Level 3 Trauma Hospital Designation Criteria Side by Side · Level 3 Trauma Hospital Designation...

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Level 3 Trauma Hospital Designation Criteria Side by side comparison of current and new criteria.

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gory

Current Criteria New Criteria Effective January 1, 2020 Change Summary

Inst

itutio

n

The board of directors, administration, and medical, nursing and ancillary staff shall make a commitment to providing trauma care commensurate to the level at which the facility is applying for categorization and or is verified.

The board of directors, administration and medical staff shall demonstrate a commitment to provide the resources and support necessary to sustain the trauma designation. This commitment shall be renewed with each application for designation.

▪ Explicit requirement to renew commitment with each application Same as L4

▪ Same as L4

The trauma program shall be established by the facility with approval from the medical staff, board of trustees, and administration, and represented on an organizational chart. This may be in conjunction with an existing department; for example, emergency or surgery appropriate.

The trauma program shall be established by the facility and shall be represented on the organizational chart, which may be within an existing department (e.g., emergency or surgery).

▪ Language consolidated; no change in meaning

▪ Same as L4

Med

ical

Dire

ctor

Trauma program medical director shall be a board-certified or boards-in-progress physician with special interest in trauma care whose job description defines his/her role and responsibilities for trauma patient care, trauma team formation, supervision/leadership, and trauma training/continuing education and acts as the medical staff liaison for trauma care with out-of-hospital medical directors, nursing staff, administration, and higher-level trauma hospitals.

Trauma program medical director or medical advisor shall be a board-certified or board-eligible physician whose job description defines his or her authority, roles and responsibilities for the leadership of the trauma program, the trauma performance improvement process and tertiary case review.

▪ Language consolidated; no change in meaning

▪ Same as L4

If the trauma medical director is not a general surgeon, there must be a co-trauma medical director who is a board-certified or boards-in-progress general surgeon.

If the trauma medical director is not a general surgeon, there must be a co-trauma medical director who is a board-certified or board-eligible general surgeon.

Change “boards-in-progress” to “board-eligible”

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Med

Dir

The trauma hospital medical director(s) must successfully complete ATLS® and/or CALS (including the Benchmark Lab or Trauma Module Course) every four years.1 The medical director(s) must re-take his/her ATLS or CALS before or during the month in which it expires.2

The trauma program medical director and co-medical director must meet the same trauma training requirements as the Emergency Department Physician. 2

▪ Same principle as L4: TMDs certified by ABEM-approved board need not maintain current ATLS/CALS

▪ Remove footnote 1

Prog

ram

Man

ager

This person shall be a RN with clinical experience in trauma care. Alternatively, other qualified allied health personnel with clinical experience in trauma care may be appropriate. It is expected that the Coordinator/Manager has allocated time for the trauma program.

The trauma manager/coordinator must be either a registered nurse or an allied health staff with emergency and trauma care experience. The manager/coordinator’s job description must define his or her roles and responsibilities for the management and leadership of the trauma program and the trauma performance improvement process.

▪ Wordsmithing to add clarity without change to intent

▪ Same as L4 If the trauma program manager/coordinator is not a registered nurse, a registered nurse must assist with the review of trauma care provided in all areas of the hospital and function as a liaison between the trauma program and the nursing staff. The program manager must have at least a portion of an FTE dedicated for trauma program responsibilities.

Clarifies expectation that a portion of FTE be committed

1 For the initial designation only, hospitals may become designated after the medical providers successfully complete the CALS Provider Course only. They must then complete the Benchmark Lab or Trauma Module Course within one year of the Provider Course. 2 There is no grace period for either ATLS or CALS training. The CALS lab component must, too, be re-taken before or during the month in which it expires.

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Trau

ma

Team

Act

ivat

ion

Trauma hospitals shall have a trauma team activation protocol/policy to include:

▪ Lists of all team members ▪ Response requirements for all team members when a trauma

patient is en route or has arrived ▪ The criteria, based on patient severity of injury, for activation

of the trauma team and ▪ The person(s) authorized to activate the trauma team

The hospital must have a trauma team activation policy, protocol or guideline that includes: ▪ A list of all team members expected to respond, which may

include telemedicine providers. ▪ The response time expectation for the team members, ▪ The physiological and clinical indicators that, when met,

require the activation of the trauma team, and ▪ The person(s) authorized to activate the trauma team.

▪ Explicit language including telemedicine providers

▪ Same as L4

The trauma team activation policy shall include both physiological and anatomical clinical indicators for when the ED physician is expected to be present in the ED within 15 minutes of EMS notification.

N/A Incorporated above

N/A The trauma team activation indicators must be readily available in locations where a trauma patient is likely to be initially encountered.

▪ New requirement ▪ Same as L4

When a tier-one trauma activation criterion is met, the general surgeon must promptly communicate with the emergency department provider by telephone or in person. This communication must be documented in the medical record.

When a tier-one trauma activation criterion is met, the general surgeon must promptly communicate with the emergency department provider by telephone or in person. This communication must be documented in the medical record.

