N.J. Admin. Code § 8:43G-12.15

Current through Register Vol. 56, No. 23, December 2, 2024

Section 8:43G-12.15 - Trauma services policies and procedures

(a) The trauma service shall have written policies and procedures that are reviewed at least once every three years, revised more frequently as needed, and implemented. These policies and procedures shall ensure a systematic and comprehensive approach to the care of trauma patients and shall include at least:

1. Trauma patient triage protocols;

2. Trauma team response protocols;

3. Trauma patient resuscitation and stabilization protocols;

4. Operating room protocols, including priority status for trauma patients, as required by 8:43G-12.19;

5. Trauma patient transport protocols;

6. Bypass and diversion protocols ensuring that major trauma patients are not diverted unless needed to ensure patient safety; and

7. Monitoring and evaluation of trauma patients throughout their hospital stay.

(b) In hospitals that are designated as a Level I or Level II trauma center, the emergency department and the trauma center shall jointly develop policies and procedures to ensure coordination and quality of care to trauma patients.

(c) All other hospitals shall develop inter-hospital transfer agreements and protocols in cooperation with, at a minimum, the designated regional Level I trauma center and the nearest designated Level II trauma center. These protocols shall be consistent with Federal regulations at 42 CFR 489.24 and shall include, at a minimum:

1. Clinical criteria for transfer consistent with the capacity of the referring hospital; and

2. Responsibilities of the transferring and receiving physicians, including:

i. The responsibility of the transferring physician to select the appropriate facility, stabilize the patient, and initiate transfer;

ii. Consultation with the receiving physician regarding pre-transfer diagnostic procedures and selection of mode of transport, equipment, and personnel needed to manage patient care during transport;

iii. The responsibility of the receiving physician to ensure capability to provide needed care and document approval for the transfer; and

3. Policies and procedures that ensure the availability of a trauma patient transport system which includes, at a minimum, a transport team staffed by health professionals with special training in trauma care in accordance with hospital policy.

(d) Each emergency department and designated trauma center shall have a written transfer agreement with an organized burn unit or center, with clinically appropriate criteria for safe transfer of patients who require specialized burn treatment.

(e) Each emergency department and designated trauma center shall have a written transfer agreement with a New Jersey hospital designated as a regional perinatal center, with clinically appropriate criteria for safe transfer of patients who require specialized perinatal or neonatal services.

(f) Each hospital and trauma center shall have a written transfer agreement with a comprehensive rehabilitation hospital to assure continuity of care for patients who may require inpatient comprehensive rehabilitation.

(g) Each Level II trauma center shall have a transfer agreement with a regional Level I New Jersey trauma center.

N.J. Admin. Code § 8:43G-12.15

New Rule, R.1999 d.436, effective 12/20/1999.
See: 31 New Jersey Register 367(a), 31 New Jersey Register 614(a), 31 New Jersey Register 4293(c).