VRC 2014 Standards Q&As

How does one submit an application for a site visit (for example, re-/verification, focused)?

Paper applications are no longer acceptable. An online application must be completed through the Trauma Center Participant (TCP) Hub. Trauma centers requiring an onsite focused review must complete an online application through the TCP Hub. Under the requested dates, use the program's default dates and, in the subsequent text box, indicate the preferred dates. In addition, we ask that an email is sent to COTVRC@facs.org confirming the preferred dates.

Who is required to have Continuing Medical Education (CME)?

The Trauma Medical Director (TMD), Trauma Program Manager (TPM), and any providers who have previously or are presently going through the Alternate Pathway are required to obtain 12 hours of CME annually (36 hours over a 3-year period). For the Pediatric TMD, 9 hours of the required 36 must be specific to pediatric trauma care. As a note, the Verification Review Committee (VRC) will accept 33 hours from board certification or recertification to count towards the external trauma-related CME. This can only be utilized once during the 3-year period.

For the trauma surgeons, pediatric surgeons, liaisons, and specialty panel members (emergency medicine, neurosurgery, orthopaedic surgery, and ICUs) participating on the trauma call panel, staying current with their board certification satisfy the CME requirement (CDs 5-24, 7-12, 7-13, 8-14, 8- 15, 9-18, 9-19, 10-39, 10-40, 11-63, and 11-64). Physicians/surgeons who are currently board-eligible (recent graduates) and those who have life-time (grandfathered) board certification, meet the CME requirement.

When can the center receive access to the online Prereview Questionnaire (PRQ)?

The VRC office will provide the center with an email receipt when the application is received. Logins to the online PRQ will be provided within the body of the email. Access the online PRQ.

If a center is only seeking a visit as an adult trauma center, does the pediatric section (Chapter X) need to be completed in the PRQ?

Trauma centers that are not seeking a separate pediatric verification, but do admit pediatric patients (regardless of the number), are required to complete the pediatric segments of Chapter X as noted below:

• Section A: question #1
• Section B: Splenic Injury, if applicable
• Section C: Pediatric Trauma Admissions (entire section, only including pediatric data)

After completing these sections, you may skip to Chapter XI. Collaborative Services.

Additionally, the question "Facility treats what type of patients" in the online application must be answered as "Adult + Children".

Trauma centers that are seeking pediatric verification are required to complete all of Chapter X. Pediatric Surgery in the PRQ.

If seeking a combined Adult Level I or II and a Pediatric Level II consultation or re-/verification, are separate PRQs required?

The center will receive access for one PRQ. The PRQ will contain a pediatric section that must be completed with just the pediatric data.

If seeking a combined Adult Level I and a Pediatric Level I consultation or re-/verification, are separate PRQs required?

Yes. The center will be provided two separate PRQs.

Is self-reporting acceptable for tracking arrival times?

Self-reporting is permissible. It is recommended that a scribe or key scanner is used to document the response time.

For a verification program, what defines a trauma admission?

Patients who meet NTDS Inclusion Criteria and are admitted to a surgical service or a non-surgical service with a stay ≥ 24 hours counts toward the admission total requirement and completing the PRQ.

Do all opportunities for improvement (OFIs) need to be resolved for the focused visit?

Not all OFIs (i.e. weaknesses) are required to be addressed at the subsequent site visit. The expectation is that that trauma program has recognized the OFI and has a plan of action on how it will be addressed.

Does my previously approved Alternate Pathway provider need to continue meeting all the standards for the Alternate Pathway Criteria?

If the provider was previously approved at your trauma center and is actively involved in the care of trauma patients, they are required to meet the following criteria at subsequent visits:

• A list of 36 hours of trauma-related CMEs during the past 3 years. This can be met by participation in the center's Internal Education Process.

What board certification organizations are recognized by the Verification Review Committee for trauma center verification for physicians who are involved in the care of trauma patients?

In all trauma centers, adult or pediatric physicians (trauma surgeons, neurosurgeons, orthopaedic surgeons, physicians who work in the Emergency Department, ICU director, and the liaisons for radiologist and anesthesia) who are involved in the care of trauma patients must be currently board certified or eligible for certification in general surgery or pediatric surgery by the American Board of Medical Specialties (ABMS), the American Osteopathic Association (AOA), or the Royal College of Physicians and Surgeons of Canada (RCPS-C) or current requirements of the Alternate Pathway.

