| (a) The department designates hospital applicants as
trauma facilities, which are part of the trauma and emergency health
care system. Hospitals must meet the designation requirements specific
to the level of designation requested by September 1, 2025. Trauma
designation surveys conducted on or after September 1, 2025, are evaluated
on the requirements in this section.
(b) The facility seeking trauma designation submits
a completed designation application packet to the department. The
department reviews the facility application documents for the appropriate
level of designation. The complete designation application packet
must include the following:
(1) a trauma designation application for the requested
level of trauma designation;
(2) a completed department designation assessment questionnaire;
(3) the documented trauma designation survey summary
report that includes findings of requirements met and medical record
reviews;
(4) evidence of documented data validation and quarterly
submission to the State Trauma Registry and National Trauma Data Bank
(NTDB) (if applicable) for the past 12 months;
(5) evidence of the facility's trauma program and Trauma
Medical Director (TMD) or designee participation at Regional Advisory
Council (RAC) meetings throughout the designation cycle; and
(6) full payment of the non-refundable, non-transferrable
designation fee.
(c) The department reviews the designation application
packet to determine and approve the facility's level of trauma designation.
The department defines the final trauma designation level awarded
to the facility and this designation may be different than the level
requested based on the designation site survey summary. If the department
determines the facility meets the requirements for trauma designation
the department provides the facility with a designation award letter
and a designation certificate. The facility must display its trauma
designation certificate in a public area of the licensed premises
that is readily visible to patients, employees, and visitors.
(d) Eligibility requirements for trauma designation.
(1) Health care facilities eligible for trauma designation
include:
(A) a hospital in Texas, licensed or otherwise, in
accordance with Texas Health and Safety Code Chapter 241;
(B) a hospital owned and operated by the State of Texas;
or
(C) a hospital owned and operated by the federal government,
in Texas.
(2) Each hospital must demonstrate the capability to
stabilize and transfer or treat an acute trauma patient, have written
trauma management guidelines for the hospital, have a written operational
plan, and have a written trauma performance improvement and patient
safety (PIPS) plan.
(3) Each hospital operating on a single hospital license
with multiple locations (multi-location license) may apply for trauma
designation separately by physical location for each designation.
(A) Hospital departments or services within a hospital
must not be designated separately.
(B) Hospital departments located in a separate building
not contiguous with the designated facility must not be designated
separately.
(C) Each non-contiguous emergency department of a hospital
operating on a single hospital license must have trauma patient care
and transfers monitored through the main hospital's trauma program.
(e) A facility is defined under subsection (d) of this
section as a single location where inpatients receive hospital services
and inpatient care.
(1) Each facility location must meet the requirements
for designation. The department defines the designation level based
on the facility's ability to demonstrate designation requirements
are met.
(2) Each facility must submit a separate trauma designation
application based on its resources and the level of designation the
facility is seeking.
(3) If there are multiple hospitals covered under a
single hospital license, each hospital or physical location where
inpatients receive hospital services and care may seek designation.
(4) Trauma designation is issued for the physical location
and to the legal owner of the operations of the designated facility
and is non-transferable.
(f) Facilities seeking trauma designation must meet
department-approved requirements and have them validated by a department-approved
survey organization.
(g) The four levels of trauma designation are as follows.
(1) Comprehensive trauma facility designation (Level
I). The facility, including a free-standing children's facility, must:
(A) meet the current American College of Surgeons (ACS)
trauma verification standards for Level I and receive a letter of
verification from the ACS;
(B) meet the state trauma designation requirements;
(C) meet the participation requirements for the local
RAC;
(D) have appropriate services for dealing with stressful
events available to emergency and trauma care providers; and
(E) submit quarterly trauma data to the State Trauma
Registry, defined in Chapter 103 (relating to Injury Prevention and
Control).
(2) Major trauma facility designation (Level II). The
facility, including a free-standing children's facility, must:
(A) meet the current ACS trauma verification standards
for Level II and receive a letter of verification from the ACS;
(B) meet the state trauma designation requirements;
(C) meet the participation requirements for the local
RAC;
(D) have appropriate services for dealing with stressful
events available to emergency and trauma care providers; and
(E) submit quarterly trauma data to the State Trauma
Registry, defined in Chapter 103 of this title (relating to Injury
Prevention and Control).
(3) Advanced trauma facility designation (Level III).
The facility, including a free-standing children's facility, must:
(A) meet the current ACS trauma verification standards
for Level III and receive a letter of verification from the ACS, or
complete a designation survey conducted by a department-approved survey
organization;
(B) meet the state trauma designation requirements;
(C) meet the participation requirements for the local
RAC;
(D) have appropriate services for dealing with stressful
events available to emergency and trauma care providers; and
(E) submit quarterly trauma data to the State Trauma
Registry, defined in Chapter 103 of this title (relating to Injury
Prevention and Control).
(4) Basic trauma facility designation (Level IV). The
facility, including a free-standing children's facility:
(A) Level IV facilities managing 101 or more trauma
patients meeting NTDB registry inclusion criteria annually must:
(i) meet the current ACS trauma verification standards
for Level IV and complete a designation survey conducted by a department-approved
survey organization;
(ii) meet the state trauma designation requirements;
(iii) meet the participation requirements for the local
RAC;
(iv) have appropriate services for dealing with stressful
events available to emergency and trauma care providers; and
(v) submit quarterly trauma data to the State Trauma
Registry, defined in Chapter 103 of this title (relating to Injury
Prevention and Control).
(B) Level IV facilities managing 100 or less trauma
patients meeting NTDB registry inclusion criteria annually must:
(i) meet the defined state trauma designation requirements
and complete a designation survey with the department or with a department-approved
survey organization;
(ii) meet the participation requirements for the local
RAC;
(iii) have appropriate services for dealing with stressful
events available to emergency and trauma care providers; and
(iv) submit quarterly trauma data to the State Trauma
Registry, defined in Chapter 103 of this title (relating to Injury
Prevention and Control).
(h) All facilities seeking trauma designation must
meet the following requirements.
(1) Facilities must have documented evidence of participation
in the local RAC.
(2) Facilities must have evidence of quarterly trauma
data submissions to the State Trauma Registry for patients that meet
NTDB registry inclusion criteria, following the National Trauma Data
Standards (NTDS) definitions and state definitions.
(3) Facilities must have emergency medical services
(EMS) communication capabilities.
Cont'd... |
