(d)

1. (1) A Level IV trauma center is expected to function at its clinical capability, which may exceed the minimum “essential” categorization criteria.
2. (2) For example, if a general surgeon is sometimes available, he or she shall be an active member of the trauma team.
3. (3) If he or she is on call for the hospital and responsible for patient care, then the surgeon shall also be responsible for trauma patient care.

   Level IV Criteria
   Level	Section	Required(R) or Desirable(D)	Criteria
   	TRAUMA PROGRAM
   	1. Support/Infrastructure
   IV	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, as 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 and TPM within the organization.
   IV	Trauma Program Administration and Infrastructure	R	(1.5) Program within an acute care facility with defined leadership (TMD, TPM) and 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
   IV	Trauma Medical Director (TMD)	R	Requirements and qualifications for the TMD:(2.1) 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.(2.2) Current in ATLS as a provider or an instructor.Responsibilities and duties of the TMD:(2.3) Lead the trauma QI and patient safety programs within the trauma center. (2.4) Have the ability to contribute to the TPM’s performance evaluation.(2.5) Demonstrate with his/her signature awareness of the facility’s invoices to the ADH for payment.(2.6) Have a method to identify injured patients, monitor the provision of health care services, and hold formal and informal discussions with individual practitioners.(2.7) 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, placemembers 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.(2.8) Have responsibility and authority for determining each call panel member’s ability to participate on the trauma call schedule based on a periodic review.(2.9) 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.** 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 when considering trauma privileges, while the TMD shall have the discretion of which providers participate in the trauma call schedule. A decision by the TMD 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.
   IV	Trauma Program Manager (TPM)	R	Requirement and qualifications for the TPM:(2.10) 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.(2.11) 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.(2.12) ATCN, TNCC, or ADH-approved equivalent course certifications shall be current.(2.13) The training of a TPM new to this position shall include a TPM course and a QI course.Responsibilities and duties of the TPM:(2.14) There shall be a verifiable, written job description for the TPM that clearly identifies expectations of leadership and authority to perform the duties required.(2.15) Dedicate at least 1.0 FTE to trauma programs having a trauma patient record volume of 500 or greater.(2.16) 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.
   IV	Trauma Registrar	R	(2.17) There shall be a verifiable, written job description for the Trauma Registrar that clearly identifies expectations.(2.18) The facility shall have adequate resources to maintain accurate and timely collection, evaluation, and submission of trauma data.(2.19) The training of a Trauma Registrar new to this position shall include a course approved by the ADH.
   IV	Trauma Program Staff	R	(2.20) Trauma Program staff shall have adequate support resources to efficiently and effectively oversee and administer the trauma program and remain engaged in an effective QI process.
   IV	Trauma Liaisons	R	(2.21) Official physician liaisons shall be named for EM. In addition, if a neurosurgery, orthopedics, anesthesia, critical care, and in-house radiology 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.(2.22) 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.
   IV	Trauma Team	R	(2.23) 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.
   IV	Consultant Coverage	R	(2.24) 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
   IV	General Surgery Participation		General surgery coverage is not required at a Level IV facility.However, if a hospital represents itself as having general surgical capability and capacity on the ATCC dashboard, the following applies and is required of the general surgeon(s):(3.1) Shall have privileges in general surgery.(3.2) 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.(3.3) Shall have taken ATLS at least once or shall be current in ATLS within one year of hire.(3.4) Shall obtain the required verifiable 18 hours of Category I trauma-specific CME, or 18 hours of trauma-specific internal education every three years.(3.5) Core surgeons shall participate in at least 50% of the Trauma Peer Review Committee meetings and disseminate information back to all surgeons.(3.6) Shall respond to the ED promptly (within 30 minutes) on an aggregate of80% of the time when on-call and when the highest level of trauma is activated.
   			(3.7) 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.