Who is required to have ATLS?

Members who require current ATLS status:

• Trauma Medical Director
• Physicians who work in the Emergency Department who are not board certified in Emergency Medicine, but who are currently board certified by the ABMS, AOA or RCPS-C in another specialty, such as Family Practice or Internal Medicine and so forth
• Advance Practice Providers for the Trauma Service and the Emergency Department who are members of the trauma activation team, and evaluate and resuscitate trauma patients

Members who must have taken ATLS at least once:

• Trauma surgeons
• Physicians who work in the Emergency Department and are board certified by the ABMS, AOA or RCPS-C in pediatric emergency medicine or emergency medicine
• Physicians who have previously been approved by the Alternate Pathway at the current institution

Do all the anesthesiologists and radiologists need to maintain board certification?

It is not required for all members of the anesthesia and radiology involved in the care of trauma patients to maintain board certification. Current board certification or eligibility for certification is required for the Anesthesiologist Liaison (CD 11-11) and the Radiologist Liaison (CD 11-43) who are involved in the care if trauma patients in Level I and II trauma centers.

CD 2-4: A Level I trauma center must admit at least 1,200 trauma patients yearly or have 240 admissions with an Injury Severity Score of more than 15 (CD 2–4). This is the minimum volume that is believed to be adequate to support the education and research requirements of a Level I trauma center.

What are the ICD-10 codes to be used for the Reporting Year to complete the PRQ?

For verification purposes, the trauma center should follow the National Trauma Data Standard (NTDS) dictionary for patient inclusion criteria (found on pages iv and v), or defer to what the hospital has set as their trauma inclusion policy. This would be applicable to all trauma center levels.

CD 4-1: Direct physician-to-physician contact is essential.

Who can conduct physician-to-physician transfers?

This may depend on the institution's protocols regarding transfers. In most centers, if a patient is being transferred, there should be direct communication between the emergency department (ED) physician and/or trauma surgeon. This will help determine if a patient can be received. In some states, there are referral centers that have been credentialed to receive and relay the communication to the ED physician and/or trauma surgeon. Again, there must be communication with the trauma surgeon and/or ED physician to determine if a patient can be received.

CD 4-3: A very important aspect of interhospital transfer is an effective PIPS program that includes evaluating transport activities.

Do all patients who are transferred in and out need to be reviewed?

All patients who are transferred out must be reviewed for appropriateness of care by the TMD and TPM. The receiving facility should provide feedback to the transferring facility regarding the patient’s condition, plan of care, and any PIPS issues identified. If there is no feedback, ensure that is documented in the medical record.

For a center pursuing Level II pediatric verification, can the Pediatric TPM/Coordinator also be the pediatric registrar?

For Level II Pediatric Trauma Centers, the Pediatric TPM may serve as a registrar as long as their primary role is not encumbered.

CD 5-8: Membership and active participation in regional or national trauma organizations are essential for the trauma director in Level I and II trauma centers and are desirable for TMDs in Level III and IV facilities

What would constitute the TMD's membership and active participation in regional or national trauma organizations?

Membership and active participation in regional or national trauma organizations are essential for the TMD and the Pediatric TMD in Level I and II Trauma Centers (as well as combined centers), and are desirable for TMDs in Level III and IV facilities (CD 5-8).

Acceptable organizations for Level I and II TMDs:

• Pediatric Trauma Society (PTS)
• American Association for the Surgery of Trauma (AAST)
• Eastern Association for the Surgery of Trauma (EAST)
• American College of Surgeons Committee on Trauma (ACS-COT)
• Western Trauma Association (WTA)
• Society of Critical Care Medicine (SCCM)
• Regional committees on trauma (including past and present region chiefs, state/provincial chairs and vice-chairs, or international chairs).

For a Level II, TMD membership in the state COT is acceptable as a regional trauma organization.

For example, if the surgeon is a Fellow of the ACS (FACS) and is an active member on the COT, this would be in compliance with the criteria.

CD 5-11: In addition, the TMD must perform an annual assessment of the trauma panel providers in the form of Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) when indicated by findings of the PIPS process.

Is the TMD required to perform an ongoing professional practice evaluation (OPPE) on all providers?