No change

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Tier

-One

Tra

uma

Team

Act

ivat

ion

Crite

ria

When one of the following tier-one trauma activation criteria is met, the general surgeon and operating room team3 must arrive at the hospital within 30 minutes of the patient’s arrival: ▪ Penetrating trauma to neck or torso▪ Evidence of hemorrhagic shock indicated by:

▪ Systolic blood pressure ≤90 mmHg at any time (or age-specific hypotension in pediatrics)

▪ Persistent heart rate >120 (or age-specific tachycardia inpediatrics)

▪ Shock index ≥1 in adults (HR>SBP)▪ StO2 ≤70% in adults▪ Positive abdominal or cardiac FAST exam▪ Provider impression of hypoperfusion (consider absent

distal pulses, agitation, anxiety, confusion, delayedcapillary refill, diaphoresis, pallor, tachypnea)

When one of the following tier-one trauma activation criteria is met, the general surgeon and operating room team3 must arrive at the hospital within 30 minutes of the patient’s arrival: ▪ Penetrating trauma to neck or torso▪ Evidence of hemorrhagic shock indicated by:

▪ Systolic blood pressure ≤90 mmHg at any time (or age-specific hypotension in pediatrics)

▪ Persistent tachycardia in a patient ≤14 years old (see Age-Specific Tachycardia table)

▪ Positive abdominal or cardiac FAST exam▪ Provider impression of hypoperfusion (consider absent

distal pulses, agitation, anxiety, confusion, delayedcapillary refill, diaphoresis, pallor, persistent heart rate>120 in a patient >14 years old, tachypnea)

▪ Shock index, StO2 removed▪ Persistent heart rate >120 in

adults removed▪ Age-Specific Tachycardia table

updated

Age-Specific Hypotension Age SBP (mmHg) 2-10yr.

≤ 70 + [2 x age in years]

≤ 1 yr. ≤ 60

Age-Specific Tachycardia Age HR 2-5 yr. >160< 2 yr. >180

Age-Specific Hypotension Age SBP (mmHg) ≤ 1 yr. ≤ 70

1-10 yr. ≤ 70 + [2 x age in years]

Age-Specific Tachycardia Age HR < 2 yr. >1802-5 yr. >1606-14yr. >140

3 The operating room team may be called off by the general surgeon after communicating with the emergency department provider.

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Tier

-One

TTA

Crit

eria

When one of the following tier-one trauma activation criteria is met, the general surgeon must arrive at the hospital within 60 minutes of the patient’s arrival unless the patient has been transferred: ▪ Respiratory distress, airway obstruction or intubation ▪ GCS ≤ 8 attributed to a traumatic mechanism ▪ Arterial tourniquet applied ▪ Pregnancy >20 weeks with vaginal bleeding or contractions ▪ Discretion of the emergency department provider (for those

patients not meeting any of the tier-one criteria)

When one of the following tier-one trauma activation criteria is met, the general surgeon must arrive at the hospital within 60 minutes of the patient’s arrival unless the patient has been transferred: ▪ Respiratory distress, airway obstruction or intubation ▪ Sustained GCS ≤ 8 attributed to a traumatic mechanism ▪ Arterial tourniquet applied ▪ Pregnancy >20 weeks with vaginal bleeding or contractions ▪ Discretion of the emergency department provider (for those

patients not meeting any of the tier-one criteria)

“Sustained” added to GCS ≤ 8

Gene

ral S

urge

on R

espo

nse

(no

TTA)

The general surgeon must respond and evaluate the patient within one hour of discovering any of the following conditions resulting from trauma unless the patient has been transferred: ▪ Serum lactate >5.0 mmol/L ▪ Solid organ injury ▪ Fluid in the abdomen ▪ Untreated hemothorax or pneumothorax requiring

thoracostomy ▪ Cardiac or major vessel injury

The general surgeon must respond and evaluate the patient within one hour of discovering any of the following conditions resulting from trauma unless the patient has been transferred: ▪ Serum lactate >5.0 mmol/L ▪ Solid organ injury ▪ Fluid in the abdomen ▪ Untreated hemothorax or pneumothorax requiring

thoracostomy ▪ Cardiac or major vessel injury

No change

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Gene

ral S

urge

ry

The operating room must be readily available for trauma care 24 hours/day.

The operating room must be continuously available for emergent surgery. Wording change only

Local criteria may be established to allow the general surgeon to take call from outside the facility, but with clear commitment on the part of the facility and the surgical staff that the general surgeon will be available to the ED physician for consultation to assist in the decision for need of surgical interventions or transfer 24 hours/day. General surgeon response to the resuscitation is required if the patient meets the minimum criteria for surgeon response or is otherwise required by hospital policy. Eighty (80) percent of the time the general surgeon response should meet the response time requirements of the trauma system.

A general surgeon must be continuously available, either on-site or on-call, and able to respond to the hospital within 30 minutes. If the general surgeon on on-call off-site, a schedule identifying the general surgeon on-call must be readily available to the emergency department and operating room staffs.

▪ Wording consolidated ▪ Explicit requirement for on-call

schedule added

The general surgeon’s response to the resuscitation is required if the patient meets the minimum criteria for surgeon response or is otherwise required by hospital policy. Eighty (80) percent of the time the general surgeon response should meet the response time requirements of the trauma system.

No change

The surgeon must also be available to care for trauma patients in the ICU. Compliance with this requirement and applicable criteria must be monitored by the trauma PI program.

