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The Washington State Department of Health (DOH) has authority to designate trauma services. DOH designates five levels of acute care trauma services, three levels of pediatric acute care trauma services and three levels of trauma rehabilitation services. Every three years, hospitals can apply and compete for trauma service designation. All applicants complete a written application. Level I-III acute care and Level I-III pediatric acute care applicants also receive a clinical on-site survey. Based on an assessment of the written application and the results of the clinical on-site survey, DOH selects the most qualified applicants. Below are links to the trauma designation application schedule and a sample trauma designation application.
Trauma Designation Application Frequently Asked Questions 1. Q: Why do we have to apply for trauma service designation, when we are already designated? A: Trauma designation rules require that DOH conduct a competitive application process every three years. The re-designation process allows for new hospitals to apply and compete (if necessary) for trauma designation. Also, currently designated hospitals may gracefully back out of their commitment, or apply and compete (if necessary) for a higher-level trauma designation. Additionally, the re-designation process provides an opportunity for the hospital and physicians to reaffirm their commitment to trauma care. The Department of Health is able to reassess the system, make adjustments as needed, and reaffirm to the public that standards of care are being met and resources are available throughout the state as needed. 2. Q: If we apply for a Level III designation, but we cannot meet all of the standards, are we automatically designated a Level IV? A: First, a slot must exist in your region, & DOH must handle those decisions on a case-by-case basis. 3. Q: What does “provisional designation” mean? A: When necessary to ensure adequate trauma care in specific areas of the state, DOH has authority to provisionally designate a trauma service that is not able to meet all of the designation requirements. Provisional designation is for no more than two years and usually requires a re-survey prior to awarding full designation status. 4. Q: What types of binding can be used for the application? A: It can be spiral, cloth, metal—anything except a notebook type binder, as a binder is too cumbersome for the reviewers to carry during travel. It doesn’t need to be fancy. Because some information is confidential, consider whether you should send it out to be bound. 5. Q: Does the application have to have page numbers? A: Application page numbers help the reviewers keep your application pages in order, and assure that pages are not missing. Page numbers can be applied as simply as handwriting numbers on the lower corner of each page on the original when it is finalized, so that subsequent photocopies have the same page numbers. 6. Q: Can the completed application be submitted electronically? A: No. It is too difficult to reconstruct and put together. You will have some documents that are not available electronically, which also need to be added to the completed application. 7. Q: In the “Trauma Service Component” section of the application, does each item listed in the “Standards of Care” sections need to be addressed? A: No. There is no need to describe how your facility meets each trauma service standard of care (WAC standards). However, each “Assurance” section directly after each “Standards of Care” section must be answered. If your facility does not meet a specific standard of care, you must explain how the service will be brought into compliance for each, including a completion date. Also, all questions and requests for materials listed in the “Documentation” section must be addressed and submitted.
8. Q: How should the questions requiring a narrative be answered? A: Answers can be in depth or bulleted, to the point is usually best. Choose as appropriate. 9. Q: In the “Trauma Service Administration” section, where it asks for “significant accomplishments or changes to the trauma service,” can this be a bulleted list? A: Yes, either a bulleted list or a narrative description would be fine. 10. Q: If our hospital has had to deal with serious organizational problems (such as three administrators in a two-year period), should I include that information in the application? A: Yes, explain that in the “Trauma Service Administration” section, question one, where we ask about trauma service changes over the previous designation cycle. 11. Q: Can a policy be referred to throughout the application, without putting a copy of it in all the sections where it applies? A: Yes. However, in some sections we explicitly ask for data with an explanation and analysis, not just a copy or referral to a policy. 12. Q: What if I don’t have control over participation grant money? A: Trauma Coordinators should know where that money is spent. Having control over it, in an account separate from the ED or general fund, would be best. DOH may ask for a more specific accounting of that money in future applications. That money is to be spent in support of your trauma service. 13. Q: Can an ED physician be the Trauma Medical Director at a Level IV? A: Yes, so long as the physician has special competence in care of the injured. The goal behind this change in WAC (246-976-530 (2) b) is to encourage the general surgeons in your service to be involved with the QI program and peer review. A general surgeon is the person needed to review opportunities for patient care improvements for surgical or critical care patients. 14. Q: What is the purpose of the Scope of Service? A: We frequently need to know what the state's resources are. Not all Level III's, for instance, have the same resources. The Scope of Service document will enable us to have a better inventory of services across the state. 15. Q: If we activate a full trauma team, but we know the patient is probably going to be transferred out, does the general surgeon have to see the patient anyway? A: Yes, the purpose of trauma team activation is to use patient information from the field to identify trauma patients who would benefit from evaluation and treatment by a general surgeon upon their arrival in the ED, regardless of whether the patient would be admitted or transferred. Trauma services are required develop and follow their patient criteria that trigger mandatory activation of the general surgeon.