The TMD is expected to assess the individual surgeon’s adequacy of trauma care knowledge in the OPPE process that stems from the trauma center’s performance improvement and patient safety (PIPS) process. For the specialty panel members (Emergency Medicine, Neurosurgery, Orthopaedic Surgery, and Intensive Care Units [ICUs]), the OPPE may be done by the specialty liaisons with approval of the TMD. This will also include the advanced practice providers (APPs) (CD 11-87). The depth of the OPPE will vary, but should include the surgeon’s performance activities. This may include attendance to peer review meetings, CME tracking, corrective action review, etc. There are a few examples for OPPE on the VRC Resources Repository website.

CD 5-16: The emergency physician may initially evaluate the limited-tier trauma patient, but the center must have a clearly defined response expectation for the trauma surgical evaluation of those patients requiring admission.

Is there an expectation for when the trauma surgeon is expected to respond to the second-tier activation (limited tier)?

There is not a response time requirement for the limited tier activation. The hospital must define the types of injuries and response for which a surgical evaluation is expected. Any delays should be reviewed through the PIPS process for adverse outcomes.
The expectation is that the hospital should:

• Know and enforce the policy
• Monitor through PIPS
• Update the policy based on PI/triage outcomes

During a site visit, the review team will verify that the trauma center is adhering to its admission policy.

Are the back-up trauma surgeons responsible for attending 50% of peer review committee meetings?

If the back-up trauma surgeons only serve in this capacity, then there are no requirements for them to meet the 50% attendance at the peer review meeting. However, the TMD should disseminate information to everyone involved in caring for trauma patients. This is does not negate the trauma panel surgeons who take trauma call from meeting the requirement.

CD 6-2: Basic to qualification for trauma care for any surgeon is current board certification in general surgery by the American Board of Surgery, the American Osteopathic Association’s American Osteopathic Board of Surgery, or the Royal College of Physicians and Surgeons of Canada. Board certification or eligibility for certification by the American Board of Surgery according to current requirements or the alternate pathway is essential for general surgeons who take trauma call in Level I, II, and III trauma centers.

Can a surgeon or physician take trauma call if they are foreign trained and not board certified in the United States or in Canada?

Surgeons who trained or are board certified overseas, and want to participate on the trauma call are required to apply and be approved by way of the Alternate Pathway Criteria (APC). Refer to the APC document. Please be sure to contact the VRC Office immediately if there are any APC candidates at your center.

CD 7-11: In Level I, II, and III trauma centers, the emergency medicine liaison on the multidisciplinary trauma peer review committee must attend a minimum of 50 percent of the committee meetings.

If the committee member cannot attend the multidisciplinary peer review meeting, what is an acceptable alternative?

Either the liaison or one predetermined alternate must attend a minimum of 50% of all multidisciplinary peer review meetings. Attendance may be met through teleconferencing or videoconferencing participation. Audio conferencing should be limited. All trauma surgeons must attend 50% of the multidisciplinary peer review meetings.

CD 7-14/7-15: In Level I, II, and III trauma centers, all board-certified emergency physicians or those eligible for certification by an appropriate emergency medicine board according to their current requirements must have successfully completed the ATLS course at least once (CD 7–14). Physicians who are certified by boards other than emergency medicine who treat trauma patients in the emergency department are required to have current ATLS status (CD 7–15).

Are ED physicians required to have Advanced Trauma Life Support (ATLS) certification?

ED physicians who are board-certified or eligible for certification in Emergency Medicine or Pediatric Emergency Medicine must have taken ATLS at least once.

ED physicians who are board-certified or eligible for certification in a specialty other than Emergency Medicine or Pediatric Emergency Medicine (such as Family Practice, Internal Medicine, Pediatrics, etc.), must maintain current ATLS certification.

In Level I and II trauma centers, physicians who completed primary training in 2016 and beyond must be board certified or eligible for certification by the American Board of Medical Specialties (ABMS) Emergency Medicine/Pediatric Emergency Medicine board according to the current requirements.

In Level I and II Trauma Centers, physicians who completed primary training in 2016 and beyond who are NOT board certified or eligible for certification by the ABMS Emergency Medicine/Pediatric Emergency Medicine board may provide care in the emergency room, but cannot participate in trauma care.

In Level III Trauma Centers with Neurosurgery capabilities and equipment, the expectation is that the center be in compliance with the criteria identified in Chapter 8 for Level IIIs (CDs 8-5 through 8-10, 8-13, and 6-3). Refer to Chapter 8 in the Resources for Optimal Care of the Injured Patient 2014 manual for a description of the above noted criteria.