N/A Eliminated; addressed adequately elsewhere

A formal plan must be in place indicating: ▪ How the trauma patient will be managed should the usual

surgical coverage be temporarily unavailable for any reason (e.g., the surgeon is already in surgery)

▪ How surgeon call will be covered when scheduled gaps in the usual coverage occur (e.g., vacations)

The hospital must establish a written plan addressing: ▪ How the trauma patient will be managed should the usual

surgical coverage be temporarily unavailable for any reason (e.g., the surgeon is already in surgery); and

▪ How surgeon call will be covered when scheduled gaps in the usual coverage occur (e.g., vacations).

Wording only

Surgeon must be present at all operative procedures performed in the operating room.

A surgeon must be present at all operative procedures performed in the operating room. Wording only

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Emer

genc

y M

edic

ine 24-hour coverage by a physician who is present at all emergency

resuscitations. If the physician is off-site, his/her response to the hospital should be within 15 minutes of EMS notification. (See “Clinical Qualifications for further emergency physician details.)

An emergency physician must be continuously available, either on-site or on-call. If the emergency department physician is off-site, an on-call schedule must identify the physician(s) covering the emergency department.

▪ Language consolidated ▪ Similar to L4

Published and posted call schedules must specifically identify the physician/provider on call for the emergency department.

When called, the emergency physician must arrive in the emergency department within 15 minutes of the patient’s arrival.

Anes

thes

ia

May be covered by certified registered nurse anesthetist (CRNA). An anesthesiologist or certified registered nurse anesthetist (CRNA) must be continuously available, either on-site or on-call.

Explicit, rather than implicit, requirement for continuous coverage

Ort

hopa

edic

Sur

gery

Hospitals must have protocols that clearly define which orthopaedic surgical cases they can manage definitively and which cases require transfer to a facility able to definitively manage the patient’s condition. The protocol must specifically address how time-sensitive orthopaedic conditions such as a threatened limb and compartment syndrome will be managed within one hour. If necessary, the same individual may cover both general surgery and orthopaedic surgery if he/she meets the clinical qualifications for each discipline.

If the hospital provides emergent orthopaedic surgery or admits patients for the care of surgical orthopaedic injuries, a schedule of the orthopaedic surgeon on-call must be maintained and accessible by emergency department and in-patient staff.

▪ On-call schedule requirement added

▪ Specific conditions addressed by Transfer section

▪ Same as L4

Post

An

esth

esia

RN available 24 hours/day A registered nurse capable of recovering a post-anesthesia patient must be continuously available. Wording

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Radi

olog

y 24-hour radiologist coverage required (may utilize in-house, on-call or tele-radiology resources). Radiology technician available or on-call 24 hours/day 24-hour availability of computed tomography

A computed tomography technician or technologist must be continuously available, either in-house or on-call. Ability of CT tech to obtain plain

films is assumed A radiologist must be continuously available, either in-house or off-site.

Resp

irato

ry

Ther

apy In-house or on-call 24-hour coverage. A nurse with specific in-house

ventilator training may provide this coverage. Records of in-house CEUs must be maintained.

A respiratory therapist, registered nurse or other allied health professional trained in ventilator management must be continuously available.

▪ CEU records no longer required ▪ “…other allied health

professional…” added

Lab

Must have a comprehensive blood bank or access to community blood bank.

There must be an in-house blood bank stocked with O-negative blood. There must be a policy establishing a procedure for the emergent release of uncross-matched blood that ensures that uncross-matched blood can be released to the emergency department staff immediately. If the blood bank staff is off-site, the policy must include a provision to release uncross-matched blood to the emergency department staff in the absence of the blood bank staff.

▪ O-negative blood required ▪ New requirement for blood

release policy ▪ Same as L4

24-hour availability of a laboratory capable of standard analysis of blood, urine and other body fluids, including micro sampling

N/A Unnecessary; required by CMS rules 24-hour availability of a laboratory capable of: ▪ Blood typing and cross matching ▪ Coagulation studies ▪ Blood gas and pH determination ▪ Microbiology

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Trau

ma

Adm

issio

ns

A surgeon should be the admitting or consulting physician for all trauma patients admitted to the hospital for trauma care. Patients with conditions represented in Table 1 must be admitted by or receive a consultation from a surgeon if admitted. The percentage of trauma patients admitted to a non-surgeon without a surgeon consultation may not exceed 10%.4 Consultations/evaluations must be performed within 18 hours of the patients’ arrival. 5,6

Table 1 Mandatory Surgeon Admit or Consult

Hemothorax or pneumothorax Pelvic fracture Two or more adjacent rib fractures Pulmonary contusion Significant fall: ▪ >15 feet ▪ >65 years old and fall from elevation or down stairs ▪ Pediatric (<10 years old): >2 x patient’s height

A surgeon should be the admitting or consulting physician for all trauma patients admitted to the hospital for trauma care. Patients with conditions represented in Table 1 must be admitted by or receive a consultation from a surgeon if admitted. The percentage of trauma patients admitted to a non-surgeon without a surgeon consultation may not exceed 20%.4 Consultations/evaluations must be performed within 18 hours of the patients’ arrival.5,6

Table 1 Mandatory Surgeon Admit or Consult

Hemothorax or pneumothorax Pelvic fracture (not isolated rami fractures) Two or more adjacent rib fractures Pulmonary contusion Significant fall: ▪ >15 feet ▪ >65 years old and fall from elevation or down stairs ▪ Pediatric (<10 years old): >2 x patient’s height

