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Home My WebLink About981804.tiff WELD COUNTY 1998 SEP 25 AM 8: 143 STATE OF COLORADO CLERK COLORADO BOARD OF HEALTH TO THE BOARD RULES AND REGULATIONS PERTAINING TO THE STATEWIDE TRAUMA SYSTEM CHAPTER 1 - THE TRAUMA REGISTRY Colorado has a comprehensive law defining and establishing a statewide trauma registry: Colorado Revised Statutes Title 25, Article 3.5, Sections 703(8), 703(9), and 704(0. These regulations are intended to provide detail and clarification regarding the operation of the statewide trauma registry. Reporting Trauma Data 1. Each licensed facility (including specialty facilities), clinic, or pre-hospital provider that provides service or care to persons with trauma injury in this state shall submit to the department the following information for deaths, transfers, or inpatient discharges for a particular month within 60 days of the end of that month: a. admission information on persons with trauma injury, as defined in C.R.S. 25-3-703(9), who are admitted to a hospital as an inpatient; such information shall include the patient's name, date of birth, sex, and address; and the patient's injury type, diagnostic codes, severity, and cause; b. readmission information on persons readmitted to a facility as a hospital inpatient for care of the trauma injury; such information shall include the patient's name, date of birth, sex, and address; and the original date of admission for the injury; c. trauma death information on persons who die from trauma injury while in the hospital (including specialty facilities), emergency department, or clinic; such information shall include the patient's name, date of birth, sex, and address; and the patient's injury type, diagnostic codes, severity, and cause; d. transfer information on persons with trauma injury, including the patient's name, date of birth, sex, and address; the patient's diagnoses; and the name of the facilities and providers involved in the transfer. Reporting of such information is required from both the transferring and receiving facility or provider. The transferring facility or provider shall be required to report such information on persons who are transferred to an out-of-state facility or provider. 1 V 114 e • 2/4 n/ti 981804 2. Facilities designated as Level I, II, and III may fulfill the reporting requirement by submitting to the department or its agent an electronic data file of all of the discharges for a particular month within 60 days of the end of that month. The electronic data file must contain a record for each: (a) trauma inpatient (b) trauma patient who was transferred from the facility to another facility (whether in- state or out-of-state); and (c) trauma patient who died from trauma injury while in the facility regardless of whether the person was admitted. The following information is required to be included in each patient record: i. Patient information: name; date of birth; medical record number; sex; race; ethnicity; patient address and locating information; pre-existing medical diagnoses. ii. Injury information: date, time, and location of injury; trauma diagnoses; injury severity; injury cause; whether or not protective devices were used by the patient; evidence of alcohol or other intoxication. iii. Inter-facility transfer information: transfer mode from the referring facility; name of referring facility, arrival and discharge times from the referring facility; source of treatment in the referring facility (ED, in-patient, etc.); iv. Pre-hospital information: transport mode from the injury scene; name of transport agency(ies); triage risk assessment, including physiologic and anatomic conditions and injury circumstances; times of notification, arrival at scene, departure from scene, and arrival at destination; clinical data upon arrival at ED; disposition from ED; v. In-patient care information: name and address of facility; identification for the data collector; admission time and date; admission service; surgical procedures performed; time and date of all surgical procedures; comorbid factors; total days in the ICU; payor source; discharge disposition; date and time of discharge; discharge diagnoses, including ICD codes, AIS scores, body region, diagnosis description, and ISS score; functional ability at discharge; and for deaths, autopsy status if performed (i.e. complete, pending, not done). "In-patient care information" shall include persons with trauma injury who are under observation in the facility or who are transferred from the emergency department to another hospital unit in the same facility even if that unit or bed is not classified by the facility as an "inpatient bed". The information required under paragraphs I through iv of this rule must be provided in a format specified by the Department. 2 3. Facilities designated as Level I, II, and III shall submit to the trauma registry such additional information regarding the care, medical evaluation, and clinical course of specified, individual patients with trauma injury as is requested by the Department for the purpose of evaluating the quality of trauma management and care. 4. Clinics or facilities which are designated as Level IV or are undesignated may fulfill the reporting requirement by submission of data through a central computerized data system operated by or for the department. The department must receive the data for a particular month within 60 days of the end of that month. The data file submitted by facilities to the central computerized data system must contain the information required in Rule 1. Confidentiality 1. Any data maintained in the trauma registry that identifies patients or physicians or is part of patient's medical record shall be strictly confidential pursuant to C.R.S. 25-3.5-704(f)(R , whether such data is recorded on paper or stored electronically. The data shall not be admissible in any civil or criminal proceeding. 2. The data in the trauma registry may not be released in any form to any agency, institution, or individual if the data identifies patients or physicians. 3. The department may provide access to aggregate information in the registry by outside agencies, institutions, or individuals. Such information may include aggregate information for a facility but shall not include data that identifies patients or physicians. Provision of technical assistance and training 1. The Department may contract with any public or private entity to perform its duties concerning the statewide trauma registry, including but not limited to duties of providing technical assistance and training to facilities within the state or otherwise facilitating reporting to the registry. 3 COLORADO TRAUMA REGISTRY ABSTRACT Data Collector ID: Hospital Code: I PATIENT DATA: - ' cal Record Number: Financial Number: Name: Address: City: County/State: Zip Code: DOB: _ Age: YMWD Race: (circle one): W B H A NA 0 Unk Sex: M F Ethnicity: II. INJURY DATA: Outcome: A D Trauma Type: B P Injury Date: / /_ Injury Time: Cause Code: ASLT BURN CHEM DIVE DROWN ELEC EXP FALL GSW HANG HYPO MCA MVA OTHER OV PED SELF SKI SMOKE SPORT STAB BIKE Injury details of cause code? Exact location: E codes: (use all that apply) 1) 2) Injury Zip Code: County injury occurred in: Location Type: Home Farm Res Rec/Sport Street Highway Public Bldg Indus Unk Other Protective Devices(circle all that apply): None Laobelt Shoulder Harness Belt(NOS) Airbag Childseat Helmet ETOH evident? Y N Tox Screen? Neg Circle if Pos: Cannabis Cocaine Qpiates Other BA BR III. INTER FACILITY TRANSFER DATA: Transfer mode from referring facility(circle all that apply): grAMB HELI fixed-WING POV OTHER Referring facility: City: Referring facility arrival date/time: Referring facility discharge date/time: Referring facility admit source(i.e. ED, In-Patient, etc.): •ima Surgeon Consultation Yes No_ Consultation time: Consultation Date: /_/. PRE-HOSPITAL DATA: Transport mode from the injury scene (circle all that apply): grAMB HELI fixed-WING POV OTHER Transport agency: Name Transport Agency: Name ALS BLS Miles_ ALS BLS Miles Time Notified: _ Date: Time Notified: __ Date: Time Respond: __ Date: Time Respond: _ Date: Am At Scene: _ Date: Arr. At Scene: _ Date: Left Scene: __ Date: Left Scene: Date: Arr. At Dest. Date: Arr.At Dest. Date: Triage Criteria(circle all that apply) HIGH RISK: MODERATE RISK SIGNIFICANT BLUNT TRAUMA with Physiologic • Flail Chest Compromise as evidenced by: • Spinal Cord injury w/neurologic deficit Systolic BP <90 or • Multisystem blunt injuries(?2 systems injured) • Long Bone Fractures In conjunction with • Pulse> 120 • Pelvic Fractures Multisystem injuries • Respiratory rate< 10 or>29 or requiring • Altered mental status (GCS < 10)with significant endotracheal intubation trauma • For age< 14 • Bums>20%or involving face, airway, hands,feet or • BP < lower limits for age or genitalia • Tachycardia for age and signs of poor perfusion • Amputation above wrist or ankle (Capillary refill time> 2 seconds, cool • Pedestrian hit @> 20 MPH or thrown> 15 feet extremities, decreased pulses, altered mental status, poor color, respiratory compromise) OTHER RISK: • Altered mental status(GCS< 10)with focal • Fall >20 feet neurologic deficit • High energy transfer situations PENETRATING TRAUMA TO: • Auto crash w/significant vehicle body damage • Thorax • Motorcycle,ATV, bicycle accident • Abdomen • Neck qgigOV Hospital Arrival Time: _— Hospital Arrival Date: —/ /__ Clinical Data: Num Resp Pulse SBP Eye Verbal Motor GCS Err Pam Field 1. ED (Admit) 2. ED (1 hr/last) 3. ED Disposition: (INPT): OR ICU FLOOR DIRECT OTHER (ED): DisCharged EXPired AMA DOA TRANSfer: (OBS): V. INPATIENT DATA: Inpt. Admit Date: / I Admit Time: _— Discharge Date: _/_/— Time: Admit Service (circle only one): TRAUMA/General Sum ORTHOpaedic NEUROsurg OMFS PEDS OTHERSurg Non-Surg OR Procedure Data: (5 index cases to be selected) ICD9 Start Time Start Date ICD9 Start Time Start Date 1. / / 4. / / 2. / / 5. // 3. / / COMORBID FACTORS ❑ CHF ❑ COPD ❑ COAG/Hemo-Congenital ❑ Renal ❑ Liver ❑ Pregnant ❑ IDDM ❑ ETOH Total ICU Days: Payor Source: Inpt Discharge Disposition: HOME HOME-health SNF-ICF AMA EXPired REHAB ACUTE care OTHER facility Facility Name: Functional Ability Pre-Injury disability present(circle one each) Locomotion: Y N Communication: Y N Post-Injury Functional Status at Discharge: IND PAR/DEP TOT/DEP AUTOPSY self-FEED Yes/No/Pending LOComotion COMmunication VI. DIAGNOSES: ICD9 Description AIS 'Region *Body Region Choices: CS TS LS ABD ARM LEG HEAD FACE EXT NECK CHEST ISS 9Yiio1 STATE OF COLORADO COLORADO BOARD OF HEALTH RULES AND REGULATIONS PERTAINING TO THE STATEWIDE TRAUMA SYSTEM CHAPTER TWO-AREA TRAUMA ADVISORY COUNCILS 201. In order to ensure effective system development and regional trauma planning,all areas must comply with the following minimum standards and planning regulations. 