emergency services, or a Critical Access Hospital, per 42 CFR 485.601, et seq., and have a policy about hours of operation as described below:

1. A Level IV or V trauma center shall have:

A. Commitment by administration and medical staff to support the trauma program demonstrated by written commitment from the facility's board of directors, owner/operator, or administrator to provide the required services.

B. A written commitment to regional planning and system development activities.

C. A trauma program with policies that identify and establish the scope of care for both adult and pediatric patients including, but not limited to:

(1) Initial resuscitation and stabilization;

(2) Rehabilitation capabilities if available;

(3) Written procedure for transfer of patients by fixed and rotary wing aircraft;

(4) Hospitals only (not applicable to Community Clinics Providing Emergency Services or FSEDs) admission criteria;

(5) Level IV only:

a. Surgical capabilities, if available;

b. Critical care capabilities, if available; and

c. Any expanded scope of care capabilities as required in Section 305.

(6) Level V only: Hours of operation. The services as defined in the scope of trauma service policy shall include an after-hours plan for availability of services.

D. A physician designated by the facility as the Trauma Medical Director who takes responsibility for the trauma program. Responsibilities include:

(1) Participation in trauma educational activities for healthcare providers or the public;

(2) Leadership for the trauma program and oversight of the trauma quality improvement process; and

(3) Administrative authority for the trauma program, including: recommendations for trauma privileges, policy and procedure enforcement, and peer review.

E. A facility-defined trauma team activation protocol that includes who is notified and the response expectations. The protocol shall base activation of personnel on anatomical, physiological, mechanism of injury criteria, and other considerations as outlined in the prehospital trauma triage algorithms as set forth in 6 CCR 1015-4, Chapter One.

F. A defined method of activating trauma response personnel consistent with the scope of trauma care provided by the facility.

G. A staff person identified as the Trauma Nurse Coordinator with clinical experience in care of the injured patient, who is responsible for coordination of the trauma program functions.

H. A quality improvement program as defined in Section 304 of this chapter.

I. Policies, procedures, and practice consistent with the scope of care and expanded scope of care, as applicable, for designated trauma centers Level IV-V as found in Section 305 of this chapter.

J. Divert protocols, to include:

(1) Coordination with the Regional Emergency Medical and Trauma Advisory Council (RETAC);

(2) Notification of prehospital providers and other impacted facilities, consistent with RETAC protocols, if any;

(3) Reason for divert; and

(4) A method for monitoring times and reasons for going divert.

K. Interfacility transfer criteria/guidelines as a transferring facility.

L. Interfacility transfer policies and protocols.

M. Participation in the state trauma registry as required in Chapter Two.

N. Participation in the RETAC and statewide quality improvement programs as required in rule.

O. If licensed as a Community Clinic Providing Emergency Services or FSED:

(1) A central log on each trauma patient/individual presenting with an emergency condition who comes seeking assistance and whether he or she refused treatment, was refused treatment, or whether the individual was transferred, admitted and treated, died, stabilized and transferred, or discharged.

(2) A policy requiring the provision of a medical screening of all individuals with trauma-related emergencies that come to the clinic and request an examination or treatment. The policy shall not delay the provision of a medical screening in order to inquire about an individual's method of payment or insurance status.

(3) Provide further medical examination and such treatment as may be required to stabilize the traumatic injury within the staff and facility's capabilities available at the clinic, or to transfer the individual. The transferring clinic must provide the medical treatment, within its capacity, which minimizes the risk to the individual, send all pertinent medical records available at the time of transfer, effect the transfer through qualified persons and transportation equipment, and obtain the consent of the receiving trauma center.

2. A Level IV or V trauma center shall have all of the following facilities, resources, and capabilities:

A. An emergency department with:

(1) A physician who must be present in the emergency department at the time of arrival of the trauma patient meeting facility-defined trauma team activation criteria, arriving by ambulance. For those patients where adequate prior notification is not possible, the emergency physician shall be available within 20 minutes of notification.

(2) Registered nurses who provide continuous monitoring of the trauma patient until release from the ED.

a. Level IV: At least one registered nurse in house 24 hours a day who maintains current Trauma Nurse Core Course certification or equivalent;

b. Level V: At least one registered nurse in-house during hours of operation that maintains current Trauma Nurse Core Course certification or equivalent.

(3) Equipment for the resuscitation of patients of all ages including, but not limited to:

a. Airway control and ventilation equipment including laryngoscopes and endotracheal tubes of all sizes, bag mask resuscitators, and oxygen;

b. Pulse oximetry;

c. End-tidal CO2 determination;

d. Suction devices;

e. Electrocardiograph and defibrillator;

f. Standard intravenous fluids and administration devices, including large bore intravenous catheters;

g. Sterile surgical sets for:

i. Airway control/cricothyrotomy;

ii. Vascular access to include central line insertion and interosseous access;

iii. Thorocostomy - needle and tube;

h. Gastric decompression;

i. Drugs necessary for emergency care;

j. X-ray availability:

i. Level IV: 24 hours per day.

ii. Level V: during hours of operation.

k. Two-way communication with emergency transport vehicles;

l. Spinal immobilization equipment;

m. Thermal control equipment for patients and fluids;

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

o. Tourniquet.

B. Level IV only: If an operating room and/or intensive care unit are utilized for the trauma patient, there must be policies that identify and define the scope of care or expanded scope of care, if applicable, that include the supervision, staffing and equipment requirements that the facility will utilize.

C. Radiological capabilities available with a radiology technician or person with limited certification in x-ray available within 30 minutes of notification of trauma team activation.

(1) Level IV: 24 hours per day.

(2) Level V: during hours of operation.

D. Clinical laboratory services available, including a spun hematocrit, dip urinalysis, and the ability to collect blood samples to be sent with transferred patients must be available.

(1) Level IV: 24 hours per day.

(2) Level V: during hours of operation.

E. Participates in local/regional/statewide injury prevention/public education.

F. Continuing education for all physicians providing trauma care, with:

(1) Level IV and V physicians providing initial resuscitation in the emergency department shall be board certified in emergency medicine or have current ATLS.

(2) Level IV general surgeons on the trauma call panel shall be current in ATLS.

(3) Level IV orthopedic surgeons, anesthesiologists, and nurse anesthetists on the trauma call panel 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.

(4) All board certifications shall be issued by a certifying entity that is nationally recognized in the United States.

(5) Physicians admitting trauma patients at Level IV facilities without the continuous availability of a surgeon on the trauma call panel, as demonstrated by a published call schedule, shall have 10 trauma-specific CME hours annually or 30 CME hours over the three year period preceding any site review.

G. Facility-defined, trauma-related continuing medical education requirements for nurses.

Notes

6 CCR 1015-4-307

39 CR 02, January 25, 2016, effective 2/14/2016 40 CR 08, April 25, 2017, effective 5/15/2017 41 CR 22, November 25, 2018, effective 12/15/2018 42 CR 10, May 25, 2019, effective 6/14/2019 43 CR 09, May 10, 2020, effective 6/14/2020 44 CR 10, May 25, 2021, effective 7/1/2021