Effective May 1, 2007, the updated criteria for trauma center verification outlined in the Resources for Optimal Care of the Injured Patient: 2006 go into effect. In addition, the Committee on Trauma (COT) of the American College of Surgeons has made substantive changes to the outcomes of a verification site visit in order to better serve the trauma community. These changes also go into effect May 1, 2007, and are detailed below.
Previously, after completion of a verification or re-verification site visit a trauma center was either “verified” (certificate for three years) or “not verified.” One of the current missions of the Verification Review Committee (VRC) is to provide guidance and recommendations for trauma programs during the site visit process, while at the same time verifying that the essential criteria of a trauma center are in place. With this emphasis the COT has added a third category as an outcome to a verification site visit. This category is “verified” with a certificate of verification for one year. This category is further described below and in the attached outline entitled Verification Site Visit Outcomes.
One of the most significant changes is the identification of the essential requirements as Type I and Type II criteria (or deficiencies). Type I criteria must be in place at the time of the verification site visit in order to achieve verification. Type II criteria are also required, but are less urgent criteria. If three or less Type II deficiencies are present at the time of the site visit, a one year certificate of verification will be issued, during which time if the trauma center successfully corrects the deficiencies, the period of verification will be extended to three years from the date of the initial verification visit.
The format and the executive summary of the site visit report will not change. The final results of the site visit (including identification of Type I and Type II criteria or deficiencies) will be determined by the VRC. The findings will be noted in the VRC’s letter to the hospital after the report has been reviewed by the committee.
This new process will be continually evaluated and future revisions of specific criteria or requirements included in each category may be necessary.
Frank (Tres) L. Mitchell, III, MD, MHA, FACS
Chair, Verification Review Committee
| Level III |
Chapter |
Requirement by Chapter |
|
| • |
2 |
2-1 There is lack of surgical commitment to the trauma center. |
TYPE I |
| • |
2 |
2-4 The trauma director does not have the responsibility or authority for determining each general surgeon's ability to participate on the trauma panel through the trauma PIPS program and hospital policy. |
TYPE I |
| • |
2 |
2-7 The 80% 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). |
TYPE I |
| • |
2 |
2-11 The trauma panel surgeons do not respond promptly to activations, remain knowledgeable in trauma care principles whether treating locally or transferring to a center with more resources, or participate in performance review activities. |
TYPE I |
| • |
2 |
2-12 The facility does not have 24-hour emergency coverage by a physician. |
TYPE I |
| • |
5 |
5-1 The hospital does not have the commitment of the institutional governing body and the medical staff to become a trauma center. |
TYPE I |
| • |
5 |
5-4 The multidisciplinary trauma program does not continuously evaluate its processes and outcomes to ensure optimal and timely care. |
TYPE I |
| • |
5 |
5-5 The trauma medical director is neither a board-certified surgeon nor an ACS Fellow. |
TYPE I |
| • |
5 |
5-6 The trauma medical director does not participate in trauma call. |
TYPE I |
| • |
5 |
5-9 The trauma director does not have the authority to correct deficiencies in trauma care or exclude from trauma call the trauma team members who do not meet specified criteria. |
TYPE I |
| • |
5 |
5-15 The structure of the trauma program does not allow the trauma director to have oversight authority for the care of injured patients who may be admitted to individual surgeons. |
TYPE I |
| • |
5 |
5-16 There is no method to identify injured patients, monitor the provision of health care services, make periodic rounds, and hold formal and informal discussions with individual practitioners. |
TYPE I |
| • |
5 |
5-18 There is no multidisciplinary peer review committee chaired by the trauma medical director or designee, with representatives from appropriate subspecialty services. |
TYPE I |
| • |
5 |
5-23 There is no Trauma Program Operational Process Performance Improvement Committee. |
TYPE I |
| • |
6 |
6-6 An attendance threshold of 80% is not met for trauma surgeon presence in the emergency department. |
TYPE I |
| • |
6 |
6-9 There is not a multidisciplinary peer review committee with participation from general surgery, orthopaedic surgery, neurosurgery, emergency medicine, and anesthesia. |
TYPE I |
| • |
7 |
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. |
TYPE I |
| • |
8 |
8-7 There is no performance improvement program that convincingly demonstrates appropriate care in the facility that treats neurotrauma patients. |
TYPE I |
| • |
9 |
9-2 Operating rooms are not promptly available to allow for emergency operations on musculoskeletal injuries, such as open fracture debridement and stabilization and compartment decompression. |
TYPE I |
| • |
9 |
9-4 There is no orthopaedic surgeon who is identified as the liaison to the trauma program. |
TYPE I |
| • |
9 |
9-5 Plastic surgery, hand surgery, and spinal injury care capabilities are not present at Level I trauma centers. |
TYPE I |
| • |
11 |
11-1 Anesthesiology services are not promptly available for emergency operations. |
TYPE I |
| • |
11 |
11-2 Anesthesiology services are not promptly available for airway problems. |