202. On or before July 1, 1997,the governing body of each city and county throughout the state shall establish an area trauma advisory council(ATAC). Area Trauma Advisory Councils (hereinafter, ATACs,referring to the councils and the geographical areas they represent)must prepare plans to create and maintain coordinated,integrated trauma system services throughout the area. In order to secure Department approval,each plan must identify the area's goals and objectives. The plan must identify existing area resources,the resources that are needed in the area, and the area's action plan to secure needed resources. The goals and objectives must relate to this information. 203. Plans must be submitted to the Department by July 1, 1998,and every other year thereafter. 204. Minimum Standards for Area Trauma Resources A. Communication The area must provide communication and dispatch systems that insure coordinated coverage, specifically: 1. Utilization of the universal 9-1-1 or a local equivalent that is well publicized and accessible for citizens and visitors to the area 2. Adequate dispatch services 3. Paging and alerting system for notification of emergency medical/trauma personnel who routinely respond to emergency medical/trauma incidents 4. Two-way communications between and among ambulances 1 5. Two-way communications between ambulances and non-designated facilities and designated trauma facilities 6. Two-way communications between ambulances and trauma facilities outside the ATAC area 7. A plan for utilization of an alternative communications system to serve as a back-up to the primary system 8. A disaster communications plan 9. A system for notification and alerting trauma teams,fixed and rotary wing emergency services,and trauma facilities 10. A system that is compatible with systems in adjacent regions or areas B. Prehospital First response units and ambulance services must meet the following criteria: 1. Minimum acceptable level of service: a. Basic life support(BLS)service-Must have at least 1 person who is at first responder or higher level of training b. Advanced life support(ALS)service-Must have at least 1 person who is at EMT-I or EMT-P level of training 2. Emergency response times for ground transport agencies: Time Limit a. High density areas(metro politan) (1) Provider service area encompasses 11 minutes, 100,000 people or more 90%of the time b. Mid-density areas(urban or mixed) (1) Provider service area encompasses 20 minutes 12,000 to 100,000 people 90%of the time c. Low density areas(rural,frontier) (1) Provider service area encompasses 45 minutes < 12,000 people 90%of the time 2 3. Optimal scene time limits 15 minutes 90%of the time Scene time=time of an-ival of transport agency at the scene to departure of the scene 4. Agencies shall QA all response and scene times that exceed these parameters and make plan of correction where necessary 5. Triage and transport of trauma patients must be in accordance with the prehospital transport destination algorithm(exhibit A to these regulations) C. Interfacility Transfer and Consultation 1. Levels II and III trauma centers caring for the critically injured adult trauma patients listed below must comply with the actions required: a. Bilateral pulmonary contusions requiring nontraditional ventilation b. Patient with multi-system trauma with pre-existing coagulopathy (hemophilia) c. Pelvic fractures with unrelenting hemorrhage d. Aortic tears e. Liver injuries requiring emergency surgery and requirement for liver packing or vena cave injury Actions Required: (1) Mandatory, timely (but within 6 hours after recognition of condition) consultation is required with a Level I trauma surgeon(who is a member of the attending staff)for consideration of transfer of the patient. The attending trauma surgeon of the referring facility should initiate the consultation. (2) Consultation with the attending trauma surgeon is required in the determination of the necessity of transfer and the circumstances of transfer, including but not limited to additional diagnostic/therapeutic issues, availability of resources, weather conditions. 2. Level III trauma centers caring for the high risk adult trauma patients with the following traumatic injuries must comply with the actions required: 3 9g1804 a. Significant head injuries(intracranial bleeding or GCS< 10)or spinal cord injury with neurologic deficit where neurosurgical consultation and evaluation are not promptly available b. Significant multi-system trauma as defined by: (1) Head injury (intracranial bleeding or GCS < 10) or spinal cord injury with neurologic deficit complicated by either significant chest and/or abdominal injuries as defined by: (a) Chest Injury(as part of multi-system injuries): i) Multiple rib fractures > 4 unilaterally or >2 bilaterally ii) Hemothorax (b) Abdominal Injury(as part of multisystem trauma): i) Significant intra or retroperitoneal bleeding ii) Hollow organ or solid visceral injury c. Bilateral femur fracture or posterior pelvic fracture complicated by significant chest and/or abdominal injuries as defined above d. Trauma patient on mechanical ventilation for>4 days • e. Life threatening complications,such as acute renal failure(creatinine>2.5) or coagulopathy(twice the normal value for individual facility) Actions required: (1) Mandatory, timely (but within 12 hours after recognition of condition) consultation is required with a Level I or key resource facility trauma surgeon(who is a member of the attending staff)for consideration of transfer of the patient. The primary attending physician at the Level HI facility should initiate the consultation. (2) Consultation with the trauma surgeon is required in the determination of the necessity of transfer and the circumstances of transfer, including but not 4 9812(1)/ limited to additional diagnostic/therapeutic issues,availability of resources, weather conditions. (3) Consultation and or transfer decisions in patients with traumatic injuries less severe than those listed above shall be determined by the ATAC based on resources,facilities,and personnel available in the region and shall be made in accordance with ATAC protocols. 3. Level IV trauma centers caring for patients with the following traumatic injuries must comply with the actions required: a. Critical injuries listed in C.1. b. Significant head injuries(intracranial bleeding or GCS< 10)or spinal cord injury with neurologic deficit c. Significant multi-system trauma as defined by: (1) Head injury (intracranial bleeding or GCS < 10) or spinal cord injury with neurologic deficit complicated by either significant chest and/or abdominal injuries as defined by: (a) Chest Injuries(as part of multisystem trauma): i) Multiple rib fractures > 4 unilaterally or > 2 bilaterally ii) Hemothorax (b) Abdominal Injuries(as part of multi-system trauma): i) Significant intra or retroperitoneal bleeding ii) Hollow organ or solid visceral injury d. Bilateral femur fracture or posterior pelvic fracture complicated by either significant chest or abdominal injuries as defined above e. Trauma patient on mechanical ventilation f. Life threatening complications,such as acute renal failure(creatinine>2.5) or coagulopathy(twice the normal value for individual facility) Actions required: (1) Mandatory timely,(but within 6 hours after recognition of condition)transfer is required for patients with the above defined injuries. 5 (ip a igCSI (2) The primary attending physician at the level IV trauma center shall consult with the attending trauma surgeon at the key resource facility prior to transfer to determine the most appropriate destination for such patients and to discuss the circumstances of transfer such as additional diagnostic/therapeutic issues,availability of resources,weather conditions, etc. (3) Consultation and or transfer decisions in patients with traumatic injuries less severe than those listed above shall be determined by the ATAC based on resources,facilities, and personnel available in the region and shall be in accordance with ATAC protocols. 