▪ Percentage of trauma patients that may be admitted to non-surgeon increased from 10% to 20%

▪ Isolated rami fractures excluded from mandatory surgeon admit/consult

4 Multi-system injury trauma cases should be admitted to the general surgeon. Single-system injury trauma cases may be admitted to a primary care physician if consultations are obtained from the appropriate surgeon (i.e., orthopaedic surgeon for isolated orthopedic injuries, neurosurgeon for isolated neurological injuries and general surgeon for all other injuries). Traumatic injury cases exclusively orthopaedic in nature may be admitted to the orthopaedic surgeon. 5 Providers should exercise judgment in obtaining consults sooner if warranted by the injury mechanism or acuity. 6 The consultation/admission may be accomplished by the surgeon’s appointed advanced practice provider on behalf of the surgeon.

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Trau

ma

Adm

issio

ns

N/A

The hospital must have a policy describing: ▪ The types of trauma patients considered for admission, ▪ The specialties responsible for admitting and providing

consults, ▪ The expectations for monitoring patients for deterioration, and ▪ The expectation that, in the event of deterioration, patients

admitted for trauma care will arrive at definitive care within 120 minutes from the time deterioration is discovered.

▪ New requirement for trauma admission policy

▪ Same as L4

N/A

Patients may be admitted only if, in the event of deterioration, emergent transfer would result in the patient arriving at the definitive care facility within 120 minutes from the time deterioration is discovered.7

▪ New requirement ▪ Same as L4

7 Hospitals unable to meet this criterion due to their geographic distance from a definitive care hospital should contact trauma system staff to discuss a waiver.

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Ca

tego

ry


Tran

sfer

An age-specific, pre-determined, pre-written plan/protocol/flow chart that directs the internal process for rapidly and efficiently transferring a trauma patient to definitive care. The plan should address such things as: appropriate ground and air transport services, along with contact numbers and backup providers; and what supplies, records, personnel and/or other necessary resources will accompany the patient. Must also clearly identify the anatomical and physiological criteria that, if met, will immediately initiate transfer to definitive care.

The hospital must have a policy directing the internal processes to emergently transfer a trauma patient from the emergency department or an in-patient area to definitive care that lists: ▪ The anatomical and physiological criteria that, when present,

result in immediate transfer, ▪ The criteria must include orthopaedic surgical conditions

and must specifically address how time-sensitive orthopaedic conditions such as a threatened limb, compartment syndrome, dislocated knee and dislocated native hip (i.e., not arthroplasty) will be managed within one hour,

▪ The primary and alternate ground and aeromedical transfer services along with contact information,

▪ The supplies, records and personnel that will accompany the patient.

▪ Lanaguge cleaned up ▪ Specific language indicating

that the policy is to address transfers from both the emergency department and the floor added

▪ Requirement to address ortho conditions added

▪ Same as L4

Designated trauma hospitals may not transfer adult or pediatric patients to undesignated hospitals. Exception: Patients may be transferred to a Veterans Administration Medical Center.

Designated trauma hospitals may not transfer adult or pediatric patients to undesignated hospitals. Exception: Patients may be transferred to a Veterans Administration medical center when medically appropriate.

No change

When a trauma patient is transferred to designated trauma hospital in another state, the sending hospital must attempt to obtain information related to the final disposition of the patient, particularly whether or not the patient required another transfer from the receiving hospital for definitive care.

N/A Eliminated; Same as L4

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Tran

sfer

The hospital must have the following transfer agreements with facilities capable of caring for major trauma patients: ▪ Hemodialysis ▪ Burn care ▪ Acute spinal cord injury In the case of burn care, a second agreement is necessary in the event the primary burn facility lacks the capacity to receive the patient. A comprehensive transfer agreement with a level I or II trauma hospital may suffice if that trauma hospital has the required capabilities.

The hospital must have transfer agreements with trauma hospitals capable of caring for major trauma patients definitively, including agreements with at least two hospitals capable of caring for burn patients,8 and at least one agreement with a designated Level 1 or Level 2 Pediatric Trauma Hospital.

▪ Specific agreements for hemodialysis and acute spinal cord injury eliminated—addressed adequately by comprehensive agreement

▪ New requirement for agreement w/ pediatric trauma hospital

▪ Same as L4

8 Burn injuries include thermal burns, chemical burns and frostbite.

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Gene

ral S

urge

on

Trai

ning

Must successfully complete ATLS® and/or CALS (including the Benchmark Lab or Trauma Module) every four years.9 Surgeons must re-take their ATLS or CALS before or during the month in which it expires.8

General surgeons must have successfully completed ATLS and/or CALS (including the Benchmark Lab or Trauma Module Course) within the last four years. General surgeons must re-take their ATLS or CALS before or during the month in which it expires. 10

▪ Wording only; no change to intent

▪ Antiquated footnote 9 removed

Emer

genc

y Ph

ysic

ian

Trai

ning

11,1

2

If currently board certified with an American Board of Emergency Medicine (ABEM)-approved or American Osteopathic Board of Emergency Medicine (AOBEM) certification, then required to only have successfully completed an ATLS® or CALS course (including Benchmark Lab or Trauma Module) once. 10 If not board certified with an ABEM-approved or AOBEM certification, then must successfully complete ATLS® and/or CALS (including the Benchmark Lab or Trauma Module Course) every four years.9 Emergency physicians must re-take their ATLS or CALS before or during the month in which it expires.12