   IV	Orthopedic Surgery Participation		Orthopedic surgery coverage is not required at a Level IV facility.However, if a hospital represents itself as having orthopedic surgical capability and capacity on the ATCC dashboard, the following applies and is required of the orthopedic surgeon(s):(3.8) Shall obtain the required verifiable 18 hours of Category I trauma-specific CME, or 18 hours of trauma-specific internal education every three years.(3.9) A liaison shall participate in at least 50% of the Trauma Peer Review Committee trauma meetings and disseminate information back to all orthopedic surgeons on the call panel.(3.10) Orthopedic surgeons shall have privileges in general orthopedic surgery. (3.11) 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.
   IV	Anesthesiology Participation		Anesthesiology coverage is not required at a Level IV facility.However, if a hospital has anesthesiology on-call to assist with urgent surgical cases, the following applies and is required of the anesthesiologist(s):(3.12) Anesthesiology services are promptly available for emergency operations; (3.13) Anesthesiology services are promptly available for airway problems if on-call for urgent surgical cases; This may be fulfilled by an anesthesiologist or a CRNA. If a CRNA is utilized, the supervising physician shall be promptly available. If a CRNA is utilized, it shall be with the approval of the chief anesthesiologist or supervising physician if the facility does not have a chief anesthesiologist;(3.14) There is an anesthesiology liaison designated to the trauma program; (3.15) The availability of the anesthesia services and the absence of delays in airway control or operations is documented by the trauma QI program; (3.16) In trauma centers without in-house anesthesia services, protocols are inplace to ensure the timely arrival at the bedside of the anesthesia provider; (3.17) In a center without in-house anesthesia services, there is documentation ofthe presence of physicians skilled in emergency airway management; (3.18) Availability of anesthesia services and the absence of delays in airwaycontrol or operations are documented in the trauma QI program; (3.19) The anesthesia liaison participates in the trauma QI program; and, (3.20) The anesthesiology representative or designee to the trauma program attends at least 50% of the Trauma Peer Review Committee meetings.
   	TRAUMA FACILITY AND OPERATIONS
   	4. Emergency Department (ED)
   IV	Leadership	R	(4.1) As with the TMD, a physician leader is essential. The TMD may also be the ED Director. The ED Director shall be an active liaison to the trauma program.
   IV	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.
   IV	Physician, Mid- level Practitioners and Nursing Availability	R	(4.3) ED that is available 24/7 with physicians and nurses rapidly available (within 10 minutes of notification of the highest level of activation) to resuscitate the injured patient. This has to be met 80% of the time.(4.4) A tracking mechanism shall be in place and reviewed in the QI program.
   IV	CMERequirements for Providers	R	(4.5) Physicians who cover the ED in rural trauma centers may not see enough trauma to stay abreast of current treatment protocols. Category I or II 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.
   IV	Trauma Educational Certification - Physician and Mid-Level Practitioners	R	(4.6) Maintaining current ATLS certification for physicians and mid-level practitioners 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, and ABP shall have completed ATLS at least once, and are encouraged but not required to be current.
   IV	Trauma Nursing Educational Preparation	R	(4.7) 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.(4.8) 80% of nurses working in the ED shall be current in ACLS and PALS or ENPC.
   IV	Trauma Nursing ContinuingEducation	R	(4.9) 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.
   IV	Activation Criteria	R	(4.10) The criteria for the highest level of trauma team activations are clearly defined and evaluated by the QI program.(4.11) 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.(4.12) 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 < 13 with a mechanism due to trauma (general surgeon response, if provided, can be at the discretion of the ED physician);3. respiratory compromise or obstruction or an intubated patient from the scene;4. gunshot to the neck, chest, or abdomen; and,5. any patient that the ED physician feels the highest level of activation is warranted.(4.13) Activation of the trauma team for the highest level shall be based on prehospital notification when available, regardless of the ultimate decision to transfer.(4.14) Facilities may create a tiered activation system with variable response from hospital and physician personnel but, at a minimum, shall have the above criteria in the highest level of activation. The facility shall determine the expectation for physician response to the various levels of activation and be able to track this as part of the QI program.(4.15) The physicians on-call for the ED shall be notified for patients’ meeting the highest level of activation when the trauma team is activated and is expected to be present in the ED within 10 minutes of team activation.(4.16) Level IV facilities are not required to have surgical capability; however, if general surgeons are participating on the Level IV facility’s trauma call panel and are on-call, they are expected to be promptly available (30 minutes) upon notification of activation of the highest level of trauma.(4.17) The facility shall be able to demonstrate under and over-triage rates based on their activation criteria.(4.18) The facility shall be able to track arrival of the physicians who should respond to a given level of activation.
