048-4 Wyo. Code R. §§ 4-2 - Area Trauma Hospitals

An Area Trauma Hospital (ATH) is an acute care facility with the commitment, medical staff, personnel, and specialty training necessary to provide primary care to the trauma patient. An ATH shall provide initial resuscitation of the trauma patient and immediate operative intervention to control hemorrhage and to assure maximal stabilization prior to referral to a higher level of care. In many instances, patients will be maintained in the ATH unless the medical needs of the patient require a higher level of care. The decisions to transfer a patient rests with the physician attending the trauma patient. All ATHs shall work collaboratively with the Regional Trauma Centers, Community Trauma Hospitals and Trauma Receiving Facilities to develop transfer protocols and a well-defined transfer sequence.

(a) Hospital Organization.

(i) Trauma Program. The trauma program shall be established and recognized by the medical staff and hospital administration. The trauma program shall come under the overall organization and direction of a general surgeon or emergency physician who is trained, experienced, and committed to the care of the injured patient.

(ii) Trauma Program Director. The director must be a board certified surgeon or a board certified emergency physician with demonstrated competency in trauma care. The director shall develop a quality improvement process and through this process, shall be responsible for all trauma patients and administrative authority for the hospital's trauma program. The director must be given administrative support to implement the requirements specified by the Wyoming Trauma Plan. The director shall work with the credentialing process of the hospital and participate with the credentialing committee to recommend participation on the trauma team.¹²

(iii) Trauma Team. The hospital shall have a policy describing the respective roles of all personnel on the trauma team. The composition of the trauma team in any hospital will depend on the characteristics of that hospital and its staff. The team leader shall be a qualified physician who is clinically capable in all aspects of trauma resuscitation. Suggested composition of the trauma team may include:

(A) Surgeons, General, and Orthopedic;

(B) Anesthesiologists;

(C) Emergency physicians;

(D) Family physicians;

(E) Laboratory technicians;

(F) Registered nurses;

(G) Physician specialists as dictated by clinical needs;

(H) Prehospital care providers;

(I) Radiology technicians;

(J) Respiratory therapists; and

(K) Social services/pastoral care.

(iv) Qualifications for Surgeons on the Trauma Team. As a general rule, all surgeons on the trauma team should be board certified in a surgical specialty recognized by the American Board of Medical Specialties, the Canadian Board or the American Osteopathic Association. An exception to this rule is Oral and Maxillofacial Surgery. These physicians should be board certified by the American Board of Oral and Maxillofacial Surgery.¹³ The surgeons shall participate in the multi disciplinary trauma committee and the quality improvement process. All general surgeons participating on the trauma team should be current in ATLS and be involved in continuing education specific to trauma sufficient to maintain quality patient care. This includes all residents.

(v) Trauma Nurse Coordinator. An ATH shall have a registered nurse working in the role of a trauma nurse coordinator. Working in conjunction with the trauma program director, the trauma nurse coordinator shall organize the program and all systems necessary for the multi disciplinary approach throughout the continuum of trauma care. The trauma nurse coordinator is responsible for coordinating optimal patient care for all injured patients.¹⁴

(vi) Multi Disciplinary Trauma Committee. The purpose of the committee is to provide oversight and leadership to the entire trauma program. The major focus shall be quality improvement activities, policy development, communication among all team members, development of standards of care, education and outreach programs and work with appropriate groups for injury prevention. The clinical managers (or designees) of the organizational areas involved with trauma care shall play an active role with the committee. The committee shall include representatives from each of the following areas, unless the hospital has no such organizational area defined:

(A) Administration;

(B) Anesthesia;

(C) Emergency Department;

(D) General Surgery;

(E) Intensive Care;

(F) Laboratory;

(G) Medical Records;

(H) Nursing;

(I) Operating Room;

(J) Orthopedics;

(K) Pediatrics;

(L) Prehospital care providers;

(M) Radiology;

(N) Rehabilitation;

(O) Respiratory Therapy; and

(P) Trauma Nurse Coordinator.

(b) Clinical Components.

(i) An ATH shall have the following medical specialists available to the injured patient:

(A) Emergency Medicine in house twenty-four (24) hours per day;

(B) Trauma/General Surgery.

(C) Anesthesia.

(D) Orthopedic Surgery;

(ii) The following specialists shall be on call and promptly available:

(A) Internal Medicine; and

(B) Radiology.

