Trauma Receiving Facilities (TRF) are generally licensed rural facilities, clinics, or medical assistance facilities with a commitment to the resuscitation and stabilization of the trauma patient and written transfer protocols in place to assure those patients who require a higher level of care are appropriately transferred for definitive care. These facilities may not be staffed by a physician, but may be staffed by a licensed mid-level practitioner (e.g., nurse practitioner or licensed/certified physician's assistant). The major trauma patient shall be resuscitated and transferred to a higher level of care from the emergency department as appropriate. This categorization does not contemplate the availability of surgeons, operating rooms or intensive care services.
(a) Facility Organization. - (i) Trauma Program. There must be a commitment on behalf of the entire facility to the organization of trauma care. A trauma program shall be established and recognized by the institution. The trauma program shall come under the overall organization of a physician who is committed and willing to provide off-line administration of the program. In a facility staffed by physician's assistants or nurse practitioners, it most likely will be their supervising physician.
- (ii) Trauma Program Director. There shall be a qualified physician director of the trauma program. In this instance, the physician shall work with all members of the trauma team to develop a quality improvement process for the facility. Through this process, he shall have overall responsibility for the quality of trauma care rendered at the facility. The director shall be given administrative support to implement the requirements specified by the Wyoming Trauma Plan. The director shall assist in the development of standards of care and assure appropriate policies and procedures are in place for the safe resuscitation and transfer of trauma patients. The physician director should be currently certified in ATLS and participate in CME related to trauma care.
- (iii) Trauma Team. The facility shall have a policy describing the role of all personnel on the trauma team. The composition of the trauma team in any facility will depend on the characteristics of the facility and its staff. The team leader shall be a qualified physician or a qualified mid-level practitioner.27 Suggested composition of the trauma team may include:
- (A) Laboratory technician;
- (C) Physician assistants;
- (E) Prehospital care providers;
- (F) Radiology technicians;
- (G) Respiratory therapists; and
- (H) Social services/pastoral care.
- (iv) Trauma Nurse Coordinator. A TRF shall have a person to conduct many of the administrative functions required by the trauma program. Specifically, this person, with the physician director, shall coordinate optimal patient care for all injured patients. Many requirements for data collection and coordination, quality improvement, education and prevention activities are incumbent upon this position.
- (v) Multi Disciplinary Trauma Committee.
- (A) 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 work with appropriate groups for injury prevention. In a TRF, this does not need to be a separate distinct body; however, the functions of this committee may be performed in conjunction with other ongoing committees in the facility.
- (B) Suggested membership for the Committee includes representatives (if available in the community) from:
- (II) Emergency Department;
- (V) Prehospital care providers;
- (VI) Radiology/Laboratory;
- (VIII) Respiratory therapy; and
- (IX) Trauma Nurse Coordinator.
- (C) The clinical managers or designees of the organizational areas involved with trauma care shall play an active role with the committee.
(b) Facility Standards. - (i) Emergency Department.
- (A) The facility shall have an emergency department staffed so that trauma patients are assured immediate and appropriate initial care. It is not anticipated that a physician will be available on call to the emergency department in a TRF. This requirement may be met by a qualified mid-level practitioner on call from outside the facility.28 A system shall be developed to assure early notification of the on call practitioner. Compliance with this criteria shall be documented and monitored by the quality improvement process.
- (B) The TRF shall have a written policy for notification and mobilization of an organized trauma team. Additionally, written policy shall be in place for pre-activation of the transfer team from the field based on prehospital triage criteria. There shall be written transfer protocols with other trauma facilities in the region. A policy shall be in place to facilitate and expedite the transfer sequence to assure the most appropriate care is rendered. Protocols shall be in place for specialty referral for pediatrics, burn, spinal cord injuries and rehabilitation.
- (C) Emergency nurses shall have special expertise in trauma care.29
- (D) Adequate numbers of registered nurses shall be available to meet the needs of the trauma patient.
(c) Clinical Support Services. In addition to licensure requirements, a TRF shall have the following service capabilities: - (i) Radiology Services. X-ray capabilities shall be immediately available twenty-four (24) hours per day to meet the resuscitative needs of the trauma patient. A licensed radiological technician shall be available to meet the immediate needs of the trauma patient. The technician may be on call from home with a mechanism in place to assure the technician is available. The quality improvement process shall document and monitor the process.
- (ii) Clinical Laboratory Services.
- (A) Clinical laboratory services shall be immediately available to the trauma patient. It is not anticipated that blood banking facilities be available; rather, access and blood storage capacities. Toxicology studies may be performed off site if necessary. The clinical laboratory shall have standard analysis of blood, urine and other body fluids services available twenty-four (24) hours per day.
- (B) If this requirement is fulfilled by technicians not in house, quality improvement shall document and monitor the availability of testing, blood access and the prompt recording of accurate results.
- (iii) Social Service/Pastoral Care. A TRF may utilize community resources as appropriate to meet the needs of trauma patients and their families.
- (iv) Prevention/Public Education. A TRF shall work collaboratively with RTCs and ATHs 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.
- (v) Transfer Protocols. Transfer protocols shall be written with all trauma receiving facilities and appropriate specialty centers (e.g., 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 trauma patients 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.
- (vi) Quality Improvement/Evaluation. All designated facilities shall participate in the trauma registry and submit data to OEMS. The RTCs, ATHs and CTHs shall be responsible to assist the TRFs in establishing the data collection process and, if necessary, provide data entry into the registry from abstracted patient records. Each TRF shall develop an internal quality improvement plan that addresses, at a minimum, the following key components:30
- (A) An organizational structure which facilitates the process of quality improvement (multi disciplinary trauma committee);
- (B) Clearly stated goals and objectives of the quality improvement plan;
- (C) The development of standards of care;
- (D) A process to delineate privileges for all physicians participating in trauma care;
- (E) Participation in the statewide trauma registry;
- (F) Established quality indicators (audit filters). The 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;
- (G) A systematic, informed peer review process utilizing a multi disciplinary method including prehospital care providers; and
- (H) A method for computing survival probability and comparing patient outcomes.
- (I) The TRFs shall participate in the statewide WTC and the RAC of their TSA.
27 Qualified physicians or mid-level practitioners directing the resuscitation of trauma patients shall have current ATLS certification or proof of audit of an ATLS course or maintain certification of attendance to an ACEP accredited trauma conference every two (2) years, and must show commitment to trauma care by maintaining competence in airway management, central venous access, cervical immobilization, and long bone fracture stabilization.
28 Qualified physicians or mid-level practitioners directing the resuscitation of trauma patients should have current ATLS certification, or proof of audit of an ATLS course, or maintain certification of attendance of an ACEP accredited trauma conference every two (2) years, and must show commitment to trauma care by maintaining competence in airway management, central venous access, cervical immobilization, and long bone fracture stabilization.
29 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.