16. Q: If EMS reports an isolated head trauma, can the neurosurgeon substitute for the general surgeon when a full trauma team activation is called? A: Only if the mechanism of injury is clearly penetrating. In blunt trauma, the first appropriate surgeon for response is the general surgeon, although the neurosurgeon is a welcome addition. “The method for activation of the full trauma team may include response by a neurosurgeon instead of a general surgeon, when based on prehospital information, the mechanism of injury clearly indicates isolated penetrating trauma to the brain;” WAC 246-976-870. 17. Q: For Levels I-III, can a general surgeon be on call at more than one facility at a time? A: WAC rules are clear about the required response times for general surgeons. If the on-call general surgeon is unavailable because he/she is managing trauma patient care or performing elective surgery at another facility, then the facility calling the trauma team activation would need to go on divert, and that facility would not be meeting trauma standards of care. 18. Q: For Levels I-III, should a general surgeon be performing elective surgery while on trauma call? A: If your general surgeon is performing elective surgery while on call, then your service is not meeting the trauma standards established in WAC. A surgeon back-up system is necessary if this is a recurring situation. 19. Q: Tracking diversions – what is acceptable for trauma designated hospitals? A: DOH will accept your statement that your facility doesn’t ever divert trauma patients and there is no tracking done. However, if services are not available for trauma patient care such as equipment; beds; surgeons (e.g. neuro); etc., and you divert a patient from the field, then that would be a divert. If you feel a patient would be better served at a facility with a comparable designation and you divert the patient, while acceptable, this should be tracked. 20. Q: In the Level III “Scope of Trauma Service” section, “Surgery Dept.,” who should be included? A: The questions only refer to your general surgeons. 21. Q: In a Level III, is it appropriate for a general surgeon's PA to respond to the ED for a full trauma team activation when the general surgeon is in the OR? A: The general surgeon must see the patient within 30 minutes. The ED physician and surgical PA can begin care until the prompt arrival of the general surgeon. 22. Q: In the Level IV “Scope of Trauma Service” section, “Surgery Department,” question one asks if, “general surgeons are available for trauma patient care 24/7?” How do you answer if a general surgeon is not available for trauma care 24/7, but is available some of the time? A: Answer “yes” only if you have a general surgeon on-call and available 24/7 for trauma. 23. Q: As a Level IV without a general surgeon, what surgical privileges must a physician have to meet the requirements? A: A Level IV facility must have a physician with the ability and resources to perform limited life-saving procedures such as surgical airway, chest tube insertion, and cutdown placement. The specific rule states, “Surgery services with a general surgeon or physician with specific delineation of surgical privileges by the medical staff for resuscitation, stabilization, and treatment of trauma patients.” 24. Q: In the “Staff Resource List with Education & Training” section, the “Emergency Department” table, who should be included in the list of physicians? A: Only include the physicians that generally staff the ED. 25. Q: In the Level IV “Scope of Trauma Service” section, “Surgery Department,” how do you answer question 3, “specialty of physicians with surgical privileges?” A: If your Level IV trauma service offers surgery services through a physician with specific delineation of surgical privileges by the medical staff for resuscitation, stabilization and treatment of trauma patients, on-call & available 24/7, who is not a general surgeon, then complete the specialty question. 26. Q: In the Level IV “Staff Resource List with Education & Training” section, within the table where it asks for, “other physicians with specific delineation of surgical privileges,” it refers to which physicians? A: For a Level IV, it would be those physicians that respond to traumas in place of a general surgeon. Make sure you have not already listed these physicians in another area. 27. Q: Is PER required for Level IV physicians board certified in emergency medicine? The footnote on the Level IV “Staff Resource List with Education & Training” section indicated that it is not. A: Level IV physicians board-certified in emergency medicine or pediatric emergency medicine are not required to have PER. Otherwise, any emergency physician who is involved in the resuscitation and stabilization of pediatric trauma patients must have PER. 28. Q: In a Level IV, must a physician see the trauma patient in the ED if a PA is present and the patient is being transferred? A: Yes, the standard of care for trauma patients at Level IV services is physician-provided care. 29. Q: Why must a Level IV have an OR if they do not have a general surgeon? A: A Level IV is required to have a surgery department even if they only have a general surgeon or other surgical specialist on occasion, to provide an environment for life-saving procedures or surgical resuscitations by any capable provider. 30. Q: What is the standard of care for the OR? A: (WAC 246-976-535) Level I-IV facilities must have an RN or designee who opens and prepares the OR within 5 minutes of TTA. This would include activities such as unlocking doors, turning on lights, turning on warmer, pulling out (not opening) trays, setting up OR chart forms. This person might also call the OR crew and get direction about what trays should be pulled for the type of injuries anticipated. This person could even be a central supply technician. 