VRC 2022 Standards Q&As

Q: Can I assume if a criterion existed in the 2014 Standards but not in the 2022 Standards, I will no longer be required to meet that 2014 criterion?

A: The 2022 Standards defines all standards required for trauma center verification by the ACS VRC program. The 2022 version should be used alone, independent from previous versions of the standards. It’s important to understand that the 2022 version organizes the standards based on the nine categories. Some criteria have moved out of their placement in the Orange Book to a new standard in the Gray Book and some criteria were absorbed into standards with broader requirements.

Q: The 2022 publication does not include standards for Level IV trauma centers. Will the Committee on Trauma (COT) provide current guidance in a separate publication for Level IV trauma centers, or should we continue to use the 2014 Standards?

A: The 2014 Resources for Optimal Care of the Injured Patient (aka, the Orange Book) contains Level IV criteria that are still relevant, current, and will continue to be used.  We have started a process to gather stakeholder input on the current Level IV standards that will form the basis of revisions. You may provide comments on Level IV standards.

Q: Do all the non-compliant standards need to be resolved at the time of the corrective action review?

A: Yes, all non-compliant standards must be compliant at the time of the corrective action review to achieve verification.

Q: Are there any credentialing requirements for advanced practice providers (APPs)?

A: The 2022 Standards does not have credentialing requirements for APPs.

Q: Do Level I Adult trauma centers that see 100 pediatric patients per year have to adhere to standards that are specific to pediatric trauma centers (e.g., CME, TMD, TPM)?

A: Standards that are specific to pediatric trauma centers only apply to ACS verified pediatric centers.

Q: In a LIII trauma center that admits closed head injury patients of mild to moderate acuity, can the center apply for Level III (not Level III-N) verification?

A: The 2022 standards define a Level III-N center as one that provides neurotrauma care to patients with moderate to severe TBI (GCS of 12 and less).  If a trauma center admits any patients with moderate to severe TBI, they must apply as Level III-N, and will be required by standard 4.10 to have board-certified or board-eligible neurosurgeons.

Q: Is a Level III-N considered a new Verification/Consultation designating category? 

A: ACS does not designate trauma centers. LIII-N is not a designating category, it’s a standards applicable level category. For example, each standard has the level it applies to: LI, LII, LIII, LIII-N, PTCI, PTCIII. The letter “N” stands for neurotrauma care. Level III trauma centers are required to report if it provides neurotrauma care to patients with moderate to severe TBI (defined as GCS of 12 or less at the time of emergency department arrival). If the trauma center provides neurotrauma care, it is categorized as LIII-N. These centers are then assigned a LIII-N PRQ that includes questions about neurotrauma. If the center does not provide neurotrauma care, centers are assigned a standard LIII PRQ (will not contain questions about neurotrauma care). In essence both types of level categories would be Level III trauma centers.

Q: Are locum tenens required to meet the same standards as the other trauma panel members?

A: For all trauma centers locums treating trauma patients must meet the same requirements as the other physicians/surgeons. This includes but is not limited to holding current board certification (refer to Appendix A in the 2022 Resources manual), attending Trauma Multidisciplinary Peer Review Committee meetings, meeting ATLS requirements, etc.

Applicable to standards: 4.1, 4.5, 4.7, 4.8, 4.10, 4.11, 7.6

Q: How to apply for the Alternate Pathway?

A: At the time of the site visit application request through QPort on the Site Visit Request form (Alternate Pathway Candidates section).

In addition, visit the "Site Profile" section of QPort, scroll down to the bottom of the screen to Additional Information and fill out alternate pathway information. Upon receipt of an alternate pathway request, VRC staff will send a list of pre-candidate requirements. All documentation must be submitted 5 months prior to site visit to determine eligibility.

Before completing the Alternate Pathway section of the PRQ, you must apply and be approved for the Alternate Pathway. Contact COTVRC@facs.org  to confirm your AP application has been approved.

Q: How to apply for the Alternate Pathway after an application has been submitted?