(iii) It is desirable to have the following specialists available to an ATH:

(A) Obstetrics/Gynecological Surgery;

(B) Pediatrics; and

(C) Urologic Surgery.

(iv) The staff specialist on call shall be notified at the discretion of the trauma surgeon or the emergency physician and shall be promptly available. This availability shall be monitored continuously by the quality improvement program. The specialist involved for consultation to the trauma patient shall be appropriately board certified and have an awareness of the unique problems of trauma patients.

(v) A general/trauma surgeon shall be qualified and have privileges to provide thoracic surgical care to patients with thoracic injuries. In instances where this is not feasible, the hospital shall apply for a waiver from the OEMS, who at its sole discretion can grant such a waiver.

(vi) Policies and procedures shall be in place to notify the patient's primary physician of the patient's condition.

(c) Facility Standards.

(i) Emergency Department.

(A) The hospital shall have an emergency department, division, service or section staffed so that trauma patients are assured immediate and appropriate initial care. ATHs shall have a physician in the emergency department twenty-four (24) hours per day capable of evaluating trauma patients and providing initial resuscitation and performing necessary surgical procedures not requiring general anesthesia.

(B) The emergency department shall have a designated medical director who is board certified in a specialty recognized by the American Board of Medical Specialties, the Canadian Board or the American Osteopathic Association.¹⁵ This requirement may be satisfied by a physician not currently board certified but meeting the requirements of the hospital for appointment as an emergency department medical director. This exception is only valid for those non-qualifying medical directors at the time these requirements become effective.

(C) All physicians covering the emergency department shall show commitment to trauma care by maintaining competency in resuscitation, airway management, central venous access, cervical immobilization and long bone fracture stabilization of the adult and pediatric trauma patient. This includes all residents.¹⁶

(D) The emergency medicine physician shall activate the trauma team based on predetermined criteria.¹⁷ The emergency department shall have established policies and procedures to ensure immediate and appropriate care for the adult and pediatric trauma patient. The physicians participating on the trauma team shall participate in CME activities related to trauma care, the multi disciplinary trauma committee and the trauma quality improvement process.

(E) General/Trauma Surgeon.

(I) A general/trauma surgeon shall be available on call twenty-four (24) hours per day to respond to the emergency department as requested. The trauma surgeon on call shall be promptly available to respond to the trauma patient. Local criteria shall be established to define conditions requiring the trauma surgeon's immediate hospital presence. The trauma surgeon's participation in major therapeutic decisions and presence in the emergency department for major resuscitation is highly recommended. The trauma surgeon's presence at operative procedures is mandatory. A system shall be developed to assure early notification of the on call surgeon and compliance with this criteria and their appropriateness must be monitored by the hospital's trauma quality improvement process. The surgeon should maintain current certification in ATLS.

(II) The surgeon shall, in conjunction with the

(F) Nursing Personnel.

(I) Emergency nurses shall have special expertise in trauma care.¹⁸

(II) Adequate numbers of registered nurses shall be available in house twenty-four (24) hours per day to staff the emergency department to meet the needs of the trauma patient.

(ii) Surgical Suites. The surgical team is not required to be in house twenty-four (24) hours per day. A team shall be on call with a well-defined mechanism for notification to expedite admission to the operating room if the patient's condition warrants. The process shall be monitored continuously by the trauma quality improvement program. Surgical nurses shall be trained in principles of resuscitation, mechanism of injury theory, multi systems trauma, and knowledge of surgical instrumentation. The surgical nurses are integral members of the trauma team and shall participate in the ongoing quality improvement process of the trauma program and shall be represented on the multi disciplinary trauma committee.

(A) Policies and Procedures. Policies and procedures shall be in place for the following:

(I) Prioritized operating room availability for the emergency trauma patient during a busy operative schedule;

(II) Notification of on call surgical teams;

(III) Managing death in the operating room and facilitating the organ procurement process;

(IV) Preservation of evidence;

(V) Patient monitoring by a registered nurse while the patient is in transport to the radiology suite or ICU from the operating room; and

(VI) Immediate access of blood and blood products to the operating room.