If the emergency physician is currently board-certified or board-eligible with an American Board of Emergency Medicine (ABEM)-approved13 or American Osteopathic Board of Emergency Medicine (AOBEM) certification, then the physician is required to have successfully completed an ATLS or CALS course (including Benchmark Lab or Trauma Module Course) once. If the emergency physician is not board-certified or board-eligible with an ABEM-approved or AOBEM certification, then the physician must have successfully completed ATLS and/or CALS (including the Benchmark Lab or Trauma Module Course) within the last four years. Emergency physicians must re-take their ATLS or CALS before or during the month in which it expires.14

▪ Footnote 11 added ▪ Footnote 13 added for clarity ▪ Wording cleaned-up ▪ Same as L4

9 For the initial designation only, hospitals may become designated after the medical providers successfully complete the CALS Provider Course only. They must then complete the Benchmark Lab or Trauma Module Course within one year of the Provider Course. 10 There is no grace period for either ATLS or CALS training. The CALS lab component must, too, be re-taken before or during the month in which it expires. 11 This requirement does not apply to those who are called in to assist the attending provider during an unusual and rare event, such as an MCI. 12 Physicians scheduled to work in the emergency department as a second provider must meet the training requirements of the trauma system. 13 Includes physicians board-certified in Pediatric Emergency Medicine by the American Board of Pediatrics 14 There is no grace period for either ATLS or CALS training. The CALS lab component must, too, be re-taken before or during the month in which it expires.

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Adva

nce

Prac

tice

Prov

ider

Tra

inin

g15 Must successfully complete ATLS® and/or CALS (including the

Benchmark Lab or Trauma Module Course) every four years.9 Providers must re-take their ATLS or CALS before or during the month in which it expires.14 This requirement is for those who are regularly scheduled in the emergency department. It does not apply to those who are called in to back-up the attending physician during an unusual and rare event. (See Performance Improvement section.)

Advance practice providers must have successfully completed ATLS and/or CALS (including the Benchmark Lab or Trauma Module Course) within the last four years. Providers must re-take their ATLS or CALS before or during the month in which it expires.16

▪ “…does not apply to those who are called in to back-up the attending physician…” moved to a footnote

▪ Same as L4; no change to intent

Ort

hopa

edic

Su

rgeo

n Tr

aini

ng

May be a surgeon with the ability to do orthopaedic surgery and who is credentialed by the hospital to do so. N/A ▪ Eliminated; unnecessary

▪ Same as L4

15 This requirement does not apply to those who are called in to assist the attending provider during an unusual and rare event, such as an MCI. 16 There is no grace period for either ATLS or CALS training. The CALS lab component must, too, be re-taken before or during the month in which it expires.

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17 Contact the designation coordinator to have in-house curriculum approved before beginning any training. In-house training may be attended concurrently by both RNs and LPNs.

18 This requirement does not apply to those who are called in to assist the attending provider during an unusual and rare event, such as an MCI.

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Regi

ster

ed N

urse

Tra

inin

g

Registered nurses responsible for emergency and/or critical care setting (i.e., ICU) must have successfully completed appropriate professional trauma education. (Example: Trauma Nursing Core Course (TNCC), Comprehensive Advanced Life Support (CALS) Provider Course, Advanced Trauma Care for Nurses (ATCN), Course in Advanced Trauma Nursing (CATN), or in-house training17 that meets the following objectives: ▪ Identify the common mechanisms of injury associated with

blunt and penetrating trauma. ▪ Describe and demonstrate the components of the primary and

secondary nursing assessment of the trauma patient. ▪ List appropriate interventions, based on the assessment

findings, for recognized and suspected life-threatening and non-life-threatening injuries.

▪ Correlate signs and symptoms to specific pathophysiological changes as it they relate to potential injuries.

▪ Describe the ongoing assessment and methods used to evaluate the effectiveness of the interventions.

▪ Examine the facility's specific criteria and protocols for admission or transfer of the trauma patient.

Registered nurses scheduled or expected to cover the emergency department must have successfully completed Trauma Nursing Core Course (TNCC), Comprehensive Advanced Life Support (CALS) Provider Course, Advanced Trauma Care for Nurses (ATCN), or in-house training18 that meets the following objectives: ▪ Identify the common mechanisms of injury associated with

blunt and penetrating injuries. ▪ Describe and demonstrate nursing trauma assessment to

identify typical injuries associated with common mechanisms of injury

▪ List appropriate interventions for injuries identified in the nursing assessment.

▪ Associate signs and symptoms with physiological changes in the patient.

▪ Describe the ongoing assessment to evaluate the effectiveness of interventions.

▪ Review the hospital’s trauma admission and transfer policies.