31. Q: Does Question 2 on page 11 of the Level IV application, asking for admission criteria for trauma patients refer to ED admission or inpatient admission? A: It refers to inpatient admission criteria. You are not required to have admission criteria. If your facility does have admission criteria, then we want a copy. DOH would like to know that your admission and transfer criteria reflect your scope of service. Your trauma service should have a plan for patients and injuries that they can provide care for, and for patients whose needs exceeds your capabilities. Either the transfer or the admission criteria should be specific about your capabilities on a daily basis. 32. Q: For our Level III Admission criteria: Can we just send you our general hospital Transfer and Referral of Patient's policy, our general Diversion policy, our Bed Placement policy, and our standards of care? A: It is unlikely that these policies will meet our documentation standards for admission criteria specific to trauma. The admission criteria for trauma patients should be based on what types of injuries you predictably receive over time, which ones you are capable of admitting and providing care for, and what physician services usually admit these patients. It is not necessary to list all possible types of injuries. Here are some examples: Orthopedic injuries: Our orthopedic surgeons admit and care for the majority of orthopedic injuries such as traumatic extremity fractures including simple pelvic fractures and vertebral fractures without neuro deficits, dislocations, ligamentous injuries, tendon lacerations, extremity amputations. Thoracic injuries: Our general and/or vascular surgeons admit and care for the majority of thoracic injuries, such as hemo/pneumothoraces, rib fractures, flail chests, lung lacerations, vascular injuries, diaphragm injuries. Then your transfer criteria should complement your admission criteria, such as: Orthopedic injuries: Our trauma service stabilizes and transfers patients with complex pelvic fractures, to ABC Hospital or to PQR Medical Center. Patients with vertebral fractures and neuro deficits are stabilized and transferred to ABC Hospital. Thoracic injuries: Our trauma service stabilizes and transfers patients with myocardial penetrations and massive or crushing chest injuries. 33. Q: Not all of our staff have met the education requirements. Is there any allowance for new staff? A: Ninety percent of all trauma personnel must meet the education and training requirements at any given time. The intent of the ninety percent rule is to allow time for new hires to receive the appropriate trauma training. If your facility is temporarily out of compliance with this rule, you must submit a written plan of compliance with an expected completion date in your application for re-designation. 34. Q: Do staff have to be current in the required courses (ACLS, ATLS, TNCC, PALS, etc.)? A: No, trauma designation rules simply require providers to have taken the course at least once during their career. Many hospitals require staff to maintain currency, which is commendable, but not required. 35. Q: If our physicians refuse to take ATLS and other required courses, how can we get the physicians to comply? A: If staff are not in compliance with education and training requirements, the hospital must take action. Non-compliance could result in a provisional trauma designation from DOH. DOH is advised on setting these standards and requirements by physicians and nurses from across the state. Most of the State’s trauma services have been designated for 12 years. The WAC rule about a 90% compliance rate was written that way to allow for new hires, who should be in compliance within a year. We have asked for more specific information in this application so those staff may be named in the final report. Using participation grant money for physician and nurse training might be a way to obtain compliance. (Pediatric Education Requirement (PER) compliance is a little different, see question 36.) 36. Q: How are facilities accomplishing PER for physicians? A: There are several ways such as PALS once a lifetime or every three years: current ATLS verification; or 5-7 hours of pediatric trauma QI; or informal/formal education covering stabilization, transfer, airway/breathing, pediatric shock and vascular access, head injuries, and blunt abdominal trauma. There are multiple options, creativity is encouraged. Pediatric trauma QI is very desirable and very effective using charts from your own trauma service. On-line pediatric trauma education from UW is being developed, but is not yet available (perhaps by 1/05). There are some other on-line CME resources for pediatric trauma. (See WAC 246-976-886 or 887 for the applicable requirements.) 37. Q: What topics must be included in the required trauma-specific education for critical care nurses? A: Currently, there are no specific topic requirements. The education must address critical care trauma nursing. Although regular continuing trauma nursing education is desirable for every critical care nurse, this education is only required once in a nurse’s career, WAC 246-976-885. The trauma nurse coordinator has the responsibility of determining the appropriateness of program content. 38. Q: What are the Level III PACU RN's educational requirements? A: Level III PACU's must have an RN available 24/7. PACU RN's must have ACLS once a lifetime, and have met PER (WAC 246-976-886 or 246-976-887). 39. Q: In the “Quality Improvement” section, can we use a QI system issue that isn’t resolved? A: Yes, just make sure you explain how you are working to close the loop on the issue. 40. Q: What if I haven’t had to address a system issue in this last designation cycle? A: Then just say that. We ask you to list all of your filters, so we will know that you are looking at system issues through your QI program. 41. Q: For Level III’s, QI question number 4, does the sample case have to have been taken to Regional QI? A: No. DOH is interested in your internal QI process. If the case went to Regional QI then that is an added piece of the QI puzzle, and we’d like to know how you shared what you learned. 