20 CAR § 80-502 – Criteria for Level III trauma centers

(a) Purpose. To define and clarify the criteria necessary for a general care facility to become a Level III trauma center and ensure optimal care of the injured.
(b) Definition. The Level III trauma center (general) serves communities that do not have immediate access to a Level I or II institution.
(c) Level III trauma centers can:
1. (1) Provide prompt assessment, resuscitation, emergency operations, stabilization; and
2. (2) Also arrange for transfer to a facility that can provide definitive trauma care.

(d) General surgeons and orthopedic surgeons are required in a Level III facility.

Level III Criteria
Level	Section	Required(R) or Desirable(D)	Criteria
	TRAUMA PROGRAM
1. Support/Infrastructure
III	Institutional Support	R	(1.1) Clear evidence of hospital board, administrative, and medical staff support in the form of a written resolution to attain and maintain the level of designation; the resolution shall be updated at least every three years.(1.2) Financial support of additional FTEs, space, and/or equipment, if required.(1.3) Authorization for the trauma program's leadership and committees to perform their required duties.(1.4) Clearly defined lines of reporting for the TMD/TMCD and TPM within the organization.
III	Trauma Program Administration and Infrastructure	R	(1.5) Program within an acute care facility with defined leadership (TMD/TMCD and TPM) with the authority to develop, oversee and improve the care of the injured within the facility, and is integrated into the local, regional, state, and national system of trauma care.(1.6) The trauma program shall participate in the development and improvement of prehospital care protocols and patient safety programs.
	2. Staffing
III	Trauma Medical Director (TMD)/Trauma Medical Co- Director (TMCD)	R	Requirements and qualifications for the TMD/TMCD:(2.1) A facility may have a co-director who is a general surgeon. If a facility has a director and a co-director, one shall be a general surgeon.(2.2) A physician in good standing in the institution with state licensure, has membership in professional organizations, possesses clinical knowledge and expertise, actively participates in the care of injured patients, and has a personal interest and the time to be the champion for trauma patient care to the medical staff and the trauma center.(2.3) Board-certified/Board-eligible in his/her specialty or a FACS, or a FACOS.(2.4) Current in ATLS as either a provider or an instructor.Responsibilities and duties TMD/TMCD:(2.5) Participate in trauma call.(2.6) Lead the trauma QI and patient safety programs within the trauma center.(2.7) Have a method to identify injured patients, monitor the provision ofhealth care services, make periodic rounds, and hold formal andinformal discussions with individual practitioners.(2.8) There shall be a verifiable, written job description that clearly identifies expectations of leadership and authority to perform the duties required, including the authority to conduct trauma-specific peer review, place members on and take members off of a trauma call schedule, be involved in the development of the trauma center’s bypass protocol and the decisions regarding bypass and “Charlie Temp” status, and affect process changes identified in the trauma multidisciplinary meetings.(2.9) Have responsibility and authority for determining each call panel member’s ability to participate on the trauma call schedule based on a periodic review.(2.10) Have responsibility and authority to ensure compliance with verification requirements; and report changes in the program that would affect the designation of the facility to the ADH.(2.11) Have the ability to contribute to the TPM’s performance evaluation. (2.12) Demonstrate with his/her signature awareness of the facility’s invoices to the ADH for payment.(2.13) TMD or TMCD (shall be a surgeon) shall perform a written annual review of the performance of all the surgeons on the call panel.Documentation of such shall be available for review at the designation site survey. The ability to grant or remove a provider’s privileges to practice in an area is reserved for the facility’s Board and Medical Staff Committee. There should be a distinction of a provider’s privileges to participate in care of the trauma patient and participation in a trauma call schedule. The facility’s Board and Medical Staff Committee shall take into consideration the input of the TMD or TMCD when considering trauma privileges, while the TMD or TMCD shall have the discretion of which providers participate in the trauma call schedule. A decision by the TMD or TMCD to place or remove a provider from the trauma call schedule shall not be viewed as affecting or restricting a provider’s hospital privileges, as that decision is reserved for the facility’s Board and Medical Staff Committee.

III	Trauma Program Manager (TPM)	R	Requirements and qualifications for the TPM:(2.14) A RN with responsibility for monitoring and evaluating nursing care of trauma patients and the coordination of QI and patient safety programs for the trauma center in conjunction with the TMD/TMCD.(2.15) He/she shall be well trained and knowledgeable in trauma. The TPM shall also obtain continuing education so as to remain up to date in regard to trauma.(2.16) ATCN, TNCC, or ADH-approved equivalent course certifications shall be current.(2.17) The training of a TPM new to this position shall include a TPM course, a QI course, and an AIS coding course or state-sponsored coding course.Responsibilities and duties of the TPM:(2.18) There shall be a verifiable, written job description for the TPM that clearly identifies expectations of leadership and authority to perform the duties required.(2.19) Dedicate at least 1.0 FTE to trauma programs having a trauma patient record volume of 500 or greater.(2.20) The time and resources allocated shall be sufficient for the TPM to be effective in the job of QI, community education, clinical education, and IVP.
