Iowa Department Of Public Health-Bureau Of Emergency .
Iowa Department of Public Health-Bureau of Emergency Medical ServicesIowa Trauma System Regional (Level II)Hospital and Emergency Care Facility Categorization Criteria (2013)CriteriaGENERAL STANDARDSRequirements1. Trauma care facility (TCF)commitmenta. Current written resolutionsupporting the Trauma CareFacility (TCF) from the hospitalboard and administration.Eb. Current written resolutionsupporting the TCF from themedical and nursing staff.Ec. Commitment to State traumacommittees.EEInterpretive Guidelines1a, b. There must be current (reaffirmed every three years) written documentation ofdedicated financial, physical, human resources, community outreach activities, andeducational activities(not limited to Trauma Nurse Core Course (TNCC), AdvancedTrauma Life Support (ATLS), and/or Rural Trauma Team Development Course (RTTDC)).The preferred commitment documentation should be in letterform, dated, and signedby, at a minimum,a. CEO and Board presidentb. Medical Staff President, Chief Nursing Officer, Trauma Nurse Coordinator/TraumaProgram Manager, Trauma Medical Director, ED Medical Director.c. Commitment to Iowa Trauma System and EMS activities, for example Iowa TraumaCoordinators, American College of Surgeons (ACS), Iowa Chapter Committee on Trauma, IowaChapter of American College of Emergency Physicians (ACEP), Iowa Emergency Medical ServiceAssociation (IEMSA),Trauma System Advisory Council (TSAC), System Evaluation QualityImprovement Committee (SEQIC), Emergency Medical Service Advisory Committee (EMSAC).INSTITUTIONAL ORGANIZATION1. Trauma program (TP)a. Official organizationalchartb. Administrative structurec. Ensures optimal and timely careEEE1. a, b. Trauma program that includes an administrator, medical director, trauma programmanager/coordinator, and trauma PIPS committees. The trauma program’s location in theorganizational structure of the facility shall be equal in authority and interaction with otherdepartments and or service lines providing patient care. The trauma program shall involvemultiple disciplines that transcend departmental hierarchies across the continuum of care. All ofthis should be shown on an official trauma program/service organizational chart thatdemonstrates the administrative and medical staff relationships of the TSMD, theTPM/Coordinator, and the trauma PIPS committees.c. To ensure optimal and timely care a multidisciplinary trauma program must continuouslyevaluate its processes and outcomes.E-EssentialD-Desirable
Regional (Level II) Trauma Care Facility Categorization and Verification CriteriaCriteriaRequirementsInterpretive Guidelines2. Trauma service (TS)E3. Trauma teama. Trauma team activation policyEEThe trauma service represents a structure of care for the injured patient. The care of the patientwith multisystem injuries shall be under the supervision of a trauma/general surgeon assignedto the trauma service. All other injured patients, with the exclusion of isolated hip fracturesfrom a same level fall or minor isolated single system injuries, must be admitted to or seen inconsultation by a trauma/general surgeon assigned to the trauma service. For example, patientswith isolated simple fractures with low-grade soft tissue injuries may be appropriately treatedby an orthopedic surgeon.The size of the trauma team may vary from facility to facility depending upon physician specialtyresources, hospital resources, severity of the patient’s injuries, and methods of patienttransportation to the trauma care facility.The highest level trauma team response to a severely injured patient typically includes: 1)general surgeon, 2) emergency physician, 3) surgical and oremergency residents if available, 4) ED nurses, 5) scribe nurse, 6) OR nurse, 7) lab technician, 8)radiology technologist, 9) ICU nurse, 10) anesthesiologist or CRNA, 11) security officer, and12) chaplain and or social worker. Facilities may use more than one level of traumateam response based on the variables listed above. The minimum criteria for a (majorresuscitation) high level trauma team response shall include any of the following:1) Confirmed blood pressure 90 at any time in adults and agespecific for pediatrics;2) Respiratory compromise/obstruction and/or intubation;3) Penetrating wounds to the head, neck, chest, or abdomen;4) GCS 8 with mechanism attributed to trauma.5) Transfer of patients from another TCF receiving blood to maintainvital signs;6) Emergency physicians discretionThe Trauma Team Activation Protocol/Policy should 1) lists all team members 2) definesresponse requirements for all team members when a trauma patient is en route or has arrivedat the TCF, 3) establishes/identifies the criteria, based on patient severity of injury, for activationof the trauma team, and 4) identifies the person(s) authorized to activate the trauma team.Time critical injuries have been identified in the OOHTTDDP (Box #1 and Box #2) and the InterTrauma Care Facility Triage and Transfer Protocol.2
