NORTH CAROLINA S TRAUMA CENTER CRITERIA October 1, 2000

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1 NORTH CAROLINA S TRAUMA CENTER CRITERIA October 1, 2000 Levels INSTITUTIONAL ORGANIZATION Trauma program E E E Trauma service 1 E E E Trauma team 2 E E E Trauma registry 3 E E E Trauma program medical director E E E Trauma nurse coordinator (must be full-time for I & II) E E E Trauma registrar (must be full-time for I & II) E E E Trauma multidisciplinary committee (at least quarterly to critique cases) E E E Written credentialing process for surgeons covering trauma service 4 E E E HOSPITAL DEPARTMENTS/DIVISIONS/SECTIONS General Surgery E E E Neurological surgery E E D Orthopaedic surgery E E D Emergency medicine E E E Anesthesia E E E CLINICAL CAPABILITIES Two distinct published call schedules one for trauma, one for general E E E surgery, with defined back-up surgeon listed on the trauma schedule if a physician may simultaneously be listed on both schedules. If a trauma surgeon is simultaneously on call at more than one hospital, there must be a defined back-up listed on the trauma schedule. Published on call schedule for neurosurgeons, orthopaedic surgeons & E E - other major specialists Standard written protocols (routinely updated) relating to trauma care E E E mgmt. Criteria to ensure trauma team activation within 20 minutes prior to E E E patient arrival 5 Prompt surgical consults initiated based upon written criteria 6 E E E On call and promptly available (within 30 minutes of notif.) 24 hours/day Cardiac surgery E D - Cardiology E E D Hand surgery E D - Infectious Disease E D - Internal Medicine & Subspecialties E E E Microvascular/replant surgery E D - Neurologic surgery E E D Dedicated to one hospital or written back-up call schedule E E D Obstetrics/gynecologic surgery E E D Page 1 of 12

2 Levels Ophthalmic surgery E E D Oral/maxillofacial surgery E E - Pathology D D - Pediatrics E E - Pediatric Surgery E D - Plastic Surgery E E D Psychiatry D D D Pulmonary Medicine E E - Radiology E E D Thoracic Surgery (provided by a board certified thoracic surgeon or E E - general trauma surgeon w/thoracic surgical privileges) Urologic Surgery E E D CLINICAL QUALIFICATIONS Trauma program medical director Board certified general surgeon E E E Minimum of 3 years clinical experience on a trauma service and/or E E - trauma fellowship training Serve on the center s trauma service E E - Participate in providing care to patients w/life-threatening or urgent E E - Injuries Participate in the NC Chapter of ACS Committee on Trauma E E - Remain a current provider in ACS/ATLS course & in provision of E E - trauma related instruction to other health care personnel Be involved with trauma research and the publication of results & E D presentations Attending general surgeons on trauma service Board certif. in general surgery w/in 5 years of completing residency E E E 20 hrs. Category I trauma-related CME every two years E E E Multidisciplinary trauma conference attendance E E E Designated emergency department physician director E E E Board certified or board prepared in emergency medicine, by the E E E American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine Emergency department physician attendings 20 hrs. Category I trauma-related CME every two years E E E Board certification & emergency medicine as a primary specialty(see E E E Footnote #2, paragraph 4) Multidisciplinary trauma conference attendance E E E Trauma Nurse Coordinator Registered nurse licensed by North Carolina Board of Nursing E E E 20 hours continuing education beyond in-house inservices every 2 years E E E Page 2 of 12