A: Notify the VRC office at COTVRC@facs.org to inform them of the Alternate Pathway (AP) request. 

Following notification, complete the AP request by logging into QPort, select the "Site Profile" section, scroll down to the bottom of the screen to Additional Information and fill out alternate pathway information. Upon receipt of an alternate pathway request, VRC staff will send a list of pre-candidate requirements. All documentation must be submitted 5 months prior to site visit to determine eligibility (Step 2). 

Before completing the Alternate Pathway section of the PRQ, You must apply and be approved for the Alternate Pathway.  Contact  COTVRC@facs.org  to confirm your AP application has been 

Q: Are trauma centers required to have a registered nurse (RN) serve as Trauma Program Manager (TPM)?

A: In all trauma centers, the TPM is not required to be a registered nurse.

Q: For a Level II or III trauma center, can the Trauma Program Manager (TPM) hold additional roles that are related to disaster response?

A: In a Level II or III trauma center, the TPM must spend at least half of their time (0.5 FTE) on TPM-related activities.  The remaining time must be dedicated to other trauma-related roles. 

Q: Can the trauma program manager (TPM) or the performance improvement (PI) personnel serve as the designated injury prevention professional?

A: In Level I trauma centers, the injury prevention professional must be someone other than the TPM or PI personnel. In Level II and III trauma centers, the TPM or the PI personnel may serve as the designated injury prevention professional as long as they meet the requirements stated in Standard 2.10 or Standard 4.34.

Q: Does "injury prevention activities" refer to one-time events or ongoing programs?

A: Both one-time events and ongoing programs meet the requirements in this standard.

Q: For Adult Level I and Pediatric Level I trauma centers, is it compliant with the standard to have one individual (1.0 FTE) fulfill the Injury Prevention role for both programs? 

A: This standard requires only that the center has an Injury Prevention professional on staff and does not specify the number of staff required.  However, the center should employ the number of staff needed to ensure that the program is able to fulfill the requirements of the standard, which include prioritizing injury prevention activities based on trends identified through data; implementing at least two activities that address major causes of injury in the community; and demonstrating evidence of partnerships with community groups that support injury prevention efforts. 

Q: Can Level I and Level II trauma centers use the dedicated operating room for non-orthopaedic surgical procedures?

A: In Level I and II trauma centers, the dedicated operating room must be prioritized for fracture care in nonemergent orthopaedic traumas. Operational details related to staffing, frequency of availability, and use by other services should be collaboratively determined and approved by the TMD and the orthopaedic trauma leader. The frequency of availability should be sufficient to provide timely fracture care for patients.

Q: For a Level I or II trauma center, is it compliant with the standard to have an urgent case booking policy that demonstrates that the center prioritizes orthopaedic trauma cases but not explicitly identify operating rooms dedicated to fracture care in the OR schedule?

A: Level I and II trauma centers must have a dedicated OR prioritized for fracture care in nonemergent orthopaedic trauma.  The frequency of availability should be sufficient to provide timely fracture care for patients.

 Q: If a Level I or II trauma center lacks cardiopulmonary bypass equipment, is it compliant with the standard for them to have a transfer agreement with a Level III trauma center as part of the contingency plan?

A: A transfer agreement with a Level III trauma center would meet the requirements of Standard 3.8 because the standard does not specify the level of the accepting facility. 

Q: Standard 4.5 states that the Geriatric Liaison could be a physician with expertise and a focus in geriatrics. It could also be an APP with certification/expertise and focus on geriatrics. Does the physician need a specific certification to meet this standard?

A: The standard does not require certification for a physician geriatric liaison, just expertise and a focus on geriatrics. For an APP, the standard requires certification, expertise, and a focus in geriatrics. 

Q: Is a neurosurgery published backup call schedule required?

A: A neurosurgery published backup call schedule is not required to meet this standard.

Q: Can anesthesia providers take call from home if they can respond timely within 15 minutes of request?

A: In Level I and II centers, anesthesia services are required to be available within 15 minutes of request. Providers can take call onsite or offsite. Time of request to time of response must be tracked.

