Md. Code Regs. 30.08.08.03
Current through Register Vol. 51, No. 12, June 14, 2024
Section 30.08.08.03 - Medical StaffA. The hospital shall have a credentialing process. Each physician and all advance practice professionals (APPs) shall be credentialed by the hospital for the appropriate specialty, including pediatric trauma care.B. The hospital shall have a process for delineation and reevaluation of privileges that includes: (1) A pediatric trauma panel, which shall be limited to those with demonstrated skills, commitment, experience, and interest in pediatric trauma care;(2) Appointment and reappointment to the pediatric trauma admitting or consulting staff that is coordinated by the medical staff office; and(3) The delineation of privileges for the pediatric trauma admitting or consulting staff approved by the pediatric TMD based on the following criteria: (a) Maintenance of good standing in the primary specialty;(b) Evidence of the required continuing medical education in trauma;(c) Documented attendance at multidisciplinary meetings, morbidity and mortality (M&M) rounds, and hospital peer-review conferences that deal with the care of injured patients; and(d) Satisfactory performance in managing pediatric trauma patients based on performance assessment and outcome analysis.C. The hospital shall have continuing medical education (CME) requirements as follows:(1) Pediatric surgeons taking trauma calls shall have evidence of 16 hours of trauma-related CME credits per year;(2) ATLS® may be counted toward the required CME credits;(3) Successful completion of an ATLS® course, at least once, is required for all attending pediatric surgeons providing pediatric trauma care;(4) The TMD and APPs providing pediatric trauma care must maintain a current ATLS® certification; and(5) Physician CME credits shall be documented in accordance with hospital policy.D. Clinical service requirements are as follows:(1) Pediatric surgery: (a) Board-certified or board-eligible pediatric surgeons trained in trauma care;(b) Either: (i) An in-house PGY3 or higher resident or attending surgeon, who shall be at the bedside within 15 minutes of being called, with compliance demonstrated at least 80 percent of the time; or(ii) An attending pediatric trauma surgeon who takes out-of-the-hospital trauma calls shall be immediately available for consultation and at the bedside within 30 minutes of being called, with compliance demonstrated at least 80 percent of the time; and(c) General surgery APPs taking trauma call who have documentation of an average of 16 hours per year of trauma-related education.(2) Pediatric neurosurgery: (a) Either: (i) A board-certified or board-eligible, trauma fellowship-trained attending neurosurgeon, or PGY2 or higher resident with an attending neurosurgeon on call, who shall be at the patient's bedside within 30 minutes after emergent consultation has been requested; or(ii) A Neurosurgery APP with an attending neurosurgeon on-call, who shall be at the patient's bedside within 30 minutes after emergent consultation has been requested;(b) Neurosurgery APPs taking trauma call shall have documentation of average of 16 hours a year of trauma-related education; and(c) A liaison to the trauma QM program with 50 percent attendance.(3) Pediatric Orthopedic surgery: (a) Either: (i) A board-certified or board-eligible trauma-fellowship-trained attending orthopedic surgeon or PGY2 or higher resident with an attending orthopedic surgeon on call, who shall be at the patient's bedside within 30 minutes after emergent consultation has been requested; or(ii) A PGY2 or higher orthopedic surgeon in house with an attending orthopedic surgeon on call, who shall be at the patient's bedside within 30 minutes after emergent consultation has been requested;(b) Orthopedic surgery APPs taking trauma call shall have documentation of average of 16 hours a year of trauma-related education; and(c) A liaison to the trauma QM program with 50 percent attendance.(4) Pediatric anesthesia: (a) A board-certified or board-eligible in-house attending physician 24 hours a day; and(b) A liaison to the trauma QM program with 50 percent attendance.(5) Pediatric emergency medicine: (a) A physician director who is board certified in pediatric emergency medicine;(b) Board-certified or board-eligible pediatricians, emergency medicine physicians, or pediatric emergency medicine physicians in house 24 hours a day;(c) Physicians who have demonstrated special capabilities through commitment, CME, and experience in the care of injured children; and(d) A liaison to the trauma QM program with 50 percent attendance.(6) Pediatric critical care: (a) A board-eligible or board-certified pediatric critical care physician in house 24 hours a day for the ICU;(b) A designated liaison from pediatric surgery; and(c) A liaison to the trauma QM program with 50 percent attendance.E. The hospital shall have the following additional pediatric surgical specialties on call and available 24 hours a day, and shall be at the bedside within 30 minutes after emergent consultation has been requested by the trauma resuscitation team leader based on institution-specific criteria: (3) Oral-maxillofacial surgery;(5) Otolaryngology, head, and neck surgery;(6) Cardiovascular surgery; andF. The hospital shall have the following additional nonsurgical pediatric specialties on call and available 24 hours a day within 60 minutes after emergent consultation has been requested by the trauma resuscitation team leader based on institution-specific criteria:(3) Interventional radiology;(12) Hematology-oncology;(16) Allergy and immunology; andMd. Code Regs. 30.08.08.03
Regulations .03 adopted effective 50:14 Md. R. 594, eff. 7/24/2023