3 Levels Trauma Registrar Working knowledge of medical terminology, is able to operate a E E E personal computer and has demonstrated ability to extract data from medical records 8 hours of trauma registry related or trauma related continuing E E E education each year RNs and LPNs in transport programs, EDs, primary intensive care units primary trauma floors, and other areas as determined by Trauma Nurse Coordinator 16 hrs. of trauma related continuing education every two years (80% E E E compliance rate) Multidisciplinary trauma conference attendance E E E ED nursing personnel who continually monitor trauma patients from E E E hospital arrival to disposition must have experience in trauma care Physician assistants and mid-level practitioners - 8 contact hours of E E E trauma related continuing education every year Prehospital personnel and other health care providers Multidisciplinary trauma conference attendance E E E FACILITIES/RESOURCES/CAPABILITIES Volume Performance For initial trauma center applicants, justification of the following: Population to be served and extent to which population is underserved for trauma care, including methodology used Geographic considerations to include catchment area and distance from other trauma centers Trauma patient volume and severity of injury for the facility for the 24 month period of time preceding application That trauma service will care for at least 200 trauma patients with an ISS > 13 during the first 24 months of its designation. This must be accomplished w/out compromising quality of care or cost effectiveness of any other designated Level I or II trauma center sharing all or part of its catchment area or by jeopardizing the existing center s ability to meet this same 200 patient minimum. E E - E E - E E - E E - Emergency Department (ED) Equipment for resuscitation for patients of all ages Airway control & ventilation equipment E E E Pulse oximetry E E E Suction devices E E E Electrocardiograph-oscilloscope-defibrillator E E E Central venous pressure monitoring E E E Intravenous fluids and administration devices E E E Large-bore intravenous catheters E E E Sterile surgical sets for Page 3 of 12

4 Levels Airway control/cricothyrotomy E E E Thoracostomy E E E Vascular access E E E Thoracotomy E E E Arterial catheters E E D X ray availability 24 hours/day E E E Traction devices, skeletal and cervical E E E Thermal control equipment For patient E E E For fluids and blood E E E Qualitative end-tidal CO 2 determination E E D Gastric decompression apparatus E E E Communication with EMS vehicles E E E Operating Room Immediately available 24 hours/day E E D Personnel In-house 24 hours/day E E D Age-specific equipment Cardiopulmonary bypass capability E D - Operating microscope E D - Thermal control equipment For patient E E E For fluids and blood E E E 24 hr./day x-ray capability, including c-arm image intensifier E E D Endoscopes E E D Craniotomy instrume nts E E D Equipment for long bone and pelvic fixation E E D Postanesthetic Recovery Room (SICU is acceptable) Registered nurses & other essential personnel available in-house 24 E E - hours/day Registered nurses within 30 minutes from inside or outside hospital 24 E hours per day Age specific equipment: For continuous monitoring of temperature, hemodynamics & gas E E E exchange For continuous monitoring of intracranial pressure monitoring E E D Pulse oximetry E E E End tidal CO 2 determination E E D Thermal control For patient E E E For fluids and blood E E E Page 4 of 12

5 Levels Intensive or Critical Care Unit for Injured Patients Designated surgical director of trauma patients E E E Surgical ICU service physician in-house 24 hours/day or immediately E E - available from within the hospital as long as this physician is not the sole physician on call for the ED Surgical ICU service physician in-house 24 hours/day or immediately E available from within the hospital (which may be a physician who is the sole physician on call for the ED) Maximum ratio of one nurse per two patients on each shift E E D Age specific equipment, to include: Airway control and ventilation equipment E E E Oxygen source with concentration controls E E E Cardiac emergency cart E E E Temporary transvenous pacemaker E E E Electrocardiograph-oscilloscope-defibrillator E E E Cardiac output monitoring capability E E E Electronic pressure monitoring capability E E E Mechanical ventilator E E E Patient weighing devices E E E Pulmonary function measuring devices E E E Temperature control devices E E E Intracranial pressure monitoring devices E E - Blood gas measurements, hematocrit level, and chest x-ray studies w/in 30 E E E minutes of request Radiological Services In-house radiology technologist 24 hours/day E E - Radiology technologist available w/in 30 minutes of notification or E documentation that procedures are available within 30 minutes Angiography E E D Sonography E E D Computed tomography E E D In-house CT technician 24 hours/day E E - If the capability of computed tomography exists within the hospital the E CT technician must be available within 30 minutes of notification Nuclear scanning E D D Neuroradiology E D - Clinical Laboratory Service (Available 24 hours/day) Standard analyses of blood, urine, and other body fluids E E E Blood typing and cross-matching E E E Coagulation studies E E E Comprehensive blood bank or access to a community central blood bank E E E and adequate storage facilities Blood gases and ph determinations E E E Page 5 of 12