Q: Does the radiologist have to interpret the patient's images within 30 minutes?

A: The radiologist must be available within 30 minutes of request to access the patient’s images for interpretation.

Q: For Level II and III trauma centers, has the option for a surgical co-director for ICU been taken off the table? Do we need to hire a board certified/eligible in surgical critical care MD?

A: In all trauma centers, the ICU surgical director, whether it is the director or co-director, must be board-certified or board-eligible in general surgery. In Level I adult trauma centers, the ICU surgical director must be board-certified or board-eligible in surgical critical care.

Q: Can the ICU clinician respond by telemedicine?

A: The ICU clinician must respond at the bedside within 15 minutes of the request at the bedside.

Q: Can the ICU provider respond by telemedicine?

A: The ICU provider must respond at the bedside within 30 minutes of the request.

Q: Can trauma centers comply with Standard 4.21 by having a contingency plan for call coverage during surgeon vacations or conference attendance, when a surgical specialist (such as hand, plastic, etc.) is not available?

A: Sporadic gaps in surgical expertise coverage can (and must) be addressed by a contingency plan. 

Q: Can the specialty surgeons respond by telemedicine?

A: The specialty surgeons must be available at the bedside.

Q: Would a trauma surgeon credentialed in Vascular Surgery by the hospital meet Standard 4.21?

A: A trauma surgeon with expertise in vascular surgery who has been credentialed by the hospital to provide acute trauma care would meet this standard.

Q: For Level I and II trauma centers, if the Ophthalmologist provides coverage 3 days per week, can a contingency plan be put in place for coverage on the other days?

A: Standard 4.22 requires continuous ophthalmologic coverage, defined as 24/7/365.

Q: Can the ophthalmologist respond by telemedicine?

A: The ophthalmologist must be available at bedside.

Q: Can psychiatry services (available seven days per week) be provided with telepsychiatry services?

A: Psychiatry services can be provided through telemedicine. While availability is required seven days per week, there is no more specific time frame required. 

Q: Can the requirement for pain management be met by having an Anesthesiologist?

A: An Anesthesiologist can meet the requirement for pain management and must have the expertise to perform regional nerve blocks.

Q: For Level I and II trauma centers, is it compliant with standard 4.28 to have social work services be available Monday through Friday?

A: The standard requires social work services be available seven days per week. However, the services can be provided remotely.

Q: Do patient entries that do not meet the NTDS Inclusion criteria count toward the annual entries?

A: As stated in the definitions and requirements section, the standard defines patient entries as all those that meet NTDS inclusion criteria, and also those that meet inclusion criteria for hospital, local, regional, and state purposes. Therefore, patients who meet your hospital’s inclusion criteria, but do not meet NTDS criteria, do count towards the FTE requirements for the standard. 

Q: Standard 4.31 says that the registrar must be dedicated to the registry.  Can this standard be met by contracting with a third party for registry services if the contract is for the required number of registrars (FTEs per entries)?

A: The standard can be met through direct or contract employment.

Q: Can a trauma program manager (TPM) who is a Certified Abbreviated Injury Scale Specialist (CAISS) meet this requirement?

A: In Level II and III trauma centers, the standard can be met by having the TPM who is CAISS certified serve as the 0.5 FTE registrar.

Q: If the hospital is using an older version of the AIS such as 2008 and the registrar(s) have taken an updated version, would they be required to take the older version?

A: If the registry staff have passed a newer version of the AIS course, such as AIS 2015, it is not expected that they take the older version the hospital is using.

Q: If new registry staff were hired during the reporting period, would they need to meet this standard?

A: Registrars hired within the Reporting Period will have 12 months from the date of hire to complete all the registry courses.

Q: Are the 24 hours of trauma-related continuing education required for both clinical and non-clinical registry staff?

A: All trauma registrars, clinical and non-clinical, are required to meet Standard 4.34.

Q: If a registrar starts at the end of the verification cycle, do they still need 24 hours of trauma-related CE?

