Section .0900 – Trauma Center Standards And Approval

Link to law: http://reports.oah.state.nc.us/ncac/title 10a - health and human services/chapter 13 - nc medical care commission/subchapter p/10a ncac 13p .0901.html
Published: 2015

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SECTION .0900 – TRAUMA CENTER STANDARDS AND APPROVAL

 

10A NCAC 13P .0901        LEVEL I TRAUMA CENTER CRITERIA

To receive designation as a Level I Trauma Center, a

hospital shall have the following:

(1)           A trauma program and a trauma service that have

been operational for at least 12 months prior to application for designation;

(2)           Membership in and inclusion of all trauma patient

records in the North Carolina Trauma Registry for at least 12 months prior to

submitting a Request for Proposal;

(3)           A trauma medical director who is a board-certified

general surgeon. The trauma medical director must:

(a)           Have a minimum of three years clinical

experience on a trauma service or trauma fellowship training;

(b)           Serve on the center's trauma service;

(c)           Participate in providing care to patients

with life-threatening or urgent injuries;

(d)           Participate in the North Carolina Chapter of

the ACS Committee on Trauma as well as other regional and national trauma

organizations;

(e)           Remain a provider in the ACS' ATLS Course

and in the provision of trauma-related instruction to other health care

personnel; and

(f)            Be involved with trauma research and the

publication of results and presentations;

(4)           A full-time TNC/TPM who is a registered nurse,

licensed by the North Carolina Board of Nursing;

(5)           A full-time TR who has a working knowledge of

medical terminology, is able to operate a personal computer, and has the

ability to extract data from the medical record;

(6)           A hospital department/division/section for general

surgery, neurological surgery, emergency medicine, anesthesiology, and

orthopaedic surgery, with designated chair or physician liaison to the trauma

program for each;

(7)           Clinical capabilities in general surgery with

separate posted call schedules. One shall be for trauma, one for general surgery

and one back-up call schedule for trauma.  In those instances where a physician

may simultaneously be listed on more than one schedule, there must be a defined

back-up surgeon listed on the schedule to allow the trauma surgeon to provide

care for the trauma patient.  If a trauma surgeon is simultaneously on call at

more than one hospital, there shall be a defined, posted trauma surgery back-up

call schedule composed of surgeons credentialed to serve on the trauma panel;

(8)           A trauma team to provide evaluation and treatment

of a trauma patient 24 hours per day that includes:

(a)           An in-house trauma attending or PGY4 or

senior general surgical resident. The trauma attending participates in

therapeutic decisions and is present at all operative procedures.

(b)           An emergency physician who is present in the

Emergency Department 24 hours per day who is either board-certified or prepared

in emergency medicine (by the American Board of Emergency Medicine or the

American Osteopathic Board of Emergency Medicine). Emergency physicians caring

only for pediatric patients may, as an alternative, be boarded or prepared in

pediatric emergency medicine. Emergency physicians must be board-certified within

five years after successful completion of a residency in emergency medicine and

serve as a designated member of the trauma team to ensure immediate care for

the injured patient until the arrival of the trauma surgeon;

(c)           Neurosurgery specialists who are never

simultaneously on-call at another Level II or higher trauma center, who are

promptly available, if requested by the trauma team leader, unless there is

either an in-house attending neurosurgeon, a PGY2 or higher in-house

neurosurgery resident or an in-house trauma surgeon or emergency physician as

long as the institution can document management guidelines and annual

continuing medical education for neurosurgical emergencies. There must be a

specified back-up on the call schedule whenever the neurosurgeon is

simultaneously on-call at a hospital other than the trauma center;

(d)           Orthopaedic surgery specialists who are

never simultaneously on-call at another Level II or higher trauma center, who

are promptly available, if requested by the trauma team leader, unless there is

either an in-house attending orthopaedic surgeon, a PGY2 or higher in-house

orthopaedic surgery resident or an in-house trauma surgeon or emergency

physician as long as the institution can document management guidelines and

annual continuing medical education for orthopaedic emergencies. There must be

a specified written back-up on the call schedule whenever the orthopaedist is

simultaneously on-call at a hospital other than the trauma center;

