The FAQ for Resources for Optimal Care of the Injured Patient: 2006 will be a working document to provide the most up-to-date interpretation or refinement of criteria. Please refer to the FAQ regularly as we will update it as needed. Dates for each change will be provided in the right-hand column.
| Chapter |
Level |
CD Number |
CD |
FAQ |
Date Updated |
| 1 |
I,II,III |
1.1 |
There is insufficient involvement by the hospital trauma program staff in state/regional trauma system planning, development, and/or operation. |
Some examples are (but not limited to): State trauma planning committees or commissions, EMS bureaus, State COT, local EMS rule-making bodies. |
5/22/2007 |
| 2 |
I |
2.3 |
The Level I Trauma Center does not meet admission volume performance requirements. |
A trauma admission includes injured patients who are either: an inpatient admission or a 23-hour observation status, regardless of the location of care.
Determination of volume of admissions per year for a Level I Trauma Center based on Injury Severity Score (ISS) of more than 15, includes either a total of 240 admissions with an ISS>15 or an average of 35 patients with an ISS>15 for the "core" trauma surgeons on the trauma call panel.
The following type of patients should not be included in the number of admissions: patients with an isolated hip fracture secondary to a same level fall from standing, drowning and near drowning, poisoning, foreign bodies, suffocation injuries, and DOAs.
|
10/8/2007 |
| 2 |
I,II,III |
2.7 |
The 80 percent compliance of the surgeon's presence in the emergency department is not confirmed or monitored by PIPS (15 minutes for Level I and II; 30 minutes for Level III).
Demonstration of the attending surgeon's prompt arrival for patients with appropriate activation criteria must be monitored by the hospital's trauma PIPS program.
|
The response times are for compliance with the hospital's criteria for the highest level of activation. The highest level of activation must include the COT's minimum requirements (refer to 6.7). |
10/8/2007 |
| 2 |
I,II,III |
2.14 |
Trauma surgeons in adult trauma centers that treat more than 100 injured children annually are not credentialed for pediatric trauma care by the hospital's credentialing body. |
Credentialing is to be determined by the hospital. Suggestions/possibilities of credentialing qualifications could be (but are not limited to) the following:
1) Completion of pediatric fellowship;
2) Pediatric Advanced Life Support completion; or
3) Involvement in the care of a significant number (ie, 90) of injured children over the last three years.
|
5/22/2007 |
| 4 |
I,II,III |
|
The facility exceeds the maximum divert time. |
The maximum amount of time a hospital can be on divert
is five percent. |
5/22/2007 |
| 5 |
I,II,III |
5.11 |
Programs that admit more than 10 percent of injured patients to nonsurgical services do not demonstrate the appropriateness of that practice through the PIPS process. |
Surgical services include: general surgery, neurosurgery, orthopaedics, urology, plastics, ENT, ophthalmology, burns, vascular, surgical critical care, pediatric surgery, trauma, and emergency general surgery.
The appropriateness of admitting more than 10 percent of injured patients to nonsurgical services must be demonstrated by criteria, such as:
1) The number of patients that had a trauma consult;
2) The number of patients with other surgical service consults;
3) The number due to same height falls;
4) The number of drownings, poisonings, or hangings;
5) ISS less than or equal to 4 and do not meet the criteria in
#s three and four;
and
6) Identification of which patients should not have been admitted to nonsurgical service and documentation of the reason, follow-up, and loop closure.
|
10/8/2007 |
| 6 |
I,II,III |
6.7 |
The criteria for the highest level of activations are not clearly defined and evaluated by the PIPS program. |
The following are the COT's minimally acceptable criteria for the highest level of activation. These six criteria must be included with a hospital's criteria for highest level of activation. Additional institutional criteria may also be included.
