American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

VRC Standards FAQs

If my center is only seeking a Level I (or II or III) consultation or verification or reverification, do I need to complete the pediatric section (section X) in the PRQ?

For those trauma centers that are not seeking a separate pediatric verification, but do admit pediatric patients, in the PRQ for section Purpose of Site Visit, if the following is true:

Level of Review:  Level I, II or III Trauma Center

Facility treats what type of patients:  Adults and Children

Only complete the following

Section A. question #1

Section B. Splenic Injury table

Section C. Pediatric Trauma Admissions-entire section and ONLY enter the pediatric data

Skip to XI. Collaborative Services

Trauma centers that are seeking pediatric verification are required to complete all of Section X. Pediatric Surgery.

Category: PRQ

Level: I, II, III

What type of courses or meetings count as external trauma-related CME?

Attending a course or National/Regional conferences will provide external CME.  If the course and/or conference subject matter is relevant to the management of the injured patient.

Category: CME

Level: I, II

How many hours of trauma CME can be claimed as part of preparing for Board Review or re-/certification? 

For verification purposes, 33 hours of CME for Board preparation or taking initial Boards or for recertification will be accepted.  The center is not required to itemize these hours; however, there must be documentation demonstrating board certification.

Note:  if the surgeon is dual boarded, for example in General Surgery and Vascular Surgery, only 33 hours of CME can be claimed once.

Category: CME

Level: I, II

What specialists are allowed to claim 33 hours of trauma-related CME?

To meet the external CME requirement, 33 hours for board preparedness or certification are acceptable from  the following specialties: 

  • Trauma Surgery/Pediatric Surgery
  • Orthopaedic Surgery
  • Neurosurgery
  • Emergency Medicine
  • Critical Care

Category: CME

Level: I, II

Can the Trauma Medical Director be part-time at one center and over see another trauma center?

The Trauma Medical Director must be a fulltime and permanent position, and dedicated to one trauma center.

Category: TMD

Level: I, II, III

We have surgeons/physicians that work 1 shift a month, are they required to meet the same criteria as the other trauma panel members?

Regardless of the number of shifts the surgeon/physician is on call, they are required to meet the same criteria as the other trauma panel members:  credentialing process, board certification, peer review attendance, OPPE:  Level I and II CME and/or Internal Education Process.

Category: Locums           

Level: I, II, III

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

The VRC will allow exemptions (prorate) surgeons/physicians who are deployed, on missionary work or on medical leave.  The center must provide documentation for these absences.

Category: Multidisciplinary Trauma Peer Review Meeting

Level: I, II, III

Can members attend the Trauma peer review meeting by phone?

The panel members required to attend the Trauma peer review meeting may attend in-person or by teleconference or skype [video].

Category: Multidisciplinary Trauma Peer Review Meeting

Level: I, II, III

We have a surgeon who is foreign trained and is not board certified in the United States or in Canada, can they be on the trauma call schedule?

Surgeons who trained or are board certified overseas, and want to participate on the trauma call schedule, are required to apply and be approved by way of the Alternate Pathway Criteria. 

 For surgeons who previously have been approved by the Alternate Pathway Criteria (APC) at the current institution, an onsite visit will NOT be required; however, the following criteria as noted in the APC document will be required at the time of the subsequent visit:

3. A list of 48 hours of trauma-related CMEs during the past 3 years. This can be met by participation in the center’s IEP.

4. Documentation that the surgeon is present at least 50% of the trauma performance improvement meetings.

5. Documentation of membership or attendance at local and regional or national trauma meetings during the past 3 years.

7. Performance improvement assessment by the Trauma Medical Director (TMD) to ensure that patient outcomes compare favorably to other members of the trauma call panel.

Criteria:  1, 2, 6, 8, and 9 have been met by the initial approval process.

Category: Alternate Pathway Criteria

Level: I, II, III

Can the Advanced Practice Provider respond to the 30 minute requirement for specific neurosurgery and orthopaedic surgery patients?

The specialist or Advanced Practice Providers (APPs)/residents* may respond for the Orthopaedic or Neurosurgery service when the request is made by the attending surgeon. 

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

Category: Response to Critical Injuries

Level: I, II, III

Are all Physician Assistants/Nurse Practitioners/ Advanced Practice Providers required to be current in ATLS?

Trauma and/or Emergency Department Advanced Practice Providers (APPs) that function as a member of the team caring for trauma activation patients via assessment or interventions must be current in ATLS.  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 does not include the consult tier or Fast-Track.

Neurosurgery and/or Orthopaedic Surgery consultants (APPs/PAs) who respond to the trauma for a consult are not required to be current in ATLS.  This would also be true for CRNAs.

Category: Advanced Trauma Life Support (ATLS)

Level: I, II, III