(e)           An in-house anesthesiologist or a CA3 resident

as long as an anesthesiologist on-call is advised and promptly available if

requested by the trauma team leader; and

(f)            Registered nursing personnel trained in the

care of trauma patients;

(9)           A written credentialing process established by the

Department of Surgery to approve mid-level practitioners and attending general

surgeons covering the trauma service. The surgeons must have board

certification in general surgery within five years of completing residency;

(10)         Neurosurgeons and orthopaedists serving the trauma

service who are board certified or eligible.  Those who are eligible must be

board certified within five years after successful completion of the residency;

(11)         Written protocols relating to trauma management

formulated and updated to remain current;

(12)         Criteria to ensure team activation prior to arrival,

and trauma attending arrival within 15 minutes of the arrival of trauma and

burn patients that include the following conditions:

(a)           Shock;

(b)           Respiratory distress;

(c)           Airway compromise;

(d)           Unresponsiveness (GSC less than nine) with

potential for multiple injuries;

(e)           Gunshot wound to neck, chest or abdomen;

(f)            Patients receiving blood to maintain vital

signs; and

(g)           ED physician's decision to activate;

(13)         Surgical evaluation, based upon the following

criteria, by the trauma attending surgeon who is promptly available:

(a)           Proximal amputations;

(b)           Burns meeting institutional transfer

criteria;

(c)           Vascular compromise;

(d)           Crush to chest or pelvis;

(e)           Two or more proximal long bone fractures;

and

(f)            Spinal cord injury.

A PGY4 or higher surgical resident, a

PGY3 or higher emergency medicine resident, a nurse practitioner or physician's

assistant, who is a member of the designated surgical response team, may

initiate the evaluation;

(14)         Surgical consults for patients with traumatic

injuries, at the request of the ED physician, will conducted by a member of the

trauma surgical team.  Criteria for the consults include:

(a)           Falls greater than 20 feet;



(b)           Pedestrian struck by motor vehicle;

(c)           Motor vehicle crash with:

(i)            Ejection (includes motorcycle);

(ii)           Rollover;

(iii)          Speed greater than 40 mph; or

(iv)          Death of another individual in the same

vehicle; and

(d)           Extremes of age, less than five or greater

than 70 years.

A senior surgical resident may initiate

the evaluation;

(15)         Clinical capabilities (promptly available if

requested by the trauma team leader, with a posted on-call schedule), that

include individuals credentialed in the following:

(a)           Cardiac surgery;

(b)           Critical care;

(c)           Hand surgery;

(d)           Microvascular/replant surgery, or if service

is not available, a transfer agreement must exist;

(e)           Neurosurgery (The neurosurgeon must be

dedicated to one hospital or a back-up call schedule must be available. If

fewer than 25 emergency neurosurgical trauma operations are done in a year, and

the neurosurgeon is dedicated only to that hospital, then a published back-up

call list is not necessary);

(f)            Obstetrics/gynecologic surgery;

(g)           Opthalmic surgery;

(h)           Oral maxillofacial surgery;

(i)            Orthopaedics (dedicated to one hospital or

a back-up call schedule must be available);

(j)            Pediatric surgery;

(k)           Plastic surgery;

(l)            Radiology;

(m)          Thoracic surgery; and

(n)           Urologic surgery;

(16)         An Emergency Department that has:

(a)           A designated physician director who is

board-certified or prepared in emergency medicine (by the American Board of

Emergency Medicine or the American Osteopathic Board of Emergency Medicine);

(b)           24-hour-per-day staffing by physicians

physically present in the ED such that:

