6 Colo. Code Regs. § 1015-4-306

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

Section 6 CCR 1015-4-306 - Trauma Facility Designation Criteria - Level III

Standards for facilities designated as Level III trauma centers - The facility must be licensed as a general or critical access hospital.

1. A Level III trauma center shall have a trauma program with:

A. An administrative organizational structure that identifies the institutional support and commitment. The program's location within that structure must be placed so that it may interact with at least equal authority with other departments providing patient care within the facility.

B. Medical staff commitment to support the program demonstrated by a written commitment to provide the specialty care needed to support optimal care of the injured patient and specific delineation of surgical privileges.

C. Policies that identify and establish the scope of care for both adult and pediatric patients including, but not limited to:

(1) Initial resuscitation and stabilization;

(2) Admission and interfacility consultation and transfer criteria;

(3) Surgical capabilities;

(4) Critical care capabilities;

(5) Rehabilitation capabilities, if available;

(6) Neurosurgical capabilities, if available;

(7) Spinal cord surgical capabilities, if available;

(8) Other capabilities, if available;

(9) Written procedure for receipt and transfer of patients by fixed and rotary wing aircraft; and

(10) Any expanded scope of care capabilities not already described.

D. A Trauma Medical Director who is a board certified general surgeon, or is board qualified working toward board certification. A facility may have another physician as a co-Trauma Medical Director. The Trauma Medical Director:

(1) Is responsible for service leadership, overseeing all aspects of trauma care, with administrative authority for the hospital trauma program including:

a. Trauma multidisciplinary program,

b. Trauma quality improvement program,

c. Provision of recommendations for physician appointment to and removal from the trauma service,

d. Policy and procedure development and enforcement, and

e. Peer review.

(2) Participates on a local or statewide basis in trauma educational activities for healthcare providers or the public.

(3) Functions as Trauma Medical Director at only one facility.

(4) Participates in the on-call schedule.

(5) Participates in regional trauma system development.

E. A facility-defined trauma team, with an identifiable team leader.

F. A facility-defined trauma team activation protocol that includes who is notified and the response requirements. The protocol shall base activation of the team on the anatomical, physiological, mechanism of injury criteria, and other considerations as outlined in the prehospital trauma triage algorithms as set forth in 6 CCR 1015-4, Chapter One.

G. A facility-defined trauma service with the personnel and resources identified as needed to provide care for the injured patient.

H. A registered nurse identified as the Trauma Nurse Coordinator with educational preparation and clinical experience in care of the injured patient as defined by the facility. This position is responsible for the organization of services and systems necessary for a multidisciplinary approach to care of the injured patient.

I. A multidisciplinary trauma committee with specialty representation. This committee is responsible for trauma program performance. Membership will be established by the facility and attendance requirements established by the committee. Minimum acceptable standards are set forth in Section 304.

J. A quality improvement program as defined in Section 304 of this chapter.

K. Policies, procedures, and practices consistent with the scope of care and expanded scope of care, as applicable, for designated Level III trauma centers as found in Section 305 of this chapter.

L. Divert protocols, to include:

(1) Coordination with the RETAC,

(2) Notification of prehospital providers and other impacted facilities, consistent with RETAC protocols, if any.

(3) Reason for divert, and

(4) A method for monitoring times and reasons for going on divert.

M. A trauma registry as required in Chapter Two of these rules, and trauma data entry support.

N. Participation in the RETAC and statewide quality improvement programs as required in rule.

2. A Level III trauma center shall meet all of the following clinical capabilities criteria:

A. Emergency Medicine in house 24 hours a day.

B. General surgery available in person 24 hours a day within 20 minutes of trauma team activation coverage shall be provided by:

(1) The attending board certified surgeon or board qualified surgeon working toward certification,

(2) Who may only take call at one facility at any one time, and

(3) Who will meet those patients meeting facility-defined Trauma Team Activation criteria upon arrival, by ambulance, in the emergency department. For those patients meeting Trauma Team Activation criteria where adequate prior notification is not possible, the surgical response shall be 20 minutes from notification.

C. The following services on call and available within 30 minutes of request by the trauma team leader:

(1) Anesthesia coverage shall be by an anesthesiologist or a certified registered nurse anesthetist (CRNA).

(2) Orthopedic surgery.

D. The following non-surgical specialists on call, credentialed, and available in person or by tele-radiology for patient service upon request of the trauma team leader:

(1) A radiologist, and

(2) Internal medicine.

3. A Level III trauma center shall have all of the following facilities, resources, and capabilities:

A. An emergency department with:

(1) Personnel, to include:

a. A designated physician director who is board certified in emergency medicine, family practice, internal medicine, or surgery, and whose primary practice is in emergency medicine.

b. Registered nurses in-house 24 hours a day who:

i. Provide continuous monitoring of the trauma patient until release from the emergency department, and

ii. At least one registered nurse in the emergency department 24 hours/day who maintains current certification in Trauma Nurse Core Course or equivalent.

