| (21) Level I, II, and III facilities, and Level IV
facilities managing 101 or more trauma patients meeting NTDB registry
inclusion criteria annually must have an identified TPM responsible
for monitoring trauma patient care throughout the continuum of care,
from pre-hospital management to trauma activation, inpatient admission,
and transfer or discharge, to include transfer follow-up as appropriate.
The TPM must be a registered nurse with clinical background in trauma
care and must have completed a trauma performance improvement course
approved by the department and the Association for the Advancement
of Automotive Medicine (AAAM) Injury Scaling Course, and have current
TNCC or ATCN, Emergency Nursing Pediatric Course (ENPC) or Pediatric
Advanced Life Support (PALS), and Advanced Cardiac Life Support (ACLS)
certifications. It is recommended for the TPM to complete courses
specific to the TPM role. The role must be only for that facility
and cannot cover multiple facilities. The TPM authority and responsibilities
are aligned with the current ACS standards for the specific level
of designation.
(22) The facility must have an organizational structure
that facilitates the TPM's review of trauma care from admission to
discharge, allowing for recommendations to improve care through all
phases of care, and a reporting structure to an administrator having
the authority to recommend and monitor facility system changes and
oversee the trauma program.
(23) All levels of trauma facilities must maintain
a continuous trauma PIPS plan. The plan must be data-driven and must:
(A) identify variances in care or system response events
for review, including factors that led to the event, delays in care,
hospital events such as complications, and all trauma deaths;
(B) define the levels of harm;
(C) define levels of review;
(D) identify factors that led to the event;
(E) identify opportunities for improvement;
(F) establish action plans to address the opportunities
for improvement;
(G) monitor the action plan until the desired change
is met and sustained;
(H) establish a concurrent PIPS process;
(I) meet staffing standards that align with the ACS
standards for performance improvement personnel; and
(J) utilize terminology for classifying morbidity and
mortality with the terms:
(i) morbidity or mortality without opportunity;
(ii) morbidity or mortality with opportunity for improvement;
and
(iii) morbidity or mortality with regional opportunity
for improvement.
(24) The trauma PIPS plan must be approved by the TMD,
TPM, and the trauma operations committee and be disseminated to all
departments providing care to the trauma patient. The departments
must ensure staff are knowledgeable of the responsibilities in the
trauma PIPS plan and the requested data and information to be presented
at the trauma operations committee.
(25) The Level I, II, and III facilities, and Level
IV facilities managing 101 or more trauma patients meeting NTDB registry
inclusion criteria annually must demonstrate that the TMD chairs the
secondary level of performance review, chairs the trauma multidisciplinary
peer review committee, and co-chairs the trauma operations committee
with the TPM.
(26) The trauma PIPS plan must outline the roles and
responsibilities of the trauma operations committee and its membership.
(27) The trauma facility must document and include
in its trauma PIPS plan the external review of the trauma verification
and designation assessment questionnaire, designation survey documents,
the designation survey summary report, including the medical record
reviews, and all communication with the department.
(28) Trauma facilities must submit required trauma
registry data every 90 days or quarterly to the State Trauma Registry
and have documented evidence of data validation and correction of
identified errors or blank fields.
(A) All levels of trauma facilities must demonstrate
the current ACS standards for staffing requirements for the trauma
registry are met.
(B) Trauma facilities utilizing a pool of trauma registrars
must have an identified trauma registrar from the pool assigned to
the facility to ensure data requests are addressed in a timely manner.
(29) All levels of trauma facilities must demonstrate
the registered nurses assigned to care for arriving patients meeting
trauma activation guidelines have current TNCC or ATCN, ENPC or PALS,
and Advanced Cardiac Life Support certifications. Those new to the
facility or the facility's trauma resuscitation area must meet these
requirements within 18 months.
(30) Level I, II, and III facilities, and Level IV
facilities managing 101 or more trauma patients meeting NTDB registry
inclusion criteria annually must have evidence the trauma program
surgeons, trauma liaisons, trauma program personnel, operating suite
leaders, and critical care medical director and nursing leaders complete
a mass casualty response training on their roles, potential job functions,
and job action sheets, to ensure competency regarding actions required
for surge capacity, capabilities, and patient flow management from
resuscitation to inpatient admission, operative suite, and critical
care units or intensive care units during a multiple casualty or mass
casualty event. If the facility has responded to an actual mass casualty
event during a 12-month period, the facility is exempt from this training
but must have documented evidence of participation in the after-action
review.
(31) Level IV facilities managing 101 or more patients
meeting NTDB registry inclusion criteria annually must:
(A) meet the current ACS Level IV standards and defined
state requirements;
(B) have 24-hour on-site coverage by an emergency physician
credentialed by the hospital and approved by the TMD to participate
in the resuscitation and treatment of trauma patients of all ages
and respond to trauma activation patients within 30 minutes of request;
(C) have documented guidelines for trauma activations,
resuscitation guidelines, documentation standards, and patient transfers,
and measures to monitor the guidelines through the trauma performance
improvement process. Transfer reviews must include the time of arrival,
transfer decision time, transfer acceptance time, transport arrival
time, and time transferred;
(D) have documented management guidelines specific
to the trauma patients admitted at the facility based on trauma registry
data;
(E) have a written trauma PIPS plan that, at minimum,
monitors:
(i) trauma team activations;
(ii) trauma team member response times;
(iii) trauma resuscitation guidelines;
(iv) documentation standards;
(v) trauma management guidelines;
(vi) pediatric trauma resuscitation guidelines;
(vii) transfer guidelines; and
(viii) all trauma deaths; and
(F) have provisions for a multidisciplinary trauma
peer review committee and a trauma operations committee.
(32) Level IV facilities managing 100 or less trauma
patients meeting NTDB registry inclusion criteria annually must:
(A) have 24-hour emergency services coverage by a physician
credentialed by the hospital and approved by the TMD to participate
in the resuscitation and treatment of trauma patients of all ages
and respond to trauma activation patients within 30 minutes of request;
(B) have a TMD overseeing and monitoring the trauma
care provided and who is current in ATLS;
(C) have a TPM who is a registered nurse and must:
(i) complete a trauma performance improvement course
and a trauma program manager course approved by the department;
(ii) complete a registry AAAM Injury Scoring Course;
(iii) have current TNCC or ATCN, ENPC or PALS, and
ACLS certifications; and
(iv) oversee and monitor trauma care provided;
(D) have documented guidelines for trauma team activation
with response times, resuscitation guidelines, and documentation standards
for resuscitation through admission, transfer, or discharge;
(E) have documented management guidelines specific
for the trauma patients admitted to the facility;
(F) have documented transfer guidelines that are monitored
to identify the arrival time, decision to transfer time, time of transfer
acceptance, time of transport arrival, and time of transfer;
(G) have a trauma PIPS plan that, at minimum, monitors:
(i) trauma team activations;
(ii) trauma team member response times;
(iii) trauma resuscitation guidelines;
(iv) documentation standards;
Cont'd... |