(B) Anesthesia. Anesthesia shall be promptly available with a mechanism established to ensure early notification of the on call anesthesiologist. Local criteria shall be established to determine when the anesthesiologist shall be immediately available for airway emergencies and operative management of the trauma patient. Anesthesia coverage may be provided by a CRNA who is supervised by an anesthesiologist as required for the CRNA's licensure. Local conditions shall be established to determine when the CRNA must be immediately available for airway emergencies and operative management. The availability of the anesthesiologist or the CRNA and the absence of delays in airway control or operative anesthesia shall be documented and monitored by the quality improvement process. The anesthesiologist/CRNA shall have the necessary education background in the care of the trauma patient, and participate in the multi disciplinary trauma committee and the trauma quality improvement process.

(iii) Intensive Care Unit. The ATH shall have an ICU which meets the requirements for licensure in the state of Wyoming. Additionally, the ICU shall have:

(A) Medical Director. The medical director for the ICU is responsible for the quality of care and administration of the ICU. The trauma program director or his designee shall work collaboratively with the ICU medical director to set policy and establish standards of care to meet the unique needs of the trauma patient.

(B) Physician Coverage. Trauma patients admitted to the ICU shall be admitted under the care of a general surgeon or a qualified board certified physician who is knowledgeable about the care of ICU patients. Guidelines may be written for the rare exception to this rule. In addition to overall responsibility for patient care by the primary surgeon or ICU physician, there shall be in house physician coverage for the ICU at all times. This coverage may be provided by a physician who is approved by the director of the ICU. This coverage is for emergencies only (e.g., an unexpected extubation of an ICU patient) and is to ensure the patient's immediate needs are met while the identified surgeon or physician is contacted.

(C) Nursing Personnel. ATHs shall provide staffing in sufficient numbers to meet the needs of the trauma patient. Critical care nurses should show evidence of completion of a structured ICU in-service program which includes didactic and clinical content related to the care of the trauma patient. ICU nurses are an integral part of the trauma team and shall be represented on the multi disciplinary trauma committee and participate in the quality improvement process of the trauma program.

(iv) Post Anesthesia Recovery Room (PAR room). An ATH shall have a PAR room with staff on call twenty-four (24) hours per day and available to the postoperative trauma patient. PAR room staffing shall be in sufficient numbers to meet the critical needs of the trauma patient. Frequently, it is advantageous to bypass the PAR room and directly admit to the ICU. In this instance, these requirements may be met by the ICU. PAR room nurses shall show evidence of completion of a structured in-service program which includes didactic and clinical content related to the care of the trauma patient. PAR room nurses are an integral part of the trauma team and, as such, shall be represented on the multi disciplinary trauma committee and participate in the quality improvement process of the trauma program.

(d) Clinical Support Services.

(i) An ATH shall have the following service capabilities:

(A) Radiological Service. A board certified radiologist or his designated mid-level practitioner shall be available to the facility for emergency procedures and on a routine basis to assure quality of services rendered. The radiologist is a key member of the trauma team and shall be represented on the multi disciplinary trauma committee. A licensed radiological technician shall be on call twenty-four (24) hours per day and readily available to meet the immediate needs of the trauma patient. The CT (specialty) technician may be on call from home with a mechanism in place to assure the technician is available. The quality improvement process shall verify all procedures are promptly available to the patient; and

(B) Clinical Laboratory Services. Sufficient numbers of clinical laboratory technologists shall be on call twenty-four (24) hours per day and promptly available at all times. The clinical laboratory service shall have the following services available twenty-four (24) hours per day:

(I) Comprehensive blood bank or access to a community central blood bank and adequate storage facilities;

(II) Standard analysis of blood, urine and other body fluids. Toxicology studies may be performed off site if necessary; and

(III) Blood gas and pH determinations. (This function may be performed by providers other than the clinical laboratory service, when applicable.)

(C) Alcohol screening is required and drug screening is highly recommended.

(D) Social Service/Pastoral Care Support. The nature of traumatic injury requires that the psychological needs of the patient and family are considered and addressed in the acute stages of injury and throughout recovery. An ATH may utilize community resources as appropriate to meet the needs of the trauma patient and their families.

(E) Rehabilitation. At the earliest stage possible after admission to the trauma center, each ATH shall address a plan for integration of rehabilitation into the acute and primary care of the trauma patient. Designated facilities shall identify a mechanism to initiate rehabilitation services and/or consultation upon admission as well as policies regarding coordination of a multi disciplinary rehabilitation team. Policies shall be in place to address the coordination of transfer between acute care facilities and rehabilitation facilities. Transfer agreements shall include a feedback mechanism for the acute care facilities to update the health care team on the patient's progress and outcome for inclusion in the trauma registry.