CD 8-2: Neurotrauma care must be continuously available for all TBI and spinal cord injury patients and must be present and respond within 30 minutes based on institutional-specific criteria.

What are some examples of the types of injuries that require a neurosurgical response within 30 minutes?

Examples may include, but are not limited to, the following:

• Penetrating injury to head with altered mental status
• Traumatic brain injury (TBI) with emergent surgical intervention
• TBI with emergent external ventricular drain (EVD) monitoring

Who can fulfill the 30-minute Neurosurgery response requirement?

The expectation is that the neurosurgeon, resident*, or APP* for that service to respond within 30 minutes when the request is made by the attending surgeon to consult on a trauma patient.

*There must be guidelines agreed upon by the specialty liaison and TMD for the types of injuries the APPs or residents will respond to, and clear documentation with the attending specialist surgeon on the plan of care.

CD 8-3: The trauma center must provide a reliable, published neurotrauma call schedule with formally arranged contingency plans in case the capability of the neurosurgeon, hospital, or system to care for neurotrauma patients is overwhelmed.

Is a neurosurgical backup call schedule required or is contingency plan acceptable?

If the trauma center does not have a published neurosurgery backup call schedule, the requirement may be satisfied with a contingency plan (CD 8-5). The plan must be formalized, and may include training/credentialing with trauma surgeons for initial stabilization. The plan must include criteria for transfer to another center of the same/higher level, and must be monitored by the PIPS.

CD 8-4: The center must have a predefined and thoroughly developed neurotrauma diversion plan that is implemented when the neurosurgeon on call becomes encumbered.

When is it appropriate to activate the Neurosurgery diversion plan?

When the on-call neurosurgeon is encumbered, the trauma center must have a diversion plan to divert trauma patients. The plan must include the following criteria:

• Emergency medical services (EMS) notification of neurosurgery advisory status/diversion.
• A thorough review of each instance by the PIPS program.
• Monitoring of the effectiveness of the process by the PIPS program.

CD 8-6: If one neurosurgeon covers two centers within the same limited geographic area, there must be a published backup schedule. In addition, the performance improvement process must demonstrate that appropriate and timely care is provided.

Can the neurosurgeon be on call at two trauma centers?

If the neurosurgeon covers two trauma centers within the same limited geographic area, there must be a published neurosurgical backup call schedule. In addition, the PIPS process must demonstrate that appropriate and timely care is provided (CD 8-6).

What is the appropriate timing for administration of intravenous antibiotics for open fractures?

The recommended time for the first antibiotic administered for an open fracture to the trauma patient that arrives in the ED is 60 minutes. Times that exceed 90 minutes will be cited as an opportunity for improvement.

What types of open fractures require antibiotic administration within 60 minutes?

For the verification program and completion of the PRQ, we only want data for antibiotics administered at your facility within 60 minutes for tibial shaft fractures. It does not include the following: ankle, pilon, amputations, plateaus, nasal, finger, etc.

CD 9-7: An orthopaedic team member must be available in the trauma resuscitation area within 30 minutes after consultation has been requested by the surgical trauma team leader for multiply injured patients based on institution-specific criteria.

Who can fulfill the 30-minute Orthopaedic Surgery response requirement?

The expectation is that the orthopaedic surgeon, resident* or APP* for that service to respond within 30 minutes when the request is made by the attending surgeon to consult on a trauma patient.

*There must be guidelines agreed upon by the specialty liaison and TMD for the types of injures the APPs or residents will respond to, and clear documentation with the attending specialist surgeon on the plan of care.

Is a separate call schedule required for Plastic, Ear/Nose/Throat (ENT), or Oral Maxillofacial Surgery (OMFS)?

A combined schedule is appropriate as long as the specialist's name and contact information is noted.

If there is lack of subspecialty coverage, how far in advance must the resolution to this be implemented prior to a verification survey?

At the time of the site visit, the program should be able to present between 6-9 months of documentation demonstrating the specialty requirement was implemented and monitored through the PIPS process to ensure compliance and that there were no adverse outcomes.

CD 11-5: When anesthesiology senior residents or CRNAs are used to fulfill availability requirements, the attending anesthesiologist on call must be advised, available within 30 minutes at all times, and present for all operations.