Regional (Level II) Trauma Care Facility Categorization and Verification CriteriaCriteriaRequirementsInterpretive Guidelines4. Trauma Service Medical Director(TSMD)a. Board-certified general surgeonwith a special interest in traumacareb. Current ATLS c. 24 hours continuing traumaeducation every four years1) 8 hours formal2) 16 hours informalEThe types of conditions and injuries listed in the physiologic and anatomic sections of thisprotocol require a trauma alert/activation. Changes in these criteria must be supported bydocumentation from the trauma PIPS program. The trauma team activation policy shall includeboth physiological and anatomic criteria for when the general surgeon and the ED physician areexpected to meet the patient upon arrival at the ED when given timely notice by EMS. Themaximum acceptable response time is 15 minutes. The response time shall be tracked frompatient arrival rather than from notification or activation. An 80% surgeon response thresholdmust be met for the highest level (Level I) activations.a. A non-boarded surgeon may qualify to serve as TSMD if he/she is a fellow of the ACS.5. Trauma Program Manager(TPM)/Trauma Nurse Coordinator(TNC)/Trauma Coordinator (TC)a. 16 hours of continuingtrauma education:4 hours formal(refresher course in traumanursing course objectivesrecommended by TSAC isrequired), 12 hours informal.b. Trauma program supportpersonnelEThe TSMD or designee should participate in trauma continuing education activities in-house andon an outreach basis up to and including participation as an ATLS instructor in Iowa.EEThe TSMD shall have “the authority” to affect all aspects of trauma care including, but notlimited to: 1) recommending trauma team privileges in cooperation with appropriate disciplines;2) developing treatment protocols; 3) leading multidisciplinary performance improvement andpatient safety committees; 4) correcting deficiencies in trauma care and excluding from traumacall those trauma team members who do not meet criteria; 5) supporting the nursing needs ofthe trauma patient; and 6) assist in the budgetary process for the trauma program. These rolesand responsibilities shall be outlined in a formal job description.EThe TPM/TNC/TC is usually a Registered Nurse and responsible for the organization ofservices and systems necessary for a multidisciplinary approach to the care of the injuredpatient. The roles and responsibilities of the TPM/TNC/TC shall be outlined in a formal jobdescription.EEa. Successful completion of trauma nursing course objectives recommended by TSAC andTrauma System Overview.b. Trauma program support personnel might include a trauma registrar, clinical support nurseand secretary. They are to be supervised by the TPM and have a formal job description.Administrative and budgetary support needed for the TPM/TNC/TC depends on the size of theprogram. As a guideline, one can identify the need for an additional full-time equivalentregistrar for each 750-1,000 admissions per year.3
Regional (Level II) Trauma Care Facility Categorization and Verification CriteriaCriteria6. Trauma committeesa. Trauma program (system)performance committeeb. Multidisciplinary physicianpeer review (PIPS) committeeRequirementsEEEInterpretive Guidelinesa. TCFs shall have a multidisciplinary trauma performance (system) Committee, chaired by theTSMD or his/her designee that identifies and corrects trauma program system and serviceprovider issues unrelated to peer review. The committee should work to correct overallprogram deficiencies and continue to optimize patient care. The committee membership shallinclude all program-related services. It should meet regularly (minimum quarterly), and takeattendance. Minutes that document the issues and any corrections should be developed andprovided to the appropriate individuals.b. TCFs shall have a multidisciplinary (physician) peer review committee, chaired by the TSMD orhis/her designee. The committee shall be comprised of but not limited to, the TSMD,representatives from general surgery, orthopedic surgery, neurosurgery, emergency medicine,anesthesia, radiology and the TPM/TNC or his/her alternate. There shall be an attendancerequirement for physician members/liaisons of 50% of the total meetings per year for thiscommittee. All physicians involved in the care of any of the trauma patients to be discussedshould be invited to attend the meeting. The committee should meet regularly (most oftenmonthly) frequently after the system committee meeting. Minutes should document thediscussions and their outcomes. This committee shall review trauma morbidity, mortality (alltrauma deaths), complications, sentinel events, physician issues, response times,appropriateness and timeliness of care, and evaluation of care priorities among physicianspecialists. Included in this process should be a review of the TSMD’s cases.It is the responsibility of this committee to identify and resolve specific problems and issues. Thecommittee should be able to demonstrate how loop closure and/or trending will beaccomplished to avoid patient care problems in the future. Loop closure may be demonstratedby attendance of the attending physician at the peer review session, through memo, letter ordocumentation of verbal consultation. Communication in return by the attending physician ispart of the loop closure process. This process may trigger new policies/protocols and shouldhave the representatives from the various departments act as a conduit for information back totheir respective departments.This review should function under the aegis of the performance improvement program of theTCF and be separate from a single specialty department-based peer review.4