6 Levels Microbiology E E E Drug and alcohol screening capability E E D Acute Hemodialysis Capability E - - Written transfer agreement E D Burn Care Organized Physician directed burn center staffed by nursing personnel trained in burn E E E care or a written transfer agreement with a burn center Acute Spinal Cord Management Acute spinal cord management capability or written transfer agreement E E E with a designated spinal cord injury rehabilitation center when one exists within the region Acute Head Injury Management Acute head injury management capability or written transfer agreement E E E with a designated head injury center when one exists within the region REHABILITATION SERVICES Full in-house rehabilitation service or a written transfer agreement with a E E E rehabilitation facility accredited by CARF Professional staff trained in rehab care of critically injured patients E E D For major trauma patients, functional assessment and recommendations E E D regarding short and long term rehab needs w/in one week of the patient s admission to the hospital or as soon as hemodynamically stable Substance abuse evaluation and counseling availability E E D ORGAN PROCUREMENT PROGRAM which includes: Medical and legal criteria for donation E E E Role of organ procurement organization E E E Role of trauma care professionals E E E QUALITY IMPROVEMENT Quality improvement programs E E E State approved trauma registry E E E Morbidity and mortality review E E E Trauma conference multidisciplinary (at least quarterly) E E E Review of times and reasons for trauma-related diversion of patients E E E Utilization review E E E Documentation and review of response times for trauma surgeons, E E - neurosurgeons, anesthesiologists and orthopedists Documentation and review of response times for: Trauma surgeons and anesthesiologists E Neurosurgeons and orthopedists D OUTREACH Programs provided by hospital for physicians within the community and E E E referral area Documented continuing education program for staff physicians, nurses, and allied health personnel E E E Page 6 of 12

7 Levels Written transfer agreements to address the transfer and receipt of trauma E E E patients Development of/participation in a Regional Advisory Committee (RAC) E E - Participation in a RAC plus a written plan specifying its role in the RAC E Development of regional criteria for coordination of trauma care E E - Assessment of impact on trauma morbidity and mortality and on patient E E - outcome Assessment of trauma system operations at the regional level E E - Annual education program on the rehabilitation of major trauma patients E E D for in-house physicians, nurses and ancillary staff, as well as community physicians that deal in the early phase of care of these patients PREVENTION Injury control studies E D - Collaboration with other institutions E D D Monitor progress/effect of prevention programs E D D Designated prevention coordinator (which may be part of the trauma nurse E E D coordinator effort) Outreach activities E E D Information resources for public E E D Collaboration with existing national, regional, and state programs E E D Surveillance methods to include trauma registry data, special ED and field E D - collection projects RESEARCH Designated trauma research director E D - Regular meetings of a research group E D - Identifiable IRB process E D - Extramural educational presentations E D - Publication of research in peer reviewed journals E D - Study designs which include the development and testing of clearly defined hypotheses E - - Page 7 of 12