III	Trauma Registrar	R	(2.21) There shall be a verifiable, written job description for the Trauma Registrar that clearly identifies expectations.(2.22) The facility shall have adequate resources to maintain accurate and timely collection, evaluation and submission of trauma data.(2.23) After passing 500 trauma patient records, there shall be an identified Trauma Registrar, who is separate from but supervised by the TPM and who has appropriate training in injury severity scaling (e.g., AAAM course or state-sponsored coding course, ATS Trauma Registrar Course).
III	Trauma Program Staff	R	(2.24) Trauma programs shall have adequate support resources to efficiently and effectively oversee and administer the trauma program and remain engaged in an effective QI process.
III	Trauma Liaisons	R	(2.25) Official physician liaisons shall be named for EM, orthopedics, anesthesia, critical care, and radiology (if available in-house). In addition, if a neurosurgery service is provided, a liaison shall be named. Liaisons are responsible for the accurate dissemination of information from the trauma committee meetings to their service members.(2.26) Liaisons are responsible for attending the Trauma Program Operational Review Committee meetings and at least 50% of Trauma Peer Review Committee meetings. The liaison responsibilities may be shared by physician members of the specialty.
III	Trauma Team	R	(2.27) A predetermined set of care providers and ancillary personnel (physicians, mid-level practitioners, nurses, X-ray technologists, laboratory, respiratory therapist, etc.) needed to provide resuscitation, rapid triage, and transfer of the severely injured.
III	Consultant Coverage	R	(2.28) Trauma centers shall have an internal policy identifying the expectations for consultant responses. Deviations to the policy shall be tracked in the QI process.
	3. Participation
III	General SurgeryParticipation	R	Requirements of the general surgeon(s):(3.1) Shall have 24/7 general surgical coverage. (3.2) Shall have privileges in general surgery.(3.3) Shall be Board-certified/Board-eligible in general surgery or a FACS, or a FACOS or satisfy the criteria for an alternate pathway if deemed necessary by the ADH.(3.4) Shall have taken ATLS at least once or shall be current in ATLS within one year of hire.(3.5) Shall obtain the required verifiable 18 hours of Category I trauma- specific CME, or 18 hours of trauma-specific internal education every three years.(3.6) Core surgeons shall participate in at least 50% of the Trauma Peer Review Committee meetings and disseminate information back to all surgeons.(3.7) Surgeons shall respond to the ED promptly (within 30 minutes) an aggregate of 80% of the time when on-call and when the highest level of trauma is activated.(3.8) Trauma panel surgeons shall respond promptly to activations, remain knowledgeable in trauma care principles, whether treating patients locally or transferring them to a center with more resources, and participate in QI activities.
III	Orthopedic Surgery Participation	R	Requirements of the orthopedic surgeon(s):(3.9) Level III trauma centers shall have orthopedic coverage. In a designation or re-designation year, Level III trauma centers that do not have 24/7 orthopedic coverage may attain the classification in one of two ways:1. In the first year, the Level III trauma center shall not transfer more than 50% of all trauma patients for treatment at another facility; in the second year, the center shall not transfer more than 45% of trauma patients; in the third year and thereafter, the center shall not transfer more than 40% of trauma patients. If the Level III trauma center fails to meet these thresholds in any year, the Level III trauma center must submit a Corrective Action Plan for approval to the Arkansas Department of Health to be implemented within one year of the approval date. If neither the threshold nor the Corrective Action Plan is attained, the Level III designation shall be suspended and the center must reapply for designation; or2. The Level III trauma center must transfer 5% fewer trauma patients for treatment at another facility than the center transferred in the previous year (the “index year”); 10% fewer than the index year in the second year; and 15% fewer than the index year in the third year. Facilities that remain above the 40% standard for transfers of trauma patients subsequent to year three shall continue to decrease by 5% annually until the 40% standard is met. If the Level III trauma center fails to meet these thresholds in any year, the Level III trauma center must submit a Corrective Action Plan for approval to the Arkansas Department of Health to be implemented within one year of the approval date. If neither the improvement threshold nor the Corrective Action Plan is attained, the Level III designation shall be suspended and the center must reapply for designation.(3.10) Shall obtain the required verifiable 18 hours of Category I trauma- specific CME, or 18 hours of trauma-specific internal education every three years.(3.11) A liaison shall participate in at least 50% of the Trauma Peer Review Committee meetings and disseminate information back to all orthopedic surgeons on the call panel.(3.12) Orthopedic surgeons shall have privileges in general orthopedic surgery. (3.13) In the cases where the orthopedist is not dedicated to the facility 24/7,an orthopedic backup plan is required and shall be approved by the TMD.(3.14) The following orthopedic specific QI filters shall be in place and tracked (other filters may be added at the discretion of the ADH Trauma Section):1. time from injury to washout for open fractures;2. time from injury to ORIF for femur fracture; and, 3. appropriateness and timing of IV antibiotics for all open fractures.
