Hospital Classification

January 23, 2006 1:07pm
Author: Michelle Ziemba

Trauma Care Facility Classification/Designation of Wisconsin Hospitals

A comprehensive trauma care system includes ensuring the right patient is taken to the right hospital in the right amount of time to give them the greatest chance of survival.

It is the goal of the statewide trauma care system to integrate all hospital facilities into an inclusive network in order to provide definitive care to all injured patients in Wisconsin. Wisconsin promotes an inclusive trauma care system by the concept that every hospital has a designated role in the trauma system and will be able to provide or facilitate the delivery of optimal care necessary to the traumatically injured patient.

Frequently Asked Questions ( Vol I )

As the STAC continues to meet and gain feedback from area hospitals regarding the classification/designation process a number of questions are being generated.

This will be the access point for the latest interpretive guidelines regarding the hospital designation guidelines and criteria

State Trauma Advisory Council Clarifcation on Level III & IV Trauma Centers

Clarification:
For the Trauma Service Director: The recommendation is for a general surgeon to serve in this capacity. However, this is not required and may be an Emergency Department Physician who cares for the trauma patients.

Question: Which physicians are required to be ATLS certified other than ED Physicians?
Answer: Note: Footnote 5 states that ‚physicians involved in the care of the trauma patients shall take the ATLS Course‚ This includes surgeons and ED Physicians because both groups lead the initial resuscitation of major trauma patients. Please also note that in Footnote 13 it states ‚ the ED physicians will have three years from the Trauma Care Facility‚ (TCF) classification date or from the date of the ED physician joining the trauma team at the TCF to successfully complete this course.‚ This will also hold true for the general/trauma surgeons and physicians who ‚moonlight‚ for the ED and will be involved in leading the initial resuscitation of the major trauma patient.

Question: What staff is required to be on the Trauma Multidisciplinary Committee?
Answer: Some of the recommendations from the American College of Surgeons (upon which the criteria for Level III and IV is based) is:

Trauma Service Director
ED Medical Director
ED Physicians
Surgeons
Trauma Program Coordinator (Manager)
It will depend on your facility and your capabilities. It is up to the hospital to determine the makeup as long as it includes those who directly care for the major trauma patient.

Question: What are the formal continuing education program requirements?
Answer: It is up to the institution to select the trauma education that will most help prepare the staff to care for the major trauma patients. Some of the recommendations include:

TNCC
ENPC
PHTLS
TNS
CATN
There are others and your RTACs can help inform you about what exists and what the above mentioned courses include.

Clarification:
‚ÄúOn-Call and promptly available‚ is up to the hospital to determine what is appropriate. This should be tracked in your PI process. Obviously there are limits to this ‚ for example ‚ a surgeon not responding for an hour would not be ‚promptly available‚ but some facilities have surgeons that respond in 5 minutes, for others it may be 15 to 20 minutes. The standard to be physically present is not more than 30 minutes. Timing of the response should be from the time they are notified per phone or pager.

Clarification:
If your facility desires to be a Level III Trauma Care Facility but is not able to have surgical coverage, per the criteria, that facility would not meet the Level III criteria and would not be eligible for Level III State Designation. The surgeon would be required for the initial resuscitation.

Clarification:
For Anesthesia ‚ see footnote 14 ‚ anesthesia must be immediately available for airway or operative management ‚ must be available to immediately care for the patient that has an airway situation and that response should also be evaluated in the PI process.

Clarification:
Arterial catheters are required for Level III ‚ this is not saying you have to put them in your major trauma patients, just that you should have the equipment and the capability if needed.

Clarification:
Hospitals are asked to determine what their State Designation (what resources) is as of July 2005, not what you hope to be in the future. (In other words, what level are you functioning at now)? You may at any time change your level of designation as long as you complete the required application process and are approved by the Department of Health and Family Services.

There has been discussion regarding how the State Designation will affect EMS. There are statewide-approved Triage and Transport Guidelines in effect throughout Wisconsin that are in place to assist EMS with this determination. This is a local and regional issue that should be brought forth to each RTAC for discussion among the various partners involved.

According to Wisconsin Statute 146.56 and Wisconsin Administrative Rule HFS 118, all hospitals shall declare their current trauma care capabilities to the Department of Health and Family Services within 180 days of the effective date of the rule, which is January 1, 2005.

The identification of trauma care facilities will occur through the state designation/classification process.

Frequently Asked Questions ( Vol II )

The process of Trauma Center Designation for the State of Wisconsin is new.Therefore, it will be necessary to provide guidelines in the interpretation of the criteria necessary to be a state designated trauma care facility.

Please note the latest document regarding the State Trauma Advisory Council's interpretation of the designation criteria.

Frquently Asked Questions Vol II

Frequently Asked Questions
State Designation of Level III and IV Trauma Care Facilities
April 2005

1.On the application, Section A, is this an initial or a re-classification?
Answer: This is the initial State designation of all hospitals in Wisconsin, therefore, the initial classification/designation box should be marked.

Please fill out the application and criteria in its entirety.

2.Is there additional paperwork beyond the application and criteria forms that is required for the State, to demonstrate the "Trauma Care Facility Commitment?"
Answer: No. By completing the application and criteria and the signature by the Administrator/Chief Executive Officer, and putting the criteria into action, the commitment is demonstrated.