▪ CATN removed ▪ Training requirement for floor

nurses moved to separate subsection

▪ Some wording cleaned up ▪ Same as L4

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Regi

ster

ed N

urse

Tra

inin

g

N/A

If the hospital admits patients to treat an injury or to monitor the patient for deterioration, registered nurses assigned to patient floors where those patients are admitted must have successfully completed Trauma Nursing Core Course (TNCC), Comprehensive Advanced Life Support (CALS) Provider Course, Advanced Trauma Care for Nurses (ATCN), Trauma Care After Resuscitation (TCAR), Course in Advanced Trauma Nursing (CATN), or in-house training19 relating to the conditions treated or monitored that meets the following objectives: ▪ Identify the common mechanisms of injury associated with

blunt and penetrating injuries. ▪ Describe nursing trauma assessment to identify typical injuries

associated with common mechanisms of injury ▪ List appropriate interventions for injuries identified in the

nursing assessment. ▪ Associate signs and symptoms with physiological changes in the

patient. ▪ Describe the ongoing assessment to evaluate the effectiveness

of interventions. ▪ Review the hospital’s trauma admission and transfer policies.

▪ New subsection to address floor nurses

▪ TCAR included ▪ Same as L4

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Lice

nsed

Pra

ctic

al N

urse

Tra

inin

g

Licensed practical nurses that care for patients in the emergency and/or critical care setting (i.e., ICU) must have successfully completed appropriate trauma education. (Example: Comprehensive Advanced Life Support (CALS) Provider Course, Rural Trauma Team Development Course (RTTDC), audit of a Trauma Nursing Core Course (TNCC), audit of a Course in Advanced Trauma Nursing (CATN), or in-house training12 that meets the following objectives: ▪ Identify the common mechanisms of injury associated with

blunt and penetrating trauma. ▪ Recognize common signs and symptoms of potentially life-

threatening and non-life-threatening injuries. ▪ Identify data needed for the ongoing monitoring of a trauma

patient. ▪ Demonstrate role-specific trauma care competencies. ▪ Examine the role-specific practice parameters for trauma care

as defined by the hospital. ▪ Examine the facility's specific criteria and protocols for

admission or transfer of the trauma patient.

Licensed practical nurses scheduled or expected to cover the emergency department must have successfully completed Comprehensive Advanced Life Support (CALS) Provider Course, Advanced Trauma Care for Nurses (ATCN), an audit of Trauma Nursing Core Course (TNCC), or in-house training20 that meets the following objectives: ▪ Identify the common mechanisms of injury associated with

blunt and penetrating injuries ▪ Recognize common signs and symptoms of injuries. ▪ Identify data needed for the ongoing monitoring of a trauma

patient. ▪ Demonstrate role-specific trauma care competencies. ▪ Examine the role-specific practice parameters for trauma care

as defined by the hospital. ▪ Review the hospital’s trauma admission and transfer policies.

▪ CATN removed ▪ Training requirement for floor

LPNs moved to separate subsection

▪ RTTDC removed ▪ Some wording cleaned up ▪ Same as L4

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Lice

nsed

Pra

ctic

al N

urse

Tra

inin

g

N/A

If the hospital admits patients to treat an injury or to monitor the patient for deterioration, licensed practical nurses assigned to patient floors where those patients are admitted must have successfully completed Comprehensive Advanced Life Support (CALS) Provider Course, Rural Trauma Team Development Course (RTTDC), Trauma Care After Resuscitation (TCAR), an audit of a Trauma Nursing Core Course (TNCC), or in-house training21 relating to the conditions treated or monitored that meets the following objectives: ▪ Identify the common mechanisms of injury associated with

blunt and penetrating injuries ▪ Recognize common signs and symptoms of injuries. ▪ Identify data needed for the ongoing monitoring of a trauma

patient. ▪ Describe role-specific trauma care competencies. ▪ Examine the role-specific practice parameters for trauma care

as defined by the hospital. ▪ Review the hospital’s trauma admission and transfer policies.

▪ New subsection to address floor LPNs

▪ TCAR, RTTDC included ▪ Same as L4

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Perf

orm

ance

Impr

ovem

ent P

roce

ss

The trauma PI program shall consist of a formal policy that includes a minimum of the following: 1. Defined population of trauma patients to be monitored 2. Set of indicators/audit filters to include:

A. General surgeon non-compliance with response time and communication requirements

B. Emergency department provider non-compliance with on-call response times

C. Trauma patient admitted to a non-surgeon and no surgeon consult

D. Trauma care provided by physicians who do not meet minimal educational requirements, i.e., ATLS® or CALS

E. Trauma activation and length of stay before transfer >60 minutes

F. Patient met trauma transfer criteria and admitted locally G. All trauma deaths H. Trauma patients transferred out I. Trauma patients received via transfer

3. Frequency of review 4. Multidisciplinary physician involvement 5. Standard of care Demonstration of loop closure and resolution

The hospital must establish a trauma performance improvement policy that: ▪ Establishes methods to identify and resolve clinical care and

process issues that are inconsistent with industry standards and best practices for trauma care.

▪ Provides for the review or surveillance of trauma cases that meet the trauma registry inclusion criteria to identify potential clinical care and process issues.

▪ Establishes trauma performance improvement filters. ▪ Establishes the frequency of case finding and case review. ▪ Incorporates performance-related information received from

receiving hospitals about patients transferred. ▪ Includes documentation of

▪ Performance improvement filters that fall out, ▪ Findings from case reviews, ▪ Actions undertaken to correct clinical care and process

issues identified during case reviews. ▪ Resolution of issues identified by surveillance or case

review.