   IV	Rural Trauma Team Development Course (RTTDC)	R	(4.19) Rural facilities shall demonstrate participation by at least three members of the trauma resuscitation team, including physicians, nurses, and allied health personnel, three times per review period.
   IV	Helipad or Landing Zone	R	(4.20) Shall have a helipad or a written, organized plan for getting the trauma patient to the ED from an established safe landing zone with alternative sites should the primary landing site be unavailable. Exceptions may be made by the ADH on an individual facility basis for urban Level IV facilities.
   IV	Trauma Image Repository	R	(4.21) Availability to send and receive images to and from TIR in the ED. (4.22) Utilization of TIR when appropriate for expediting trauma patient care.
   IV	Roles and Responsibilities in the Trauma Bay	R	(4.23) Written protocol for roles and responsibilities of all team members during trauma team resuscitations.
   IV	Safe Transport of Patients Within and Out of the EmergencyDepartment	R	(4.24) 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)
   IV	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
   IV	Airway Monitoring	R	(5.4) Pulse Oximetry(5.5) Qualitative End-tidal CO2 Determination – Color Change Detectors (5.6) Continuous End-tidal CO2 Monitoring (Desired)
   IV	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
   IV	Large Bore IV Catheters	R	(5.10) 14 – 18 gauge IVs(5.11) Interosseous catheters
   IV	Focused Assessment with Sonography forTrauma (FAST)	D	(5.12) Machine available to the trauma team and members of the trauma team trained in its use.
   IV	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)
   IV	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
   IV	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.2009-1807.citation
   IV	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.
   IV	Suction Devices	R	(5.21) Oral and tracheal suction devices for adult and pediatric patients, as well as tubing required for connection, shall be present in the trauma bay and CT scanner.
   	6. Other Trauma Care Areas and Services
   IV	Pediatric Care	R	(6.1) 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.(6.2) Pediatric resuscitation equipment shall be available in all pediatric care areas.
   IV	Geriatric Care/Special Needs	R	(6.3) The facility shall have a protocol for the admission and care of geriatric/special needs patients (age > 65 years).(6.4) 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.
   IV	Laboratory Services Available 24/7	R	(6.5) Standard analysis of blood, urine, and other body fluids, including micro- sampling for pediatric patients when appropriate. Blood gases and pH determination is required.
   IV	Blood Bank Ability to Transfuse Blood24/7	R	(6.6) The ability to provide oxygen carrying capacity along with volume expansion in an actively bleeding injured patient. The facility shall have the ability to perform a type and cross match or have at least two units of O negative blood available.(6.7) 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.
   IV	Radiological Services Available 24/7	R	(6.8) X-ray technologists shall be promptly available 24/7 upon activation of the trauma team.(6.9) The TIR shall be utilized to expedite care of patients being transferred in and out when appropriate.
   IV	Respiratory Therapy	R	(6.10) Shall have a respiratory therapist or other personnel trained to fulfill that function (evaluated at the time of verification) who is on-call and promptly available.
   IV	Rehabilitation Services	R	(6.11) 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.
   IV	Therapy Services	D	Physical therapy Occupational therapy Speech therapy
   IV	Social Services	D	Social workCase management Chaplain services
   	7. Effective Transfer of Patients
   IV	Coordinate All Trauma Transfers Through the ATCC	R	(7.1) All trauma transfers shall be coordinated through the ATCC with an expectation of compliance at 95% of the time as an aggregate (average) over the reporting period.(7.2) Utilization of the ATCC shall be actively tracked in the facility’s QI program with a list of all patients transferred out and the corresponding trauma band number.(7.3) A trauma facility shall not be on diversion for any required category listed on the ATCC dashboard for more than 5% of the time during any three month period.
