To be designated a Regional Trauma Center (RTC), a licensed general acute care hospital shall have at least the following:
(a) Hospital Organization. - (i) Trauma Service. The trauma service shall be established and recognized by the medical staff and its bylaws and be responsible for the overall coordination and management of the system of care rendered to the injured patient. The trauma service must come under the organization and direction of a general surgeon or emergency physician who is trained, experienced, and committed to the care of the injured patient. All patients with multiple system trauma or major injury must be evaluated by the trauma service. The surgeon or emergency physician responsible for the overall care of each patient must be specifically identified.
- (ii) Trauma Program Director. The director must be a board certified surgeon or a board certified emergency physician with demonstrated competency in trauma care. The director shall develop a quality improvement process and, through this process, shall be responsible for all trauma patients and administrative authority for the hospital's trauma program. The director shall be given administrative support to implement the requirements specified by the Wyoming Trauma Plan. The director shall work with the credentialing process of the hospital and participate with the credentialing committee to recommend participation on the trauma team 4. The trauma director or his designee shall be actively involved with trauma care development at the community, state, and national level.
- (iii) Trauma Team. The hospital shall have a policy describing the respective roles of all personnel on the trauma team. The composition of the trauma team in any hospital will depend on the characteristics of that hospital and its staff The team leader shall be a qualified surgeon or emergency physician who is clinically capable in all aspects of trauma care. Suggested composition of the trauma team may include:
- (C) Emergency physicians;
- (D) Laboratory technicians;
- (F) Physician specialists as dictated by clinical needs;
- (G) Prehospital care providers;
- (H) Radiology technicians;
- (I) Respiratory therapists; and
- (J) Social services/pastoral care.
- (iv) Qualifications for Surgeons on the Trauma Team. As a general rule, all surgeons on the trauma team shall be board certified in a surgical specialty recognized by the American Board of Medical Specialties, the Canadian Board or the American Osteopathic Association. An exception to this rule is Oral and Maxillofacial Surgery. These physicians shall be board certified by the American Board of Oral and Maxillofacial Surgery 5. The surgeons shall participate in the multi disciplinary trauma committee and the quality improvement process. All general surgeons participating on the trauma team shall be current in ATLS and be involved in continuing education specific to trauma sufficient to maintain quality patient care. This includes all residents.
- (v) Trauma Nurse Coordinator. A RTC shall have a registered nurse working in the role of trauma nurse coordinator. Working in conjunction with the trauma director, the trauma nurse coordinator shall organize the program and all systems necessary for the multi disciplinary approach throughout the continuum of trauma care. The trauma nurse coordinator shall coordinate optimal patient care for all injured patients6.
- (vi) Multi Disciplinary Trauma Committee. The purpose of the committee is to provide oversight and leadership to the entire trauma program. The major focus shall be quality improvement activities, policy development, communication among all team members, development of standards of care, education, and outreach programs and working with appropriate groups for injury prevention. The clinical managers (or designees) of the organizational areas involved with trauma care shall play
- (C) Emergency Department;
- (D) Family Practice Residency Program;
- (N) Prehospital care providers;
- (Q) Respiratory Therapy; and
- (R) Trauma Nurse Coordinator.
(b) Clinical Components. - (i) A RTC shall have the following medical specialists available to the injured patient:
- (A) Emergency Medicine in house twenty-four (24) hours per day;
- (B) Trauma/General Surgery; and
- (ii) The following specialists shall be on call and promptly available from inside or outside the hospital:
- (D) Obstetrics/Gynecological Surgery;
- (J) Physical Medicine and Rehabilitation;
- (K) Pulmonary/Intensive Care Medicine;
- (N) Urologic Surgery; and
- (iii) It isdesirable to have the following specialists available to a RTC:
- (C) Infectious Disease; and
- (D) Microvascular Surgery.
- (iv) The staff specialist on call shall be notified at the discretion of the trauma surgeon or emergency physician and will be promptly available. This availability will be monitored continuously by the quality improvement program. The specialist involved for consultation to the trauma patient shall be appropriately board certified and have an awareness of the unique problems of trauma patients.
- (v) A general/trauma surgeon shall be qualified and have privileges to provide thoracic surgical care to patients with thoracic injuries. In instances where this is not feasible, the hospital shall apply for a waiver from the OEMS which at its sole discretion can grant such a waiver.