1) Confirmed blood pressure <90 at any time in adults and age-specific hypotension in children;
2) Gunshot wounds to the neck, chest, or abdomen;
3) GCS <8 with mechanism attributed to trauma;
4) Transfer patients from other hospitals receiving blood to maintain vital signs;
5) a. Intubated patients transferred from the scene, OR
b. Patients with respiratory compromise or obstruction
- Includes intubated patients who are transferred from another facility, with ongoing respiratory compromise (does not include patients intubated at another facility who are now stable from a respiratory standpoint;
6) Emergency physician's discretion.
|
10/8/2007 |
| 6 |
I,II |
6.13 |
Other trauma surgeons who take trauma call do not have the documented 16 hours annually or 48 hours in three years of trauma-related CME or an internal educational process conducted by the trauma program based on the principles of practice-based learning and the PIPS program. |
Internal CME may count towards CME requirements for the other members of the trauma surgeon call panel. Examples of internal CME include the following: In-service, educational conference, grand rounds, internal trauma symposium, in-house publication disseminating information gained from a local conference, or an individual's recent participation (through trained analysis) in the review of a trauma center.
The Internal Educational Process (IEP) may be used for the trauma surgeons in place of the required 16 trauma-related CME hours per year on average. The IEP should include presentations/discussions on a quarterly basis, ideally related to issues identified in the PIPS process, with either the TMD, or designee, providing the leadership of this educational process for the physicians in the department. These presentations should be documented in the PI process.
CME will be prorated for surgeons new to the trauma service or new liaisons. If a surgeon has been taking trauma call for one year, he or she must have 1/3 CME. CME will be prorated for a hospital seeking ACS verification for the first time; it will not be prorated because of the publication of updated versions of the Resources for Optimal Care of the Injured Patientdocument.
|
5/22/2007 |
| 6 |
I,II |
6.14 |
The trauma medical director is not a member of and does not participate in regional or national trauma organizations. |
For a Level I Trauma medical director, national organizations include: EAST, AAST, COT, WTA, and Regional Committees on Trauma (including past and present region chiefs, State Chair and Vice-Chair, Provincial, or International Chairs). This does NOT include members of the state COT, other than State Chairs and Vice-Chairs.
For a Level II trauma medical director national organizations include: EAST, AAST, COT, WTA, and Regional Committees on Trauma (including past and present region chiefs, State Chair and Vice-Chair, provincial, or international chairs). A Level II Trauma medical director may also be an active participant in the state COT.
APSA for pediatric trauma medical directors does not meet this requirement.
|
10/8/2007 |
| 7 |
I,II,III |
7.1 |
The emergency department does not have a designated emergency physician director supported by an appropriate number of additional physicians to ensure immediate care for injured patients. |
The designated emergency physician director duties may be fulfilled by a surgeon who is in charge of the surgical side of the ED. |
5/22/2007 |
| 7 |
I,II |
7.13 |
Other emergency physicians who take trauma call do not have the documented 16 hours annually or 48 hours in three years of trauma-related CME and do not participate in an internal educational process conducted by the trauma program based on the principles of practice-based learning and the PIPS program. |
Internal CME may count towards CME requirements for the other members of the trauma surgeon call panel. Examples of internal CME include the following: In-service, educational conference, grand rounds, internal trauma symposium, in-house publication disseminating information gained from a local conference, or an individual's recent participation (through trained analysis) in the review of a trauma center.
The Internal Educational Process (IEP) may be used for the trauma surgeons in place of the required 16 trauma-related CME hours per year on average. The IEP should include presentations/discussions on a quarterly basis, ideally related to issues identified in the PIPS process, with either the TMD, or designee, providing the leadership of this educational process for the physicians in the department. These presentations should be documented in the PI process.