TYPE I |
| • |
11 |
11-3 There is no anesthesiologist liaison designated to the trauma program. |
TYPE I |
| • |
11 |
11-7 Anesthesia services are not available 24 hours a day and present for all operations. |
TYPE I |
| • |
11 |
11-12 The anesthesia liaison has not been identified. |
TYPE I |
| • |
11 |
11-18 The operating room is not adequately staffed and readily available. |
TYPE I |
| • |
11 |
11-20 The operating room does not have the essential equipment. |
TYPE I |
| • |
11 |
11-24 The PACU does not have qualified nurses available 24 hours per day as needed during the patient's postanesthesia recovery phase. |
TYPE I |
| • |
11 |
11-26 The PACU does not have the necessary equipment to monitor and resuscitate patients. |
TYPE I |
| • |
11 |
11-28 Radiologists are not promptly available, in person or by teleradiology, when requested, for the interpretation of radiographs, performance of complex imaging studies, or interventional procedures. |
TYPE I |
| • |
11 |
11-36 Conventional radiography and CT are not available in all trauma centers 24 hours per day. |
TYPE I |
| • |
11 |
11-49 When the patient is critically ill, there is no mechanism in place to provide prompt availability of ICU physician coverage 24 hours per day. |
TYPE I |
| • |
11 |
11-53 The trauma service does not retain responsibility for patients and coordinate all therapeutic decisions appropriate for its level. |
TYPE I |
| • |
11 |
11-54 The trauma surgeon is not kept informed of and does not concur with major therapeutic and management decisions made by the ICU team. |
TYPE I |
| • |
11 |
11-58 A qualified nurse is not available 24 hours per day to provide care during the ICU phase. |
TYPE I |
| • |
11 |
11-60 The ICU does not have the necessary equipment to monitor and resuscitate patients. |
TYPE I |
| • |
11 |
11-65 The Level III center does not have the availability of orthopaedic surgery. |
TYPE I |
| • |
11 |
11-71 There is not a respiratory therapist available and on call 24 hours per day. |
TYPE I |
| • |
11 |
11-75 Laboratory services are not available 24 hours per day for the standard analyses of blood, urine, and other body fluids, including microsampling when appropriate. |
TYPE I |
| • |
11 |
11-76 The blood bank is not capable of blood typing and cross-matching. |
TYPE I |
| • |
11 |
11-77 The blood bank does not have an adequate amount of red blood cells, fresh frozen plasma, platelets, cryoprecipitate, or appropriate coagulation factors to meet the needs of injured patients. |
TYPE I |
| • |
11 |
11-78 The capability for coagulation studies, blood gases, and microbiology is not present. |
TYPE I |
| • |
11 |
11-8 In trauma centers without in-house anesthesia services, no protocols are in place to ensure the timely arrival at the bedside of the anesthesia provider. |
TYPE I |
| • |
11 |
11-9 In a center without anesthesia services, there is no documentation of the presence of physicians skilled in emergency airway management. |
TYPE I |
| • |
12 |
12-2 The hospital has no physical therapy services. |
TYPE I |
| • |
15 |
15-1 Trauma registry data are not collected and analyzed. |
TYPE I |
| • |
16 |
16-1 The trauma center does not demonstrate a clearly defined PIPS program for the trauma; population. |
TYPE I |
| • |
16 |
16-2 The PIPS program is not supported by a reliable method of data collection that consistently gathers valid and objective information necessary to identify opportunities for improvement. |
TYPE I |
| • |
16 |
16-5 The process of analysis does not occur at regular intervals to meet the needs of the program. |
TYPE I |
| • |
16 |
16-6 The results of analysis do not define corrective strategies. |
TYPE I |
| • |
16 |
16-7 The results of analysis and corrective strategies are not documented. |
TYPE I |
| • |
16 |
16-8 The trauma program is not empowered to address issues that involve multiple disciplines. |
TYPE I |
| • |
16 |
16-9 The trauma program has neither adequate administrative support nor defined lines of authority that ensure comprehensive evaluation of all aspects of trauma care. |
TYPE I |
| • |
16 |
16-10 The trauma program does not have a medical director with the authority and administrative support to lead the program. |
TYPE I |
| • |
16 |
16-11 The trauma medical director does not have sufficient authority to set the qualifications for the trauma service members. |
TYPE I |
| • |
16 |
16-12 The trauma director does not have the authority to recommend changes for the trauma panel based on performance review. |
TYPE I |
| • |
16 |
16-13 Identified problem trends do not undergo multidisciplinary peer review by the Trauma Peer Review Committee. |
TYPE I |
| • |
16 |
16-14 The trauma center is not able to separately identify the trauma patient population for review. |
TYPE I |
| • |
16 |
16-15 There is no process to address trauma program operational issues. |
TYPE I |
| • |
16 |
16-16 There is no documentation reflecting the review of operational issues and, when appropriate, the analysis and proposed corrective actions. |
TYPE I |
| • |
16 |
16-17 The process does not identify problems. |
TYPE I |
| • |
16 |
16-18 The process does not demonstrate problem resolution (loop closure). |
TYPE I |
| • |
16 |
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. |
TYPE I |
| • |
16 |
16-25 Deaths are not systematically categorized as preventable, nonpreventable, or potentially preventable. |
TYPE I |
| • |
16 |
16-26 When a consistent problem or inappropriate variation is identified, corrective actions are not taken and documented. |
TYPE I |
| • |
6 |
6-1 The trauma medical director lacks responsibility and authority to ensure compliance with verification requirements. |
TYPE I |
| • |
11 |
11-46 The trauma surgeon does not remain in charge of patients in the ICU. |
TYPE I |