- (vi) Policies and procedures shall be in place to notify the patient's primary physician of the patient's condition.
(c) Facility Standards. - (i) Emergency department.
- (A) The hospital shall have an emergency department, division, service, or section staffed so that trauma patients are assured immediate and appropriate initial care. The emergency physician shall be in house twenty-four (24) hours per day and immediately available at all times, capable of evaluating trauma patients, providing initial resuscitation, and performing necessary surgical procedures not requiring general anesthesia.
- (B) The emergency department medical director shall be board certified in emergency medicine7.
- (C) The emergency medicine physician shall activate the trauma team based on predetermined criteria8. He will provide team leadership and care for the trauma patient until the arrival of the trauma surgeon in the resuscitation area. The emergency department shall have established standards and procedures to ensure immediate and appropriate care for the adult and pediatric trauma patient. The emergency department medical director or his designee shall participate with the multi
- (D) General/Trauma Surgeon.
- (I) A general/trauma surgeon shall be available on call twenty-four (24) hours per day to respond to the emergency department as requested. The trauma surgeon on call shall be promptly available to respond to the trauma patient. Local criteria shall be established to define conditions requiring the trauma surgeon's immediate hospital presence. The trauma surgeon's participation in major therapeutic decisions and presence in the emergency department for major resuscitation is highly recommended. The trauma surgeon's presence at operative procedures is mandatory. A system shall be developed to assure early notification of the on call surgeon and compliance with this criteria and their appropriateness must be monitored by the hospital's trauma quality improvement process. The surgeon shall maintain current certification in ATLS.
- (II) The surgeon shall, in conjunction with the emergency physician, make key decisions about management of the trauma patient's care and determine if the patient needs transport to a higher level of care. If transfer is required, either the surgeon or emergency physician shall be accountable to coordinate the process with the receiving physician at the receiving facility. Generally, if an injured patient requiring surgery is to be admitted to the RTC, the surgeon shall be the admitting physician and will coordinate the patient care while hospitalized. Guidelines shall be written at the local level to determine which types of patients should be admitted to the RTC and which patients should be considered for transfer to a higher level of care.
- (E) Nursing Personnel.
- (I) Emergency nurses shall have special expertise in trauma care9.
- (II) There shall be a minimum of two (2) registered nurses available in house twenty-four (24) hours per day to staff the emergency department to meet the needs of the trauma patient.
- (ii) Surgical Suites. The surgical team is not required to be in house twenty-four (24) hours per day. This requirement may be met by a technician or nurse who is capable of responding to the trauma resuscitation area, anticipating the operative needs of the patient, initiating the call process for on call staff, and preparing the operating room for the patient. A team shall be on call with a well-defined mechanism/criteria for notification.
- (A) Nursing Personnel. Surgical nurses shall participate in the
- (B) Policies and Procedures. Policies and procedures shall be in place for the following:
- (I) Prioritized room availability for the emergency trauma patient during a busy operating schedule;
- (II) Notification of on call surgical teams for both single and multiple patient admission;
- (III) Managing death in the operating room and facilitating the organ procurement process;
- (IV) Preservation of evidence;
- (V) Patient monitoring by a registered nurse while the patient is in transport to the radiology suite or intensive care unit (ICU) from the operating room; and
- (VI) In hospital access of blood and blood products to the operating room.
- (C) Anesthesia. Anesthesia shall be promptly available with a mechanism established to ensure early notification of the on call anesthesiologist. Local criteria shall be established to determine when the anesthesiologist shall be immediately available for airway emergencies and operative management. The anesthesiologist participating on the trauma team shall be appropriately board certified or board eligible, have the necessary educational background in the care of the trauma patient, and participate in the multi disciplinary trauma committee and the quality improvement process.
- (iii) Intensive Care Unit. The RTC shall have an ICU which meets the requirements of licensure in the state of Wyoming. Additionally the ICU shall have:
- (A) Medical Director. The medical director for the ICU is responsible for the quality care and administration of the ICU. The trauma program director or his designee will work collaboratively with the ICU medical director to set policy and establish standards of care to meet the unique needs of the trauma patient.