CME will be prorated for surgeons new to the trauma service or new liaisons. If a surgeon has been taking trauma call for one year, he or she must have 1/3 CME. CME will be prorated for a hospital seeking
ACS verification for the first time; it will not be prorated because of the publication of updated versions of the Resources for Optimal Care of the Injured Patient document.
|
5/22/2007 |
| 8 |
I,II |
8.2 |
Neurotrauma care is not promptly and continuously available for severe traumatic brain injury and spinal cord injury and for less severe head and spine injuries when necessary. |
It is acceptable, but not required, for an institution to credential both neuro and ortho to treat spine injuries or to share spine call. |
5/22/2007 |
| 8 |
I,II |
8.14 |
Other neurosurgeons who take trauma call do not have the documented 16 hours annually or 48 hours in three years of verifiable, external trauma-related CME and do not participate in an internal educational process conducted by the trauma program based on the principles of practice-based learning and the PIPS program. |
Internal CME may count towards CME requirements for the other members of the trauma surgeon call panel. Examples of internal CME include the following: In-service, educational conference, grand rounds, internal trauma symposium, in-house publication disseminating information gained from a local conference, or an individual's recent participation (through trained analysis) in the review of a trauma center.
The Internal Educational Process (IEP) may be used for the trauma surgeons in place of the required 16 trauma-related CME hours per year on average. The IEP should include presentations/discussions on a quarterly basis, ideally related to issues identified in the PIPS process, with either the TMD, or designee, providing the leadership of this educational process for the physicians in the department. These presentations should be documented in the PI process.
CME will be prorated for surgeons new to the trauma service or new liaisons. If a surgeon has been taking trauma call for one year, he or she must have 1/3 CME. CME will be prorated for a hospital seeking ACS verification for the first time; it will not be prorated because of the publication of updated versions of the Resources for Optimal Care of the Injured Patient document.
|
5/22/2007 |
| 9 |
I,II |
9.7 |
An orthopaedic team member is not promptly available in the trauma resuscitation area when consulted by the surgical trauma team leader for patients with multiple injuries. |
Promptly available: Within thirty minutes of being consulted. Documentation of response times are not required, but the program needs to assure that documentation is possible and the chart review should confirm the response times. |
10/8/2007 |
| 9 |
I,II |
9.9 |
Level I and II Centers do not provide sufficient resources, including instruments, equipment, and personnel, for modern musculoskeletal trauma care, with readily available operating rooms for musculoskeletal trauma procedures. |
Best method for providing a readily available OR is to have a designated orthopaedic fracture room that can be posted the night before. It is acceptable to document sufficient, available unblocked OR time to accommodate these fractures. |
5/22/2007 |
| 9 |
I,II,III |
9.15 |
The orthopaedic surgeon does not have privileges in general orthopaedic surgery. |
It is not acceptable for ortho coverage to be provided by surgeons who are not on the staff and credentialed by the hospital to provide general acute hospital coverage. |
5/22/2007 |
| 9 |
I,II |
9.17 |
The orthopaedic trauma team member does not have documentation of the acquisition of 16 hours of CME per year on average and has not participated in an internal educational process conducted by the trauma program and the orthopaedic liaison based on the principles of practice-based learning and the PIPS program. |
Internal CME may count towards CME requirements for the other members of the trauma surgeon call panel. Examples of internal CME include the following: In-service, educational conference, grand rounds, internal trauma symposium, in-house publication disseminating information gained from a local conference, or an individual's recent participation (through trained analysis) in the review of a trauma center.
The Internal Educational Process (IEP) may be used for the trauma surgeons in place of the required 16 trauma-related CME hours per year on average. The IEP should include presentations/discussions on a quarterly basis, ideally related to issues identified in the PIPS process, with either the TMD, or designee, providing the leadership of this educational process for the physicians in the department. These presentations should be documented in the PI process.
CME will be prorated for surgeons new to the trauma service or new
liaisons. If a surgeon has been taking trauma call for one year, he or she must have 1/3 CME. CME will be prorated for a hospital seeking ACS verification for the first time; it will not be prorated because of the publication of updated versions of the Resources for Optimal Care of the Injured Patient document.
|
5/22/2007 |
| 10 |
PTC I,II |
10.2-3 |
A Level I pediatric trauma center does not annually admit 200 or more injured children younger than 15 years of age.