III	Neurosurgical Participation	D	Neurosurgical coverage is not required in a Level III facility.However, if a Level III facility represents itself as having neurosurgical capability and capacity on the ATCC dashboard, the following applies and is required of the neurosurgeons at the facility:(3.15) Shall obtain the required verifiable 18 hours of Category I trauma- specific CME, or 18 hours of trauma-specific internal education every three years.(3.16) The liaison shall participate in at least 50% of the Trauma Peer Review Committee meetings and disseminate information back to all neurosurgeons on the call panel.(3.17) The following neurosurgical-specific QI filters shall be tracked (others may be developed at the discretion of the ADH Trauma Section):1. all cases requiring the backup to be called in or the patient to be diverted or transferred due to unavailability of the neurosurgeon on-call; and,2. neurotrauma care shall be reviewed for compliance with the Brain Trauma Foundation Guidelines. https://www.braintrauma.org/pdf/protected/Guidelines_Manag ement_2007w_bookmarks.pdf
III	Anesthesiology Participation	R	Requirements of the anesthesiologist(s):(3.18) Anesthesiology services are promptly available for emergency operations.(3.19) Anesthesiology services are promptly available for airway problems. This may be fulfilled by an anesthesiologist or a CRNA. If a CRNA is utilized an anesthesiologist shall be promptly available. If a CRNA is utilized it shall be with the approval of the Chief of Anesthesiology.(3.20) There is an anesthesiologist liaison designated to the trauma program. (3.21) The availability of the anesthesia services and the absence of delays inairway control or operations are documented by the trauma QI program. (3.22) In trauma centers without in-house anesthesia services, protocols are inplace to ensure the timely arrival at the bedside of the anesthesia provider.(3.23) In a center without in-house anesthesia services, there is documentation of the presence of physicians skilled in emergency airway management.(3.24) The anesthesia liaison participates in the trauma QI program.(3.25) The anesthesiology representative or designee to the trauma program attends at least 50% of the Trauma Peer Review Committee meetings.
III	Emergency Medicine Participation	R	Requirements of emergency medicine physician(s):(3.26) There is a liaison from the EM Service to the Trauma Program who effectively disseminates information back to the EM service.(3.27) The EM liaison has the required verifiable 18 hours of Category I trauma-specific CME, or 18 hours of trauma-specific internal education every three years.(3.28) The EM liaison regularly attends the trauma QI meeting and has documented 50% attendance at the Trauma Peer Review Committee meetings.
III	Medical Specialty Support	R	(3.29) The following specialty shall be on-call and promptly available at the request of the trauma service:  Internal medicine
	TRAUMA FACILITY AND OPERATIONS
	4. Emergency Department (ED)
III	Leadership	R	(4.1) The ED has a designated emergency physician director supported by an appropriate number of additional physicians to ensure immediate care for injured patients.
III	Communication with ED Physicians and Nurses	R	(4.2) A reliable method shall exist to communicate changes in trauma process to all staff members caring for injured patients in the ED. An example of this would be a communication book in the ED, requiring a signature by nurses and physicians when changes or other important updates to the trauma process are determined through the QI program.
III	Physician, Mid- level Practitioners and Nursing Availability	R	(4.3) ED shall have 24/7 in-house emergency coverage by physicians andnurses.(4.4) A tracking mechanism shall be in place and reviewed in the QI program.The QI program shall review all times the ED physician leaves the ED uncovered in order to respond to an emergency in-house.(4.5) EM physicians on the call panel are regularly involved in the care of injured patients.(4.6) The EM representative or designee to the Trauma Peer Review Committee attends a minimum of 50% of these meetings.(4.7) There is EM physician participation with the overall trauma QI program and the Trauma Program Operational Process Performance Committee (dealing with systems issues).
III	CMERequirements for Providers	R	(4.8) Physicians who cover the ED in rural trauma centers may not see enough trauma to stay abreast of current treatment protocols. Category I CME is necessary to maintain knowledge in the field. The physician or mid-level practitioner caring for trauma patients in the ED shall obtain the required verifiable 18 hours of Category I trauma-specific CME, or 18 hours of trauma-specific internal education every three years.
III	TraumaEducationalCertification forPhysicians andMid-LevelPractitioners	R	(4.9) Maintaining current ATLS certification for physicians and mid-levelpractitioners is essential for those who cover the ED as participants on the trauma team who are not Board-certified in EM. Physicians Board-certified/Board-eligible in EM, as recognized by ABEM, AOBEM or ABP, shall have completed ATLS at least once, and are encouraged but not required to be current.