- (B) Physician Coverage. Trauma patients admitted to the ICU shall be admitted under the care of a general surgeon or a qualified board certified physician who is knowledgeable about the care of ICU patients. Guidelines may be written for the rare exception to this rule (e.g., isolated head injury that the neurosurgeon agrees to manage). In addition to overall responsibility for patient care by the primary surgeon or ICU physician, there shall be in house physician coverage for intensive care at all times. This coverage may be provided by a physician who is approved by the director of the ICU. This coverage is for emergencies only (e.g., an unexpected extubation of an ICU patient) and is to ensure the patient's immediate needs are met while the identified surgeon or physician is contacted.
- (C) Nursing Personnel. RTCs shall provide staffing in sufficient numbers to meet the critical needs of the trauma patient. Critical care nurses shall show evidence of completion of a structured in-service program which includes didactic and clinical content related to the care of the trauma patient10. ICU nurses are an integral part of the trauma team and as such, shall be represented on the multi disciplinary trauma committee and participate in the quality improvement process of the trauma program.
- (iv) Post Anesthesia Recovery Room (PAR room). A RTC shall have a PAR room with staff on call twenty-four (24) hours per day and available to the postoperative trauma patient. PAR room staffing shall be as required for the critical needs of the trauma patient. Frequently it is advantageous to bypass the PAR room and directly admit to the ICU. In this instance, these requirements may be met by the ICU. PAR room nurses shall provide evidence of completion of a structured in-service program which includes didactic and clinical content related to the care of the trauma patient. PAR room nurses are an integral part of the trauma team and as such, shall be represented in the multi disciplinary trauma committee and participate in the quality improvement process of the trauma program.
(d) Clinical Support Services. - (i) A RTC shall have the following service capabilities:
- (A) Radiological Service. A radiological service shall have a licensed radiological technician in house and immediately available at all times for general radiological procedures, angiography, imaging services, sonography, and computerized tomography (CT), for both head and body. If a technician is not in house twenty-four (24) hours per day for CT, angiography or sonography, the quality improvement process must document and monitor that the procedure is promptly available. A board certified radiologist shall administer the department and participate actively in the trauma quality improvement process. Written policy shall delineate the prioritization/availability of the CT scanner for trauma patients;
- (B) Clinical Laboratory Service. Sufficient numbers of clinical
- (I) Comprehensive blood bank or access to a community central blood bank and adequate storage facilities;
- (II) Standard analysis of blood, urine, and other body fluids;
- (III) Blood gas and pH determinations. (This function may be performed by providers other than the clinical laboratory service, when applicable); and
- (IV) Massive transfusion policy.
- (C) Alcohol screening is required and drug screening is highly recommended.
- (D) Social Service/Pastoral Care Support. The nature of traumatic injury requires that the psychological needs of the patient and family are considered and addressed in the acute stages of injury and throughout the continuum of recovery. Adequate numbers of trained personnel shall be readily available to trauma patients and their families. Programs shall be available to meet the unique needs of the trauma patients and their families.
- (E) Rehabilitation. At the earliest stage possible after admission to the trauma center, each RTC shall address a plan for integration of rehabilitation into the acute and primary care of the trauma patient,. Designated hospitals shall identify a mechanism to initiate rehabilitation services and/or consultation upon admission as well as policies regarding coordination of the multi disciplinary rehabilitation team. Policies shall be in place to address the coordination of transfers between acute care facilities and rehabilitation facilities. Transfer agreements shall include a feedback mechanism for the acute care facilities to update the health care team on the patient's progress and outcome for inclusion in the trauma registry.
- (F) Outreach. As a RTC, the trauma program shall develop programs for consultation with physicians in the region. Additionally, the trauma center shall provide leadership in professional education programs for prehospital care providers, nurses, and physicians in the hospitals and clinics in their region.
- (G) Prevention/Public Outreach. The RTC shall take a leadership role in coordination of appropriate agencies, professional groups and hospitals in their region to develop a strategic plan for public awareness. This plan shall take into consideration public awareness of the trauma system, access to the system, public support of the system, as well as specific prevention strategies. Substance abuse is consistently linked with traumatic injury and should be a key focus for prevention. Prevention programs shall be specific to the needs of the region. Trauma registry data shall be utilized to identify injury trends and focus prevention needs.