4. Nondesignated Facilities Until October 1, 1998,the primary attending physician at nondesignated facilities that have submitted by January 1, 1998 an application request per rule 301(A)(3)or 301(A)(4)for designation or re-designation and that receive and are accountable for trauma patients with any traumatic conditions other than as defined in 204(C)(5) must consult with an attending trauma surgeon at the ATAC key resource facility to determine if the patient requires transfer to a designated facility. Timing of such consultations must occur within six hours of recognition for all traumatic conditions other than as defined in 204(C)(5). Nondesignated facilities that do not submit by January 1, 1998 an application in writing for designation or re-designation must transfer all trauma patients except those defined in rule 204(C)(5)to the appropriate, designated trauma center beginning January 1, 1998. Transfer agreements are required. 5. Noncomplicated Trauma Injuries Interfacility transfer ofnoncomplicated,non-life threatening single system injury(i.e. isolated hip fracture) trauma patients shall be made in accordance with ATAC protocols. ATACs must monitor transport within their regions and report systematic exceptions to the protocols or regulations to the Department. 6. ATACs must monitor treatment and transfer of patients with the above conditions. Documentation and QA must be completed on such patients. Systematic exceptions of the standards must be reported to the Department. For example,if significantly injured patients with multi-system trauma injuries are consistently transported to undesignated or level IV facilities,such transport deviation from the standards would constitute a systematic exception that must be reported. 7. Areas are responsible for ensuring that interfacility transfer agreements exist in all facilities transferring patients within and outside the area. 6 9f11gy011 D. Interfacility Transfer and Consultationia-Pediatrics* 1. For the purpose of 204.D., `critical injuries"are defined as any of the following: a. Bilateral pulmonary contusions requiring non-traditional ventilation b. Multi-system trauma with preexisting or life threatening coagulopathy c. Pelvic fractures with unrelenting hemorrhage d. Aortic tears e. Liver injuries with vena cava injury or requiring emergency surgery with liver packing f. Coma for longer than 6 hours or with focal neurologic deficit. 2. For the purpose of 204.D., "high risk injuries"are defined as any of the following: a. Penetrating injuries to head,neck,torso,or proximal extremities b. Mechanical ventilation of> 16 hours c. Persistent in-hospital evidence of physiologic compromise including: tachycardia relative to age plus signs of poor perfusion (CFT > 2 seconds, cool extremities, decreased pulses,altered mental status,or respiratory distress),hypotension d. Hemodynamically stable children with documented visceral injury admitted for "observational"management and requiring blood transfusion or fluids>40cc/kg. e. Injury Severity Score>9 ,including,but not limited to: i. Multi-system blunt injuries(>2 systems) ii. Pelvic or long bone fractures in conjunction with multi-system injuries iii. Altered mental status(GCS< 10)with significant trauma 3. For the purpose of 204.D.,"high risk mechanisms"are defined as any of the following high energy transfer mechanisms: a. falls>20 feet b. auto crashes with significant vehicle body damage c. significant motorcycle crashes d. all terrain vehicle(ATV)crashes 4. Level II trauma centers with pediatric commitment designation (LH/PC) that care for pediatric patients (age 0-12 years ) with critical injuries must comply with the actions required: Actions required: a. Mandatory,timely(but within 6 hours after recognition of condition) consultation`'2 is required with an attending trauma surgeon from a Regional Pediatric Trauma Center (RPTC)or a Level I trauma center with Pediatric Commitment(LI/PC). 5. Level I and II trauma centers without pediatric commitment and Level III centers caring for pediatric trauma patients (age 0-12 years)with critical injuries or high risk injuries must comply with the actions required: • Actions required: a. Children 0 - 5 years of age with critical injuries shall be transferred with prior consultation to a Regional Pediatric Trauma Center(RPTC). If such a center is not available, then transfer" shall be to a Level I Trauma Center with Pediatric Commitment(LI/PC). If such a center is not available,then transfer shall be to a Level II Trauma Center with Pediatric Commitment (LI /PC). If no center with pediatric commitment is available,transfer"shall be to the highest level trauma center available. b. Children 6 - 12 years of age with critical injuries. Mandatory, timely (but within 6 hours after recognition of condition)consultation"is required with an attending trauma surgeon at a RPTC or a LI/PC for consideration of transfer of the patient. c. Children 0 - 12 years of age with high risk injuries. Mandatory,timely(but within 6 hours of recognition of condition)consultation"is required with an attending trauma surgeon at a RPTC or LI/PC for consideration of transfer of the patient. 6. Level IV trauma centers and nondesignated facilities caring for pediatric patients (age 0-12 years)with critical injuries or high risk injuries must comply with the actions required: Actions required: a. Children 0-5 years of age with critical injuries shall be transferred"to a Regional Pediatric Trauma Center(RPTC). If such a center is not available,then transfer" shall be to a Level I Trauma Center with Pediatric Commitment(LI/PC). If such a center is not available,then transfer shall be to a Level II Trauma Center with Pediatric Commitment(LIUPC). If no center with pediatric commitment is available,transfer"shall be to the highest level trauma center available. b. Children 6 - 12 years of age with critical injuries shall be transferred" to a RPTC or a LI/PC. If such a center is not available then to a LI//PC. If no center with pediatric commitment is available,transfer"to the highest level trauma center available. c. Children 0 - 5 years of age with high risk injuries shall be transferred'Z to either a RPTC or a LI/PC. If such a center is not available then to a LI/PC. If no center with pediatric commitment is available transfer"to the highest level trauma center available d. Children 6 - 12 years of age with high risk injuries shall be transferred with prior consultation"to either a RPTC,LI/PC or LIUPC. If no center with pediatric commitment is available then transfer to the highest level trauma center available. 7. Level IV trauma centers and nondesignated facilities caring for pediatric patients(age 0-12 years) who are injured by high risk mechanisms shall be treated as follows: Actions required: a. Mandatory, timely (but within 6 hours) consultation" is required with an attending trauma surgeon from a RPTC , LUPC or Li/PC for consideration of transfer. 8 8. Consultation and/or transfer decisions in pediatric patients with traumatic injuries less severe than those listed above shall be determined by the ATAC based on resources, facilities,and personnel available in the region and shall be in accordance with the ATAC protocols. 9. Nondesignated Facilities Nondesignated facilities that receive and are accountable for pediatric trauma patients with any traumatic conditions other than non-complicated,non-life threatening, single system injuries must transfer those patients to the appropriate,designated trauma center. Transfer agreements are required. 10. ATACs must monitor transport of pediatric trauma patients within their regions and report systematic exceptions to the protocols or regulations to the Department. `For individuals 13 to 18 years of age, interfacility consultation or transfer can follow adult or pediatric interfacility regulations based on severity of illness. 'Consultation is required in the determination of the necessity of transfer and the circumstances of transfer, including but not limited to additional diagnostic/therapeutic issues, availability of resources, weather conditions. 'Consultation must be initiated by the attending trauma surgeon of the referring Level I, II,or III trauma center or attending physician of the Level IV or nondesignated facility. E. Divert If coordinated within the ATAC and pursuant to protocol,facilities may go on divert status for the following reasons: 1. Lack of critical equipment 2. Operating room saturation 3. Emergency department saturation 4. Intensive care unit saturation 5. Facility structural compromise 6. Disaster 7. Lack of critical staff Redirection of trauma patient transport shall be in accordance with the triage and trauma algorithm(exhibit A) and these regulations when a trauma center is on divert status. 9 987 EMI Trauma facilities must keep a record of times and reasons for going on divert status. This information must be made available for ATAC and/or Department audit. ATACs must audit facility diversion of trauma patients in their areas. Upon consideration of the reason for divert status,the authorizing personnel and other pertinent facts,ATACs may institute corrective action if the diversion was not reasonable or necessary. F. Bypass At times the triage and transport algorithm (exhibit A)may require that prehospital providers bypass the nearest facility to transport the patient to a higher level trauma center. The necessity for such bypass must be initially determined by the physiologic criteria in the algorithm. However, certain situations may require different transport(such as excessive expected transport time to the nearest trauma center, or lengthy extrication time requiring air evacuation,or other emergency conditions(traumatic cardiac arrest or transfer to a subspecialty center). ATACs must develop protocols for patient destination within their areas that address bypass for situations not addressed in the algorithm. Bypass situations must be monitored and the ATAC must require justification for deviation. 