(2) Equipment for the resuscitation of patients of all ages shall include but not be limited to:

a. Airway control and ventilation equipment including: laryngoscopes and endotracheal tubes of all sizes, bag mask resuscitators, and oxygen;

b. Pulse oximetry;

c. End-tidal CO2 determination;

d. Suction devices;

e. Electrocardiograph and defibrillator;

f. Internal paddles - adult and pediatric;

g. Apparatus to establish central venous pressure monitoring;

h. Standard intravenous fluids and administration devices, including large bore intravenous catheters;

i. Sterile surgical sets for:

i. Airway control/cricothyrotomy,

ii. Thorocostomy - needle and tube,

iii. Thoracotomy, and

iv. Vascular access to include central line insertion and interosseous access;

j. Gastric decompression;

k. Drugs necessary for emergency care;

l. X-ray availability, 24 hours a day;

m. Two-way communication with emergency transport vehicles;

n. Spinal immobilization equipment/cervical traction devices;

o. Arterial catheters;

p. Thermal control equipment for:

i. Patients, and

ii. Blood and fluids;

q. Rapid infuser system;

r. Medication chart, tape, or other system to assure ready access to information on proper dose-per-kilogram for resuscitation drugs and equipment sizes for pediatric patients; and

s. Tourniquet.

B. An operating room available 24/hours a day with:

(1) Facility-defined operating room team on-call and available within 30 minutes of request by trauma team leader;

(2) Equipment for all ages shall include, but not be limited to:

a. Thermal control equipment for:

i. Patients, and

ii. Blood and fluids;

b. X-ray capability, including c-arm image intensifier;

c. Endoscope, broncoscope;

d. Equipment for fixation of long bone and pelvic fractures;

e. Rapid infuser system; and

f. Equipment for the continuous monitoring of temperature, hemodynamics, and gas exchange.

C. Postanesthesia Care Unit (surgical intensive care unit is acceptable) with:

(1) Registered nurses available within 30 minutes of request, 24 hours a day;

(2) Equipment for the continuous monitoring of temperature, hemodynamics, and gas exchange; and

(3) Thermal control equipment for:

a. Patients, and

b. Blood and fluids.

D. Intensive Care Unit for injured patients with:

(1) Personnel, to include:

a. A director, or co-director, who is a surgeon with facility privileges to admit patients to the critical care area, and is responsible for setting policies and oversight of the care related to trauma ICU patients;

b. A physician, approved by the trauma director who is available within 30 minutes of notification to respond to the needs of the trauma ICU patient; and

c. Registered nurses.

(2) Equipment for the continuous monitoring of temperature, hemodynamics, and gas exchange.

E. Radiological Services, available 24 hours a day, with:

(1) A radiology technician available within 30 minutes of notification of Trauma Team Activation;

(2) A Computed Tomography technician available within 30 minutes of request;

(3) Computed tomography (CT); and

(4) Ultrasound.

F. Clinical Laboratory Services, to include:

(1) Standard analysis of blood, urine, and other body fluids;

(2) Blood typing and cross matching;

(3) Coagulation studies;

(4) Blood and blood components available from in-house, or through community services, to meet patient needs and blood storage capability;

(5) Blood gases and pH determination;

(6) Microbiology;

(7) Serum alcohol and toxicology determination; and

(8) A clinical laboratory technician in-house.

G. Respiratory therapy services, in-house.

H. Neuro-trauma management as required in Sections 305.3 and 305.4.

I. Organized burn care for those patients identified in Section 308 of this chapter, and transfer and consultation guidelines with a burn center as defined in Section 308 of this chapter.

J. Rehabilitation services with:

(1) A physician who is credentialed by the facility to provide leadership for physical medicine and rehabilitation, and

(2) Policies and procedures for the early assessment of the rehabilitation needs of the injured patient, and

(3) Physical therapy, and

(4) Occupational therapy, and

(5) Speech therapy, and

(6) Social Services; or

(7) Transfer guidelines for access to rehabilitation services.

K. Injury Prevention/Public Education, with:

(1) Outreach activities and program development;

(2) Information resources for the public; and

(3) Facility developed or collaboration with existing national, regional, and/or state programs.

L. In-house trauma-related continuing education, for:

(1) Non-physician trauma team members, and

(2) Nurses in the emergency department and intensive care unit with facility-defined competency testing and orientation programs.

M. Continuing Medical Education Requirements

(1) Level III physicians providing initial resuscitation in the emergency department shall have successfully completed ATLS at least once, and

a. Shall be board certified in emergency medicine, or

b. Have current ATLS.

(2) Level III general surgeons on the trauma call panel shall be current in ATLS.

(3) Level III orthopedic surgeons, neurosurgeons, anesthesiologists, and nurse anesthetists must be:

a. Board certified, or

b. Board eligible and less than seven years from residency, or

c. Have current ATLS, if no longer boarded or board eligible.

(4) All board certifications shall be issued by a certifying entity that is nationally recognized in the United States.

6 CCR 1015-4-306

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