A Level II pediatric trauma center does not annually admit 100 or more injured children younger than 15 years of age.
|
A pediatric admission is defined as a child less than 15 years of age who has either inpatient admission or 23-hour observation status, regardless of the location of care. The following type of patients should not be included in the number of admissions: patients with an isolated hip fracture secondary to a same level fall from standing, drowning and near drowning, poisoning, foreign bodies, suffocation injuries, and DOAs. |
10/8/2007 |
| 10 |
PTC I,II |
10.4 |
A pediatric trauma center does not have a pediatric trauma program manager or coordinator. |
It is acceptable to have the pediatric TPM report to the overseeing TPM in a facility that treats both adults and children. Within the pediatric service the pediatric TPM may be responsible for the pediatric PIPS program, pediatric prevention, pediatric research, pediatric surgery service, and other programs within pediatrics. The pediatric TPM must be dedicated to the pediatric trauma program in a Level I Pediatric Trauma Center and should be dedicated to the pediatric trauma program in a Level II Pediatric Trauma Center.
The pediatric injury prevention coordinator, like in adult centers (18.2) can be the TPM, as long as there is adequate time.
|
5/22/2007 |
| |
PTC I,II |
10.5 |
A pediatric trauma center does not have a pediatric trauma registrar. |
The pediatric trauma registrar should be dedicated to the trauma program, and not also to hospital medical records. If there are multiple trauma registrars a single registrar needs to be responsible for the pediatric data. If this is not a full-time position then the pediatric registrar may also work as a trauma registrar for adult data. |
10/8/2007 |
| 10 |
PTC I,II |
10.8 |
A pediatric trauma center does not have all of the following programs: pediatric rehabilitation; child life and family support programs; pediatric social work and child protective services; pediatric injury prevention and community outreach programs; and pediatric trauma education programs. |
This does not imply a specific FTE per program. A pediatric trauma center may have less or more than 1 FTE per program. |
5/22/2007 |
| 10 |
PTC I |
10.9 |
A pediatric trauma center does not have identifiable pediatric trauma research. |
For a pediatric trauma center within a general hospital, the 20-paper total can come from both centers. Adult-based trauma research is acceptable; however, there must also be some research that is pediatric.
Stand-alone pediatric trauma centers may also use adult-based trauma research.
Trauma centers undergoing ACS Level I Pediatric Trauma Center verification for the first time may prorate their research.
|
5/22/2007 |
| |
PTC I |
10.10 |
A Level I Pediatric Trauma Center does not have at least two surgeons, board certified or board eligible in pediatric surgery by the American Board of Surgery. |
Pediatric surgeons who are non-boarded or board-eligible (after five years), may be included on the call panel at Level I and II Pediatric Trauma Centers if they are members of the American Pediatric Surgical Association or the Surgical Section of the American Academy of Pediatrics. |
5/22/2007 |
| |
PTC I |
10.12 |
A Level I Pediatric Trauma Center does not have at least one board certified or board eligible neurosurgeon who has had pediatric fellowship training. |
If there is not a neurosurgeon with pediatric fellowship training, there must be at least one board-certified or board-eligible neurosurgeon on staff who has demonstrated expertise and interest in the care of pediatric trauma patients. A second neurosurgeon with similar credentials (10.14) is also required. |
5/22/2007 |
| 10 |
PTC I |
10.15 |
A Level I Pediatric Trauma Center does not have at least two physicians who are board certified or board eligible in pediatric critical care medicine (pediatric or surgical). |
These physicians may be certified in medical or surgical critical care. |
5/22/2007 |
| |
PTC II |
10.19 |
A Level II Pediatric Trauma Center does not have at least one surgeon who is board certified or board eligible in pediatric surgery. |
Alternate Criteria for Non-Pediatric-Fellowship-Trained Surgeons in a Level II Pediatric Trauma Center. All of the following eight criteria must be met:
1) A letter from the chief of the medical staff indicating this critical need in the trauma program because of limited physician resources in pediatric surgery within the hospital medical staff.
2) Credentialed by the hospital to provide pediatric injury care.
3) Evidence that the alternate pediatric surgeon is currently board eligible or board certified in general surgery.
4) Documentation of current status as a provider or instructor in the Advanced Trauma Life Support® (ATLS®) program.