(i)            At least one physician on every shift in

the ED is either board-certified or prepared in emergency medicine (by the

American Board of Emergency Medicine or the American Osteopathic Board of

Emergency Medicine) to serve as the designated member of the trauma team to

ensure immediate care until the arrival of the trauma surgeon. Emergency

physicians caring only for pediatric patients may, as an alternative, be

boarded in pediatric emergency medicine. All emergency physicians must be board-certified

within five years after successful completion of the residency;

(ii)           All remaining emergency physicians, if not

board-certified or prepared in emergency medicine as outlined in Subitem

(16)(b)(i) of this Rule, are board-certified, or eligible by the American Board

of Surgery, American Board of Family Practice, or American Board of Internal

Medicine, with each being board-certified within five years after successful

completion of a residency; and

(iii)          All emergency physicians practice emergency

medicine as their primary specialty.

(c)           Nursing personnel with experience in trauma

care who continually monitor the trauma patient from hospital arrival to

disposition to an intensive care unit, operating room, or patient care unit;

(d)           Equipment for patients of all ages to

include:

(i)            Airway control and ventilation equipment

(laryngoscopes, endotracheal tubes, bag-mask resuscitators, pocket masks, and

oxygen);

(ii)           Pulse oximetry;

(iii)          End-tidal carbon dioxide determination

equipment;

(iv)          Suction devices;

(v)           Electrocardiograph-oscilloscope-defibrillator

with internal paddles;

(vi)          Apparatus to establish central venous

pressure monitoring;

(vii)         Intravenous fluids and administration

devices that include large bore catheters and intraosseous infusion devices;

(viii)        Sterile surgical sets for airway

control/cricothyrotomy, thoracotomy, vascular access, thoracostomy, peritoneal

lavage, and central line insertion;

(ix)          Apparatus for gastric decompression;

(x)           24-hour-per-day x-ray capability;

(xi)          Two-way communication equipment for

communication with the emergency transport system;

(xii)         Skeletal traction devices, including

capability for cervical traction;

(xiii)        Arterial catheters;

(xiv)        Thermal control equipment for patients;

(xv)         Thermal control equipment for blood and

fluids;

(xvi)        A rapid infuser system;

(xvii)       A dosing reference and measurement system to

ensure appropriate age related medical care;

(xviii)      Sonography; and

(xix)        A doppler;

(17)         An operating suite that is immediately available 24

hours per day and has:

(a)           24-hour-per-day immediate availability of

in-house staffing;

(b)           Equipment for patients of all ages that

includes:

(i)            Cardiopulmonary bypass capability;

(ii)           Thermal control equipment for patients;

(iii)          Thermal control equipment for blood and

fluids;

(iv)          24-hour-per-day x-ray capability including

c-arm image intensifier;

(v)           Endoscopes and bronchoscopes;

(vi)          Craniotomy instruments;

(vii)         The capability of fixation of long-bone and

pelvic fractures; and

(viii)        A rapid infuser system;

(18)         A postanesthetic recovery room or surgical intensive

care unit that has:

(a)           24-hour-per-day in-house staffing by

registered nurses;

(b)           Equipment for patients of all ages that

includes:

(i)            The capability for resuscitation and

continuous monitoring of temperature, hemodynamics, and gas exchange;

(ii)           The capability for continuous monitoring of

intracranial pressure;

(iii)          Pulse oximetry;

(iv)          End-tidal carbon dioxide determination

capability;

(v)           Thermal control equipment for patients; and

(vi)          Thermal control equipment for blood and

fluids;

(19)         An intensive care unit for trauma patients that has:

(a)           A designated surgical director for trauma

patients;

(b)           A physician on duty in the intensive care

unit 24 hours per day or immediately available from within the hospital as long

as this physician is not the sole physician on-call for the Emergency

Department;

(c)           Ratio of one nurse per two patients on each

shift;

(d)           Equipment for patients of all ages that includes:

