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Overview and Site Review Process

An Overview of Key Trauma Service Components within the Application

Trauma Team Activation: Be sure trauma team activation (TTA) criteria reflect what your trauma service actually does. Is your criteria appropriate? Are you adhering to your criteria? Is the general surgeon responding within the designated time period?

Overtriage: The patient received a TTA, but didn't meet TTA criteria.

Undertriage: The patient did not receive a TTA, but did meet TTA criteria.

Full TTA: Involves the entire team, including a general surgeon or physician with specific delineation of surgical privileges who can take the patient to the operating room (OR) if necessary.

Modified TTA: As defined by the facility. Typically involves only the in-house staff and physicians.

Trauma Consult: Patient is seen by the general surgeon in the emergency department (ED) on a non-emergent basis, that is, the general surgeon is not called with a time response to see the patient immediately. Trauma consult does not refer to specialty surgeons, such as orthopedic surgeons, nor does it include a phone consult to a trauma surgeon affiliated to your hospital or to one in a receiving hospital. The trauma consult general surgeon must provide hands-on assessment and care to the patient.

Diversion and Interfacility Transfer: Admission criteria and transfer criteria should be in agreement. If not, then your quality improvement (QI) program should reflect that you're working on this. If your hospital diverts, are you tracking trauma diversions? Are the diversions appropriate? If you divert frequently, can you provide patient volumes to each receiving hospital.

Quality Improvement: Must clearly show how issues are being addressed to improve patient care, whether you have a site review or not. If you have a site review, all pertinent QI materials (chart review forms, filter results, trauma committee and departmental meeting minutes, tracking sheets, etc.) must be with any requested medical records.

Registry: Using your data to analyze your trauma service for patient care improvement is going to be emphasized in this round of designation. Be prepared to talk about your data. What is your submission history? How accurate and complete is your registry?

Site review process

  • Trauma coordinators will receive a "Facility Instruction Manual" no less than one month before the site review.
  • Levels I, II, III must pay an established fee for their site review. Please check with the department if you need specific information in order to budget for the review.
  • The department will send you chart numbers to be pulled. You may also select a few charts you would like reviewed, perhaps some that are more current than what the department has in the trauma registry.
  • Include any and all quality assurance and quality improvement information with all charts that are requested for review.
  • The site review takes at least one day. It starts with an opening conference where introductions are made and the trauma coordinator gives an overview of the trauma service; then a facility tour is conducted; on to the medical record and quality improvement review; a brief time period is set aside for the reviews to get together with the trauma coordinator and trauma medical director individually, to provide education and determine the needs of the trauma service; and the day finishes with a closing conference where initial findings are presented. Designation decisions aren't provided at the site review.
  • It's a good idea to have facility administrators (CEO), and medical directors present for the opening and closing conferences. It makes a better impression for the reviewers and indicates that everyone is aware of, committed to, and involved with, the trauma service.

It's absolutely crucial that the facility keep one complete copy of the application easily accessible for future use by the facility and for any future trauma coordinators, trauma medical directors and hospital administration. Your completed application will be needed again, especially when completing final report requirements and when preparing for the next round of designation.

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