Can certified registered nurse anesthetists (CRNAs) or certified anesthesiologist Assistants (C-AAs) begin administering anesthetics without the anesthesiologist present in the operating room (OR)?

No, this is not permissible. The CRNA or C-Aas may begin to prepare the OR and patient while waiting for the arrival of the anesthesiologist. In Level III facilities, operative anesthesia may be provided by a CRNA under onsite physician supervision (CD 11-8). The specialty of the supervising physician should follow state and local/institutional practices. In states where CRNAs are licensed to practice independently, CRNAs should follow local or institutional practices and may not require physician supervision.

CD 11-14: An operating room must be adequately staffed and available within 15 minutes at Level I and II trauma centers.

How would compliance with CD 11-14 be demonstrated?

The expectation is that the OR team is notified when a trauma patient is going to be sent to the OR. That initial call and the team members response must be tracked. This can be documented on a logbook, electronic medical record (EMR), or badge swipe.

Is the in-house OR team a requirement?

The best method to meet this time requirement is by having the OR team in-house. If tracking the response times for each of the team member from outside the hospital, you must demonstrate that the response time of 15 minutes is always met. There is no variance for this.

What is an effective PIPS process to monitor that an OR is always immediately available?

Ensure there are policies and procedures established to adequately review and measure outcomes relative to this requirement. Demonstrate this process by having, for example:

• Adequate ORs during various times throughout the day so that an emergency procedure can “bump” a case
• Audit filters to track delays/notification system
• Surveillance reports that show periodic analysis and rate trending
• True effort to meet the goal of providing rapid access to needed operative intervention

CD 11-33: In Level I and II trauma centers, qualified radiologists must be available within 30 minutes to perform complex imaging studies, or interventional procedures.

What types of interventional radiology procedures fall under the 30-minute rule for response time?

The ACS does not define types of interventional procedures.

When does the clock start and stop for the 30-minute response time for interventional radiology?

The response time is tracked from when the call is made requesting the service. The clock stops when the radiologist arrives at bedside.

CD 11-49: A surgeon with current board certification in surgical critical care must be designated as the ICU director.

Does the pediatric surgical director of the ICU have to be boarded in surgical critical care (SCC)?

For Level I pediatric trauma centers, the ICU surgical director does not have to be board certified in SCC. However, they must be board-certified general surgeons.

Can the SCC liaison of the trauma program serve as the TMD?

If the TMD meets the requirement, then he or she may fulfill both roles.

CD 11-51: Appropriately trained physicians must be available in-house within 15 minutes to provide care for the ICU patients 24 hours per day.

Who can cover the ICU?

Appropriately trained physicians must be available in-house within 15 minutes to provide care for the ICU patients 24 hours per day. This must be tracked and documented. This coverage may be performed by an appropriately supervised senior surgery resident or an in-house trauma attending credentialed to provide critical care.

CD 11-53: In Level II and III trauma centers, a surgeon must serve as co-director or director of the ICU and be actively involved in, and responsible for, setting policies and administrative decisions related to trauma ICU patients.

Can the SCC director or co-director serve as the TMD?

The director or co-director for the ICU may also serve as the TMD.

CD 11-55: In Level II trauma centers, physician coverage of critically ill trauma patients must be available within 15 minutes 24 hours per day for interventions by a credentialed provider.

Provide examples of situations where a credentialed provider has to be available within 15 minutes.

Example Scenario: The patient returns from an OR postoperatively, and the nurse notices the abdomen is swollen. The patient’s blood pressure drops. The goal is to get someone to the bedside immediately.

For the above scenario, you would need to get the trauma attending to evaluate that patient.

CD 11-60: For all levels of trauma centers, the PIPS program must document that timely and appropriate ICU care and coverage are being provided.

Is subspecialist arrival time tracking necessary for those patients who are not considered emergent/urgent?

The requirement is for the trauma program to track the time the trauma surgeon or consultant (subspecialist) was paged/called to the ICU for emergent issues related to the trauma patient, and document the response time at the bedside. Any issues or delays in care must be reviewed through the PIPS process by the trauma program.

CD 11-70: Level I facilities are prepared to manage the most complex trauma patients and must have available a full spectrum of surgical specialists, including specialists in orthopaedic surgery, neurosurgery, cardiac surgery, thoracic surgery, vascular surgery, hand surgery, microvascular surgery, plastic surgery, obstetric and gynecologic surgery, ophthalmology, otolaryngology, and urology.