(i)            Airway control and ventilation equipment

(laryngoscopes, endotracheal tubes, bag-mask resuscitators, and pocket masks);

(ii)           An oxygen source with concentration

controls;

(iii)          A cardiac emergency cart;

(iv)          A temporary transvenous pacemaker;

(v)           Electrocardiograph-oscilloscope-defibrillator;

(vi)          Cardiac output monitoring capability;

(vii)         Electronic pressure monitoring capability;

(viii)        A mechanical ventilator;

(ix)          Patient weighing devices;

(x)           Pulmonary function measuring devices;

(xi)          Temperature control devices; and

(xii)         Intracranial pressure monitoring devices.

(e)           Within 30 minutes of request, the ability to

perform blood gas measurements, hematocrit level, and chest x-ray studies;

(20)         Acute hemodialysis capability;

(21)         Physician-directed burn center staffed by nursing

personnel trained in burn care or a transfer agreement with a burn center;

(22)         Acute spinal cord management capability or transfer

agreement with a hospital capable of caring for a spinal cord injured patient;

(23)         Radiological capabilities that include:

(a)           24-hour-per-day in-house radiology

technologist;

(b)           24-hour-per-day in-house computerized

tomography technologist;

(c)           Sonography;

(d)           Computed tomography;

(e)           Angiography;

(f)            Magnetic resonance imaging; and

(g)           Resuscitation equipment that includes airway

management and IV therapy;

(24)         Respiratory therapy services available in-house 24

hours per day;

(25)         24-hour-per-day clinical laboratory service that

must include:

(a)           Analysis of blood, urine, and other body

fluids, including micro-sampling when appropriate;

(b)           Blood-typing and cross-matching;

(c)           Coagulation studies;

(d)           Comprehensive blood bank or access to

community central blood bank with storage facilities;

(e)           Blood gases and pH determination; and

(f)            Microbiology;

(26)         A rehabilitation service that provides:

(a)           A staff trained in rehabilitation care of

critically injured patients;

(b)           Functional assessment and recommendations

regarding short- and long-term rehabilitation needs within one week of the

patient's admission to the hospital or as soon as hemodynamically stable;

(c)           In-house rehabilitation service or a

transfer agreement with a rehabilitation facility accredited by the Commission

on Accreditation of Rehabilitation Facilities;

(d)           Physical, occupational, speech therapies,

and social services; and

(e)           Substance abuse evaluation and counseling

capability;

(27)         A performance improvement program, as outlined in

the North Carolina Chapter of the American College of Surgeons Committee on Trauma

document "Performance Improvement Guidelines for North Carolina Trauma

Centers," incorporated by reference in accordance with G.S. 150B-21.6,

including subsequent amendments and editions.  This document is available from

the OEMS, 2707 Mail Service Center, Raleigh, North Carolina 27699-2707, at no cost.  This performance improvement program must include:

(a)           The state Trauma Registry whose data is

submitted to the OEMS at least weekly and includes all the center's trauma

patients as defined in Rule .0102(68) of this Subchapter who are either

diverted to an affiliated hospital, admitted to the trauma center for greater

than 24 hours from an ED or hospital, die in the ED, are DOA or are transferred

from the ED to the OR, ICU, or another hospital (including transfer to any

affiliated hospital);

(b)           Morbidity and mortality reviews including

all trauma deaths;

(c)           Trauma performance committee that meets at

least quarterly and includes physicians, nurses, pre-hospital personnel, and a

variety of other healthcare providers, and reviews policies, procedures, and

system issues and whose members or designee attends at least  50 percent of the

regular meetings;

(d)           Multidisciplinary peer review committee that

meets at least quarterly and includes physicians from trauma, neurosurgery,

orthopaedics, emergency medicine, anesthesiology, and other specialty

physicians, as needed, specific to the case, and the trauma nurse

coordinator/program manager and whose members or designee attends at least  50

percent of the regular meetings;

(e)           Identification of discretionary and

non-discretionary audit filters;

(f)            Documentation and review of times and

reasons for trauma-related diversion of patients from the scene or referring

hospital;

(g)           Documentation and review of response times

for trauma surgeons, neurosurgeons, anesthesiologists or airway managers, and

orthopaedists.  All must demonstrate 80 percent compliance.