205. Minimum Standards and Organizational Requirements for ATAC A. County commissioners from the counties comprising each ATAC shall determine how council members will be selected. B. Each ATAC shall meet at least four times per year.A chairperson of the Council shall be selected and that person or his/her designee shall serve as the liaison for that area's communications with the Department. The Councils may appoint subcommittees,advisory groups or otherwise obtain community assistance in completion of council business. After the appointment of members to the ATAC,the Council shall establish by-laws which include council member terms of office and other pertinent matters. C. Multi-county ATACs must be comprised of counties that are contiguous. When establishing ATACs,areas must attempt to represent all participant counties if possible. At least seventy five percent of council membership must reside in,or provide health care services within, the area. Statutorily specified members must reside in or provide services within the area. D. Areas must identify at least one key resource facility that will be used,and that will be represented on the area council. The key resource facility shall be a Level I or II facility,and shall provide consultation and technical assistance to the area regarding education, quality, training, communications,and other trauma issues. E. Areas must develop system monitoring protocols that allow for oversight of state and area standards and require communication among area prehospital physician advisors. F. Areas must establish oversight quality of care goals for the ATAC. These goals (QA/QI)and standards must conform to the QA/QI standards set forth elsewhere in these regulations. 10 9�igv41 G. Areas must develop injury prevention goals and objectives. The area must monitor injury prevention programs within their ATAC,and develop coordination where possible. H. Areas must integrate the provision of trauma services with other local and statewide disaster plans (such as State Patrol, county administration,Office of Emergency Management). 206. Plan Requirements A. Existing Area Resources 1. Identify the population density of the area including: a. Total population b. Population per square mile c. Population of major towns/cities d. Other pertinent information 2. Submit a map of the area,showing cities and towns,and any geographical barriers to air and ground transportation of trauma patients 3. For each hospital available in the area identify: a. Name of hospital(list all) b. Number of total staffed beds for each hospital and area total c. Number of total staff for each hospital d. ED and/or services that are available 24 hr./day e. Trauma center status and level of each trauma facility 4. For each clinic available which provides trauma care identify: a. Name of clinic and location b. Hours of operation at each c. Number of physicians available vs.nurses vs.physicians assistants available at each(list) d. Whether or not EMTs or paramedics staff clinics(if so-name clinic) 5. For each EMS service available identify: 11 a. Name of agencies(list and include ALS and BLS) b. Number of paid staff and number of volunteers c. Location(show on two separate maps)as to: (1) 24 hour ALS availability (2) BLS availability d. Indicate agencies that routinely use or have access to air transport 6. Identify trauma centers to which trauma patients are currently transferred. a. Identify which trauma centers are used for staff education 7. Identify total volume of trauma patients on an annual basis. a. Stratify volume according to severity of injury(ISS): (1) <9 (2) 10-15 (3) 16-25 (4) >25 8. List any specialized trauma care services in the area(such as burn centers,rehabilitation, pediatric, spinal cord injury) 9. Identify what communications systems are used currently. Specifically identify: a. How citizens and %isttors access emergency medical and trauma services through telephone access. radio, call box systems b. Primary communications channels for dispatch of emergency medical personnel who routinely respond to emergency medical/trauma incidents c. Primary communications channels utilized by on scene personnel for the purpose of communication ben een the field personnel and the local trauma facility d. Primary communications channels utilized for communication between ambulances e. Primary communications channels utilized for communication between EMS and law enforcement and fire f. Level of training for dispatchers who routinely receive calls for emergency medical and • trauma services 12 9g) 8-/ g. The communication equipment that is or would be used in the event of a multiple casualty incident or disaster (including but not limited to number of channels and repeaters) h. The methods used for activating trauma teams and for activating fixed and rotary wing emergency services (examples:pager,phone) i. Communication methods between trauma facilities(examples: telephone,radio, video, telemedicine) j. How the communications system interfaces with adjacent regions; k. Any telemetry or telemedicine systems in place and their primary utilization (list in summary form) 1. How EMS agencies communicate when transporting patients 10. Briefly describe any disaster management programs currently in place. 11. List any trauma prevention,public information or education programs currently provided. 12. Identify trauma data collection practices and capacity for expansion: a. CHA b. UB92 c. Trauma Base d. MVA e. Other 13. Describe current quality improvement/assurance activities in place for trauma care. B. Resources Needed 1. Identify predicted population growth or loss that would impact trauma service delivery. 2. Identify on a map the predicted changes in the layout of population and any new barriers to trauma care that are expected due to these changes. 3. Identify hospital resources that are needed in the area to properly address trauma patient or system needs. 4. Identify prehospital services that are needed for proper transfer and care of trauma patients. 5. Identify the types of services from key resource facilities that are needed for essential trauma care in the area. 13 q�/Sy 6. Identify what specialized trauma care services are needed in the area to serve the patient population. 7. Identify what communications capabilities the area needs to effectively operate the trauma system,and where shortfalls currently exist. 8. Identify what prevention programs are needed. 9. Identify what disaster management assistance and resources and/or are required. 10. Identify what type of community resources and/or public information and education programs are needed. 11. Specify if data collection systems must be enhanced or changed in order to capture the data needed for the trauma system(essential minimum data specified by the Board of Health)and estimate what(finances,personnel, and training)would be required. 12. Identify what changes need to be made in quality improvement/assurance activities to ensure accurate quality assessment. C. Area Analysis 1. Based upon the area needs assessment and resources inventory, identify the two most important goals in the ATAC over the next two year period. State why these goals were chosen(goals must relate to resources needed section). 2. Explain how the above stated goals promote efficiency, integration and coordination of trauma service provision throughout the ATAC. 3. Identify all counties that were invited to participate in the ATAC,and how the fmal group was determined. Explain why that composition was chosen, and how it promotes the integration and coordination of trauma service provision in the ATAC and in adjacent geographical areas. 4. Identify the optimal number of trauma centers needed in the ATAC,their proposed location and the rationale for additional centers beyond what is currently available. 5. Identify how the ATAC will prevent duplication of services in the area. 14 g,Y/0/ 6. Identify what efficiencies are anticipated or experienced by multicounty participation in the ATAC. 7. Identify how the ATAC will address multiple and/or different sets of protocols from different providers and physician advisors in the area. 8. Identify how the ATAC will address back up issues among the various providers(when back up is not completely available within each provider organization). 9. Identify how the ATAC will communicate with providers to seek input, to disseminate information,and to ensure participation in the system. 10. Identify how the ATAC will coordinate care with adjacent ATACs,neighboring states if relevant, and/or counties not within the ATAC area. 207. The Council may grant exemptions from one or more standards of these regulations if the applicant can submit information that demonstrates that such exemption is justified. The council must fmd,based upon the information submitted and other pertinent factors,that particular standards is inappropriate because of special circumstances which would render such compliance unreasonable,burdensome or impractical. Exemptions or variances may be limited in time or may be conditioned as the Council considers necessary to protect the public welfare. 208. ATACs must submit a biennial report to the state Trauma Council indicating progress on system implementation and matters of citizen or provider concern in the area. 209. ATACs must estimate approximate costs for implementation of the trauma system in the area and submit these estimates to the Department along with the plan.Known actual costs shall be submitted with plan updates. 