5) Documentation of current status as a provider or instructor in the Pediatric Advanced Life Support program.
6) Documentation that the surgeon participates in the pediatric trauma performance improvement program.
7) Documentation of membership or attendance at local, regional, and national trauma meetings during the past three years.
8) A list of at least 75 patients < 15 years of age treated by the surgeon during the past three years with accompanying Injury Severity Score and outcome data.
|
10/8/2007 |
| 10 |
PTC I,II |
10.22 |
The pediatric trauma medical director is not board certified or board eligible in general surgery. |
The pediatric TMD is board eligible or board certified in general surgery, and has a certificate of special competency in pediatric surgery. |
5/22/2007 |
| 10 |
PTC I,II |
10.24 |
There are nonpediatric-trained surgeons serving on the pediatric panel without proper qualifications: (1) not credentialed by the hospital to provide pediatric trauma care, (2) not members of the adult trauma panel, (3) the pediatric trauma medical director has not agreed to their having sufficient training and experience in pediatric trauma care, (4) their performance has not been reviewed by the pediatric PIPS program. |
Credentialing is to be determined by the hospital. Suggestions/possibilities of credentialing qualifications could be (but are not limited to) the following:
1) Completion of pediatric fellowship,
2) Pediatric Advanced Life Support completion, or
3) Involvement in the care of a significant number (ie, 90) of injured children over the last three years.
|
10/8/2007 |
| 10 |
PTC I,II |
10.25 |
Trauma surgeon attendance in the emergency department for the highest level of activations is not documented to be greater than 80 percent. |
The response times are for compliance with the hospital's criteria for the highest level of activation for pediatric trauma patients, which must include the COT's minimum requirements for the highest level of activation. The COT's criteria are listed below:
The following are the COT's minimally acceptable criteria for the highest level of activation. These six criteria must be included in each hospital's criteria for highest level of activation (additional institutional criteria may also be included in the highest level of activation.)
1) Confirmed age-specific hypotension* in children;
*(Systolic blood pressure <70+ (twice the age in years)
2) Gunshot wounds to the neck, chest, or abdomen;
3) GCS <8 with mechanism attributed to trauma;
4) Transfer patients from other hospitals receiving blood to maintain vital signs;
5) a. Intubated patients transferred from the scene, OR
b. Patients with respiratory compromise/obstruction
-Includes intubated patients who are transferred from
another facility, with ongoing respiratory compromise (does not
include patients intubated at another facility who are now stable
from a respiratory standpoint)
-Includes patients who are intubated after arrival in the ED;
6) Emergency physician's discretion.
|
5/22/2007 |
| 10 |
PTC I,II |
10.27 |
The program does not offer specialty-specific pediatric education for the specialists. |
ACS Reviewers will look for documentation of lectures or educational offerings. |
5/22/2007 |
| 10 |
A/PTC I,II |
10.29 |
All hospitals seeking verification as an adult and pediatric trauma center do not meet the criteria for the verification level sought in each type of center. |
The ACS no longer verifies centers as "Adult with Pediatric Commitment" or "Adult and Pediatric." The categories of trauma centers include: Trauma Center (formerly "Adult") Level I, II, or III, and Pediatric Trauma Center Level I or II. For institutions that wish to be verified as an adult trauma center and a pediatric trauma center, they must meet the criteria listed for both adult centers and for pediatric centers. The centers will be reviewed independently (including a pediatric surgeon reviewer) and two separate plaques will be distributed.
For Trauma Center Level I, II, or III verification combined with a Pediatric Level II verification there will only be one PRQ to complete by the hospital. The visit will occur at the same time and one report written by the reviewers. For Trauma Center Level I, II, or III verification combined with Pediatric Level I verification, two separate PRQs must be completed by the hospital, and two reports will be written by the reviewers. The visits may occur at the same time.
A hospital seeking both verification for their trauma center and pediatric trauma center will have the ability to choose different levels for each trauma center. For instance, a trauma center may wish to seek Level I verification, but also apply for verification as a Pediatric Level II Trauma Center.