A: For registrars hired during the verification cycle, 2 hours of trauma-related CE is required per quarter, based on the month of hire.

Q: Standard 4.34 Performance Improvement Staffing Requirements states: “When the annual volume exceeds 1,000 registry patient entries, the trauma center must have at least 1 FTE PI personnel.” Does this mean 1 FTE PI for volume more than 1,000 patient entries or 1 FTE for every 1,000? For example, if the center has 4,000 patients annually, would they need 4 FTEs?

A: When the annual volume exceeds 1,000 registry patient entries, the trauma center must have at least 1 FTE PI personnel. However, in the Additional Information section, it states that greater trauma center volumes might necessitate additional personnel. The trauma center determines PI personnel needs based on its patient volume.

Q: Is Disaster Management and Emergency Preparedness (DMEP) the only course that meets the standard?

A: The only disaster course that meets this standard is the DMEP or eDMEP course.

Q: Where can I find information on upcoming onsite or online DMEP courses?

A: An online version of the course, eDMEP, will be launched in the spring of 2023. Please check the course webpage for current offerings and updates.

Q: If a patient arrives by private vehicle and upon evaluation meets activation criteria for the highest level, when does the attending trauma surgeon’s response time start?

A: The response time starts when activation is called. These occurrences must be reviewed through the PIPS for appropriateness.

Q: If a center performed the pediatric readiness assessment in year one of their verification cycle, does this meet the requirement? 

A: The pediatric readiness assessment must be conducted once during the verification cycle.

Q: Is a pediatric readiness assessment required for a trauma center that only admits adult patients? 

A: All trauma centers, regardless of patient population, are required to perform a pediatric readiness assessment and have a plan to address identified gaps.

Q: Can a trauma center use a nurse-staffed transfer center with an auto accept process that: allows transfer center nurses to accept patients based on activation criteria; provides messages to the receiving trauma surgeon with patient specifics; and allows both the sending and receiving surgeon to request to communicate with each other?

A: In all trauma centers, when trauma patients are transferred, the transferring provider must directly communicate with the receiving provider to ensure safe transition of care. This communication may occur through a transfer center. Examples of transfer communication documentation may include call logs, emails, and patient summary reports.

Q: If a patient has a nonsurvivable head injury (i.e. GSW to head), does this patient still need to be evaluated by the neurosurgeon within 30 minutes?

A: Evaluating the patient within 30 minutes is required; it is necessary to determine whether the injury is nonsurvivable

Q: Is a neurosurgery evaluation expected to occur at bedside, or can it be done remotely?   

A: Evaluation within 30 minutes is required for the injuries specified in the standard and can be done remotely.

Q: Can a Trauma resident or APP act as the neurosurgery consultant?

A: A neurosurgery resident or neurosurgery APP may act as the consultant as long as there is documented communication with the neurosurgery attending.

Q: Is an orthopaedic surgery evaluation expected to occur at the bedside, or can it be done remotely? 

A: An orthopaedic surgeon (orthopaedic resident or orthopaedic APP) must respond at the bedside within 30 minutes of request for the injuries specified in the standard. The orthopaedic surgery resident or APP may act as the consultant as long as there is documented communication with the orthopaedic surgeon attending.

Q: For compartment syndrome associated with a compression, burn, and/or penetrating injury without fracture, is orthopaedic surgery response required? 

A: The surgical specialist(s) who can manage the compartment syndrome associated with a compression, burn, and/or penetrating injury is required to respond at bedside within 30 minutes of request.

Q: Is a trauma center expected to screen all patients for specific psychological sequelae?

A: This standard requires that the center has a protocol to screen patients at high risk for psychological sequelae with subsequent referral, and a process for referral.  The standard does not specifically require the screening of all patients, nor does it require screening for specific psychological sequelae. At minimum, the protocol should include screening for patients at high risk for PTSD.

Q: Does having a protocol to screen for suicide meet this standard? 