8 FOOTNOTES 1 Trauma center applicants must have their trauma service operational at least 6 months prior to making their first application. 2 A Level I trauma team must include an in-house PGY4 (see the clarification section at the end of the footnotes) or senior general surgical resident, at a minimum, who is a member of that hospital s surgical residency program and responds within 20 minutes of notification. A Level I and II team must have a trauma attending who responds (see the clarification section) within 20 minutes of notification and participates in therapeutic decisions and is present at all operative procedures. A Level III team must have a trauma attending who responds within 30 minutes of notification and participates in therapeutic decisions and is present at all operative procedures. Each trauma team (at all levels) must include an emergency physician who is present in the ED 24 hours per day who is either board certified or prepared in emergency medicine (by the American Board of Emergency Medicine or the American Board of Osteopathic Board of Emergency Medicine) or board certified or eligible by the American Board of Surgery, American Board of Family Practice, or American Board of Internal Medicine and practices emergency medicine as a primary specialty. This physician serves as a designated member of the trauma team until the arrival of the trauma surgeon. For Level I and II centers, the trauma team shall include neurosurgery and orthopaedic surgery specialists who are never simultaneously on call at another Level II or higher trauma center, who are available within 30 minutes of notification as long as there is either an in-house attending neurosurgeon/orthopaedic surgeon; 2) a PGY2 or higher in-house neurosurgery/orthopaedic surgery resident or an in-house trauma surgeon or emergency physician as long as the institution can document management guidelines and annual continuing medical education for neurosurgical/orthopaedic emergencies. There must be a specified written back-up on the call schedule whenever the neurosurgeon/orthopaedist is simultaneously on call at a hospital other than the trauma center. For a Level I, there must be an in-house anesthesiologist or a PGY4 anesthesiology chief resident, as long as an anesthesiologist on call is advised and promptly available within 20 minutes. For a Level II, there must be an in-house anesthesiologist or a PGY4 anesthesiology chief resident, as long as an anesthesiologist on call is advised and promptly available within 20 minutes or an in-house CRNA under physician supervision, practicing in accordance with G.S (7)e., pending the arrival of the anesthesiologist. For a Level III, an anesthesiologist must be on call and available within 20 minutes of notification or an in-house CRNA under physician supervision, practicing in accordance with G.S (7)e., pending the arrival of the anesthesiologist within 20 minutes of notification. Page 8 of 12

9 3 A hospital must have membership in, and include all trauma patient records in, the North Carolina trauma registry for at least six months prior to submitting an RFP application 4 These surgeons must have a minimum of board certification in general surgery within 5 years of completing residency 5 Activation of the trauma team: The trauma team should be notified 20 minutes prior to the arrival of a trauma patient with, or upon earliest recognition of, the following physiologic criteria: Shock Respiratory Distress Airway Compromise Spinal Cord Injury Unresponsiveness (Glasgow Coma Scale < 8) with potential for multiple injuries Revised Trauma Score < 8 (when in the field) 6 Prompt trauma surgical consults shall be initiated based upon the criteria listed below: Falls > 20 Feet Pedestrian Struck by Motor Vehicle Motor Vehicle Crash with: a) Ejection (includes motorcycle) b) Rollover c) Speed > 40 mph or d) Death at Scene Proximal Amputations Burn Plus Trauma Vascular Compromise Crush to Chest or Pelvis Two or More Proximal Long Bone Fractures Gunshot Wound to Torso, Neck or Proximal Extremities Operational implementation of the trauma team and consults will vary from hospital to hospital, depending upon local criteria. Activation of the trauma team shall occur upon physiologic deterioration of the trauma patient. These criteria should not be considered comprehensive. They are minimal criteria only. Page 9 of 12

10 ADDENDUM TO NORTH CAROLINA S TRAUMA CENTER CRITERIA October 1, 2000 In some instances some sections of the current trauma rules have left room for interpretation that was unforeseen at the time of rule promulgation. Since it can take up to two years to go back and amend the rules, OEMS often renders interpretations, guidance or clarifications in order to strive for some standardization or common agreement for all designated trauma centers or hospitals seeking designation in the interim. To this end, this is to serve as a support document to North Carolina s current trauma rules and trauma center criteria. In all likelihood, some, if not all, of these interpretations will be incorporated into the next set of trauma rules. It is important to note that OEMS often confers with appropriate professional organizations or groups before rendering interpretations. In the past, we have discussed items with groups such as the North Carolina Committee on Trauma, the trauma nurse coordinators and trauma registrars. Questions on the items addressed below should be directed to Sharon Rhyne, Hospital Programs Specialist, North Carolina Office of Emergency Medical Services at Telephone (919) or sharon.rhyne@ncmail.net Guidance on Continuing Education for Nursing With respect to nursing continuing education, preference is for approved contact hour programs, but appropriate types of alternative education are exemplified by in-service education programs, videos, educational demonstrations by manufacturers representatives, etc. It is recommended that nurses completing the following courses receive full credit hours for attendance: Advanced Trauma Life Support (ATLS) Basic Trauma Life Support (BTLS) Course for Advanced Trauma Nursing (CATN) Emergency Nurses Pediatric Course (ENPC) EMS for Children Child Abuse Recognition Education (EMS C C.A.R.E. ) Prehospital Trauma Life Support (PHTLS) Sexual Assault Nurse Examiners Course (SANE) Trauma Nursing Core Course (TNCC) 18 hours 16 hours 15 hours 18 hours 4 hours for instructor course 2 hours (max) for provider course 16 hours 40 hours (must be the NC course) 18 hours Partial credit hours should be granted for the following courses: Advanced Cardiac Life Support (ACLS) Basic Cardiac Life Support (BCLS) Pediatric Advanced Life Support (PALS) Pediatric Education for Prehospital Professionals (PEPP) 8 hours or 9 hours if trauma case included/4 hours (recert) 4 hours/2 hours (recert) 8 hours/4 hours (recert) 8 hours Page 10 of 12