III	Trauma Nursing Educational Preparation	R	(4.10) Current certification in one of the trauma nursing courses is essential for nurses who assist in trauma resuscitations. ATCN, TNCC, or ADH- approved equivalent course will be obtained. 80% of ED trauma nurses shall be certified and newly hired ED trauma nurses shall be certified within their first year of hire.(4.11) 80% of nurses working in the ED shall be current in ACLS and PALS or ENPC.
III	Trauma Nursing Continuing Education	R	(4.12) It is necessary that nurses who assist with trauma resuscitations continue to be educated on trauma treatment and issues and shall obtain 12 hours of trauma-specific nursing CE or 12 hours of trauma- specific internal education every three years.
III	Activation Criteria	R	(4.13) The criteria for the highest level of trauma team activations shall be clearly defined and evaluated by the QI program.(4.14) A patient ≤ 15 years of age who meets a center’s criteria for the highest level of activation or is classified as either a major or moderate trauma patient under the Arkansas Trauma Triage Protocol and requires transfer, shall be transferred to a designated pediatric trauma center.(4.15) The facility shall activate the predetermined trauma team based on a set of written activation criteria that include:1. confirmed hypotension (< 90mmHg adults or age appropriate for children) attributed to trauma;2. GCS < 9 with a mechanism due to trauma (general surgeon response can be at the discretion of the ED physician);3. respiratory distress attributed to trauma;4. gunshot wound to the neck, chest or abdomen;5. transfer of a patient from another facility receiving blood or pressure support to maintain vital signs; and,6. any patient for whom the ED physician feels the highest level of activation is warranted.(4.16) Activation of the trauma team for the highest level shall be based on prehospital notification when available.(4.17) Facilities may create a tiered activation system with variable response from hospital and physician personnel, but shall have the above criteria in the highest level of activation. For the program's highest level of activation, the surgeon shall be in the ED on patient arrival, with adequate notification from the field. The maximum acceptable response time is 30 minutes tracked from time of activation. Activation occurs based on prehospital criteria when available. The program shall demonstrate that the surgeon’s presence is in compliance at least 80% of the time. Demonstration of the attending surgeon’s prompt arrival for patients with appropriate activation criteria shall be monitored by the hospital’s trauma QI program.(4.18) The facility shall be able to demonstrate under and over-triage rates based on their activation criteria.(4.19) The facility shall be able to track the arrival of the physicians who should respond to a given level of activation.
III	Rural Trauma Team Development Course (RTTDC)	R	(4.20) Rural facilities shall demonstrate participation by members of the trauma resuscitation team, including physicians, nurses and allied health personnel within a regional facility by attending once during a review period.
III	Helipad or Landing Zone	R	(4.21) Shall have a helipad or a written, organized plan for getting the trauma patient to a safe landing zone with alternative sites should the primary landing site be unavailable.
III	Trauma Image Repository	R	(4.22) Availability to send and receive images to and from TIR in the ED. (4.23) Utilization of TIR when appropriate for expediting trauma patient care.
III	Roles and Responsibilities in the Trauma Bay	R	(4.24) Written protocol for roles and responsibilities of all team members during trauma team resuscitations.
III	Safe Transport of Patients Within and Out of the Emergency Department	R	(4.25) A policy is required describing the level of resources required for the safe movement of patients out of the trauma bay, either within the ED or to other departments in the trauma center.
	5. Essential Equipment (shall include but not be limited to)
III	Airway Control and Ventilation Equipment (Adult andPediatric)	R	(5.1) Neonatal to adult oxygen masks, ambu bags, and ETTs(5.2) Every facility shall have equipment and a plan for difficult intubations. (5.3) Cricothyrotomy supplies and drugs necessary for emergency intubation
III	Airway Monitoring	R	(5.4) Pulse Oximetry(5.5) Qualitative End-tidal CO2 Determination – Color Change Detectors (5.6) Continuous End-tidal CO2 Monitoring if neurosurgery services areprovided
III	Thermal Regulation	R	(5.7) The ability to regulate the room temperature in the trauma bay in a reasonable amount of time.(5.8) Fluid warming devices (5.9) Thermal control blankets
III	Large Bore IV Catheters	R	(5.10) 14 – 18 gauge IVs(5.11) Interosseous catheters
III	Focused Assessment with Sonography forTrauma (FAST)	R	(5.12) Machine available to the trauma team and members of the trauma team trained in its use.
III	Standard Procedure Trays	R	(5.13) Thoracotomy (adult and pediatric)(5.14) Tube thoracostomy tray with tubes (adult and pediatric) (5.15) Surgical tray with airway equipment (adult and pediatric)
III	Standard Airway Equipment	R	Ensure equipment is available in both adult and pediatric sizes. (5.16) Oral and nasal airway(5.17) Ambu bags(5.18) ETT - with cuffed ETT down to size 4.0
III	Pediatric Resuscitation Equipment	R	(5.19) Color-coded, length-based resuscitation tape Weight-based, color-coded resuscitation cartPediatric equipment available as listed in the American Academy of Pediatrics Joint Policy Statement-Guidelines for Care of Children in the Emergency Department (2009) http://pediatrics.aappublications.org/content/early/2009/09/21/peds.2 009-1807.citation
III	PACS and Lab Results Computer	R	(5.20) Shall be in reasonable proximity to the trauma bay for ease of access by the trauma team.