▪ PI section reworked ▪ Trauma case population defined ▪ Feedback from receiving

hospitals must be incorporated ▪ Documentation requirements

added ▪ Required filters moved to their

own sub-section

http://www.health.state.mn.us/traumasystem/registry/registry_inclusion.pdf

2 0

Cate

gory


Perf

orm

ance

Impr

ovem

ent P

roce

ss

N/A The scope of case review must include care provided in the emergency department, in-patient units and all areas and departments of the hospital that provide or affect trauma care.

▪ Scope of case review defined ▪ Same as L4

N/A Results of the trauma case reviews that identify opportunities to improve clinical care must be communicated with the medical providers.

▪ Information sharing w/ medical providers required

▪ Same as L4

N/A

Case finding and primary case review must occur, at a minimum, every two weeks. Medical director review of trauma cases must occur, at a minimum, monthly.

▪ Minimum case finding, primary and secondary review frequency established

▪ Same as L4

N/A

The hospital must establish and monitor performance improvement filters that include: ▪ General surgeon non-compliance with response time and

communication requirements ▪ Emergency department provider non-compliance with on-call

response times ▪ Trauma patient admitted to a non-surgeon without surgeon

consult ▪ Trauma care provided by physicians who do not meet minimal

educational requirements ▪ Trauma team activation and length of stay before transfer >60

minutes ▪ Met trauma transfer criteria and admitted locally

Eliminated deaths & transfers; addressed above by case definition

2 1

Ca

tego

ry


Perf

orm

ance

Impr

ovem

ent P

roce

ss

The PI process should review all cases when medical providers who do not normally provide emergency department coverage are called in to back-up the attending physician during a rare and unusual event.

N/A

Addressed by required filter, “Trauma care provided by physicians who do not meet minimal educational requirements”

The overall responsibility of concurrent and retrospective review of the care of trauma patients lies with the trauma program medical director/advisor and the trauma program coordinator/manager in conjunction with the trauma PI committee and the physician multidisciplinary peer review committee.

The trauma performance improvement process may be integrated with the hospital’s quality improvement processes; but the trauma program leaders must retain oversight over the program’s performance improvement initiatives. Potential clinical care issues referred to other bodies within the hospital or health system, such as peer review, or other organizations must be made available to the trauma program leadership.

▪ Consolidation of concepts ▪ Requirement for TPM, TMD to

retain oversight over all trauma PI initiatives added

▪ Same as L4

The trauma PI program shall be consistent with medical staff and facility policies. All trauma hospitals shall work with the MDH in statewide PI activities The PI process may be performed by the trauma hospital’s trauma committee or by an appropriate PI standing committee.

If tele-radiology is utilized, this process shall be monitored and evaluated by the trauma PI program.

The trauma program must monitor imaging interpretation turnaround times and review missed diagnoses identified from over-read reports.

▪ Specificity added ▪ Requirement to apply to all

radiology providers, not just tele-radiology.

▪ Same as L4

2 2

Cate

gory


Prov

ider

Cas

e Re

view

A mechanism shall be established by which all physicians caring for trauma patients are involved in confidential peer review of the care in accordance with facility and medical staff policy. These physicians will regularly review and discuss: ▪ Results of trauma peer review activities. ▪ Problematic cases including complications. ▪ All trauma deaths, identifying each death as non-preventable,

possibly preventable, or preventable. * The peer review process and minutes of this committee should be confidential and in accordance with facility and medical staff policy. Utilization of trauma registry data will facilitate the entire PI and peer review process. *The STAC has adopted standardized definitions based on industry standards. See the Trauma Hospital Resource Manual.

The hospital must establish a mechanism by which all physicians and advance practice providers that care for trauma patients review cases identified by the trauma program leaders in a committee format to identify opportunities to improve trauma care and prescribe remedies.

▪ References to “peer review” removed

▪ Requirement to classify deaths removed

▪ Wording consolidated

General surgeons, general surgical advance practice providers involved in trauma care, emergency department physicians and emergency department advance practice providers on staff must attend a minimum of 50% of the scheduled meetings. If liaisons attend as a representative of their disciplines, other members of the discipline must attend a minimum of 50% of their disciplines’ case review meetings.

General surgeons, general surgical advance practice providers involved in trauma care, emergency department physicians and emergency department advance practice providers on staff must attend a minimum of 50% of the scheduled meetings. If liaisons attend as a representative of their disciplines, other members of the discipline must attend a minimum of 50% of their disciplines’ case review meetings.

No change

2 3

Cate

gory


Mul

tidisc

iplin

ary

Case

Rev

iew

Must have an established mechanism by which all those involved in caring for trauma patients are involved in a review of the care. In addition to attendance by emergency, general surgery, anesthesia, radiology and ICU staff; administration, nursing, radiology, lab, anesthesia and other ancillary personnel might attend.

The hospital must establish a mechanism by which clinical disciplines involved in providing care for trauma patients review cases identified by the trauma program leaders in a committee format to identify opportunities to improve trauma care processes and prescribe remedies.

Establishes focus on care processes

Emergency medicine, general surgery, orthopaedic surgery, neurosurgery, radiology, laboratory, blood bank and critical care disciplines must participate in multidisciplinary case review. Representatives from other surgical subspecialties, anesthesia, administration, nursing, emergency medical services and ancillary service personnel must also attend when required by the trauma program manager and the trauma medical director.