(h)           Monitoring of trauma team notification

times;

(i)            Review of pre-hospital trauma care that

includes dead-on-arrivals; and

(j)            Review of times and reasons for transfer of

injured patients;

(28)         An outreach program that includes:

(a)           Transfer agreements to address the transfer

and receipt of trauma patients;

(b)           Programs for physicians within the community

and within the referral area (that include telephone and on-site consultations)

about how to access the trauma center resources and refer patients within the

system;

(c)           Development of a Regional Advisory Committee

as specified in Rule .1102 of this Subchapter;

(d)           Development of regional criteria for

coordination of trauma care;

(e)           Assessment of trauma system operations at

the regional level; and

(f)            ATLS;

(29)         A program of injury prevention and public education that

includes:

(a)           Epidemiology research that includes studies

in injury control, collaboration with other institutions on research,

monitoring progress of prevention programs, and consultation with researchers

on evaluation measures;

(b)           Surveillance methods that includes trauma

registry data, special Emergency Department and field collection projects;

(c)           Designation of a injury prevention

coordinator; and

(d)           Outreach activities, program development,

information resources, and collaboration with existing national, regional, and

state trauma programs.

(30)         A trauma research program designed to produce new

knowledge applicable to the care of injured patients that includes:

(a)           An identifiable institutional review board

process;

(b)           Educational presentations that must include

12 education/outreach presentations offered outside the trauma center over a

three-year period; and

(c)           10 peer-reviewed publications over a

three-year period that could come from any aspect of the trauma program; and

(31)         A written continuing education program for staff

physicians, nurses, allied health personnel, and community physicians that

includes:

(a)           A general surgery residency program;

(b)           20 hours of Category I or II trauma-related

continuing medical education (as approved by the Accreditation Council for

Continuing Medical Education) every two years for all attending general

surgeons on the trauma service, orthopedists, and neurosurgeons, with at least  50

percent of this being external education including conferences and meetings

outside of the trauma center.  Continuing education based on the reading of

content such as journals or other continuing medical education documents is not

considered education outside of the trauma center;

(c)           20 hours of Category I or II trauma-related

continuing medical education (as approved by the Accreditation Council for

Continuing Medical Education) every two years for all emergency physicians,

with at least 50 percent of this being external education including conferences

and meetings outside of the trauma center or visiting lecturers or speakers

from outside the trauma center.  Continuing education based on the reading of

content such as journals or other continuing medical education documents is not

considered education outside of the trauma center;

(d)           ATLS completion for general surgeons on the

trauma service and emergency physicians. Emergency physicians, if not boarded

in emergency medicine, must be current in ATLS;

(e)           20 contact hours of trauma-related

continuing education (beyond in-house in-services) every two years for the TNC/TPM;

(f)            16 hours of trauma-registry-related or

trauma-related continuing education every two years, as deemed appropriate by

the trauma nurse coordinator/program manager for the trauma registrar;

(g)           At least an 80 percent compliance rate for

16 hours of trauma-related continuing education (as approved by the TNC/TPM)every

two years related to trauma care for RN's and LPN's in transport programs,

Emergency Departments, primary intensive care units, primary trauma floors, and

other areas deemed appropriate by the TNC/TPM; and

(h)           16 hours of trauma-related continuing

education every two years for mid-level practitioners routinely caring for

trauma patients.

 

History Note:        Authority G.S. 131E-162;

Temporary Adoption Eff. January 1, 2002;

Eff. April 1, 2003;

Amended Eff. January 1, 2009; January 1, 2004.