	6. Operative Services
III	Operating Room (OR)	R	(6.1) The ORs are promptly available within 30 minutes of notification of the need for an urgent case to allow for emergency operations on musculoskeletal injuries, such as open fracture debridement and stabilization and compartment decompression.(6.2) The OR is adequately staffed and promptly available. (6.3) The OR has the essential equipment.(6.4) There is craniotomy equipment available in trauma center that offers neurosurgery services.(6.5) The QI program evaluates OR availability and delays when an on-call team is used.
III	Post-anesthesia Care Unit (PACU)	R	(6.6) The PACU has qualified nurses available 24/7 as needed during the patient's post-anesthesia recovery phase.(6.7) The PACU is covered by a call team from home with documentation by the QI program that PACU nurses are available and delays are not occurring.(6.8) The PACU has the necessary equipment to monitor and resuscitate adult and pediatric patients. In facilities where pediatric patients are cared for, this equipment shall include ambu bags, ETTs and oral airways appropriate to the age of the patients.(6.9) The QI program ensures that the PACU has the necessary equipment to monitor and resuscitate patients.(6.10) If the PACU acts as an overflow area for the ICU, and trauma patients are housed there while waiting for an ICU bed, the nurses in the PACU shall have similar qualifications as the ICU nurse for the care of trauma patients.
	7. Intensive Care Unit
III	Intensive CareUnit (ICU)	R	(7.1) When a critically ill trauma patient is treated locally, there shall be a mechanism in place to provide prompt availability of a physician, who has the ability to care for critically ill patients 24/7.(7.2) The surgical director or the surgical co-director shall be a surgeon, who is credentialed by the hospital to care for ICU trauma patients, and who participates in the QI program.(7.3) Coverage of emergencies in the ICU does not leave the ED without an appropriate physician coverage plan.(7.4) The trauma center has a surgical director or co-director for the ICU who participates in setting policies and administration related to trauma ICU patients.(7.5) The trauma surgeon remains in charge of trauma patients in the ICU and is kept informed of and concurs with major therapeutic and management decisions.(7.6) A qualified nurse is available 24/7 to provide care during the ICU phase. (7.7) The patient/nurse ratio does not exceed 2:1 for critically ill patients inthe ICU.(7.8) The ICU has the necessary equipment to monitor and resuscitate patients.(7.9) There are written protocols for declaration of brain death. (7.10) When ICU patients are held in other locations (PACU, ED) due totemporary lack of bed space, all requirements for ICU care would apply. (7.11) Intracranial pressure monitoring in facilities with neurosurgicalcoverage.
	8. Other Trauma Care Areas and Services
III	Pediatric Care	R	(8.1) Any adult trauma center that annually admits 100 or more injured children ≤15 years of age shall fulfill the following additional criteria demonstrating its capability to care for injured children: trauma surgeons shall be credentialed for pediatric trauma care by the hospital’s credentialing body, and there shall be a pediatric ED area, pediatric intensive care area, appropriate resuscitation equipment, and a pediatric-specific trauma QI program.(8.2) Hospitals admitting fewer than 100 injured children annually, ≤15 years of age, shall review and document the review of all pediatric patients in the QI program.(8.3) Pediatric resuscitation equipment shall be available in all pediatric care areas.
III	Geriatric Care/Special Needs	R	(8.4) The facility shall have a protocol for the admission and care of geriatric/special needs patients (age > 65 years).(8.5) There shall be a protocol in place in the facility for the rapid evaluation of patients with head injuries who are on anticoagulants, which shall include a component addressing the rapid reversal of such agents when possible. The protocol may exclude patients who are on aspirin only.
III	Laboratory Services Available 24/7	R	(8.6) Standard analysis of blood, urine, and other body fluids, including micro- sampling for pediatric patients when appropriate. Blood gases and pH determination is required.(8.7) The capability for coagulation studies, blood gases, and microbiology shall be available 24/7.
III	Blood Bank/Ability to Transfuse Blood 24/7	R	(8.8) The blood bank shall be capable of blood typing and cross matching. (8.9) The blood bank shall have an adequate supply of red blood cellsavailable with additional red blood cells, fresh frozen plasma, platelets and cryoprecipitate to meet the needs of injured patients through a regional source and tracked through the QI program.(8.10) Mass transfusion protocol that results in a balanced resuscitation with red cells, plasma and platelets.(8.11) Prompt availability of universal donor blood.(8.12) Facilities shall have a protocol for the rapid reversal of anticoagulants when available. Facilities may develop their own protocol until such time that state guidelines are adopted.