A: Suicide screening, such as the Columbia Suicide Screening tool done in the emergency department, is not sufficient to meet the standard. The program must develop a protocol to screen patients who are at high risk for psychological sequelae such as that occurs post injury such as depression and post-traumatic stress disorder (PTSD).

For more information refer to the Best Practice Guidelines on Mental Health and Substance Use Guidelines.

Q: Are all patients who are admitted required to be screened, regardless of the length of stay?

A: All admitted patients greater than 12 years old, regardless of length of stay, must be screened.  Trauma centers must achieve a screening rate of at least 80 percent to meet the standard. 

Q: Are Level III trauma centers required to have at least 80% of patients who have screened positive for alcohol misuse receive a brief intervention by an appropriately trained staff prior to discharge? 

A: In Level III trauma centers, at least 80 percent of patients who have screened positive for alcohol misuse must receive a brief intervention by appropriately trained staff prior to discharge. This intervention must be documented. If brief intervention is not available as an inpatient, there must be a mechanism for referral.

Q: What constitutes an intervention?

A: The Intervention component of Standard 5.31 refers to the motivational interview/conversation that is focused on behavior modification in a vulnerable patient that could effect change. The person(s) providing this intervention/conversation is credentialled by the facility. Only providing informational materials to the patient is not an intervention and does not meet the intent of the standard, however, they may be provided as an adjunct with the conversation.

Q: Is it sufficient to use the Data Center Validation Summary Report and the TQP Data Center Submission Frequency Report as a Data Quality Plan?

A: To be compliant with Standard 6.1, all trauma centers must have a written data quality plan AND demonstrate compliance with that plan. At minimum, the plan must require quarterly review of data quality.  The written data quality plan should allow for a continuous process that measures, monitors, identifies and corrects data quality issues and ensures the data is usable.

Q: Are standards that did not carry over to the 2022 Resources manual still applicable? For example, requirements related to undertriage.

A: The 2022 version should be used alone, independent from previous versions of the standards. It’s important to understand that the 2022 version organizes the standards differently.  For PIPS, many of the requirements from the 2014 Standards are listed in the Resources section as audit filters, event review, and report reviews.  For example, ‘Accuracy of trauma team activation protocols’ should flag both undertriage and overtriage situations for review.

Q: Is a written PIPS plan required to include a clearly defined relationship to the hospital PI program? 

A: To be compliant with the standard, all trauma centers much have a written PIPS plan that:

• Outlines the organizational structure of the trauma PIPS process, with a clearly defined relationship to the hospital PI program
• Specifies the processes for event identification. As an example, these events may be brought forth by a variety of sources, including but not limited to: individual personnel reporting, morning report or daily signouts, case abstraction, registry surveillance, use of clinical guideline variances, patient relations, or risk management. The scope for event review must extend from prehospital care to hospital discharge
• Includes a list of audit filters, event review, and report review that must include, at minimum, those listed in the Resources section;
• Defines levels of review (primary, secondary, tertiary, and/or quaternary), with a listing for each level that clarifies:
• Which cases are to be reviewed
• Who performs the review
• When cases can be closed or must be advanced to the next level
• Specifies the members and responsibilities of the trauma multidisciplinary PIPS committee
• Outlines an annual process for identification of priority areas for PI, based on audit filters, event reviews, and benchmarking reports

Q: What are the attendance requirements for the Geriatric Trauma Liaison?

A: There are no attendance requirements for geriatric liaisons.

Q: Are all of the following rotations required to meet standard 8.4: general surgery, orthopaedic surgery, neurosurgery, and emergency medicine?

A: All of the listed rotations are not required. The list refers to the type of residents, not rotations. This standard requires that trauma rotations are available to, at a minimum, residents in general surgery, orthopaedic surgery, neurosurgery, and emergency medicine.

Q: In order for research articles to count toward meeting this standard, must they be included in a specific journal index (e.g., PubMed/Index Medicus)?

A: Articles must be published or accepted for publication in peer-reviewed and indexed journals. The standard does not list specific index services/databases to meet this requirement.