What is required to demonstrate Microvascular Surgery capabilities?

The facility must have a microvascular surgeon, or coverage may be satisfied by having a surgeon who uses an operating microscope for nerve repair, free tissue transfer, and so forth. The Microvascular Surgery capability is not required in-house 24/7, but there must be a surgeon consultant available to respond, in person, when requested by the attending surgeon.

If there is no subspecialty coverage, should the institution divert?

Level I and II trauma centers must have all the subspecialists described on page 83 (with the exception of Cardiac Surgery for Level II), available in person at bedside when a consult is requested by the trauma attending.

What are the requirements for centers to have Obstetric and Gynecologic Surgery (OB/GYN) capabilities?

Level I and II Trauma Centers are required to develop guidelines with a plan of care for the mother and the unborn child, including impending delivery:

• Utilize OB and Neonatal ICU (NICU) as part of the trauma team
• Specialized equipment
• Consider transfer agreements for services not available

CD 11-85: Coagulation studies, blood gas analysis, and microbiology studies must be available 24 hours per day.

Is thromboelastography (TEG) required?

TEG should be available at Level I and II trauma centers, but it is not required.

CD 11-86: Advanced practitioners who participate in the initial evaluation of trauma patients must demonstrate current verification as an Advanced Trauma Life Support (ATLS) provider.

Are APPs (midlevel) required to be current in ATLS?

ACS uses the following provider terms interchangeably: advanced practitioner (AP), physician assistants (PA), nurse practitioners (NP), and mid-level provider.

APPs who are clinically involved in the initial evaluation and the resuscitation of trauma patients during the activation phase, are required to have current ATLS certification. This would therefore include ED and trauma APPs. It does not include orthopaedic and neurosurgery practitioners who are consulting.

If the trauma and/or ED APPs only role is as a scribe or entering orders, they would not need to meet the ATLS requirement. This excludes the consult tier or Fast-Track.

Should isolated hip fracture patients and falls be captured in the trauma registry?

If these patients meet the NTDS inclusion criteria or your hospital's trauma inclusion criteria, they should be captured in your trauma registry. If the center includes these patients in the volume admission numbers (on the PRQ), then the non-surgical admission process as outlined in the Resources manual on page 121 should be followed.

Please note: This may differ from your state inclusion criteria. Therefore, you may have to capture two sets of data points. In addition, if the center is in a highly populated elder area, having this patient demographic in your registry would be valuable for an injury prevention activity.

CD 12-2: Rehabilitation consultation services, occupational therapy, speech therapy, physical therapy, and social services are often needed in the critical care phase and must be available in Level I and II trauma centers.

Does a social worker need to be dedicated to the trauma program?

No. A medical social worker should be available 24/7 in Level I and II trauma centers. However, the VRC does not require they be dedicated to the trauma program. The best practice to demonstrate commitment to the trauma program would be for the social worker be made part of the trauma team or at a minimum, be provided updates in regard to activities within the trauma program. In addition, the social worker should document their evaluation in the medical record.

The center should develop a policy for when the social worker will be needed for trauma cases, such as with patients. The list will be determined by the institution.

Will the TQIP reports be used during the visit?

To clarify, a summary of the center's most recent TQIP report will be provided to the review team. The trauma center should have a copy of the full TQIP report readily available onsite during the visit. The report is used to start the conversation on how the trauma center is using the TQIP report.

CD 15-5: All trauma centers must use a risk-adjusted benchmarking system to measure performance and outcomes.

Is the trauma center required to participate in the Trauma Quality Improvement Program (TQIP)?

All trauma centers must use a risk-adjusted benchmarking system to measure performance and outcomes. Centers using other risk-adjusted benchmarking programs will be considered and must include the components outlined in the CD 15-5 Requirements and Rationale document.

Are locums required to meet the same requirements as the other members taking trauma call?

For all trauma centers, locums treating trauma patients must meet the same requirements as the other physicians/surgeons—including, but not limited to, board certification and peer review meeting attendance—regardless of the frequency.

How is dead on arrival (DOA) or died in the ED (DIED) defined?

The definition of DOA or DIED will vary from center to center and should be determined by each facility or state regulations.

What should the peer review minutes reflect?

The expectation is that there is a summary for each of the cases that were presented at the morbidity and mortality (M&M)/trauma peer review meeting. The name of this meeting varies.