III	Radiological Services Available 24/7	R	(8.13) Radiologists are promptly available, in person or by teleradiology, when requested for the interpretation of radiographs.(8.14) X-ray technologists shall be promptly available 24/7 upon activation of the trauma team.(8.15) Diagnostic information is communicated in a written form and in a timely manner.(8.16) Critical information is verbally communicated to the trauma team. (8.17) Final reports accurately reflect communications, including changesbetween preliminary and final interpretations.(8.18) Changes in interpretation shall be monitored through the QI program. (8.19) The trauma center shall have policies designed to ensure that traumapatients who may require resuscitation and monitoring are accompanied by appropriately trained providers during transportation to and while in the radiology department.(8.20) Conventional radiography and CT are available 24/7.(8.21) When the CT technologist responds from outside the hospital, the Trauma Program documents the response time.(8.22) TIR is utilized to expedite care of patients being transferred in and out when appropriate.
III	Respiratory Therapy Services	R	(8.23) There shall be a respiratory therapist available and on-call 24/7.
III	Rehabilitation Services	R	(8.24) Facilities shall be required to provide rehabilitation services or have transfer agreement(s) signed with rehabilitation facilities to ensure the timely transfer of patients requiring these services.
III	Therapy Services	R	(8.25) Facilities are required to provide these services or have transfer agreement(s) signed to ensure the timely transfer of the following services:  Physical therapy Occupational therapy Speech therapy
III	Social Services	R	(8.26) Social workCase management Chaplain services
	9. Effective Transfer of Patients
III	Coordinate All Trauma Transfers Through the ATCC	R	(9.1) All trauma transfers shall be coordinated through the ATCC. Compliance shall be 95% of the time as an aggregate (average) over the reporting period (this does not apply to out-of-state hospitals transferring to out- of-state hospitals). The program shall monitor transfers in its QI program and be able to demonstrate compliance. The decision to accept or not accept a patient to the facility shall be made within 10 minutes of contact by the ATCC at least 90% of the time. The exception to this 10 minute requirement is for stable, single system orthopedic, ophthalmologic, or maxillofacial injuries where discussion with the specialist would be beneficial (all communication shall still come though ATCC and an answer given as to acceptance within 20 minutes). The acceptance time shall be tracked in the facility’s QI program. A direct physician-to-physician contact is not required for acceptance of a transfer. The acceptance may be granted by anyone designated by the facility to accept a patient on behalf of the facility, including an ED nurse.(9.2) Denials for acceptance of transfers shall be tracked through the trauma program’s QI process. Utilization of the ATCC shall be actively tracked in the facility’s QI program with a list of all patients transferred out with the corresponding trauma band number.(9.3) All diversions (Bravo, Charlie Temp, and Delta) shall be documented and tracked in the hospital's trauma QI program. Diversions that exceed 5% of the time for required services shall be reported quarterly with a corrective action plan to the TRAC and the ADH.
III	Appropriate Documentation of Patient Records for TransferredPatients	R	(9.4) Transferring facilities shall send a copy of the patient’s pertinent medical record along with radiographic studies (by the TIR when available or readable CD when the TIR is not available).(9.5) Final readings by the referring facility’s radiologists shall be sent to thereceiving facility as soon as available when requested by the receiving facility. Transfer shall not be delayed waiting on this final reading report.(9.6) Copies of original run sheets and readings of the X-ray studies shall be sent to the receiving hospital no later than the next business day.
III	Well-defined Transfer Plans are Essential	R	(9.7) The plan shall be codified in the facility, approved by the Trauma Program Operations Review Committee, and disseminated to ED physicians and surgeons in the program. All transfers out are reviewed in the review committee by the TMD/TMCD and TPM and documented as appropriate or inappropriate. The decision to transfer an injured patient to a specialty facility in an acute situation shall be based solely on the needs of the patient; for example, the method of payment is not considered.
III	Teletrauma	R	(9.8) The hospital shall have collaborative agreements with referral trauma centers and demonstrate successful use.
	10. Quality Improvement and Peer Review Process
III	Quality Improvement (QI)	R	(10.1) The center shall have a clearly defined QI program for the trauma patient population. The QI program shall be supported by a reliable method of data collection that consistently gathers valid and objective information necessary to identify opportunities for improvement. The results of analysis shall define corrective strategies, the results of which shall be documented. The trauma program shall be empowered to address issues in multiple disciplines.(10.2) The TMD/TCMD (or his/her respective physician designee), the TPM (or his/her respective nurse designee), and specialty representatives in EM, orthopedics, neurosurgery, anesthesia, critical care, and radiology (if available in-house) shall attend at least 50% at the Trauma Peer Review Committee meetings.
