A Level V trauma receiving hospital shall meet the following criteria:

1. (1) The hospital organization shall have:

   1. (a) A trauma program recognized by the hospital, including a physician medical director and trauma nurse leader;
   2. (b) A hospital-specific definition of a trauma team alert patient;
   3. (c) A multidisciplinary operational and performance improvement review committee with a defined purpose and meeting format. The committee may be combined with another performance improvement committee established by the hospital;
   4. (d) Defined trauma team roles and responsibility;
   5. (e) Defined trauma team activation guidelines; and
   6. (f) Defined trauma transfer protocols;

2. (2) The hospital's emergency department shall include the following capabilities and equipment:

   1. (a) Twenty-four hours a day, seven days a week operation;
   2. (b) A designated medical director;
   3. (c) Physician, physician assistant, or nurse practitioner on-call coverage with a maximum 30 minute response time. Response time shall be documented and monitored;
   4. (d) A registered nurse available in the hospital and promptly available to the emergency department;
   5. (e) Airway control and ventilation equipment including laryngoscope and endotracheal tubes of all sizes, other invasive airway adjuncts, bag-mask resuscitator, pocket masks, and oxygen;
   6. (f) Pulse oximetry;
   7. (g) End-tidal carbon dioxide detectors;
   8. (h) Suction devices;
   9. (i) Electrocardiograph-oscilloscope-defibrillator;
   10. (j) Pediatric resuscitation equipment;
   11. (k) Standard intravenous fluids and administration devices, including large bore intravenous catheters;

   12. (l) Sterile surgical sets, including:

       1. (i) Airway control, cricothyrotomy, tracheostomy trays, or thoracotomy;
       2. (ii) Vascular access; and
       3. (iii) Needle decompression or chest tubes (varioussizes);
   13. (m) Gastric decompression or nasal gastric tubes;
   14. (n) X-ray availability 24 hours a day, seven days a week;
   15. (o) Two-way communication with vehicles of emergency transport;
   16. (p) Thermal control equipment for patients; and
   17. (q) Vascular Doppler;

3. (3) The hospital's radiology services shall include:

   1. (a) A radiology technologist on-call with a maximum 30 minute response time. Response times shall be documented and monitored; and
   2. (b) Conventional radiography;

4. (4) The hospital's laboratory services and capabilities shall include:

   1. (a) A clinical laboratory available 24 hours a day, seven days a week;
   2. (b) Standard analysis of blood, urine, and other body fluids;
   3. (c) An O-negative blood supply; and
   4. (d) Coagulation studies;
5. (5) The hospital shall have respiratory services available;
6. (6) The hospital's trauma prevention and outreach shall include injury prevention and public awareness activities;

7. (7) The hospital's performance improvement and patient safety shall include:

   1. (a) An organized and structured performance improvement program;
   2. (b) A multidisciplinary performance improvement review committee. The committee may be combined with another performance improvement committee established by the hospital;
   3. (c) The collection and submission of trauma data pursuant to chapter 44:68:04;
   4. (d) A hospital and pre-hospital trauma care performance improvement review;
   5. (e) A quarterly mortality and morbidity case review;

   6. (f) An operation performance improvement review program including notification and arrival times for the following team members:

      1. (i) An on-call physician, physician assistant, or nurse practitioner;
      2. (ii) A radiology technologist;
      3. (iii) A laboratory technician; and
      4. (iv) A respiratory therapist, if part of the trauma team;
   7. (g) A published on-call schedule for trauma team members; and
   8. (h) A collaborative involvement in pre-hospital care protocols; and

8. (8) The hospital's staff educational requirements shall be as follows:

   1. (a) The physician medical director shall have current certification in ATLS education;

   2. (b) The surgeon, if on staff, shall:

      1. (i) Have current certification in ATLS education; or
      2. (ii) Have documentation indicating successful completion of ATLS education at least once and a minimum of 16 hours of trauma continuing medical education credits every four years;

   3. (c) The physician covering the emergency department shall:

      1. (i) Have current certification in ATLS education; or
      2. (ii) Have documentation indicating successful completion of ATLS education at least once and a minimum of 16 hours of trauma continuing medical education credits every four years;

   4. (d) The physician assistant or nurse practitioner covering the emergency department shall:

      1. (i) Have current certification in ATLS education; or
      2. (ii) Have documentation indicating successful completion of ATLS education at least once and a minimum of 16 hours of trauma continuing medical education credits every four years; and
   5. (e) Each emergency department nurse shall be current in TNCC education.

Source: 35 SDR 304, effective June 29, 2009.

General Authority: SDCL 34-12-54.

Law Implemented: SDCL 34-12-53 , 34-12-54.