6 Colo. Code Regs. § 1015-4-305

Current through Register Vol. 47, No. 24, December 25, 2024

Section 6 CCR 1015-4-305 - Scope of Care for Designated Trauma Centers Level III-V

1. General Requirements

A. All designated Level III-V trauma centers shall define their Scope of Care (SOC) based on the resources that are available at the facility.

B. A decision to transfer a patient shall be based on the clinical needs of the patient. Physicians shall be allowed to transfer when in the best interest of the patient and shall not be encumbered by restrictions to keep patients within a particular healthcare organization or based on the patient's ability to pay.

2. Emergent Surgery at Level III and IV Trauma Centers

A. All Level III and IV trauma centers may perform emergent surgery if appropriate resources are available. If after the emergent surgery is performed, the facility does not have the post-operative resources to care for the patient and for potential complications, the facility shall transfer to a trauma center with the necessary resources to meet the patient's needs.

B. If the surgeon on call at a Level III or IV trauma center is encumbered in the operating room, the attending emergency department physician shall consult the surgeon to determine the plan of care, including the potential to consult with or transfer to a higher level trauma center.

C. For patients at Level IV trauma centers that require emergent surgery, the emergency physician shall consult the trauma surgeon on call. If the time to surgeon and operating room availability exceeds the transfer time to a trauma center with the necessary resources, the patient shall be transferred.

3. Mandatory Transfer and Consultation, Level III-V Trauma Centers

A. General Requirements for Transfer

(1) Every trauma center shall establish a policy and procedure for addressing when a patient or patient's representative refuses transfer and for when weather, disaster, or other extreme conditions prohibit the safe transfer of the patient.

(2) Nothing in these rules shall preclude any facility with the appropriate resources from providing emergency surgery as provided in Section 305.2.

(3) Patients of any age with a traumatic injury requiring resources beyond those available in the facility's scope of care shall be transferred.

(4) Pediatric patients requiring transfer but not requiring emergent intervention shall be transferred to a Regional Pediatric Trauma Center or to a Level I or II trauma center that admits pediatric patients. The receiving trauma center must meet requirements set forth in 6 CCR 1015-4, Chapter Three, Section 303.9.D.

B. Mandatory Consultation

(1) All Level III and IV trauma centers treating patients with a traumatic injury requiring a massive transfusion shall consult a trauma surgeon at a Level I or II key resource facility for diagnostic and care consideration purposes, including consideration of transfer.

(2) Level III trauma centers with no neurosurgical/orthopedic spine coverage and all Level IV trauma centers treating any patient with intracranial hemorrhage or evidence of cerebral edema due to trauma shall consult a neurosurgeon at a higher level of care for consideration of transfer. If the patient is admitted at the Level III or IV trauma center, after consultation, a general surgeon on the trauma panel shall admit and manage the patient through the course of high acuity care.

(3) All Level III and IV trauma centers shall consult a spinal specialist at a higher level of care to determine the need for transfer for any spinal column fracture other than a lumbar or thoracic transverse process fracture.

(4) All Level III-V facilities admitting pediatric patients with nonaccidental traumatic injury shall consult with a specialist in child maltreatment affiliated with a trauma center for diagnostic and care purposes.

C. Mandatory Transfers for Patients of All Ages

(1) Level III-V trauma centers shall transfer patients with the following traumatic injuries:

a. Hemodynamically unstable pelvic fracture.

b. Pelvic fracture requiring operative fixation.

c. Fracture or dislocation with vascular injury requiring operative vascular repair.

d. Aortic tears.

e. Abdominal or pelvic injury requiring emergent surgery and packing with non-definitive closure.

f. Burns in accordance with 6 CCR 1015-4, Chapter Three, Section 308.

(2) All Level III-V trauma centers shall transfer patients if the facility does not have the resources and clinical expertise to manage their medical co-morbidities, including, but not limited to:

a. Severe chronic obstructive pulmonary disease with home O2 requirement > 4L.

b. Pulmonary hypertension.

c. Critical aortic stenosis.

d. Coronary artery disease and/or recent myocardial infarction within 6 months.

e. Renal disease requiring dialysis.

f. End stage liver disease.

g. Unmanageable coagulopathy.

h. Body mass index > 40.

i. Pregnancy > 20 weeks.

(3) Level III trauma centers with no neurosurgical/orthopedic spine coverage and all Level IV and V trauma centers receiving trauma patients shall transfer under the following conditions:

a. Glasgow Motor Score [SMALLER THAN EQUAL TOO] 4 due to trauma with a normal CT scan.

b. Any intracranial hemorrhage on anti-coagulation or anti-platelet therapy.

c. Lateralizing or focal neurologic deficit.

d. Any open, depressed, or basilar skull fracture.

e. Any unstable spinal column fracture.

f. Spinal column fracture with any motor or sensory deficit.

g. No spinal column fracture but nerve root injury with focal motor deficit or bilateral sensory deficit.

(4) All Level III trauma centers with full or part-time neurosurgical/orthopedic spine coverage shall transfer any patient with a Glasgow Coma Score < 9 due to trauma or any spinal cord injury except those with a transient or unilateral sensory deficit.