III	Audit Filters	R	(10.3) Use of the current Arkansas State QI Audit Filters is mandatory. (10.4) The facility shall track and trend the cases that trigger one of the stateaudit filters. The trauma center may add additional filters to suit its specific needs. The facility shall use the trended information gathered from review of the audit filters to guide the QI program.(10.5) Identified problem trends shall undergo review in the multidisciplinary QI meetings with action plans generated, documented, and followed by loop closure.(10.6) Orthopedic, neurosurgical and geriatric/special needs-specific audit filters shall be tracked. (see orthopedic, neurosurgical and geriatric/special needs sections). Shall track neurosurgical audit filters in facilities when neurosurgery is available.(10.7) Non-surgical admission (NSA) Trauma centers may admit more than 10% of the admitted trauma patients to a non-surgical service.If a trauma service admits more than 10% of injured patients to a non- surgical service, the trauma program shall:1. be able to run a Trauma Registry report of all patients admitted to a non-surgical service (total number of NSAs);2. determine the number of NSAs that had an appropriate surgical service consult;3. determine the number of NSAs resulting from same level falls;4. determine the number of NSAs resulting from drowning and hanging; and,5. determine the number of NSAs with ISS < 9.(10.8) All NSA patients not meeting criteria 2-5 shall be reviewed in the QI meeting for appropriateness of admission to a non-surgical service.
III	Trauma Chart Reviews	R	(10.9) Review charts on all trauma patients meeting state Trauma Registry inclusion criteria, including deaths, unexpected outcomes, all pediatric patients, and other patients who meet state QI audit filter criteria.(10.10) Review of the entire patient's encounter with the trauma system, from EMS through hospital treatment and discharge, transfer, or death, with identification of opportunities for improvement in any and all aspects of care.(10.11) Identified opportunities for improvement shall be followed by an action plan and loop closure documenting the effect of the action plan.
III	Trauma-Specific QI Program	R	(10.12) This program shall be a structured process, led by the trauma program, to demonstrate continuous evaluation to improve care for injured patients that is coordinated with the hospital-wide QI program.The components of an organized trauma QI program shall be:(10.13) a reliable method of identifying trauma patients presenting to and/or admitted to the facility;(10.14) the infrastructure to abstract patient information from the hospital and prehospital records in order to identify quality of care issues that is reliable and consistently obtains valid and objective information necessary to identify opportunities for improvement;(10.15) a clearly defined set of data points and audit filters to be abstracted from the patient’s record;(10.16) proper identification and ICD-9, ICD-10 (or newer version), and AIS coding of all injuries;(10.17) selection of facility-specific process and outcome measures that are related to patient care and can be benchmarked to national standards;(10.18) a functional trauma registry that supports the QI program;(10.19) validation of data abstraction, injury identification, and ISS coding is mandatory;(10.20) a multidisciplinary review process that occurs at frequent, regular intervals and analyzes trauma care in the institution in order to identify opportunities for improvement;(10.21) multidisciplinary involvement as evidenced by both meeting an attendance threshold and submission of case reviews in specialty areas;(10.22) the results of this multidisciplinary review process leads to corrective actions that are documented may include a letter to inform the responsible party with or without response, an educational offering related to the identified issue, a policy change or development of new policy, counseling of the responsible person, or removal from the trauma call panel;(10.23) when a consistent problem or inappropriate variation is identified, corrective actions are taken and documented;(10.24) tracking and trending of identified performance issues is necessary to ensure compliance to process changes;(10.25) the TMD/TCMD and TPM shall be empowered by the hospital’s administration to address issues that involve multiple disciplines and perform loop closure for issues identified;(10.26) the TMD/TCMD and TPM shall be aware of current national standards of trauma care and hold their call panel physicians to this expectation;(10.27) creation of protocols, guidelines, or pathways based on the findings from multidisciplinary meetings;(10.28) there is a QI program that convincingly demonstrates appropriate care in the facility that treats neurotrauma patients; and,(10.29) the QI program reviews the appropriate referral of patients to the regional organ procurement organization and subsequent organ donation rate.
III	Trauma Multidisciplinary Review (TMR) Process	R	(10.30) This process shall be led by the TMD/TCMD and the TPM with representation from all core surgeons, specialties, and services, participates on the trauma team at the facility, which is authorized by the facility to establish, review, and improve the care of the injured. The TMR process shall:1. establish trauma treatment protocols;2. oversee compliance with these protocols;3. identify opportunities for improvement;4. develop plans for resolution and ensures improvement of identified issues; and,5. monitor loop closure of issues identified in the process. (10.31) While there may be a single multidisciplinary meeting in a facility, this multidisciplinary process shall consist of two distinct parts:1. Trauma Program Operations Review Committee; and,2. Trauma Peer Review Committee.(10.32) The minutes of these discussions shall be recorded separately. (10.33) The peer review portion shall report through the hospital's trauma QI program to assure protection and continuity of practitioner data for credentialing processes. The conduct of the peer review meeting shall be compliant with state and federal law to ensure confidentiality and patient protection.(10.34) Meetings shall occur with a frequency that ensures timely resolution of issues identified through the trauma QI program. Trauma centers with few trauma patients may accomplish this on a quarterly basis while hospitals with more trauma volume may need to hold such meetings on a weekly basis.(10.35) Attendance by the ED director or EM liaison, TMD/TCMD, all core surgeons, specialties, services when available, and radiology when available in-house, is required and they shall attend at least 50% of the Trauma Peer Review Committee meetings.(10.36) In circumstances when attendance is not mandated (non-core members), the TMD/TCMD ensures dissemination of information from the trauma peer review committee. The TMD/TCMD shall document the dissemination of information from the trauma peer review committee.