210. ATACs must submit plans to the Department by July 1 of every other year. Each plan must be approved or returned to the ATAC for revision within three months by the Department. Plans may be resubmitted twice for approval.Resubmissions should incorporate any required changes and must be made within three months of the plan's rejection. If the Department does not approve the plan on the third submission, the Department will develop an acceptable plan for that area that the area must implement. If an ATAC does not resubmit the amended plan within the three month limit, the opportunity for resubmission is forfeited. 211. Plans remain in effect unless the ATAC notifies the Department the plan is not functional as implemented and the ATAC wishes to replace the plan. A replacement plan must be submitted within two months after such notification. Minor modifications to a plan can be submitted with the annual report of the region,and approved by the Department at that time. Major modifications must go through the plan process specified in these rules. 15 COLORADO STATEWIDE TRAUMA SYSTEM RULES AND REGULATIONS-CHAPTER 2 AREA TRAUMA ADVISORY COUNCILS EXHIBIT A-ADULT PREHOSPITAL TRAUMA TRIAGE ALGORITHM Triage and transport decisions for adult trauma patients must be classified and transported as follows: HIGH RISK ADULT TRAUMA PATIENT ,f XD. E' fg .b ... 1.: ..° . . ,..,,.x :.,�. N: � .'?�#2:a ";. ."5'.. N $ivnificant Blunt'Trauma With Physiologic Compromise as Evidenced Systolic BP<90 m Transport to Level I trauma center if available in< 15 minutes Pulse> 120 additional prehospital time. Respiratory rate<10 or>29 or requiring endotracheal intubation Altered mental status(GCS< 10)with focal neurologic deficit If Level I trauma center is not available, transport to nearest trauma center unless a higher level center is available in < 15 minutes additional prehospital time. If a trauma center is not available within 60 minutes of additional prehospital time, refer to medical control for appropriate destination. Penetratinv Trauma To: Thorax Abdomen Neck High Risk Criteria(Without Physiologic Compromise): Death of same car occupant Triage to an upper level trauma center when available. Consult Extrication time>20 minutes with medical control for appropriate destination as needed. MO FATE RISK ADULT TRAUMA PATIENT Flail Chest Transport to Level I or II trauma center if available in < 15 Spinal Cord injury w/neurologic deficit minutes additional prehospital time. Multi-system blunt injuries(>2 systems injured) Long Bone Fractures n conjunction with If Level I or II trauma center is not available transport to nearest Pelvic Fractures multi-system injuries trauma center unless a higher level trauma center is available in< Altered mental status(GCS<10)with significant trauma 15 minutes additional prehospital time. Bum>15%or involving face,airway, Amputation above wrist or ankle If a trauma center is not available within 60 minutes of transport, Pedestrian hit A>20 MPH or thrown>15 ft. contact medical control for appropriate destination. OTHER RISK FACTOR&OR INJURY Falls>20 feet Transport to nearest trauma center if available or other facility as High energy transfer situations such as: determined by medical control. Auto crash w/significant vehicle body damage,motorcycle, ATV,bicycle accident lalittlatqfprnettatAtttnatalatatiannikletainapprinntanatrat Extremes of age(>60) Transport to nearest trauma center if available or other facility as Medical illness(COPD,CHF,renal failure,anticoagulant therapy determined by medical control. etc.) 2nd/3rd trimester • et anc If there are equivalent trauma centers in an area destination will be made in accordance with the regional ATAC plan. Ste 0 PATIENTS WITH UNCOMPLICATED SINGLE SYSTEM EXTREMITY INJURIES MAY BE TRANSPORTED TO THE NEAREST FACILITY OR IN 9g/ 0 ACCORDANCE WITH ATAC PROTOCOLS. COLORADO TRAUMA SYSTEM EXHIBIT B-PEDIATRIC PREHOSPITAL TRAUMA TRIAGE ALGORITHM Triage and transport requirements for pediatric(<12 years old*)trauma patients. HIGH RISK PEDIATRIC TRAUMA PATIENT FIELD CRITERIA TRANSPORT DESTINATION Significant Blunt Trauma with Physiologic Compromise as Blunt&Penetrating Trauma Evidenced By: • 1. For children< 5 years of age: transport shall be to a regional Tachycardia for age plus at least 2 signs of poor perfusion: pediatric trauma center if available within < 15 minutes • Capillary refill>2 seconds additional prehospital time. If a regional pediatric trauma center • Cool extremities is not available, transport to a Level I trauma center with • Decreased pulses pediatric commitment. If a Level I trauma center with pediatric • Altered mental status commitment is not available,transport to a Level II trauma center • Respiratory distress with pediatric commitment. OR • BP<lower limits for age 2. For children 6-12 years of age: transport shall be to a regional • Altered mental status(GCS< 10)with significant head trauma pediatric trauma center or a Level I trauma center with pediatric or focal neurologic deficit commitment if available within < 15 minutes additional • Spinal cord injury with neurologic deficit prehospital time. If neither of those is available,transport to a Level II trauma center with pediatric commitment. Penetrating Trauma To: • Thorax 3. If none of the above centers is available,transport to the nearest • Abdomen trauma center unless a higher level trauma center is available • Neck within< 15 minutes additional prehospital time. • Head 4. If a trauma center is not available within 60 minutes additional prehospital time, refer to medical control for appropriate destination. Burns Burns • Second degree bums > 10%body surface area(TBSA) 1. Transfer to a specialized pediatric burn facility after initial • Third degree bums>5%(TBSA) assessment and stabilization at an emergency department. MODERATE RISK PEDIATRIC TRAUMA PATIENT FIELD CRITERIA TRANSPORT DESTINATION • Flail Chest 1. Transport to a regional pediatric trauma center or a Level I or • Multisystem blunt injuries(>2 systems injured) Level II trauma center with pediatric commitment if available • Long Bone Fractures l In conjunction with within< 15 minutes additional prehospital time. • Pelvic Fractures f multi-system urines • Altered mental status(GCS< 10)with arm(leant trauma 2. If a regional pediatric trauma center or a Level I or Level II • Amputation above wrist or ankle trauma center with pediatric commitment is not available within • Pedestrian hit @>20 MPH or thrown> 15 ft <15 minutes additional prehospital time,transport to the highest level trauma center available; if none, transport to nearest facility. _9THLR RISIS,FACTff FOR INJURY FIELD CRITERIA TRANSPORT DESTINATION • Falls>20 feet 1. Transport to a regional pediatric trauma center or a Level I or • High energy transfer situations Level II trauma center with pediatric commitment if available • Auto crash w/significant vehicle body damage within< 15 minutes additional prehospital time. • Motorcycle,ATV 2. If a regional pediatric trauma center or a Level I or Level II trauma center with pediatric commitment is not available within <15 minutes additional prehospital time,transport to the highest level trauma center available; if none, transport to nearest facility. If there are equivalent trauma centers in an area destination will be made in accordance with the regional ATAC plan. •Individual. 13 to 15 rears of age, transport can follow adult or pediatric Yrshospital destination algorithms band on severity of illness. 98/ k STATE OF COLORADO COLORADO BOARD OF HEALTH RULES AND REGULATIONS PERTAINING TO THE STATEWIDE TRAUMA SYSTEM CHAPTER THREE- DESIGNATION OF TRAUMA FACILITIES Definitions June 3, 1998 On or after July 1, 1997,every facility in this state required to be licensed in accordance with article 3 of title 25 and that receives ambulance patients shall participate in the statewide trauma care system. In the following rules,the term"council"shall refer to the state trauma advisory council created by 25-3.5- 104.3, C.R.S., and the term"ATAC"shall refer to the area trauma advisory council as defined in 25-3.5- 703(1),C.R.S. (1995). Advanced Trauma Life Support(ATLS) or Equivalent—the training provided in accordance with the American College of Surgeons curriculum for Advanced Trauma Life Support. An equivalent program is one which has been approved by the Department. The burden shall be upon the applicant to prove that the program is equivalent to ATLS. Consultation—telephone or telemedicine,as specified in this chapter,to determine the necessity of transfer and the circumstances of transfer, including but not limited to additional diagnostic/therapeutic issues,availability of resources, and weather conditions. Consultation occurs between the attending trauma surgeon(or physician in a Level IV facility)of a referring facility and an attending trauma surgeon (who is a member of the attending staff)at a receiving facility. Trauma consultation shall include written documentation completed by the trauma surgeon at the Levels II and III facilities, or the attending physicians at the Level IV facilit). Disagreements as to patient disposition will be documented at both facilities. Continuing Medical Education ;CM£l. For Levels I, II,III—trauma surgeons, emergency physicians,anesthesia providers, orthopedic surgeons, and neurosurgeons shall have Facility or ATAC defined trauma related CME over a three year period with at least half provided outside of own institution. For Level IV—physicians providing trauma care shall have Facility or ATAC defined trauma related CME 1 over a three year period. General surgeons taking trauma call at Level III and all physicians taking trauma call at Level IV centers must have successfully completed an ATLS course. Critical