Community Trauma Hospitals (CTH) are generally small, rural facilities with a commitment to the resuscitation of the trauma patient and with written transfer protocols in place to assure those patients who require a higher level of care are appropriately transferred for definitive care. The hospital is predominantly staffed with family physicians experienced and/or trained across a broad composite field of medicine including appropriate areas of acute trauma management. Frequently, these physicians are the obstetric and intensive care providers of the TSA. They commonly work in consultation with a board certified general surgeon who is committed to trauma management. A system for early notification of the physician on call shall be developed so that he can consistently be present at the time of arrival of the major trauma patient in the emergency department. This level of designation requires a general/trauma surgeon on call and promptly available to respond to the trauma patient. However, this level contemplates that there may be only one surgeon in the community and he may not be available at all times. During periods when the surgeon is not available, the hospital must notify other facilities that routinely transfer/refer patients to the CTH for emergency surgical services.20 Since this level contemplates a surgeon in the community who is committed to trauma care, it is anticipated that the CTH shall provide initial resuscitation and immediate operative intervention to control hemorrhage to assure maximum stabilization prior to transfer to a higher level of care. In many instances, patients will be maintained in the CTH unless the medical needs of the patient require secondary transfer. The decision to transfer a patient rests with the physician attending the trauma patient. An institution intending to provide prolonged ventilatory care must assure that a physician qualified to provide ventilatory care is available at all times. If physician support is not available twenty-four (24) hours per day, transfer to a higher level of care is recommended.
(a) Hospital Organization. - (i) Trauma Program. The trauma program shall be established and recognized by the medical staff and hospital administration. The trauma program shall come under the overall organization and direction of a general surgeon or emergency physician who is trained, experienced, and committed to the care of the injured patient.
- (ii) Trauma Program Director. The director must be a board certified general surgeon, a board certified emergency physician, or a board certified 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 must be given administrative support to implement the requirements specified by the Wyoming Trauma Plan.21
- (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 development, communication among all team members, development of standards of care, education and outreach programs, and interaction with appropriate groups for injury prevention. Suggested membership for the committee include representatives (if available in the community) from:
- (B) Emergency physicians;
- (D) Laboratory technician;
- (E) Physician with emergency department privileges;
- (F) Prehospital care providers;
- (G) Respiratory therapist;
- (H) Family physician(s) skilled in trauma care;
- (J) Physician specialists as dictated by clinical needs;
- (K) Radiology technician; and
- (L) Social services/pastoral care.
- (iv) Trauma Nurse Coordinator. A CTH shall have at least a part-time registered nurse working in the role of a trauma nurse coordinator. Working in conjunction with the trauma program 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 patients.22
- (v) Multi Disciplinary Trauma Committee. The purpose of the committee is to provide oversight and leadership to the entire trauma program. The committee shall focus on quality improvement activities, policy development, communication among all team members, development of standards of care, education and outreach programs, and interaction with appropriate groups for injury prevention. The clinical managers (or designees) of the organizational areas involved in trauma care shall play 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:
- (C) Emergency department;
- (J) Prehospital care providers;
- (M) Respiratory therapy; and
- (N) Trauma Nurse Coordinator.
(b) Facility Standards. - (i) Emergency Department.
- (A) The hospital shall have an emergency department staffed so that trauma patients are assured immediate and appropriate initial care. CTHs may not have a physician in the emergency department twenty-four (24) hours per day. Therefore, adequately trained registered nurses shall be available to initiate basic trauma life support care. Local policy shall be written to assure early notification of the on call physician and/or surgeon to meet the trauma patient in the emergency department.
- (B) The emergency department shall have a designated medical director who is board certified in a specialty recognized by the American Board of Medical Specialties, the Canadian Board or the American Osteopathic Association.23 This requirement may be satisfied by a physician not currently board certified but meeting the requirements of the hospital for appointment as an emergency department medical director. This exception is only valid for those non-qualifying medical directors at the time these requirements become effective.24 The physicians participating on the trauma team shall participate in continuing education activities related to trauma care, the multi disciplinary trauma committee and the trauma quality improvement process.
- (C) Nursing Personnel.
- (I) Emergency nurses shall have special expertise in trauma care.25
- (II) Adequate numbers of registered nurses must be available in house twenty-four (24) hours per day to staff the emergency department to meet the needs of the trauma patient.
- (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. This level contemplates a community where only one surgeon may reside. During those periods when the surgeon is not available, the hospital shall notify other facilities who routinely transfer/refer patients to the CTH for emergency surgical care. The trauma surgeon on call shall be promptly available to respond to the trauma patient. The surgeons should have current certification in ATLS.
- (II) 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 consultations and presence in the emergency department for major resuscitation is highly recommended. The trauma surgeon's presence at major 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 shall be monitored by the hospital's trauma quality improvement process.
