Figure: 25 TAC §157.125(x)(2)
Advanced (Level III) Trauma Facility
1. Absence of an EMS patient care report on the medical record for a patient transported by pre-hospital EMS personnel.
2. EMS scene time of greater than 20 minutes.
3. Absence of pre-hospital essential data items on EMS patient care report.
4. No, or absence of documentation of, trauma team activation for a potential major or severe trauma patient per protocol.
5. Trauma team member response times of greater than 10 minutes for those in-house or greater than 30 minutes for those off-site.
6. Absence of a trauma flow sheet.
7. Absence of documentation of trauma team response times, mechanism of injury, assessments, interventions, and response to interventions.
8. Absence of at least hourly documentation of blood pressure, pulse, respirations, Glasgow coma scale (GCS), and fluid intake and output for a major or severe trauma patient, beginning with arrival in the emergency department (ED), including time spent in radiology, up to admission, death, or transfer.
9. Absence of documented temperature on arrival, discharge, intra-operatively and when indicated.
10. Resuscitation protocol, treatment protocols, and/or standards of care not followed.
11. A patient with a GCS of less than 14 did not receive a CT of the head.
12. A comatose patient (GCS of 8 or less) leaving the ED before a definitive airway is established.
13. Required equipment, which is shared with other departments (i.e. fluid warmer), is not immediately available when requested.
14. Absence of physician notes, including daily physician notes on admitted trauma patients.
15. Major or severe trauma patients transferred to another health-care facility or admitted to surgery or ICU after spending greater than 2 hours in the ED.
16. A major or severe trauma patient admitted to the hospital under the care of a physician who is not a surgeon.
17. Patient sustaining a gunshot wound to the abdomen who is managed non-operatively.
18. Patient with abdominal injuries and hypotension (systolic BP less than 90 or age-appropriate hypotension) who does not undergo laparotomy within 1 hour of arrival in the ED.
19. Patient undergoing laparotomy performed greater than 4 hours after arrival in the ED.
20. Patient with epidural or subdural brain hematoma receiving craniotomy greater than 4 hours after arrival at the ED, excluding those performed for ICP monitoring.
21. Interval of greater than 8 hours between arrival and the initiation of debridement of an open fracture.
22. Abdominal, thoracic, vascular, or cranial surgery performed greater than 24 hours after arrival.
23. Non-fixation of femoral diaphyseal fracture in an adult trauma patient.
24. Patient requiring re-intubation of the airway within 48 hours of extubation.
25. Selected in-patient complications monitored as trends or sentinel events.
26. All delays in identification of injuries.
27. Major or severe trauma patient admitted to OR, ICU, or inpatient and then transferred to a higher level of care.
28. Denials of acceptance by a higher level of care facility.
29. Major or severe trauma patient transferred to a non-designated or lower level designated facility.
30. Diversion of major or severe trauma patients and/or denial of transfers-in from other facilities.
31. All trauma deaths.