11 The Trauma Nurse Coordinator at each trauma center will approve other acceptable educational offerings and the hours to be granted for attendance. The independent review of videos or articles without a developed means of evaluating learner outcome is not acceptable. The criteria requiring that nurses in trauma care areas complete sixteen hours of trauma related education every two years should have an 80% compliance rate PGY3 and PGY4 Staff OEMS informed all trauma medical directors and trauma nurse coordinators, via a memo of May 24, 2000, that OEMS agrees to utilize the following guideline during trauma center site visits: Any surgery resident having completed 3 clinical years of general surgical training will meet the state criteria for an in-house Post Graduate Year 4 or senior general surgical resident, at a minimum, who is a member of that hospital s surgical residency program and responds within 20 minutes of notification. A pure laboratory year will not constitute a clinical year. This refers back to our state rules, 10 NCAC 3D.2101(a)(7)(A). This position is in keeping with the American College of Surgeon s Committee and their trauma verification review criteria. Any hybrid years will need to be considered on a case-by-case basis (i.e., a lab year in which the resident takes regular night call on a trauma or similar emergency care service, thus gaining experience in managing seriously injured/ill patients). OEMS would strongly urge any trauma center with a hybrid situation to provide written details well in advance of a trauma site visit in order to allow adequate time for consideration of the situation by the agency Trauma Surgeon Response Time For Level I trauma centers, the trauma surgeon is to be present at the patient s bedside within twenty minutes of the alert for a Level or Code 1 patient. The clarification is on physical presence versus phone response, for example Multiple Emergency Departments and Orthopedic Coverage A question has arisen in the past as to whether a hospital needs to continue its back-up orthopedic call schedule if, for example, it chooses to send all of its isolated orthopedic cases to another hospital in its immediate locale that is under its management. In this situation, two separate emergency departments still exist and both handle orthopedic patients and require orthopedic coverage. OEMS will render a decision on this type situation on a case-by-case basis. In order to decide whether back-up orthopedic coverage can be dropped, OEMS will need the following documentation: (1) the protocol or policy as to when and how patients are triaged between the two facilities operating rooms (i.e., if one is busy, are patients sent to the other?); (2) how patients are triaged between the two emergency departments (i.e., are ambulances rerouted to the second emergency department if the first one is swamped?); and (3) how the trauma patients are triaged within EMS (i.e., what is the protocol for trauma and its EMS destination?). Page 11 of 12

12 Multiple Emergency Departments and Trauma Registry Reporting In situations where a trauma center has merged with or purchased another facility within its immediate locale such that there are two emergency departments and physical facilities being operated under the same management, the question has arisen as to whether trauma patients from both facilities have to be entered into the trauma registry. This question has largely arisen with orthopedic patients, as described in the section immediately above this one. In this situation, the registry shall include all the trauma patients, including those seen at the trauma center itself or at its affiliated hospital that might, for example, handle all the isolated orthopedic injuries. If the state is eventually able to get a trauma database established at every hospital in the state, OEMS will reconsider this since it may be acceptable, given the above scenario, to at some point maintain a reduced set of data on isolated orthopedic injuries. File: c:\srhyne\word97\trauma criteria state 2000 Page 12 of 12