- (III) The emergency physician is expected to make key decisions about management for the trauma patient's care and determine if the patient needs transport to a higher level of care in association with the surgeon. The emergency department physician or surgeon shall coordinate the process with the receiving surgeon at the receiving facility when transfer is necessary. If the patient is admitted to the CTH, the admitting physician shall provide care and utilize surgical consultation according to the CTH guidelines for trauma patient care. Guidelines shall be written at the local level to determine which types of patients should be admitted to the CTH and which patients should be considered for transfer to a higher level of care. Telephone, teleradiology and telemedicine consultation capabilities are highly desirable for internal medicine, orthopedic surgery, obstetric/gynecological surgery and radiology. If practical, local coverage of these services is desirable. The CTH's protocol and the skill levels of the surgeon and physician staff of the CTH will determine the transfer protocols to facilitate the movement of the patient to a higher level of care.
- (ii) Surgical Suites. The surgical team is not required to be in house twenty-four (24) hours per day. A team shall be on call with a well-defined mechanism for notification to expedite admission to the operating room if the patient's condition warrants. This process shall be monitored continuously by the trauma quality improvement program. Surgical nurses shall be trained in principles of resuscitation, mechanism of injury theory, multi system 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.
- (A) Policies and Procedures. Policies and procedures shall be in place for the following:
- (I) Prioritized hospital room availability for the emergency trauma patient;
- (II) Notification of on call surgical teams;
- (III) Managing death in the OR 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 ICU from the operating room; and
- (VI) Immediate access of blood and blood products to the operating room.
- (B) Anesthesia. Anesthesia shall be promptly available with a mechanism established to ensure early notification of the on call anesthesiologist/CRNA. Anesthesia coverage may be provided by a CRNA who is supervised by an anesthesiologist as required for the CRNA's licensure. The CTH shall document conditions when the anesthesiologist/ CRNA must be immediately available for airway emergencies and operative management of the trauma patient. The availability of the anesthesiologist and the absence of delays in airway control or operative anesthesia shall be documented and monitored by the quality improvement process.
- (iii) Intensive Care Unit/Monitored Bed Unit (MBU).
- (A) An institution intending to provide prolonged ventilatory care shall assure that a physician qualified to provide ventilatory care is available at all times. If physician support is not available twenty-four (24) hours per day, transfer to a higher level of care is recommended.
- (B) The CTH shall have an ICU or MBU which meets the requirements of licensure in the state of Wyoming or the JCAHO. Additionally, the ICU/MBU shall have:
- (I) Medical Director. The medical director for the ICU/MBU is responsible for the quality of care and administration of the ICU/MBU. The trauma program director or his designee shall work collaboratively with the ICU/MBU medical director to set policy and establish standards of care to meet the unique needs of the trauma patient.
- (II) Physician Coverage. Trauma patients admitted to the ICU/MBU shall be admitted under the care of the patient's physician or an attending physician with ICU/MBU admission privileges. Consultation with the general surgeon is expected. In addition to the primary physician and general surgeon, there shall be physician coverage for the ICU/MBU as specified by local criteria. The coverage shall be provided by a physician experienced and trained to recognize and manage conditions of the trauma patient as determined by the multi disciplinary trauma committee; and
- (III) Nursing Personnel. CTHs shall provide staffing in sufficient numbers to meet the needs of the trauma patient. Critical care nurses shall show evidence of completion of a structured ICU in-service program which includes didactic and clinical content related to the care of the trauma patient. ICU nurses are an integral part of the trauma team and 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) A CTH shall have a PAR room staff on call twenty-four (24) hours per day and available to the postoperative trauma patient. PAR room staffing shall be in sufficient numbers to meet the critical needs of the trauma patient. Frequently, it is advantageous to bypass the PAR room and directly admit to the ICU/MBU. In this instance, these requirements may be met by the ICU/MBU.
- (B) PAR room 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 patient. PAR room nurses are an integral part of the trauma team and shall be represented on the multi disciplinary trauma committee and participate in the quality improvement process of the trauma program.
(c) Clinical Support Services. In addition to licensure requirements, a CTH shall have the following service capabilities: - (i) Radiology Services. It is highly desirable for a CTH to have a board certified radiologist or his designated mid-level practitioner available to the facility for emergency procedures, and on a routine basis, to assure quality of services rendered. The radiologist is a key member of the trauma team and shall be represented on the multi disciplinary trauma committee. A licensed radiological technician shall be on call twenty-four (24) hours per day and readily available to meet the immediate needs of the trauma patient. Twenty-four (24) hour teleradiology service is necessary if a radiologist is not available. A formal plan for emergency reading of films is necessary as backup, e.g., administrative commitment to twenty-four (24) hour available on call road transport of films to a radiologist. The CT technician may be on call from home with a mechanism in place to assure the technician is available. The quality improvement process shall verify the procedure is promptly available to the patient.