- (H) Transfer Protocol. RTCs shall work collaboratively with the referral trauma facilities in their region and develop interfacility transfer protocols. These guidelines shall address criteria to identify high risk trauma patients that could benefit from a higher level of trauma care. All trauma facilities shall provide services to the trauma patient regardless of their ability to pay. All transfer protocols shall be written in accordance with COBRA/OBRA and EMTALA regulations. Transfer protocols shall be written for specialty referral centers such as burn or spinal cord injury centers if the services are not available at the trauma center. The transfer agreement shall include a feedback loop so the primary provider has a good understanding of the patient outcome.
- (I) Quality Improvement/Evaluation.
- (I) All designated facilities shall participate in the trauma registry and submit data to OEMS as requested. The RTCs shall assist other facilities in their referral area in establishing the data collection process and, if necessary, provide data entry into the registry from abstracted patient records.
- (II) Each RTC shall develop an internal quality improvement plan that, at a minimum, addresses the following key components11:
- (1) An organizational structure which facilitates the process of quality improvement (multi disciplinary trauma committee);
- (2) Clearly stated goals and objectives of the quality improvement plan;
- (3) The development of standards of care;
- (4) A process to delineate privileges for all physicians participating in trauma care;
- (5) Participation in the trauma statewide registry;
- (6) Established quality indicators (audit filters). The plan must include, at a minimum, the recommended audit filters by the ACS and the JCAHO. The plan shall define adverse outcomes by using an explicit list of well-defined complications;
- (7) A systematic informed peer review process utilizing a multi disciplinary method including prehospital care providers; and
- (8) A method for computing survival probability and comparing patient outcomes.
- (III) The RTCs shall be required to take a lead role in the statewide WTC and the RAC of their TSA.
4 It is strongly recommended that the director be an instructor in the American College of Surgeons Advanced Trauma Life Support (ATLS) course and maintain current ATLS certification or maintain certification of attendance to an American College of Emergency Physicians (ACEP) accredited trauma conference every two (2) years, maintain personal involvement in care of the injured, be educated in trauma care, and involved in professional organizations.
5 It is understood that many boards require a practice period, and that complete certification may take three (3) to five (5) years after residency. If an individual has not been certified five (5) years after successful completion of residency, that individual is unacceptable for inclusion on the trauma team.
6 Recommended credentials for this position include: Certified Emergency Nurse (CEN), Trauma Nurse Core Course (TNCC) (or equivalent education), demonstrated expertise in trauma care, five (5) or more years clinical nursing experience, experience with hospital quality assurance programs including a trauma registry, experience in education program development and membership in professional organizations. an active role with the committee. The committee shall include representatives from each of the following areas, unless the hospital has no such organizational area defined:
7 It is highly recommended that the emergency medical physician be currently certified in ATLS or maintain certification of attendance to an ACEP accredited trauma conference every two (2) years. It is recommended that the emergency medicine physician participating with the trauma team should be board certified in a specialty recognized by the American Board of Medical Specialties, the Canadian Board, or the American Osteopathic Association. It is understood that many boards require a practice period, and the complete certification may take three (3) to five (5) years after residency. If an individual has not been certified five (5) years after completion of a residency, that individual is unacceptable as the medical director of the emergency department.
8 Each facility may develop local written protocol for the activation of the trauma team. disciplinary trauma committee and the trauma quality improvement process.
9 It is highly recommended that emergency nurses demonstrate successful completion of TNCC (or equivalent education), evidence of continuing education in trauma nursing, and participation in the ongoing quality improvement process of the trauma program. care of the trauma patient and be competent in the surgical stabilization of the major trauma patient. Surgical nurses shall be trained in principles of resuscitation, mechanism of injury theory, multiple systems trauma, and knowledge of surgical instrumentation. The surgical nurses are integral members of the trauma team and shall participate in the ongoing quality improvement process of the trauma program and shall be represented on the multi disciplinary trauma committee.
10 It is highly recommended that nurses in the ICU demonstrate special expertise in critical care by acquisition and maintenance of a CCRN certification. laboratory technologists shall be promptly available at all times. A clinical laboratory service shall have the following services available twenty-four (24) hours per day:
11 It is highly recommended that the plan incorporate autopsy information on all trauma patients. Complete anatomical diagnosis of injury is essential to the quality of trauma care.