Volume from the pediatric trauma center may be counted in the total volume of the trauma center if the adult center is involved in the care of pediatric patients. If the trauma surgeons are not able to treat pediatric patients, then the number of pediatric patients may not be counted as part of the volume.
|
6/28/2007 |
| 10 |
ATCTIC I,II,III |
10.30 |
Trauma surgeons in adult trauma centers that admit 100 or more injured children annually are not credentialed for pediatric trauma care by the hospital's credentialing body. |
Age limits for patient transfer/triage should be defined by local community standards (written EMS system policy). However, the VRC will use < 15 years of age for the definition of a child solely for the volume/performance criteria during the visit, if there is no community standard. |
5/22/2007 |
| 10 |
ATCTIC I,II,III |
10.32 |
The adult trauma center that admits fewer than 100 injured children annually does not review the care of injured children through the PIPS program. |
If the hospital admits any injured children they must review their pediatric admits in the PI process. |
5/22/2007 |
| 10 |
PTC I,II |
10.33 |
There is no multidisciplinary peer-review committee with participation by the trauma medical director or designee and representatives from pediatric/general surgery, orthopaedic surgery, neurosurgery, emergency medicine, critical care medicine, and anesthesia that reviews selected deaths, complications, and sentinel events to identify issues and appropriate responses. |
Note that critical care is needed for pediatric trauma centers. |
5/22/2007 |
| 10 |
PTC I,II |
10.34 |
Attendance by the required representatives to at least 50 percent of the multidisciplinary peer review meetings is not documented. |
Besides the TMD or designee, representatives must include: pediatric/general surgery, orthopaedic surgery, neurosurgery, emergency medicine, critical care medicine, and anesthesia. |
5/22/2007 |
| 11 |
I,II,III |
11.3 |
There is no anesthesiologist liaison designated to the trauma program. |
A liaison needs to be appointed who can provide the anesthesiologists' perspective on trauma patients going to the OR and express the surgeons' perspective to anesthesia; this is also important for airway issues. There are no CME requirements for the anesthesia liaison. The attendance to the PIPS could be met by a designee; however, ideally, the liaison would fulfill this. |
5/22/2007 |
| 11 |
I |
11.15 |
The operating room is not adequately staffed and immediately available. |
There must be a full operating room team in house 24/7, 365 days-a-year. There are many ways to demonstrate immediate availability of an operating room. For example:
1) designated trauma room,
2) staggered start in the morning, or
3) demonstrate there are enough operating rooms during various times of the day so that an emergency patient will have access to bump a case and that there are policies and procedures in place to bump a start case when necessary.
|
5/22/2007 |
| 11 |
II,III |
11.18 |
The operating room is not adequately staffed and readily available. |
The hospital may call people in during off hours; ideally arrival should be within 30 minutes. The hospital must demonstrate that volume is low, and that there is a call-in procedure which is public and known to the surgeons on call. An effective and common mechanism for a call-in procedure is to notify the call-in team when a Level I activation occurs. The PI data must show no delays in obtaining an operating room, and chart reviews at the time of site survey need to support that assertion. |
5/22/2007 |
| 11 |
I,II |
11.37 |
There is no in-house radiographer at Level I and II trauma centers. |
An in-house radiographer position can be fulfilled by an x-ray technician. |
5/22/2007 |
| 11 |
II,III |
11.39 |
When the CT technologist responds from outside the hospital, the PIPS program does not document the response time. |
Response time is the time that they arrive at the hospital. |
5/22/2007 |
| 11 |
I |
11.42 |
The PIPS program does not document the appropriate timeliness of the arrival of the MRI technologist. |
In a Level I Trauma Center it is essential to have MRI 24/7. There does not have to be an in-house technician; however, one must be available and the PIPS program must document and review appropriate timeliness of their arrival. This can be accomplished by maintaining a log that shows when the tech was needed, called (off hours), and arrival time. This time should not exceed two hours. There is a growing trend in developing acute spine management programs, in which case urgently available MRIs will be required and a two-hour response time may be insufficient. |
5/22/2007 |
| 11 |
I |
11.44 |