- (ii) Clinical Laboratory Services.
- (A) The standards for clinical laboratory services in CTHs differ very little from other designated facilities. Blood banking capability or access to community facilities shall be available. Toxicology studies may be performed off site if necessary.
- (B) The clinical laboratory service shall have the following services available twenty-four (24) hours per day:
- (I) Access to a community central blood bank and adequate storage facilities;
- (II) Standard analysis of blood, urine and other body fluids; and
- (III) Blood gas and pH determinations (this function may be performed by providers other than the clinical laboratory service, when applicable).
- (C) Alcohol screening is required and drug screening is highly recommended.
- (D) Sufficient numbers of clinical laboratory technologists shall be promptly available twenty-four (24) hours per day. If this requirement is fulfilled by technicians not in house, quality improvement must document and monitor the availability of testing, blood access, and the prompt recording of accurate results.
- (iii) Social Service/Pastoral Care. A CTH may utilize community resources as appropriate to meet the needs of trauma patients and their families.
- (iv) Rehabilitation. Each CTH shall address a plan for integration of rehabilitation into the acute and primary care of the trauma patient, at the earliest stage possible, after admission to the trauma center. Designated facilities shall identify a mechanism to initiate rehabilitation services and/or consultation upon admission as well as policies regarding coordination of a 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.
- (v) Outreach. The CTH shall work collaboratively to plan, facilitate and teach professional education programs for the prehospital care providers, nurses, and physicians in the CTHs and TRFs in their region.
- (vi) Prevention/Public Education. The CTH shall collaborate with all other designated facilities to develop education and prevention programs for their professional staff and the public. The plan shall include implementation strategies to assure information dissemination to all residents in the region.
- (vii) Transfer Protocols. CTHs shall have transfer protocols in place with receiving trauma facilities as well as all specialty referral centers (i.e., burn, pediatrics and rehabilitation). All facilities shall work together to develop transfer guidelines indicating which patients should be considered for transfer and procedures to assure the most expedient, safe transfer of the patient. All designated facilities shall agree to provide services to the trauma patient regardless of their ability to pay. The transfer guidelines need to assure feedback is provided to the facilities and assure this information eventually becomes part of the trauma registry. All transfer protocols shall be written in accordance with COBRA/OBRA and EMTALA regulations.
- (viii) Quality Improvement/Evaluation.
- (A) All designated facilities shall participate in the trauma registry and submit data to the OEMS as requested. The CTHs shall assist the TRFs in establishing the data collection process and, if necessary, provide data entry into the registry from abstracted patient records.
- (B) Each trauma center shall develop an internal quality improvement plan that, at a minimum, addresses the following key components:26
- (I) An organizational structure which facilitates the process of quality improvement (multi disciplinary trauma committee);
- (II) Clearly stated goals and objectives of the quality improvement plan;
- (III) The development of standards of care;
- (IV) A process to delineate privileges for all physicians participating in trauma care;
- (V) Participation in the statewide trauma registry;
- (VI) Established quality indicators (audit filters). The
- (VII) A systematic, informed peer review process utilizing a multi disciplinary method including prehospital care providers; and
- (VIII) A method for computing survival probability and comparing patient outcomes.
- (C) The CTH shall participate in the statewide WTC and the RAC of their TSA.
20 Each facility shall develop written notification protocols.
21 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 ACEP accredited trauma conference every two (2) years, and maintain personal involvement in care of the injured, education in trauma care, and involvement in professional organizations.
22 Recommended credentials for this position include: Trauma Nurse Core Curriculum (TNCC) (or equivalent education), demonstrated expertise in trauma care and five (5) or more years clinical nursing experience.
23 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 years after residency, that individual is ordinarily unacceptable as the medical director of the emergency department.
24 All physicians covering the emergency department shall be currently certified in ATLS, or maintain certification of attendance to an ACEP accredited trauma conference every two years, and shall show commitment to trauma care by maintaining competency in resuscitation, airway management, central venous access, cervical immobilization and long bone fracture stabilization of the adult and pediatric trauma patient. This includes all residents assigned to the emergency department and responsible for the resuscitation of the trauma patient.
25 It is highly recommended that emergency nurses successfully complete TNCC (or equivalent education), show evidence of continuing education in trauma nursing, and participate in the ongoing quality improvement process of the trauma program.
26 Autopsy information on all trauma patients is highly recommended. Complete anatomical diagnosis of injury is essential to the quality improvement process. plan must include, at a minimum, the recommended audit filters by the ACS and the JCAHO. The plan should define adverse outcomes by using an explicit list of well-defined complications;