CD 16-15: Each member of the committee must attend at least 50 percent of all multidisciplinary trauma peer review committee meetings.

What are the trauma peer review meeting requirements for a combined adult and pediatric program?

For combined adult and pediatric trauma centers, the peer review meetings may be held on the same day. However, there must be clear start and end times for each meeting along with separate minutes. In centers with combined programs, a representative (TMD or designee) from the adult program or from the pediatric program may attend the other program's meeting. The TMD must ensure dissemination of communication is sent to the other panel members.

Can members attend the trauma peer review meeting by phone?

Trauma surgeons and liaisons or their alternate must attend the trauma peer review meeting in person, by teleconference, or by video.

Does the representative for peer review have to be a physician?

Yes. All peer review attendees, excluding the TPM, must be surgeons/physicians.

Does the VRC allow exemptions for members who are required to attend the trauma peer review meeting?

The VRC will prorate the attendance requirement only for surgeons/physicians who are deployed, on missionary work, or on medical leave. The center must provide documentation for these absences.

CD 2-18: Peer review must occur at regular intervals to ensure that the volume of cases is reviewed in a timely fashion.

How often is the trauma systems/operations committee expected to meet?

The trauma systems/operations committee may be held as often as deemed necessary. The manual states it should be held quarterly with physicians, prehospital personnel, nurses, technicians, administrators, and other ancillary personnel.

CD 16-6: Mortality review. All trauma-related mortalities must be systematically reviewed and those mortalities with opportunities for improvement identified for peer review.

1. Total trauma-related mortality rates. Outcome measures for total, pediatric (younger than 15 years), and geriatric (older than 64 years) trauma encounters should be categorized as follows:
   • DOA (pronounced dead on arrival with no additional resuscitation efforts initiated in the emergency department).
   • DIED (died in the emergency department despite resuscitation efforts).
   • In-hospital (including operating room).
2. Mortality rates by Injury Severity Scale (ISS) subgroups using Table 1.

Do all hospice cases have to be reviewed?

The intent of any hospice case is to review the care leading up to death or the transfer. If the death occurred while under care of the trauma service, then that case must be reviewed. If the patient is transferred to another facility/hospice care center, only the care leading up to the transfer is required to be evaluated.

Is screening for posttraumatic stress disorder (PTSD) required?

There currently are no ACS requirements for PTSD screening. However, the trauma center should develop guidelines on evaluating, treating, and managing patients with PTSD.

CD 18-2: The organization of these efforts begins with effective leadership. Each trauma center must have someone in a leadership position who has injury prevention as part of his or her job description. In Level I centers, this individual must be a prevention coordinator (separate from the trauma program manager) with a job description and salary support.

Is it required to have an injury prevention coordinator designated for the trauma program?

In Level II and III trauma centers, the TPM may also serve in the role of the injury prevention coordinator as long as their primary role is not encumbered. In Level I trauma center, the injury prevention coordinator must be fulltime and separate from the TPM, as demonstrated with a job description and salary support.

CD 18-3: Universal screening for alcohol use must be performed for all injured patients and must be documented.

Who is required to receive a universal screening for alcohol?

This requirement is applicable to eligible patients (alive and participatory), regardless of activated or non-activated, who meet inclusion criteria with a hospital stay of greater than 24 hours. Eighty percent (80%) of these patients must be screened. This includes all admitted trauma patients including orthopaedic and neurosurgery.

CD 18-4: At Level I and II trauma centers, all patients who have screened positive must receive an intervention by appropriately trained staff, and this intervention must be documented.

Do all patients who have screened positive need an intervention?

Yes, any patient with a positive screening must receive an intervention. Those that are missed would subsequently be reviewed through the PIPS process.

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CD 19-1, 19-7, 10-11: For a Level I trauma center, at a minimum, a program must have 20 peer-reviewed articles published in journals included in Index Medicus or PubMed in a 3-year period (CD 19–1) or in the alternate method (CD 19-7).

What are the publication requirements for combined adult Level I and pediatric Level I Trauma Centers?

In combined Level I adult and pediatric centers, half (50%) of the research requirement must be pediatric research.

CD 19-3: Of the 20 articles, at least one must be authored or co-authored by members of the general surgery trauma team.

Does being an author on a book chapter count towards one of the required papers for research?

Yes, an author on a PubMed-verified book chapter is acceptable as long as the author’s name is published.