▪ Requirement for all providers to attend supplanted with requirement for specific disciplines to attend

▪ Required disciplines expanded

Dive

rsio

n Trauma hospitals shall have a formal, trauma-related diversion policy and a mechanism established to review times and reasons for trauma-related diversion.

The hospital must establish a policy that: ▪ Identifies the circumstances that may require trauma patients

to be diverted to another hospital; ▪ Lists the hospital personnel responsible for the decision to

divert trauma patients; ▪ Establishes the procedure to notify hospital departments, EMS

agencies and other area hospitals of the need to divert trauma patients and when the need to divert patients has ended.

▪ Policy requirements detailed ▪ Requirement to review

individual diversions supplanted with requirement to review divert status

Instances in which the hospital implements divert status must be reviewed through the trauma performance improvement process.

2 4

Cate

gory


Trau

ma

Regi

stry

Collect trauma data using either the state Web-based system or an in-house program and submit the required data to the statewide trauma system within 60 days of the patients’ discharge or transfer.

The hospital must submit data as defined by the State Trauma Advisory Council within 60 days of the patients’ discharge or transfer. Data imported from other sources must be submitted in a manner and format that is acceptable to MDH.

▪ Wording cleaned-up ▪ Requirement to import data in

acceptable format added ▪ Same as L4

Regi

onal

Tr

aum

a Ad

i The trauma hospital must actively participate in at least one

Minnesota regional trauma advisory committee (RTAC) or subcommittee of a Minnesota RTAC. Active participation is defined as attending at least 50% of the scheduled meetings.

The hospital must actively participate in at least one Minnesota regional trauma advisory committee (RTAC) or subcommittee of a Minnesota RTAC. Active participation is defined as attending at least 50% of the scheduled meetings.

No change

Inju

ry

Prev

entio

n

Coordination and/or participation in community prevention activities

The hospital must participate in community injury prevention activities. Wording cleaned-up

2 5

22 For pediatric sizes, ensure that there is one size for each age/size category of the length-based resuscitation tape or reference manual.

Cate

gory


Equi

pmen

t22

Emer

genc

y De

part

men

t Airway control and ventilation equipment Arterial tourniquet Pulse oximetry Suction devices Electrocardiograph/oscilloscope/defibrillator Standard IV fluids and administration sets Large bore IV catheters Drugs necessary for emergency care Nasal gastric & oral gastric tubes Spine immobilization boards and C-collars Pediatric length-based resuscitation tape Thermal control for patient and fluids/blood Rapid infuser system (may use pressure bag) End-tidal CO2 detector (may be disposable) Communications with EMS Mechanism for IV flow-rate control Intraosseous administration sets Supplies for surgical airway & thoracostomy Central lines (desired; not required)

Airway control and ventilation equipment Arterial tourniquet Pulse oximetry Suction devices and supplies EKG monitor and defibrillator Crystalloid IV fluids and administration sets IV catheters from 14 – 22 Ga. Drugs necessary for emergency trauma care Nasal gastric & oral gastric tubes Cervical collars Pediatric length-based resuscitation tape or reference manual Blanket warmer or overhead radiant heater Warming cabinet for IV fluids or inline IV fluid warmer Rapid IV fluid infuser system (may use pressure bag) Quantitative end-tidal CO2 Method to communicate with EMS Mechanism for IV flow-rate control Intraosseous needles and administration sets Supplies for surgical airway & thoracostomy Mechanism for pelvic stabilization Central lines (desired; not required)

▪ Mechanism for pelvic stabilization added

▪ Warming mechanisms modified slightly

▪ Spine boards removed ▪ CO2 detector supplanted with

“quantitative end-tidal CO2” ▪ Same as L4 w/ exception of

central lines

2 6

Cate

gory


Equi

pmen

t23

Imag

ing

Dept

. N/A Airway control and ventilation equipment

Suction device and suction supplies ▪ New sub-section ▪ Same as L4

Ope

ratin

g Ro

om Thermal control for patient and fluids/blood

X-ray capabilities including C-arm intensifier Rapid infuser system (may use pressure bag)

Blanket warmer or other mechanism for thermoregulation Warming cabinet for IV fluids or inline IV fluid warmer X-ray capabilities including C-arm intensifier Rapid infuser system (may use pressure bag)

Warming mechanisms modified slightly

Post

An

esth

esia

Re

cove

ry

Equipment for monitoring and resuscitation Pulse oximetry Thermal control for patients and fluids/blood

Equipment for monitoring and resuscitation Pulse oximetry Blanket warmer or other mechanism for thermoregulation Warming cabinet for IV fluids or inline IV fluid warmer

Warming mechanisms modified slightly

Inte

nsiv

e Ca

re

Uni

t Equipment for monitoring and resuscitation Ventilator (transport ventilator is not sufficient)

Equipment for monitoring and resuscitation Ventilator (transport ventilator is not sufficient) No change

In-p

atie

nt

Uni

t

N/A Equipment for monitoring and resuscitation ▪ New sub-section ▪ Same as L4

23 For pediatric sizes, ensure that there is one size for each age/size category of the length-based resuscitation tape or reference manual.

Level 3 Trauma Hospital Designation Criteria Side by Side · Level 3 Trauma Hospital Designation...

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