(5) In addition, Level IV-V trauma centers shall transfer trauma patients of any age with the following traumatic injuries:

a. Bilateral femur fractures.

b. Femoral shaft fracture with any of the following:

i. Head injury with any evidence or intracranial hemorrhage, depressed skull fracture, or skull fracture with sinus involvement.

ii. Chest injury - Multiple rib fractures (> 4 unilaterally or > 2 bilaterally) or hemothorax.

iii. Abdomen - Hollow organ or solid visceral injury, intra- or retroperitoneal bleeding.

c. Flail chest.

d. Age greater than 65 years with multiple rib fractures (> 4 unilaterally or > 2 bilaterally).

e. Persistent pneumothorax that is unresponsive after adequately placed chest tube having a massive or prolonged air leak.

f. Hemothorax treated with an initial chest tube that does not achieve complete evacuation within twenty four (24) hours.

g. Mechanical ventilation anticipated to be greater than twenty four (24) hours, if the facility does not have the necessary resources to provide ongoing ventilator management.

h. Solid visceral or hollow organ injury, if the facility does not have the necessary resources to care for the patient.

i. Vascular injury requiring operative vascular repair.

j. Crushed, de-gloved, or mangled extremity.

k. Suspected or evidence of nonaccidental trauma requiring social or clinical care beyond the facility's resources.

D. Mandatory transfers for pediatric patients: In addition to the injuries listed above, all Level III-V trauma centers shall transfer patients ages 0-14 with:

(1) Intracranial hemorrhage, evidence of cerebral edema due to trauma, Glasgow Motor Score [SMALLER THAN EQUAL TOO] 4 with a normal CT scan, or lateralizing or focal neurologic deficit.

(2) Intracranial, intrathoracic, or intra-abdominal penetrating injuries or penetrating injuries with orthopedic or neurovascular compromise.

(3) Injuries resulting in the need for mechanical ventilation.

(4) Injuries resulting in the need for a transfusion of packed red blood cells.

(5) Hemothorax.

(6) Pulmonary contusions resulting in associated hypoxia.

(7) Multiple rib fractures or flail chest.

(8) Abdominal hollow organ or solid visceral injury, intra- or retroperitoneal bleeding.

(9) Vascular injury requiring operative vascular repair.

4. Level III and IV trauma centers providing an expanded scope of care shall have:

A. A written policy for the management of each expanded scope service line being offered, for example, orthopedic surgery, plastic surgery, general surgery, or neurosurgery.

B. For Level IV facilities, if there is an emergency physician serving as the Trauma Medical Director, there shall be a physician with surgical expertise to assist with performance improvement.

C. A written policy and plan for patient management when each service is not available, to include:

(1) A defined service that manages inpatient care for continuity.

(2) A written plan to ensure continuity of care for all admitted patients.

(3) Regular communication with transport providers and referring hospitals on availability of the expanded scope service(s).

(4) A hospital-defined continuity of care plan that includes time of availability and proof of communication between services.

D. Formal transfer guidelines for times when a facility does not have specialty coverage.

E. Management guidelines based on the defined expanded scope of care and nationally recognized best practice standards.

F. An emergency department with:

(1) A defined call response time for each specialty consultation.

(2) A massive transfusion protocol.

G. An Operating Room with:

(1) Defined operating room availability, within 30 minutes, if the facility is providing emergent surgery as part of an expanded scope of care.

(2) Anesthesia service and appropriate operating room staff shall match fully functional operating room availability.

(3) Facilities shall match specialty provider availability with operating room availability.

(4) Intra-operative equipment and radiology capability commensurate with the expanded scope of care provided.

H. Inpatient services with medical consultation with a physician appropriately credentialed by the facility to treat medical co-morbidities.

I. Education, including:

(1) Administrative support for the trauma program and the Trauma Medical Director in providing appropriate staff education commensurate with the expanded scope of care and based on patient population served.

(2) The facility shall ensure that the physician specialists direct and/or provide education to the team looking after their patients, including:

a. Post-operative care.

b. Recognition and care of potential complications.

c. Recognition and care of hemodynamic instability.

J. With respect to Levels III-IV trauma centers that provide an expanded scope of care with part-time specialty coverage:

(1) All Level III trauma centers with part-time neurosurgical/orthopedic spine coverage shall:

a. Have a published call schedule.

b. Communicate with prehospital regarding availability of neurosurgical/orthopedic spine coverage.

c. Meet the standards in 6 CCR 1015-4, Chapter Three, 305.3.C.(3) when there is no neurosurgical/orthopedic spine coverage.

(2) Level IV facilities with part-time orthopedic coverage shall not operate on femoral fractures unless there is general surgery availability.

(3) Cases shall be reviewed for projected length of stay and monitored through the performance improvement process. If the length of stay for any patient requiring an expanded scope service is greater than the specialty coverage and general surgery availability, then the patient shall be transferred.

6 CCR 1015-4-305

39 CR 02, January 25, 2016, effective 2/14/2016

40 CR 08, April 25, 2017, effective 5/15/2017

41 CR 22, November 25, 2018, effective 12/15/2018

42 CR 10, May 25, 2019, effective 6/14/2019

43 CR 09, May 10, 2020, effective 6/14/2020

44 CR 10, May 25, 2021, effective 7/1/2021