Regional (Level II) Trauma Care Facility Categorization and Verification rementsInterpretive guidelines1. SurgeryE2. Neurological surgeryE3. Orthopedic surgeryE4. Emergency medicineEThere shall be an attendance requirement of 50% of the total meetings per year for bothtrauma program performance (system) committee and multidisciplinary physician peer reviewcommittee.The department/division/section of neurosurgery should have a liaison to the trauma servicewho is a member of both trauma committees. This individual is either the chief/director orhis/her designee and is responsible for communication between the TSMD, trauma committeeand the members of his/her department/division/section.The department/division/section of orthopedic surgery should have a liaison to the traumaservice who is a member of both trauma committees. This individual is either the chief/directoror his/her designee and is responsible for communication between the TSMD, traumacommittee and the members of his/her department/division/section.The department/division/section of emergency medicine should have a liaison to the traumaservice who is a member of both trauma committees. This individual is either the chief/directoror his/her designee and is responsible for communication between the TSMD, traumacommittee and the members of his/her department/division/section.5. AnesthesiaE6. RadiologyEThe department/division/section of anesthesia should have a liaison to the trauma service whois a member of both trauma committees. This individual is either the chief/director or his/herdesignee and is responsible for communication between the TSMD, trauma committee and themembers of his/her department/division/section.The department/division/section of radiology should have a liaison to the trauma service who isa member of both trauma committees. This individual is either the chief/director or his/herdesignee and is responsible for communication between the TSMD, trauma committee and themembers of his/her department/division/section5
Regional (Level II) Trauma Care Facility Categorization and Verification CriteriaCriteriaCLINICAL CAPABILITIESRequirementInterpretive Guidelines1. Published on-call scheduleEPublished and posted call schedules must specifically identify the physician’s on-call and back-upcall for general/trauma surgeons and as required for neurosurgeons and orthopedic surgeons.The call schedules shall be posted in all areas of the TCF caring for the trauma patient (ED, ICUor medical floor).The active involvement of the trauma/general surgeon is crucial to optimal care of theinjured patient in all phases of management. The trauma/general surgeon is expected to be inthe emergency department upon arrival of the time critical injured patient. The 24-hour inhouse availability of the trauma/general surgeon is the most direct method for providing thisinvolvement. Alternate methods of providing this involvement are acceptable. In trauma carefacilities with residency programs, evaluation and treatment may be started by a team ofsurgeons that will include post graduate year 4 (PGY4) or more senior surgical residents who aremembers of that facilities residency program. This may allow the attending surgeon to take callfrom outside the facility. Local criteria must be established to define conditions requiring theattending surgeon’s immediate facility presence. The attending surgeon’s participation in majortherapeutic decisions, operative procedures are mandatory.a. General surgeryECompliance with these criteria and their presence in the emergency department for majorresuscitations must be monitored by the trauma Performance Improvement Patient Safety(PIPS) program.In trauma care facilities without residency programs, local conditions may allow the surgeons tobe rapidly available on short notice. Under these circumstances local criteria must beestablished that allow the general surgeon to take call from outside the facility, but with clearcommitment on the part of the facility and the surgical staff that the general surgeon will bepresent in the emergency department at the time of arrival of the trauma patient to superviseresuscitation and major therapeutic decisions, provide operative treatment, and be available tocare for trauma patients in the ICU. Compliance with this requirement and applicable criteriamust be monitored by the trauma PIPS program.The presence of the trauma/general surgeon in the emergency department at the time of arrivalof the patient is expected for all high level trauma alert activations when the hospital was giventimely notice by out-of-hospital providers as to the expected arrival of the patient. If thehospital is not given timely notice by out-of-hospital providers as to the expected arrival of the6