(F) Outreach. The ATH shall work collaboratively to plan, facilitate and teach professional education programs for the prehospital care providers, nurses and physicians in their own facility and in the Community Trauma Hospital (CTH) and Trauma Receiving Facilities (TRF) in their region.

(G) Prevention/Public Education. The ATH is responsible for collaborating with RTCs, CTHs, and TRFs to develop education and prevention programs for their professional staff and the public. The education and prevention programs shall include implementation strategies to assure information dissemination to all residents in the region.

(H) Transfer Protocols. The facilities shall have transfer protocols in place with receiving trauma facilities, as well as all specialty referral centers (e.g., burn, pediatrics and rehabilitation). All facilities shall work together to develop transfer guidelines indicating which patients should be considered for transfer and procedures to assure the most expedient, safe transfer of the patient. All trauma facilities shall agree to provide services to the trauma patients regardless of their ability to pay. The transfer guidelines need to assure feedback as provided to the facilities and assure this information eventually becomes part of the trauma registry. All transfer protocols shall be written in accordance with COBRA/OBRA and EMTALA regulations.

(I) Quality Improvement/Evaluation.

(I) All designated facilities will be required to participate in the trauma registry and submit data to OEMS as requested. The ATHs shall assist the CTHs and the TRFs in establishing the data collection process and, if necessary, provide data entry into the registry from abstracted patient records.

(II) Each ATH shall develop an internal quality improvement plan that, at a minimum, addresses the following key components:¹⁹

(1) An organizational structure which facilitates the process of quality improvement (multi disciplinary trauma committee);

(2) Clearly stated goals and objectives of the quality improvement plan;

(3) The development of standards of care;

(4) A process to delineate privileges for all physicians participating in trauma care;

(5) Participation in the statewide trauma registry;

(6) Established quality indicators (audit filters). The plan must include, at a minimum, the recommended audit filters by the American College of Surgeons and the JCAHO. The plan should define adverse outcomes by using an explicit list of well-defined complications;

(7) A systematic, informed peer review process utilizing a multi disciplinary method including prehospital care providers; and

(8) A method for computing survival probability and comparing patient outcomes.

(III) The ATH shall participate in the statewide WTC and the RAC of their TSA.

¹² It is strongly recommended that the director be an instructor in the American College of Surgeons Advanced Trauma Life Support (ATLS) course, maintain current ATLS certification or maintain certification of attendance to an ACEP accredited trauma conference every two (2) years, and maintain personal involvement in care of the injured, education in trauma care, and involvement in professional organizations.

¹³ It is understood that many boards require a practice period, and that complete certification may take three (3) to five (5) years after residency. If an individual has not been certified five (5) years after successful completion of residency, that individual is ordinarily unacceptable for inclusion on the trauma team.

¹⁴ Recommended credentials for this person include: Trauma Nurse Core Course (TNCC) (or equivalent education), Certified Emergency Nurse (CEN), demonstrated expertise in trauma care, five (5) or more years clinical nursing experience, experience with hospital quality assurance programs including a trauma registry, experience in education program development, and membership in professional organizations.

¹⁵ It is understood that many boards require a practice period, and the complete certification may take three (3) to five (5) years after residency. If an individual has not been certified five (5) years after residency, that individual is ordinarily unacceptable as the medical director of the emergency department.

¹⁶ Current certification in ATLS is highly recommended or maintenance of certification of attendance to an ACEP accredited trauma conference every two (2) years.

¹⁷ Each facility may develop local written protocol for the activation of the trauma team. emergency physician, make key decisions about management of the trauma patient's care and determine if the patient needs transport to a higher level of care. If transfer is required, either the surgeon or emergency physician shall be accountable to coordinate the process with the receiving physician at the receiving facility. Generally, if an injured patient requiring surgery is to be admitted to the ATH, the surgeon shall be the admitting physician and will coordinate the patient care while hospitalized. Guidelines shall be written at the local level to determine which types of patients should be admitted to the ATH and which patients should be considered for transfer to a higher level of care.

¹⁸ It is highly recommended that emergency nurses demonstrate successful completion of TNCC (or equivalent education), evidence of continuing education in trauma nursing, and participation in the ongoing quality improvement process of the trauma program.

¹⁹ It is highly recommended that the plan incorporate autopsy information on all trauma patients. Complete anatomical diagnosis of injury is essential to the quality of trauma care.

Notes

048-4 Wyo. Code R. §§ 4-2