Injuries-Adult. Critical injuries for adult patients are defined as any of the following: a. Bilateral pulmonary contusions requiring nontraditional ventilation b. Multi-system trauma with pre-existing coagulopathy(hemophilia) c. Pelvic fractures with unrelenting hemorrhage d. Aortic tears e. Liver injuries with vena cava injury or requiring emergency surgery with liver packing Critical Injuries-Pediatric. Critical injuries for pediatric patients(age 0-12 years)are defined as any of the following: a. Bilateral pulmonary contusions requiring nontraditional ventilation b. Multi-system trauma with pre-existing or life threatening coagulopathy(hemophilia) c. Pelvic fractures with unrelenting hemorrhage d. Aortic tears e. Liver injuries with vena cava injury or requiring emergency surgery with liver packing. f. Coma for longer than 6 hours or with focal neurologic deficit. Divert-Redirection of the trauma patient to a different receiving facility. Redirection shall be in accordance with the prehospital trauma triage algorithm, as set forth in Chapter 2. Reasons for going on divert are limited to lack of critical equipment or staff; operating room, emergency department,or intensive care unit saturation; disaster or facility structural compromise. High Risk-Adult trauma patients: High risk adult trauma patients are defined as any of the following: a. Level IV—Significant head injuries(intracranial bleeding or GCS < 10)or spinal cord injury with neurologic deficit. Level III—Significant head injuries(intracranial bleeding or GCS < 10)or spinal cord injury with neurologic deficit where neurological consultation and evaluation are not promptly available. b. Significant multi-system trauma as defined by: (1) Head injury(intracranial bleeding or GCS s 10)or spinal cord injury with neurologic deficit complicated by either significant chest and/or abdominal injuries as defined by: (a) Chest injury(as part of multi-system trauma): i) Multiple rib fractures>4 unilaterally or>2 bilaterally ii) Hemothorax 2 9gj gut! (b) Abdominal injury(as part of multi-system trauma): i) Significant intra and retroperitoneal bleeding ii) Hollow organ or solid visceral injury c. Bilateral femur fracture or posterior pelvic fracture complicated by significant chest and/or abdominal injuries as defined above. d. Level IV—All trauma patients on mechanical ventilation. Level III—Trauma patients on mechanical ventilation for>4 days. e. Life threatening complications, such as acute renal failure(creatinine>2.5)or coagulopathy (twice the normal value for individual facility). High Risk-Pediatric trauma patients. High risk pediatric trauma patients (age 0-12 years)are defined as any of the following: a. Penetrating injuries to head, neck,torso,or proximal extremities b. Mechanical ventilation of> 16 hours c. Persistent in-hospital evidence of physiologic compromise including: tachycardia relative to age plus signs of poor perfusion(CFT>2 seconds, cool extremities, decreased pulses, altered mental status, or respiratory distress),hypotension d. Hemodynamically stable children with documented visceral injury admitted for"observational management and requiring blood transfusion or fluids>40cc/kg e. Injury Severity Score>_9, including but not limited to: I. Multi-system blunt injuries(>2 systems) ii. Pelvic or long bone fractures in conjunction with multi-system injuries iii. Altered mental status(GCS<10)with significant trauma High Risk Mechanisms. These are defined as any of the following high energy transfer mechanisms for pediatric patients: a. Falls>20 feet b. Auto crashes with significant vehicle body damage c. Significant motorcycle crashes d. All terrain vehicle(ATV)crashes Minimum data set—data specified pursuant to Chapter 1 of these regulations. 3 9l/8OLl Morbidity and Mortality Review—a case presentation of all complications, deaths, and cases of interest for educational purposes to improve overall care to the trauma patient. Case presentations shall include all aspects and contributing factors of trauma care from pre-hospital care to discharge or death. The multi-disciplinary group of health professionals shall meet on a regular basis, but not less than every two months. The documentation of the review may include date, reason for review,problem identification, corrective action,resolution and education. Documented minutes shall be maintained on site and readily available. Outreach—the act of providing resources to other facilities in order to improve response to the injured patient. These resources shall include, but not be limited to,clinical consultation and public and professional education. Trauma centers shall be centers of excellence and shall share this expertise with other trauma centers and non-designated facilities. Timely and appropriate communication,consultation and feedback is imperative to patient outcome. Key Resource Facilities are Level I &II trauma centers which have an expanded responsibility in providing on-going consultation,education and technical support to referring facilities, individuals, or Area Trauma Advisory Councils. On Call and Promptly Available. Level I— Level II—available on short notice to meet patient requirements as defined in Rule 303 B.2.a. (footnote 1). Level III—the surgeon will meet high and moderate risk trauma patients and those with significant mechanism (as defined in the prehospital trauma triage algorithms)upon arrival,by ambulance, in the emergency department. For those patients where adequate prior notification is not possible,the surgical response shall be 20 minutes from arrival. Level IV —per requirements as defined in Rule 303 B.2.c. (footnotes 2, 3, 12). Quality Improvement Program —A defined plan for the process to monitor and improve the performance of a trauma program is essential. This plan shall address the entire spectrum of services necessary to ensure optimal care to the trauma patient, from pre-hospital to rehabilitative care. This plan may be parallel to,and interactive with,the hospital-wide quality improvement program but may not be replaced by the facility process. Special Audit for Trauma Deaths. All trauma deaths shall be audited. A comprehensive review audit shall be initiated by the Trauma Service Director in Levels I,II, III facilities and by the appropriate personnel designated by the Level IV facilities. The trauma nurse coordinator shall participate in these audits. A written critique shall be used to document the process to include the assessment, corrective action and resolution. Trauma Multidisciplinary Committee—This Committee is responsible for the development, implementation, and monitoring of the trauma program at each designated trauma center. Functions include but are not limited to: establishing policies and procedures; reviewing process issues,e.g., communications; promoting educational offerings; reviewing systems issues,e.g.,response times and 4 notification times; and reviewing and analyzing trauma Registry data for program evaluation and utilization. Attendance required will be established by the committee. Membership will be established by the facility. Trauma Nurse Coordinator — The terms"trauma nurse coordinator"and"trauma coordinator" are used interchangeably in these regulations (6 CCR 1015). The trauma nurse coordinator(TNC)works to promote optimal care for the trauma patient through the clinical program,administrative functions, and professional and public education. The TNC shall be actively involved in the state trauma system. The essential responsibilities of the TNC include maintenance of the trauma registry, continuous quality improvement in trauma care, and educational activities to include injury prevention. Trauma Service—The Trauma Service is an organized, identifiable program which includes: a Trauma Service Director, a Trauma NURSE Coordinator,a Multi-disciplinary Trauma Committee, Quality Improvement Program, Injury Prevention, and Data Collection/Trauma Registry. Trauma Service Director—The Trauma Service Director is a board certified general surgeon who: is responsible for: service leadership, overseeing all aspects of trauma care,and administrative authority for the hospital trauma program including: trauma multidisciplinary committee,trauma quality improvement program,physician appointment to and removal from trauma service,policy and procedure enforcement,peer review,trauma research program, and key resource facility functions, if applicable; participates in the on-call schedule; practices at own institution on a full time basis; and participates in all facility trauma related committees. In Level I facilities,the trauma service director shall participate in an organized trauma research program with regular meetings with documented evidence of productivity. In Level IV,the Trauma Service Director may be a physician so designated by the hospital who takes responsibility for overseeing the program. Trauma Team-A facility defined team of clinicians and ancillary staff, including those required by these rules. Trauma Team Activation-A facility defined method(protocol)for notification of the trauma team of the impending arrival of a trauma patient based on the prehospital trauma triage algorithms as set forth in Chapter 2. TNCC or Equivalent-the training provided in accordance with the Emergency Nurses Association Trauma Nurse Core Course curriculum. An equivalent program is one which has been approved by the Department. The burden shall be upon the applicant to prove that the program is equivalent to TNCC. 5 9 got/ 301. Designation Process A. Applications 1. By January 1, 1998, all licensed Colorado facilities receiving trauma patients by ambulance or other means shall submit an application in writing for designation or re- designation as a trauma center an agreement of non-designation to the Department. 