42. Q: What are some best practices for trauma QI in small facilities? A: Some small facilities have invited surgeons from other areas to review their trauma cases, and attend a trauma QI committee meeting to provide input and education. These have been successful in bringing new information to the community physicians, enhancing the relationship between sending and receiving facilities and staff, and providing objective review of trauma care. 43. Q: What is the purpose of regional QI? What cases should be brought to regional QI? A: The purpose is for caregivers to evaluate and improve the performance of the Washington State trauma system. Broad cases such as those involving EMS and the regional system, patient destination decisions, transfers, collaboration of more than one agency/facility, or cases providing specific educational benefit are appropriate for regional QI. 44. Q: What is learned at regional QI versus hospital QI? A: The focus of regional trauma QI is determined by the members of the committee, and usually addresses broad trauma system issues that need actions or input by several entities, or is an opportunity for learning that benefits all facilities within the region. In hospital QI, the facility’s trauma committee identifies in-house and provider-based processes or performances that need improvement, develops action plans, and evaluates the final outcome to close the loop. Hospital QI also provides educational opportunities. 45. Q: Can tele-radiology replace the need for a radiologist to respond for a trauma team activation? A: Activation of the radiologist for trauma is at the request of the trauma team leader. The team leader can request that the on-call radiologist come in to the hospital to assist with the evaluation of the trauma patient. Or, the team leader can request that the on-call radiologist provide interpretation of films via tele-radiology. 46. Q: Have response times been changed in WAC, specifically regarding technicians? A: No. Clinical lab technologists and radiological technicians have always had to respond within 20 minutes of a trauma team activation for Level III’s and IV’s. 47. Q: Does a facility’s program for EMS training of invasive procedures need to be formal? A: This is not a new WAC requirement for Level IV’s. A formal training program is preferred. 48. Q: Where can the Hospital Trauma Registry Data Dictionary be found? A: On the DOH website at www.doh.wa.gov/hsqa/emstrauma/download/hospitaldictionary.pdf 49. Q: HIPPA has become a problem when trying to follow-up on patients at receiving hospitals. A: Harborview Medical Center (HMC) has set up a U-Link system for physicians to access electronic info on referred patients. Call the Physicians Liaison Program at 206-731-8846 (HMC) to sign up; or www.uwmedicine.org/patientcare/informationforhealthcareprofessionals/makeareferral/ulink.htm. For other facilities, call the Trauma Coordinator directly for follow-up. 50. Q: Do we have to test all trauma patients for alcohol? A: No, trauma designation rules do not require you to test for drugs or alcohol. However, there are required data elements in the Collector software for BAC Tox screen results. In the past, in the trauma service designation application, DOH asked trauma services to provide a policy for assessment and intervention for trauma patients admitted with a positive blood alcohol level or drugs of intoxication screen. Research demonstrates that assessing and addressing drug and alcohol abuse as part of the initial trauma assessment reduces the rate of trauma recidivism. 51. Q: How do we get a transfer agreement, & what facilities do we have to have an agreement with? A: You are required to have a transfer agreement with all designated trauma services that receive your trauma patients. Contact the Trauma Service Coordinator at the receiving trauma service to initiate a standard trauma transfer agreement. 52. Q: Where can I find the American Burn Association’s transfer guidelines? A: To access the guidelines go to, http://www.ameriburn.org/pub/guidelinesops.pdf 53. Q: Our facility does not provide rehab care. How should we answer the requirement to describe the process to screen and refer patients to rehab services? A: Each facility should have personnel who can evaluate the trauma patient’s need for referral for trauma rehabilitation. These might include the attending surgeon, physical, occupational, and/or speech therapy staff. The receiving trauma rehabilitation facility and physiatrist can also provide guidance by phone. 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 did not 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 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 ED on a non-emergent basis, that is, the general surgeon is not called with a timed 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 & Interfacility Transfer: Admission criteria and transfer criteria should be in agreement. If not, then your QI program should reflect that you are working on this. If your hospital diverts, are you tracking trauma diversions. Are the diversions appropriate? If you divert frequently, can 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 record.
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.
• Trauma Coordinators will receive a “Facility Instruction Manual” no less than one month before the site review. • Level’s I-III must pay an established fee for their site review. Please check with DOH if you need specific information in order to budget for the review. • DOH 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 DOH has in the Trauma Registry. • Include any and all QA/QI 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 reviewers 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 are not provided at the site review. • It is 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 is 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. [include/BusPortalLinkBottom.htm] |
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