   IV	Appropriate Documentation of Patient Records for TransferredPatients	R	(7.4) 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).(7.5) 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. (7.6) Copies of original run sheets and readings of X-ray studies shall be sent tothe receiving hospital no later than the next business day.
   IV	Well-defined Transfer Plans are Essential	R	(7.7) The plan shall be codified in the facility, approved by the Trauma Program Operations Review Committee, and disseminated to the ED physicians and surgeons in the program. All transfers out shall be reviewed in the review committee by the TMD and TPM and documented as appropriate or inappropriate. The decision to transfer an injured patient to a specialty facility in acute situation shall be based solely on the need of the patient; for example, the method of payment is not considered.
   IV	Teletrauma	R	(7.8) The hospital shall have collaborative agreements with referral trauma centers and demonstrate successful use.
   	8. Quality Improvement and Peer Review Process
   IV	Quality Improvement (QI)	R	(8.1) 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.(8.2) The TMD (or his/her respective physician designee), the TPM (or his/her respective nurse designee) and, if available, specialty representatives in EM, orthopedics, neurosurgery, anesthesia, critical care, and radiology (if in-house) shall attend at least 50% at the Trauma Peer Review Committee meetings.
   IV	Audit Filters	R	(8.3) Use of the current Arkansas State QI Audit Filters is mandatory.(8.4) The facility shall track and trend the cases that trigger one of the state audit 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.(8.5) Identified problem trends shall undergo review in the multidisciplinary QI meetings with action plans generated, documented, and followed by loop closure.(8.6) Orthopedic and geriatric/special needs-specific audit filters shall be tracked (see orthopedic, and geriatric/special needs sections). Applies to Level IV if orthopedic services care for injured patients in the facility.(8.7) 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 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.(8.8) All NSA patients not meeting criteria 2-5 shall be reviewed in the QI meeting for appropriateness of admission to a non-surgical service.
   IV	Trauma Chart Reviews	R	(8.9) Review charts on all trauma patients meeting state Trauma Registry inclusion criteria, including deaths, unexpected outcomes, all pediatric patients, and any other patients that meet state QI audit filter criteria.(8.10) 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.(8.11) Identified opportunities for improvement shall be followed by an action plan and loop closure documenting the effect of the action plan.
   IV	Trauma-Specific QI Program	R	(8.12) 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:(8.13) a reliable method of identifying trauma patients presenting to and/or admitted to the facility;(8.14) 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;(8.15) a clearly defined set of data points and audit filters to be abstracted from the patient’s record;(8.16) proper identification and ICD-9, ICD-10 (or newer version), and AIS coding of all injuries;(8.17) selection of facility-specific process and outcome measures that are related to patient care and can be benchmarked to national standards;(8.18) a functional Trauma Registry that supports the QI program;(8.19) validation of data abstraction, injury identification and ISS coding is mandatory;(8.20) a multidisciplinary review process that occurs at frequent, regular intervalsand analyzes trauma care in the institution in order to identify opportunities for improvement;(8.21) multidisciplinary involvement as evidenced by both meeting an attendance threshold and submission of case reviews in specialty areas;(8.22) the results of this multidisciplinary review process lead 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;(8.23) when a consistent problem or inappropriate variation is identified, corrective actions are taken and documented;(8.24) tracking and trending of identified performance issues is necessary to ensure compliance to process changes;(8.25) the TMD and TPM shall be empowered by the hospital’s administration to address issues that involve multiple disciplines and perform loop closure for issues identified;(8.26) the TMD and TPM shall be aware of current national standards of trauma care and hold their call panel physicians to this expectation;(8.27) creation of protocols, guidelines, or pathways based on the findings from multidisciplinary meetings; and,(8.28) the QI program reviews the appropriate referral of patients to the regional organ procurement organization and subsequent organ donation rate.