2. A facility requesting non-designation status must file a non-designation agreement that at minimum states: a. The facility understands and agrees that trauma patients as defined by rule 204(C), are intended by law to be treated at designated trauma centers which have demonstrated the capacity to competently care for such patients. b. The facility chooses not to seek such designation c. The facility understands that trauma patients are defined as patients who must be transported to a designated trauma facility as determined in the triage/transport/transfer regulations in rule 204(C)and the prehospital algorithm. d. If the trauma patient as defined in rule 204(C) is transported to a non-designated facility,the resuscitation, stabilizatioin and/or transfer of that patient to a designated trauma facility will be arranged according to 204(C)(4). 3. An application for trauma center designation or re-designation must contain a signed board of director's resolutuion affirming the facility's commitment to seek designation and participate in the statewide trauma system. It also must state,at a minimum,: a. The level of designation the facility requests b. Unique attributes or circumstances that make the facility capable of meeting particular of special community needs c. Why or how the facility views itself as a necessary component of the state-wide trauma system d. How the facility's designation or re-designation fits into its Area Trauma Advisory Council (ATAC)plans,organization and geography 4. A facility requesting specialty status as a burn or pediatric trauma care center must file a request that at a minimum states: 6 a. The type of specialty status requested b. The special attributes that justify such a designation(including but not limited to such things as specialized staff, expertise,equipment, or space for the treatment of particular types of traumatic injuries) c. How the facility's specialty designation will integrate into its ATAC plan, specifically why it is a necessary component to the area ATAC and how it will enhance trauma care, as well as how it integrates into the organization and geography of the area 5. Effective January 1, 1998, applicants for designation and re-designation shall submit the required fee with their application . Applicants that submit their request prior to January 1, 1998 shall submit the designation fee following notification of the required fee by the department. 6. The designation and redesignation fees for trauma centers are as follows: A. Levels I through IV: Level I - $26,600 Level II- $25,900 Level III- $16,600 Level IV- $ 6,800 B. The specialty designation and redesignation fees below shall be separate from and in addition to the above fees: Independent - $ 17,400 Concurrent - $ 8.400 7. The criteria to be applied for designation facilities are provided in the in rule 303 (general criteria), rule 304 (pediatric facilities),and rules 305 and 306(burn facilities), but shall also include: A. any unique attributes or circumstances that make the facility capable of meeting particular or special community needs, B. how the facility's designation fits into the design and plans of the ATAC, and C. for emergency sc%ices in level III facilities,the alternative pathway criteria listed in 301(C)(1)where appropriate. B. Review Process 7 1. The Department shall assemble review teams to conduct on-site reviews of facilities requesting designation. If a facility is dissatisfied with a team member chosen for its review, upon request by the facility,the department may replace that member prior to the site visit. I 2. Such review shall be conducted by the following teams: a. Level I facilities-team of 4 members: (1) Out-of-state reviewers are required (2) Multi disciplinary team is required(2 trauma surgeons, 1 trauma nurse coordinator, 1 emergency physician) (3) State observer b. Level II facilities-team of 4 members: (1) Out-of-state reviewers are required (2) Multi disciplinary team is required(2 trauma surgeons, 1 trauma nurse coordinator, 1 emergency physician) (3) State observer c. Level III facilities-team of 3 members: (1) 3 members,2 may be from in-state (2) Multi disciplinary team is required(1 trauma surgeon, 1 emergency physician, 1 trauma nurse coordinator) (3) State observer d. Level IV facilities-team of 2 members: (1) Reviewers must reside outside of the ATAC in which the facility under review is located (2) Multi-disciplinary team is required(I emergency physician, 1 trauma nurse coordinator) 8 9gi57ot/ (3) State participation 3. The on-site review team shall evaluate the appropriateness, capabilities, and commitment of the applicant facility to meet the responsibilities,required equipment,and performance standards set forth in the facilities designation criteria for the level of designation sought. The team's evaluation and recommendation to the Department shall be based upon consideration of all pertinent information, including but not limited to: a. Inspection of the facility b. Review of presurvey questionnaire c. Review of medical records, including patient records d. Review of patient discharge summaries e. Review of patient care logs f. Review of QA/QI trauma records g. Review of rosters, schedules, meeting minutes h. Interviews with appropriate individuals i. Review of research,prevention, and educational programs j. Other documentation where appropriate 4. The on-site review team shall make a verbal report of its findings(exit interview)to the applicant prior to leaving the facility. It shall forward written findings and recommendations to the Council within 30 days of the review date. The Council,or a subcommittee thereof, shall review the reports of the on-site review team, consider any unique attributes or circumstances that make the facility capable of meeting particular or special community needs2, and render a recommendation to the Department within 60 days of receipt of the team's findings. 5. The Department shall make the final determination of designation regarding each application upon consideration of all pertinent factors, including but not limited to the application,the evaluation and recommendations by the on-site review team,the best interests of trauma patients,any unique attributes or circumstances that make the facility capable of meeting particular or special community needs2,and the manner in which this application integrates into the statewide trauma system. 9 6. The Department shall notify the applicant in writing of its decision within 30 days of receiving the recommendation from the Council. 7. Designation shall last three years from the date of notice of designation, unless otherwise revoked for cause. Trauma centers that had been certified under the system of certification and recertification through the Colorado Trauma Institute on of before July, 1997shall continue to be designated a trauma facility at the same level until redesignated, provided the center submits an application for re-designation in writing prior to January 1, 1998. 8. Six months prior to the end of the designation period,the applicant shall file a notice to continue or withdraw from its designated status. If a notice to continue is filed,the Department shall verify the facility's compliance with the designation standards and these regulations and perform a new site visit which shall conform to the visits addressed in section I.B. of these regulations. 9. Appeals- Facilities that disagree with departmental designation decisions may appeal those decisions of the Board of Health within 30 days of receipt of the Department's notice of non-designation. The board shall consider the appeal based upon the written documentation, briefs submitted by the parties and oral argument, and render a final decision for the department. C. Alternative criteria for trauma facilities 1. Level III trauma facilities that apply for"alternative pathway"criteria per rule 303(B)(2)(C)must demonstrate that they can meet the following criteria: a. The facility is a rural facility.3 b. The facility has an Annual ED census of 10,000 or less. c. In-house 24 hour ED services are available. d. ED staff may include physicians board certified in family practice, internal medicine, surgery, or emergency medicine. e. For ED physicians hired with less than 5 years post-residency experience,facilities must secure a letter from the residency director of each such hire, documenting that physician's experience in trauma care. Such letters must be kept on file and made available to suneyors. f. Facilities with ED physicians not board certified in emergency medicine must 10 98i80`71 document that each such physician works at least 750 hours per year in that facility's ED. g. Facilities with ED physicians not board certified in emergency medicine must document ATLS certification for each such physician, as well as 75 hours of ACEP Level I and trauma CME every three years. h. Facilities with ED physicians not board certified in emergency medicine must document attendance by these physicians at not less than 33% of the hospital's trauma meetings and educational meetings related to trauma care. i. The facility's application meets the intent of the"alternative pathway"criteria; 2. Level III facilities may apply for the"alternative pathway"criteria in their application for designation or redesignation to the Department. The Council will recommend for or against approval of such application to the Department upon review of the requesting letter and other pertinent information. If such request is not recommended,the Council will inform the facility of the reasons for its recommendation. 