(4) Facilities must have provisions to capture the
EMS wristband number or measures for patient tracking in resuscitation
documentation.
(5) Facilities must have provisions to provide and
document EMS hand-off.
(6) Facilities must have landing zone capabilities
or system processes to establish a landing zone (when rotor-wing capabilities
are available) with appropriate staff safety training.
(7) Facilities must have a process to provide feedback
to EMS providers.
(8) All levels of trauma facilities must have written
trauma management guidelines specific to the hospital that align with
evidence-based practices and current national standards, which must
be reviewed a minimum of every three years. These guidelines must
be specific to the trauma patient population managed by the facility.
Guidelines must be established for the following:
(A) trauma activation and response time based on national
recommendations;
(B) trauma resuscitation and documentation;
(C) consultation services requests and response;
(D) admission and transfer;
(E) screening, management, and appropriate interventions
or referral for both suspected and confirmed abuse of all patient
populations; and
(F) massive transfusion.
(9) Facilities must have defined documentation of trauma
management guidelines pertinent to the care of trauma patients in
all nursing units providing care to the trauma patient.
(10) The written trauma management guidelines must
be monitored though the trauma PIPS process.
(11) The trauma program must have provisions for the
availability of all necessary equipment and services to administer
the appropriate level of care and support for the injured patient
meeting the hospital's trauma activation guidelines and meeting NTDB
registry inclusion criteria through the continuum of care to discharge
or transfer.
(12) All levels of adult trauma facilities must meet
and maintain the Emergency Medical Services for Children's Pediatric
Readiness Criteria, as evidenced by the following:
(A) annual completion of the on-line National Pediatric
Readiness Project assessment (https://pedsready.org), including a
written plan of correction (POC) for identified opportunities for
improvement that is monitored through the trauma PIPS plan until resolution;
(B) pediatric equipment and resources immediately available
at the facility, and staff with defined and documented competency
skills and training on the pediatric equipment;
(C) education and training requirements for Emergency
Nursing Pediatric Course (ENPC) or Pediatric Advanced Life Support
(PALS) for the nurses responding to pediatric trauma activations;
(D) assessments and documentation include Glasgow Coma
Score (GCS); complete vital signs to include temperature, heart rate,
respirations, and blood pressure; pain assessment; and weight recorded
in kilograms;
(E) serial vital signs, GCS, and pain assessments are
completed and documented for the highest level of trauma activations
or when shock, a traumatic brain injury, or multi-system injuries
are identified;
(F) pediatric imaging guidelines and processes addressing
pediatric age or weight-based appropriate dosing for studies imparting
radiation consistent with the ALARA (as low as reasonably achievable)
principle; and
(G) documented evidence the trauma facility has completed
a pediatric trauma resuscitation simulation with medical staff participation
every six months, including a completed critique identifying opportunities
for improvement integrated into the trauma performance improvement
initiatives and tracked until the identified opportunities are corrected.
An adult trauma facility managing 200 or more patients less than 15
years of age with an injury severity score (ISS) of 9 or greater is
exempt from this requirement of pediatric trauma simulations. If the
facility has responded to an actual pediatric trauma resuscitation
event during a six-month period, the facility is exempt from this
training but must have documented evidence of participation in the
after-action-review.
(13) Free-standing children's trauma facilities must
have resources and equipment immediately available for adult trauma
resuscitations, adherence to the nursing requirements for Trauma Nurse
Core Course (TNCC) or Advanced Trauma Care for Nurses (ATCN), documented
evidence the trauma program has completed an adult trauma resuscitation
simulation with medical staff participation every six months, including
a completed critique identifying opportunities for improvement integrated
into the trauma performance improvement initiatives and tracked until
the identified opportunities are corrected. Free-standing children's
trauma facilities managing 200 adult patients 15 years or older with
an ISS of 9 or greater are exempt from this requirement for adult
trauma simulations.
(14) Rural Level IV trauma facilities in a county with
a population less than 30,000 may utilize telemedicine resources with
an Advanced Practice Provider (APP) available to respond to the trauma
patient's bedside within 30 minutes of notification, with written
resuscitation and trauma management guidelines monitored through the
trauma performance improvement and patient safety processes.
(A) The APP must be current in Advance Trauma Life
Support (ATLS) training, annually maintain an average nine hours of
trauma-related continuing medical education, and demonstrate adherence
to the trauma patient management guidelines and documentation standards.
(B) The facility must have a documented telemedicine
physician credentialing process.
(C) All assessments, physician orders, and interventions
initiated through telemedicine must be documented in the patient's
medical record.
(15) Telemedicine in trauma facilities in a county
with a population of 30,000 or more, if utilized, must have a documented
physician credentialing process, written trauma protocols for utilization
of telemedicine including physician response times, and measures to
ensure the trauma management guidelines and evidence-based practice
are monitored through the trauma performance improvement and patient
safety processes.
(A) Telemedicine cannot replace the requirement for
the trauma on-call physician to respond to the trauma activations
in-person, to conduct inpatient rounds, or to respond to emergency
requests from the inpatient units, when requested.
(B) All telemedicine assessments, physician orders,
and interventions initiated through telemedicine must be documented
in the patient's medical record.
(C) Telemedicine services or the telemedicine physician
may be requested to assist in trauma performance improvement committee
reviews.
(16) The trauma medical director (TMD) must define
the role and expectations of the hospitalist or intensivist in providing
care to the admitted injured patient meeting trauma activation guidelines
and meeting NTDB registry inclusion criteria.
(17) A trauma program manager (TPM) or designee must
be a participating member of the nurse staffing committee.
(18) The facility must maintain medical records facilitating
the documentation of trauma patient arrival, level of activation,
physician response and team response times, EMS hand-off, wristband
number or patient tracking identifier, resuscitation, assessments,
vital signs, GCS, serial evaluation of needs, interventions, patient
response to interventions, reassessments, and re-evaluation through
all phases of care to discharge or transfer out of the facility.
(19) 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 organized, effective trauma
service recognized in the medical staff bylaws or rules and regulations
and approved by the governing body. Medical staff credentialing must
include a process for requesting and granting delineation of privileges
for the TMD to oversee the providers participating in trauma call
coverage, the trauma panel, and trauma management through all phases
of care.
(20) Level I, II, and III facilities must have a TMD
with requirements aligned with the current ACS standards specific
to the level of designation requested and Level IV facilities managing
101 or more trauma patients meeting NTDB registry inclusion criteria
annually must have a TMD with a defined job description that is a
surgeon, emergency medicine physician, or family practice physician
that is board-certified in their specialty, current in ATLS, and meet
the other ACS standards specific to the TMD for the level of designation
requested. The TMD must complete a trauma performance improvement
course approved by the department.
Cont'd... |