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: If a trauma center was reviewed under the 2014 Standards and requires a focused visit, will the focused visit be based on the 2014 Standards or the new 2022 Standards?

A: For focused visits, the trauma center will be reviewed using the same standards by which it was previously reviewed. In this instance, the focused visit will be reviewed using the 2014 Standards.

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: 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: 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: What qualifications are required for Intensive Care Unit (ICU) physicians?

A: The standard does not have qualification requirements

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

A: Standard 4.22 requires continuous ophthalmologic coverage, defined as 24/7/365. Sporadic gaps in coverage due to vacations, conference attendance, etc. can (and must) be addressed by a contingency plan.   

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: 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: In all trauma centers, trauma registrars must have 24 hours of CE during the 3-year verification cycle.  CE earned at a different trauma center prior to employment at the current center counts toward this requirement. 

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 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: 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 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: 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: 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: 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.