302. Denial or Revocation of Designation or redesignation. A. Denial 1. The Department may deny designation or redesignation to a facility if the facility: a. Does not meet the requirements for designation as set forth in these regulations b. Makes a false statement of material fact in its application or in documents submitted in support of its application c. Refuses inspection or a part of inspection d. Submits an application that does not comply with or integrate into its ATAC plan B. Revocation 1. The Department may revoke designation of a facility if any owner, officer, director, manager, or other employee: a. Fails or refuses to comply with the provisions of these regulations 11 b. Fails to provide data to the trauma registry in a timely, complete and accurate fashion c. Makes a false statement of a material fact about facility capabilities or other pertinent circumstances in any record or in a matter under investigation for any purposes connected with this chapter d. Prevents, interferes with, or attempts to impede in any way, the work of a representative of the Department in implementing or enforcing these regulations or the statute e. Falsely advertises or in any way misrepresents the facility's ability to care for trauma patients based on its designation status f. Is substantially out of compliance with these regulations and has not rectified such noncompliance g. Fails to provide reports required by the registry or the state in a timely and complete fashion C. Procedures for Revocation or Denial 1. Procedures for revocation or denial of designation or redesignation are as follows: a. The Department will notify a facility in writing of such an action, incorporating its reasons for the action and the facility's rights on appeal. b. The facility shall be given 10 days from receipt of the notice of the action to submit a written plan of correction to the Department for consideration. c. The Department shall approve or disapprove the plan within 10 days from the date of receipt of that plan. d. If the corrective action plan is approved by the Department the facility shall implement the changes within 20 days of receipt of the Department's approval. e. Upon satisfactory evidence of correction,the Department shall either dismiss its action,designate the facility or reinstate the previous designation. Satisfactory evidence may include an on-site review, documentation as requested or other factors. f. If a facility chooses not to pursue the corrective plan of action, it may surrender its designation and sign a non-designation agreement,or it may appeal the denial or revocation in accordance with section. I.B.9. above. 12 9g/R `-/ NOTES All physicians surveying for designation purposes must be certified by the American Board of Medical Specialties,and associated with a trauma center at or above the level for which they are surveying. All surveyors completing site reviews must have work experience at the level for which they are surveying,and must be currently active in trauma care at that level or above. Team members chosen for site review must not have acted previously as a consultant to the facility currently under review. 2 An example of a special circumstance criteria would be as follows: If a Level III facility is unable because of geographic location to provide 24 hour in-house emergency medicine coverage,it will guarantee and demonstrate 100%compliance with the following: a.) A physician will be present at the time of arrival of trauma patients arriving by ambulance; b.) A registered nurse with TNCC and ACLS certification will be present in the ED 24 hours a day; c.) Physicians will respond to the ED within 10 minutes of when a trauma patient arrives unannounced,and must live within 10 minutes of the hospital if covering the ED; d) The facility has an average annual census in the emergency department of< 10,000 patients,and experiences significant cyclical variation in census during the year,such as the monthly census is <15 ED patients/day at least 3 months per year;and the community in which the facility resides experiences>400,000 skier days/year; 3 The intent of the"alternative pathway"criteria is to allow non-urban or non-suburban Level III facilities to seek and maintain Level III designation when it is impossible or improbable for them to hire only board certified emergency medicine physicians for their ED. 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PEDIATRIC TRAUMA FACILITY DESIGNATION CRITERIA REGIONAL PEDIATRIC TRAUMA CATEGORY TRAUMA CENTER WITH PEDIATRIC CENTER COMMITMENT (Must meet all Level I criteria) _ (Must meet Level I or II criteria) children's hospital Hospital general hospital with an organized pediatric service pediatric emergency department with Emergency pediatric capabilities in an emergency appropriate personnel, equipment, and Department department equipped and staffed by facilities personnel trained to care for pediatric trauma victims pediatric ICU with pediatric surgery and ICU ICU with personnel and equipment other surgical, medical, and nursing appropriate for care of the injured child; personnel and equipment needed to care for pediatric intensivist or board certified the injured child' pediatric surgeon pediatric trauma service organized and run Trauma Service pediatric trauma program administered by a by a pediatric surgeon surgeon2 1. Pediatric Surgeon' 1. Pediatric Surgeon 2. Pediatric Orthopedist 2. General Surgeon 3. Pediatric Neurosurgeon 3. Orthopaedics 4. Pediatric Anesthesiologist 4. Neurosurgeon 5. Pediatric Intensivist 5. Pediatric Intensivist or board certified 6. Pediatric Emergency Physicians pediatric surgeon 7. Pediatric Radiologists 6. Emergency Physician 8. Other Pediatric Surgical Specialists 7. Radiologists 9. Other Medical Pediatric Specialists 8. Trauma Coordinator 10. Pediatric Trauma Coordinator 9. Pediatric-trained Trauma Nurses 11. Pediatric Trauma Nurse E Pediatric Trauma E Quality Improvement E Psychosocial Services E E Rehabilitation D3 NOTES: E =essential D = desirable ' A pediatric surgeon credentialed in trauma care a dl be promptly available. This responsible pediatric surgeon will be present in the operating room for any and all operative procedures A general surgical resident at a minimum PGY4 level may initiate resuscitative care until the attending pediatric surgeon arrives. 2 The trauma surgeon available for pediatric trauma care must have special interest in and commitment to care of the injured child. This should be demonstrated by documented CME. s If formal pediatric rehabilitation services are not available, transfer agreement with appropriate facility must be in evidence. *Pediatric subspecialists defined as boarded in the appropriate pediatric subspecialty or if sub-boards are not available, then the majority of the subspecialists' practice shall be in patients < 12 years old. 30 9p )�`7 w w w w w w o w uw w o ! c E _cx & a) O O — ` ° A �4x^at� .n .'30 1A°.� a3 0 T W eh A y: ;" ca N (0 W ,,.:5�..:z. a) u) C 0W . . . w u) .- 'c c = F E ° c c am c-4 F C C � y U Cm) c c L w a F. 2 >- a) a CON 1- - v • F a ° .- ° as a) 3 J < w E m y O U c n M '•' '61&q`�,'A D L. a3 ¢▪ W } at' 0 3 w C U N j s _ ` O U 0 m ¢ m w C U rn c to O z a u, .� c Er) a) a) °a ¢ a ui 1 n ° o N c ° It h �, o a) E O J « V ` N c) as 4) J C c N O T U c a O O a) 03 L E a �` C X O Uosr .. -c O �_ O W .. O a) )n E a) `O ja U U O m O IOWli E E O H w N N E cTo a) >` O c) 2 U O . 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Q a \ o tN r 0PO ( § / k 2 2 \\ k ] c \ \ \ 1.4 w / # ) ctiw / >. \ / f ] 2 { § & ; § • [ c J \ § , k > j Cl" s ƒ o § \ / f [ o f I Cl)v k ® ) & ) 2 ] en t 0 0 ( 0 a - k k 0 \ \ ] k ) $ 5) / \ c f a wi \z ' » CO co 15 g b o o k ƒ o z o o = § c I j } ƒ i .? o / al a s -6 a 6 a = z . k a e a a) • Is 5 r w y. /6g1 COLORADO STATEWIDE TRAUMA SYSTEM RULES AND REGULATIONS - CHAPTER 3 SPECIALTY FACILITY CRITERIA 306. BURN CENTER CONSULTATION AND TRANSFER CRITERIA nvanspReaasessempantworeawformansrairovern arataSISavvriwassimedswateS MISS Second and third degree bums> 10%body surface area Consultation with the attending burn surgeon at a (TBSA) in patients< 10 or> 50 years old specialty burn facility is required in order to evaluate and consider appropriateness of transfer of adult and pediatric Second and third degree burns > 20% TBSA in other bum patients. The attending physician at the age groups nonspecialty center must initiate the consultation. Second and third degree bums with serious threat of functional or cosmetic impairment to face, hands,feet, genitalia,perineum, and major joints Third degree burns> 5%TBSA in any age group High voltage electrical bums including lightning injury Chemical bums with serious threat of functional or cosmetic impairment Inhalation injury with burn injury Circumferential bums of the extremity and chest Burn injury in patients with pre-existing medical disorders which could complicate management,prolong recovery,or affect mortality itiperalifistipepeisiniter<aky "." V. 110 Any burn patient with concomitant trauma(for When a patient with both a severe burn and nonburn example fractures)in which the bum injury poses the trauma injury is admitted to a facility without burn greatest risk of morbidity or mortality, speciality designation,consultation about treatment and transfer issues is required. Such consultation shall be initiated by the attending physician at the nonspecialty facility to the attending burn surgeon at a facility with specialty bum designation. 3 3 9E/gOV • Hello