The surgical director or co-director of the ICU does not have appropriate training and experience for the role. |
The surgical director must be trained/credentialed as an ICU director, or must be a trauma surgeon with six weeks per year of trauma care, or a trauma fellowship. |
5/22/2007 |
| 11 |
I |
11.51 |
The surgical director of the ICU does not have added qualifications in surgical critical care from the American Board of Surgery and does not meet the Alternate Pathway for critical care. |
Alternate pathway for board certification includes successfully completing a trauma fellowship or documentation of active participation during the preceding 12 months in trauma patients' ICU care, ICU administration, and critical care-related CME. Once a physician has successfully completed the alternate pathway and has had an onsite review, they do not need to reapply for the alternate pathway, even if they change institutions. |
5/22/2007 |
| 11 |
I |
11.55 |
The patients in Level I facilities do not have in-house physician coverage for ICU at all times. |
A hospital must demonstrate no untoward events. In a Level I Trauma Center, we expect the physician for trauma services to be available all the time--can be a resident or in-house attending. In a busy Level II, there will be an in-house physician--trauma surgeon, hospitalist, anesthesiologist or pulmonologist--for immediate response. |
5/22/2007 |
| 11 |
II,III |
11.56 |
Coverage of emergencies in the ICU leaves the emergency department without appropriate physician coverage. |
A hospital must demonstrate no untoward events. In a Level I Trauma Center, we expect the physician for trauma services to be available all the time--can be a resident or in-house attending. In a busy Level II, there will be an in-house physician--trauma surgeon, hospitalist, anesthesiologist or pulmonologist--for immediate response. |
5/22/2007 |
| 11 |
I,II,III |
11.58 |
A qualified nurse is not available 24 hours per day to provide care during the ICU phase. |
A qualified nurse is a registered nurse who meets the hospital’s criteria to work in the ICU. |
5/22/2007 |
| 11 |
II |
11.68 |
Specialty consultations for problems related to internal, medicine, pulmonary medicine, cardiology, gastroenterology, and infectious disease are not available. |
The consultants can be from another hospital. |
5/22/2007 |
| 11 |
I,II,III |
11.76 |
The blood bank is not capable of blood typing and cross-matching. |
Platelets should be available in less than one hour at Level I and II Trauma Centers. |
5/22/2007 |
| 11 |
I,II |
11.78 |
Plate Coagulation studies, blood gases, and microbiology must be available 24 hours per day. |
Platelets should be available within one hour for Level I and II Trauma Centers. |
5/22/2007 |
| 13 |
II |
13.2 |
The PIPS process does not demonstrate the appropriate care or response by providers. |
Examples: ER coverage or the ICU, CT tech availability, surgeon response to the ICU, surgeon response to Level I activations. |
5/22/2007 |
| 15 |
I,II,III |
15.2 |
The data are not submitted to the National Trauma Data Bank (NTDB). |
All levels of trauma centers must attempt to make their data available to the NTDB. NTDB is capable of receiving data from every commercial registry vendor. If you are not submitting data to the NTDB, contact the NTDB office. |
6/20/2007 |
| 16 |
I,II,III |
16.19 |
There is no trauma multidisciplinary peer review committee with participation by the trauma medical director or designee and representatives from general surgery, orthopaedic surgery, neurosurgery, emergency medicine, and anesthesia. |
This can be accomplished by multiple meetings that encompass all the disciplines. |
5/22/2007 |
| 17 |
I |
17.4 |
The Level I Trauma Center neither provides nor participates in an ATLS® course at least annually. |
A hospital can participate in ATLS through another institution. |
5/22/2007 |
| 17 |
I |
17.5 |
The Level I Trauma Center neither provides a continuous rotation in trauma surgery for senior residents that is part of an Accreditation Council for Graduate Medical Education–accredited program in any of the following disciplines: general surgery, orthopaedic surgery, or neurosurgery; nor supports an acute care surgery fellowship consistent with the educational requirements of the American Association for the Surgery of Trauma. |
Senior level resident: equivalent to a house officer IV or above. |
5/22/2007 |
| 17 |
I,II |
17.8 |
The trauma director and the liaison representatives from neurosurgery, orthopaedic surgery and emergency medicine have not accrued an average of 16 hours annually or 48 hours in three years of external trauma-related CME. |
Examples of external CME include outside meetings, ATLS (including internal ATLS), outside lectures or outside lecturers who visit the facility, Web seminars, and etc.