3.What does "participation" in Regional Trauma Advisory Councils (RTACs) mean?
Answer: As part of being a State designated Level III or IV Trauma Care Facility, a representative of your hospital must attend the Regional Trauma Advisory Council meetings on a regular basis and keep the hospital administration informed of regional actions and issues. This will be an important criteria that will be looked at during a site visit review.

4.What about the site visits?
Answer: Site visits are an essential component of a trauma system and shall occur for all Level III and IV facilities in the future. The process and dates are still to be determined. Stay tuned to your Regional Trauma Advisory Council for further information.

5.What happens if a hospital decides not to designate as a Level III, IV or "unclassified" and does not send in the application?
Answer: 1997 Act 154 states that "The rules shall include a method by which to classify all hospitals as to their respective emergency care capabilities." If a hospital chooses not to classify at all, the State may do a site visit and classify the hospital.

6.Who is required to take Advanced Life Support Course?
Answer: * Footnote 5 states "Level III and IV Trauma Care Facility physicians involved in the care of trauma patients shall take the Advanced Trauma Life Support Course and the refresher course every four years to meet Continued Medical Education requirements. If a physician currently is Emergency Medicine Board Certified, Advanced Trauma Life Support course only needs to be completed once." This means that the Emergency Department physicians and general surgeons who will be caring for that trauma patient in a major resuscitation should be Advanced Trauma Life Support certified. Currently, the Surgeons should re-certify every four years. However, if the new American College of Surgeons recommendations include the Surgeons only taking Advanced Trauma Life Support Course once if they maintain their Board Certification, then the State Trauma Advisory Council and the State shall follow the same recommendation.

*Footnote 13 states: "The Emergency Department physicians will have three years, from the trauma care facility's classification (July 1, 2005) or from the date of the Emergency Department physician joining the trauma team at the Trauma Care Facility to successfully complete this course." This will also hold true for the general surgeons.

7.Does the Trauma Service Director have to be a General Surgeon?
Answer: No, recommended, but not required.

8.If the Emergency Department Physician in a Level III or IV Trauma Care Facility has decided to transport the patient to a trauma center, does the general surgeon on call still have to come in?
Answer: Yes. When the general surgeon is paged for a major trauma patient, he/she must respond to the Emergency Department regardless of the decision to transfer the patient out. In a Level III Trauma Care Facility, as the general surgeon is expected to respond for all major trauma patients he/shall shall be a part of the trauma team activation, which is explained in *footnote 6. The surgeon may need to give operative control of hemorrhage or other necessary treatment prior to transfer.
On the web-site, EMTALA.com under "frequently asked questions", it states: "As noted above, Section 1395dd(d)(1)(C) imposes a penalty on a physician who fails to respond to an emergency situation when he is assigned as the on-call physician."
For Level III and IV Trauma Care Facility's, 30 minutes is the maximum time for the surgeon to respond and this begins at the time of notification.
A major trauma patient means he/she has sustained major or severe injuries to more than one system of a person's body or major injury to a single system of the body that has the potential of causing death or major disability as defined in Administrative Rules Chapter 118. (There will be further information for hospitals regarding definition of major trauma, and triage and transport protocols that Emergency Medical Services use in the near future after the designation process is completed).

9.Do we still mark "yes" to the trauma registry though the state has not implemented it yet?
Answer: Yes. By marking "yes" you are committing to participating in the state trauma registry when applicable. It is a requirement to be a Trauma Care Facility.

10. Clarification: Footnote 4 - "Any inpatients admitted to a Level IV Trauma Care Facility shall not have injuries requiring major surgical or surgical specialty care."This is referring to major trauma patients, not the single limb or hip fracture or other less traumatic injuries.

11. What are some of the recommended educational courses for nurses?
Answer:
Trauma Nursing Core Course (TNCC)
Emergency Nursing Pediatric Course (ENPC)
Trauma Nurse Specialist (TNS)
Course in Advanced Trauma Nursing (CATN)
Pediatric Advanced Life Support (PALS)
Advanced Trauma Care for Nurses (ATCN)

Trauma Coordinators from your Level I and II Verified Centers can provide further information for you.

12. Do new committees have to be established to perform Performance Improvement on trauma patients?
Answer: No. You may incorporate your trauma Performance Improvement into existing Performance Improvement/Quality Assurance committees as long as the required criteria are met.

13.Clarification: Level III and IV Trauma Care Facilities need to have transfer agreements with at a minimum their Level I or II American College of Surgeons Verified Trauma Centers in their region. It is up to the hospital to decide which hospitals they will have transfer agreements with depending on where their trauma patients referral and transfer patterns exist.

14. When is the final due date for all hospitals to designate?
Answer: All hospitals must be classified by July 1, 2005 according to statute - 1997 ACT 154. Therefore, to accomplish this goal, all applications must be turned in to Marianne Peck, State Trauma Coordinator by June 17, 2005.

*Footnotes can be found at the Trauma System website: www.dhfs.wisconsin.gov/ems
under the section titled "Trauma Care Facility Classification/Designation of Wisconsin Hospitals in the Level III and IV Hospital Assessment and Classification Criteria document. Please refer to footnotes as requested in the document.

This document shall be added to as more questions arise. Feel free to contact Marianne Peck, State Trauma Coordinator at 608-266-0601 or peckme@dhfs.state.wi.us to add questions or to clarify.

Thank you to everyone for their continued dedication and hard work to implement the Trauma Care System to care for our visitors and citizens in Wisconsin.