Regional (Level II) Trauma Care Facility Categorization and Verification CriteriaCriteriab. General surgery callschedule1). Published call and back-upCall schedule2). Dedicated to single hospitalwhen on first/primary callRequirementInterpretive GuidelinesEpatient it is expected that the trauma team respond immediately upon notification of a highlevel trauma alert. The maximum acceptable response time is 15 minutes, tracked from patientarrival rather than from notification or activation. The program must demonstrate that thesurgeon’s presence is in compliance at least 80% of the time for the highest level activations.RequiredEEc. AnesthesiaEAnesthesia services must be available in-house 24 hours a day. This requirement may be fulfilledby anesthesiology chief residents or Certified Registered Nurse Anesthetists (CRNAs). Whenanesthesiology chief residents or CRNAs are used to fulfill the anesthesiology availabilityrequirements, the staff anesthesiologist on call must be advised, promptly available at all times,and present for operative procedures. With regard to anesthesia, requirements may be fulfilledwhen local conditions assure that the staff anesthesiologist will be in the hospital at the time ofarrival of the trauma patient. During the interim period prior to the arrival of the staffanesthesiologist an in-house certified registered nurse anesthetist (CRNA) capable of assessingemergent situations in trauma patients, and initiating and providing any indicated treatment willbe available. In some hospitals without a CRNA in-house, local conditions may allowanesthesiologists to be rapidly available on short notice. Under these circumstances, localcriteria must be established to allow anesthesiologists to take call from outside the hospital andto define conditions requiring the anesthesiologist’s immediate presence at the bedside. Theavailability of the anesthesia services and the absence of delays in airway control or operativeanesthesia must be documented by the trauma or hospital PIPS program.d. Emergency medicineEEmergency medicine residents may be used to fulfill this requirement however, supervisionmust be provided by an in-house attending emergency physician 24 hours per day.7
Regional (Level II) Trauma Care Facility Categorization and Verification CriteriaCriteriaOn-call and promptly available 24hours/daya. Neurologic surgery1)Dedicated to one hospitalor backup call schedulerequiredRequirementsEEInterpretive GuidelinesThe trauma PIPS program shall clearly define the expected response and monitor availability ofthe staff specialists on call.Neurotrauma care must be promptly and continuously available for severe TBI and spinal cordinjury and for less severe head injuries or injuries of the spine, when necessary.It is essential that Trauma Care Facility have a reliable neurosurgeon on-call schedule with aformal contingency plan for the care of neurotrauma patients if the capability of theneurosurgeon(s), hospital, or system to care for these patients is overwhelmed. In communitieswhere the number of neurosurgeons are limited or required to cover more than one TCF at atime, a plan shall be in place that defines how neurotrauma patients are managed; specificallywhat patient may be managed at this TCF or which patients need to be transferred. The care ofthese patients shall be monitored as part of the Performance Improvement Patient Safety (PIPS)program. The plan will remain acceptable as long as PIPS confirms optimal delivery ofneurotrauma care and outcome.The contingency plan for the care of neurotrauma patients shall include one of the followingmodels for providing back-up neurosurgical call:1. In TCFs with an accredited neurosurgical residency-training program, the neurosurgeryresident may provide back up call, and/or,2. A trauma/general surgeon, who has been credentialed in the initial management ofneurotrauma as determined by the director of neurosurgery, may provide initial triage andback-up call, and/or3. A plan to transfer the neurotrauma patient to a similar or higher level Trauma Care Facilitycapable of caring for neurotrauma patients. This plan must include communication with EMSregarding neurosurgical coverage.The above back-up call models may be acceptable as long as PIPS confirms optimal delivery ofneurotrauma care and outcome.Neurosurgeons taking neurotrauma call should recognize and support the clinical care parametersestablished in the Brain Trauma Foundation:
c. Commitment to Iowa Trauma System and EMS activities, for example Iowa Trauma Coordinators, American College of Surgeons (ACS), Iowa Chapter Committee on Trauma, Iowa Chapter of American College of Emergency Physicians (ACEP), Iowa Emergency Medical Service Association (IEMSA),Trauma System Advisory Council (TSAC), System Evaluation Quality
Iowa Chapter, American Academy of Pediatrics Iowa Dental Association Iowa Department of Public Health Iowa Health Care Association Iowa Hospital Association Iowa Medical Society Iowa Nurses Association Iowa Pharmacy Association Iowa Veterinary Medical Association Iowa‘s Statewide Epidemiology Education and Consultation Program State Hygienic .
Stephanie Trusty, Nurse Clinician, Iowa Department of Public Health-Patrick J. Carr and Marka J. Kefalas. Hollowing Out the Middle: The Rural Brain Drain and What It Means for America. Beacon Press, 2009. Iowa Department of Public Health-Obstetrical Care in Iowa: A Report on Health Care Access to the Iowa State Legislature -Year 2019
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