If completed all of SESAP, then six hours count toward trauma-related CME.
|
5/22/2007 |
| 18 |
I |
18.3 |
The trauma center does not demonstrate the presence of prevention activities that center on priorities based on local data. |
There is an error in the Resources 2006 document on page 160. CD 18.3 only applies to Level I centers, not Level II centers. |
5/22/2007 |
| 18 |
I |
18.6 |
The trauma center does not have the capability to provide intervention or referral for patients identified as problem drinkers. |
The hospital will need to show a mechanism to identify their problem drinkers and have a plan. IE registry, check alcohol reading. |
5/22/2007 |
| 19 |
I |
19.4 |
Of the 20 articles, there is not at least one that includes authorship or co authorship by members of the general surgery trauma team and at least one each from three of six disciplines; neurosurgery, emergency medicine, orthopaedics, radiology, anesthesia, and rehabilitation. |
Papers should be in Index Medicus journals. However, if an article is not in the Index Medicus, the article can be included if the trauma program can prove that it was from a peer-reviewed journal.
A Level I trauma surgeon's research cannot be counted at another center.
For trauma centers undergoing ACS Level I verification for the first time, papers will be prorated.
|
10/7/2007 |
| 19 |
I |
19.5 |
The trauma center does not meet the alternative criteria for research: 10 peer-reviewed articles published in journals included in Index Medicus resulting from work in the trauma center with at least one authored or coauthored by members of the general surgery trauma team and at least one each from three of six disciplines (neurosurgery, emergency medicine, orthopaedics, radiology, anesthesia, and rehabilitation) AND four of seven scholarly activities as stated in Chapter 19, Trauma Research and Scholarship. |
Papers should be in Index Medicus journals. However, if an article is not in the Index Medicus, the article can be included if the trauma program can prove that it was from a peer-reviewed journal.
Leadership includes membership in trauma committees or other national organizations, such as serving as an officer, on the board of directors, serving as a chair of a subcommittee ATA, AAST, WST, and etc.
Resident papers competition papers that are not published can be counted as scholarly activity, not research.
|
10/7/2007 |
| 22 |
I,II,III |
|
Verification dates for successful reverification and verification visits. |
Upon successful completion of a verification site visit, a certificate will be sent to the hospital. Even if this is the facility's first visit or a reverification visit, the certificate will be dated from the date of the site visit and be good for three years. For instance, if the site visit occurred May 1-2, 2007 the plaque would read May 2, 2007- May 2, 2010, regardless of when the results of the visit are received by the hospital. If a one-year verification was granted then the certificate is dated from the date of the visit for one year. |
5/22/2007 |
| 22 |
I,II,III |
|
Verification dates for focus visits. |
After a successful focus visit, the certificate will be dated from the date of the initial site visit. For instance if the initial verification visit occurred May 1-2, 2007 and a subsequent focus visit occurred December 1, 2007, the certificate would be dated May 2, 2007- May 2, 2010. |
5/22/2007 |
| 22 |
I,II,III |
|
Appeal process |
If the hospital does not agree with the review process, the reviewers’ findings, or the final report, the hospital may appeal in writing to the VRC. Appeals must be signed by either the trauma medical director or appropriate hospital administrator and sent directly to the verification review program office. Any supporting information cannot include patient identifiers. The VRC may require additional documentation, a new review team may be sent for another review, or the issue may be referred to the ACS-COT Executive Committee. |
5/22/2007 |