	11. Responsibility to the Arkansas Department of Health (ADH)
III	Trauma Registry Data and Submission to the Trauma Registry	R	(11.1) Timely abstraction of the charts of injured patients who meet inclusion criteria; data shall be entered into the Trauma Registry and closed within 60 days of discharge.(11.2) Data shall be submitted to the Trauma Registry when requested by the ADH.(11.3) At the time of submission of the designation site survey pre-review questionnaire, the trauma center shall submit all trauma patient records to the Trauma Registry even if the submission is not within the standard reporting period.(11.4) Trauma Registry data are collected and analyzed.
III	Accuracy of the Trauma Data Submitted to the Trauma Registry	R	(11.5) The trauma center shall create and implement a verifiable process to ensure accuracy and completeness of the data submitted to the Trauma Registry.(11.6) Trauma centers are required to document complete and accurate data for all trauma patients meeting Trauma Registry inclusion criteria.
III	Participation in Trauma Regional Advisory Council (TRAC)	R	At least 50% of the required (to be determined by the TRAC) regional meetings shall be attended by the:(11.7) TMD/TCMD or physician designee; and, (11.8) TPM or nurse designee.
III	Active Participation in the Regional and State Peer Review Process	R	(11.9) The TMD/TCMD (or his/her respective physician designee) and TPM (or his/her respective nurse designee) shall attend 50% of the regional peer review meetings.(11.10) The TMD/TCMD (or his/her respective physician designee) and TPM (orhis/her respective nurse designee) shall attend 100% of the regional and state peer review meetings when the facility’s cases are discussed. (11.11) The trauma center shall provide adequate clinical patient information for meaningful discussion in the protected QI meetings sanctioned by the ADH.(11.12) The Trauma Program shall provide data and participate meaningfully in the regional and state QI meetings as required by the chair of the committee, TRAC MD, or state TMD.
III	Community Outreach and Educational Programs in Trauma-specific Opportunities Sponsored by the Hospital	R	(11.13) The facility shall provide opportunities for staff and community physicians, nurses, allied health personnel, and prehospital providers to receive CME credits. The facility may satisfy this requirement by working independently or with other facilities, the TRAC, regional organizations, or ADH-approved education foundation to provide this education. The facility’s contribution to education and outreach shall be verifiable at review.
	12. Other Responsibilities of General Trauma Facilities
III	Injury and Violence Prevention (IVP)	R	(12.1) The facility shall have an identified staff member who is the point of contact for IVP activities and notify the Trauma Section and the TRAC IVP Committee regarding the identity of the designated person.(12.2) The facility shall demonstrate involvement with the TRAC in regional IVP planning efforts.(12.3) The facility shall work with the ADH-affiliated IVP programs by participating in evidence-based prevention programs, either alone or in collaboration with other facilities, such as the regional Hometown Health Initiative, local EMS agencies, or the TRAC.(12.4) The facility shall demonstrate participation in ADH-affiliated IVP programs and shall participate in evaluation efforts for regional IVP programs.
III	Alcohol Screening and Intervention	R	(12.5) The facility shall have a method to screen admitted trauma patients for risky alcohol use or abuse and have a plan to assist patients with positive screens. Screening can be in the form of a consumption questionnaire or biological measurements. Assistance can be provision of appropriate referrals or in-house intervention, such as brief motivational interviewing.
III	Disaster Management	R	(12.6) The hospital shall participate in regional disaster planning and drills. (12.7) The hospital shall meet the disaster-related requirements of TJC, theAOA/HFAP or an equivalent licensing body.(12.8) A trauma panel surgeon or clinical member of the trauma team shall be involved in the hospital's disaster committee.(12.9) As an emergency response exercise, the hospital shall activate its Emergency Operations Plan twice a year at each site included in the plan. If the hospital activates its Emergency Operations Plan in response to one or more actual emergencies, these emergencies can serve in place of emergency response exercises. Tabletop sessions, though useful, are not acceptable substitutes for these exercises.(12.10) The trauma center shall have an Emergency Operations Plan described in the hospital disaster manual.
III	Organ Procurement Organization (OPO)	R	(12.11) The trauma center shall have an established relationship with a recognized OPO.(12.12) The facility shall have written policies for triggering notification of the OPO.(12.13) The facility shall track its percentage of referral of eligible patients and track the percentage of successful donors from the pool of referredpatients.