   IV	Trauma Multidisciplinary Review (TMR) Process	R	(8.29) This process shall be led by the TMD and the TPM with representation from all surgeons/specialties (if available) 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 assure improvement of identified issues; and,5. monitor loop closure of issues identified in the process. (8.30) 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.(8.31) The minutes of these discussions shall be recorded separately.(8.32) 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.(8.33) 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 centers with more trauma volume may need to hold such meetings on a weeklybasis.(8.34) The attendance requirement for physicians (ED director, TMD, and general surgeon liaison (if the facility provides general surgical coverage, even on a part time basis) and mid-level practitioners is at least 50% of the Trauma Peer Review Committee meetings.(8.35) Hospitals that have general surgeons, orthopedic surgeons, radiologists (if in-house), neurosurgeons, EM physicians, anesthesiologists or rehabilitation specialists participating in the trauma team in the facility are required to have a liaison from these specialties participate in at least 50% of the Trauma Peer Review Committee meetings, if those providers participate in the care of trauma patients, even if the level of designation does not require that specialty.(8.36) The TMD shall provide to the non-liaisons the information from the process and peer review meetings. This process of dissemination of information shall be monitored through the QI program and be verifiable at review.If general surgery or orthopedic coverage is less than 33% of the total time, the requirement to have a liaison attend the meetings is waived. The other requirements will remain in force as is the responsibility of the TMD to effectively disseminate information.
   	9. Responsibility to the Arkansas Department of Health (ADH)
   IV	Trauma RegistryData andSubmission tothe TraumaRegistry	R	(9.1) 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.(9.2) Data shall be sent to Trauma Registry when requested by the ADH.(9.3) 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.(9.4) Trauma Registry data are collected and analyzed.
   IV	Accuracy of the Trauma Data Submitted to the Trauma Registry	R	(9.5) The trauma center shall create and implement a verifiable process to ensure accuracy and completeness of the data submitted to the Trauma Registry.(9.6) Trauma centers are required to document complete and accurate data for all trauma patients meeting state Trauma Registry inclusion criteria.
   IV	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:(9.7) TMD or physician designee; and, (9.8) TPM or nurse designee.
   IV	ActiveParticipation inthe Regional andState PeerReview Process	R	(9.9) The TMD (or his/her respective physician designee) and TPM (or his/her respective nurse designee) shall attend 50% of the regional peer review meetings.(9.10) The TMD (or his/her respective physician designee) and TPM (or his/her respective nurse designee) shall attend 100% of the regional and state peer review meetings when the facility’s cases are discussed.(9.11) The trauma center shall provide adequate clinical patient information for meaningful discussion in these protected QI meetings which have been sanctioned by the ADH.(9.12) The 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.
   IV	Community Outreach and Educational Programs in Trauma-specific Opportunities Sponsored by theHospital	R	(9.13) 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 an ADH- approved education foundation to provide this education. The facility’s contribution to education and outreach shall be verifiable at review.
   	10. Other Responsibilities of Basic Trauma Facilities
   IV	Injury and Violence Prevention (IVP)	R	(10.1) 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.(10.2) The facility shall demonstrate involvement with the TRAC in regional IVP planning efforts.(10.3) 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 group, local EMS agencies, or the TRAC.(10.4) The facility shall demonstrate participation in ADH-affiliated IVP programs and shall participate in evaluation efforts for regional IVP programs.
   IV	Alcohol Screening and Intervention	R	(10.5) The facility shall have a method to screen admitted trauma patients for risky alcohol use or abuse and to 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.
   IV	Disaster Management	R	(10.6) The hospital shall participate in regional disaster planning and drills. (10.7) The hospital shall meet the disaster-related requirements of TJC, the AOA/HFAP or an equivalent licensing body.(10.8) A trauma panel surgeon or clinical member of the trauma team shall be involved in the hospital's disaster committee.(10.9) 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 it’s 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.(10.10) The trauma center shall have an Emergency Operations Plan described in the hospital disaster manual.
   IV	Organ Procurement Organization (OPO)	R	(10.11) The trauma center shall have an established relationship with a recognized OPO.(10.12) The facility shall have written policies for triggering notification of the OPO. (10.13) The facility shall track its percentage of referral of eligible patients and track the percentage of successful donors from the pool of referred patients.