Figure: 25 TAC §157.125(x)(1)

Advanced (Level III) Trauma Facility
Standards

1.   A Level III Trauma Facility shall be an active participant on the regional advisory council (RAC) of its trauma service area (TSA).

2.   A Level III Trauma Facility is available to care for all major and severe trauma patients 24 hours per day/ 7 days per week. Diversion of such patients to other facilities should be made rarely and only when resources are not available in the emergency department (ED) to stabilize and transfer these patients.

3.   A Level III trauma facility with specialized trauma capabilities may not refuse a request for a trauma transfer from another hospital if it has the capacity to accept.  Specialized trauma capability is any capability necessary for screening or stabilizing patients with emergency medical conditions that the transferring hospital may lack.   The only two reasons a Level III trauma facility may refuse a trauma transfer request are lack of capability to handle the patient’s emergency condition or when it is at capacity.

4.   A log of all trauma transfer-in denials shall be maintained, reviewed through the facility’s trauma performance improvement (PI) process, and referred to the appropriate RAC’s systems PI process.

5.   A Level III trauma facility shall have an established relationship with tertiary trauma facility (ies) to which it transfers patients and with all designated Level IV trauma facilities that regularly initiate transfers-in, to include such things as:

•         written transfer agreements
•         prospective dialogue regarding appropriate pre-transfer diagnostic laboratory and radiological
          studies so that each is cognizant of the other’s performance expectations
•         consideration of a single phone call transfer-request process
•         provision of feedback regarding transfers as part of the PI program

6.   A Level III trauma facility shall have age-specific policies\processes that demonstrate knowledge of the special resources potentially needed by injured patients of all ages, and is cognizant of the pediatric capabilities of the hospitals to which it customarily effectuates transfers so that it can determine the most appropriate facility.

7.   A Level III trauma facility shall have an established relationship with the EMS providers, who transport to the facility, to facilitate adequate pre-arrival notification, appropriate documentation, and appropriate pre-hospital care.

8.   A Level III trauma facility shall present its pediatric capabilities to the RAC so that both EMS providers and other hospitals can determine the most appropriate facility to transport or transfer critically injured pediatric patients.

9.   The patient shall be treated per established trauma care standards and protocols within the capability of the facility. A Level III trauma facility shall notify the regional emergency healthcare community when a usually-provided service, either “essential” or “desired”, is not available.

10.  The major or severe trauma patient shall be met on arrival in the ED by a team of healthcare professionals as defined in the trauma activation protocols, credentialed by the hospital.  The emergency physician shall direct the resuscitation until the arrival of the general surgeon.

12.  The major or severe trauma patient shall be rapidly assessed, resuscitated, and stabilized according to established trauma management guidelines including ATLS, TNCC, ATCN, and ENPC.

13.  Persons who have been involved in a high-energy event that results in a high index of suspicion for major or severe injury shall be evaluated expeditiously upon arrival by the emergency physician to determine if a surgical consult is necessary.  Surgical consultations shall occur at the time of injury identification.

14.  Disposition decisions shall be made expeditiously by a physician at the hospital and preparations for transfer or admission begun as soon as possible after arrival at the facility.

15.  Major or severe trauma patients who are intentionally retained longer than 2 hours, except where medically appropriate, shall receive the same level of care as the highest available within its TSA or within the TSA to which the patient’s condition warrants transfer-out.

16.  The trauma medical director (TMD) shall formally review trauma panel members on an annual basis, to include at a minimum the review of number of admissions, deaths, complications, audit filter fallouts, and timeliness of response to trauma activations and consults.

17.  All healthcare professionals participating in the care of major or severe trauma patients shall participate in the PI program, and each discipline shall have representation at PI meetings.

18.  All major or severe trauma patients' charts, including autopsy results when available, shall be reviewed concurrently and retrospectively by the trauma program’s PI process for appropriateness and quality of care provided by the hospital. Deviations from standards shall be addressed through a documented trauma PI process.

19.  Standards and time frames for trauma registry data entry shall be developed, and shall be no longer than 45 days after the patient’s hospital discharge date.

20.  The Texas Hospital Data Set essential items shall be electronically submitted to the State EMS/Trauma Registry on at least a quarterly basis, either directly or through a regional registry. Final autopsy results shall be included in the hospital trauma registry.

21.  A Level III trauma facility shall participate in the PI program of the RAC in the TSA where it is located, and shall also participate as requested by executive boards, in the PI program of RACs into which the facility has transferred a patient.