Alabama Administrative Code › Title 420 - ALABAMA STATE BOARD OF HEALTH › Chapter 420-2-2 - ALABAMA STATEWIDE TRAUMA SYSTEM › Appendix A - Alabama Trauma Center Designation

Current through Register Vol. 42, No. 9, June 28, 2024
Trauma Facilities Criteria: APPENDIX A Trauma
				Rules
The following table shows levels of categorization and
				their
essential (E)
or
desirable (D)
criteria
				necessary for designation as a Trauma Facility by the Alabama Department of
				Public Health
Level I
Level II
Level III
INSTITUTIONAL ORGANIZATION
Trauma Program (Attached)
E
E
E
Trauma Service (Attached)
E
E
-
Trauma Team (Attached)
E
E
E
Trauma Program Medical Director (Attached)
E
E
D
Trauma Multidisciplinary Committee (Attached)
E
E
D
Trauma Coordinator/ TPM (Attached)
E
E
E
HOSPITAL DEPARTMENTS/ DIVISIONS/
							 SECTIONS
Surgery
E
E
E
Neurological Surgery
E
D
D
Neurological trauma liaison
E
-
-
Orthopedic Surgery
E
E
-
Orthopedic trauma liaison
E
E
-
Emergency medicine
E
E
-
Anesthesia3
E
E
-
*Pediatrics
E
D
-
CLINICAL CAPABILITIES
Published on-call schedule
E
E
E
General Surgery (attending surgeon promptly
							 available1 to maintain green status)
E
E
D
Published back-up schedule or written back-up
							 method2
E
D
D
Dedicated to single hospital when on-call
E
D
D
Anesthesia (promptly
							 available3 to maintain green status)
E
E
E
Emergency Medicine (Immediately available in-house 24
							 hours/day)
E
E
E
On-call and promptly available to maintain green
							 status:
Cardiac surgery
E
-
-
Hand surgery (does not include micro
							 vascular/reimplantation)
E
D
-
Micro vascular/replant surgery
D
-
-
Neurologic Surgery
E
D
-
Dedicated to one hospital or back-up call
E
D
-
Obstetrics/gynecologic
							 surgery4
E
D
-
Ophthalmic surgery
E
D
-
Oral/maxillofacial surgery
E
D
-
Orthopedic
E
E
D
*Pediatric Surgery
E
D
-
Dedicated to one hospital or back-up call
E
D
-
Plastic surgery
E
D
D
Critical care medicine-*to include neonatal/pediatric
							 intensive care unit
E
D
-
*Pediatrics
E
E
D
Radiology
E
E
D
*Pediatric Radiology
D
D
-
Thoracic surgery
E
D
-
CLINICAL QUALIFICATIONS
General/ trauma surgeon
Current board certification or eligible
E
E
E-
Average of 6 hours of trauma related
							 CME/year5
E
E
D
ATLS completion
E
E
E
Trauma Multidisciplinary Committee Attendance/Peer
							 review committee attendance > 50%
E
E
E
Emergency Medicine.
Board certification6 or
							 eligible
E
D
D
ATLS completion7
E
E
E
Average of 6 hours of trauma related
							 CME/year5
E
E
-
Trauma Multidisciplinary Committee Attendance/Peer
							 review committee attendance > 50%
E
E
-
Neurosurgery
Current board certification or eligible
E
D
D
Average of 6 hours of trauma related
							 CME/year5
E
D
D
ATLS completion
D
D
D
Trauma Multidisciplinary Committee Attendance/Peer
							 review committee attendance > 50%
E
E
D
Orthopedic surgery
Board certification or eligible
E
D
D
Average of 6 hours of trauma related
							 CME/year5
E
E
D
ATLS Completion
D
D
D
FACILITIES/ RESOURCES/ CAPABILITIES
Trauma Multidisciplinary Committee Attendance/Peer
							 review committee attendance > 50%
E
D
D
Volume Performance
Trauma admissions 1200/year or 240 patients with
							 ISS>15/Pediatric Centers 200 under the age of 16
E
-
-
Presence of surgeon at resuscitation
E
E
D
Presence of surgeon at operative procedures
E
E
E
Emergency Department (ED)
Personnel - designated physician director
E
E
E
Equipment for resuscitation for patients of all
							 ages
Airway control and ventilation equipment
E
E
E
Pulse oximetry
E
E
E
Suction devices
E
E
E
Drugs and supplies for emergency care of adult and
							 pediatric patients
E
E
E
Electrocardiograph-oscilloscope-defibrillator with
							 infant and pediatric paddles
E
E
E
Internal paddles
E
E
-
Special color coding of equipment based on age and
							 size
E
E
E
CVP monitoring equipment
E
E
D
Standard IV fluids and administration sets
E
E
E
Large-bore intravenous catheters
E
E
E
Sterile surgical sets for:.
Airway control/ cricothyrotomy
E
E
E
Thoracostomy
E
E
E
Venous cutdown
E
E
E
Central line insertion
E
E
-
Thoracotomy
E
E
-
Peritoneal lavage
E
E
E
Arterial catheters
E
D
D
Ultrasound
E
E
D
Drugs necessary for emergency care
E
E
E
X-ray available to maintain green
							 status11
E
E
D
Cervical traction devices
E
E
D
Broselow tape
E
E
E
Rapid infuser system
E
E
D
Qualitative end-tidal CO2
							 determination
E
E
E
Communications with EMS vehicles
E
E
E
OPERATING ROOM
Immediately available to maintain green status 
							 8
E
D
D
Operating Room Personnel
In house to maintain green status 
							 8
E
-
-
Available to maintain green status
E
E
Age Specific Equipment
Cardiopulmonary bypass
E
-
-
Operating microscope
D
D
-
Thermal Control Equipment
For patient
E
E
E
For fluids and blood
E
E
E
X-ray capability, including c-arm image
							 intensifier
E
E
E
Endoscopes, bronchoscopes
E
E
D
Craniotomy instruments
E
D
-
Equipment for long bone and pelvic fixation
E
E
D
Rapid infuser system
E
E
D
Post Anesthetic Recovery Room (SICU is
							 acceptable)
Registered nurses available to maintain green
							 status
E
E
-
Equipment for monitoring and resuscitation of adult
							 and pediatric patients
E
E
E
Intracranial pressure monitoring equipment
E
D
-
Pulse oximetry
E
E
E
Thermal control
E
E
E
Intensive or Critical Care Unit for Injured
							 Patients
Registered nurses with trauma
							 education13
E
E
-
Designated surgical director or surgical
							 co-director12
E
D
D
Surgical ICU service physician in-house 24 hours/day
							 (Emergency physician will satisfy this requirement)
E
D
-
Equipment for monitoring and resuscitation
E
E
-
Intracranial monitoring equipment
E
-
-
Pulmonary artery monitoring equipment
E
E
-
Respiratory Therapy Services
Available in-house to maintain green status
E
E
D
On-call to maintain green status
-
-
D
Radiological services
In house radiology technologist to maintain green
							 status
E
E
D
Angiography
E
D
-
Sonography
E
E
D
Computer Tomography (CT)
E
E
D
In house CT technician
E
-
-
Magnetic Resonance Imaging (Technician not required
							 in house)
E
D
-
Clinical laboratory services
(Available
							 to maintain green status)
E
E
E
Standard analyses of blood, urine, and other body
							 fluids, including microsampling when appropriate
E
E
E
Blood typing and cross-matching
E
E
E
Coagulation studies
E
E
E
Comprehensive blood bank or access to a community
							 central blood bank and adequate storage facilities
E
E
E
Blood gasses and pH determinations
E
E
E
Microbiology
E
E
E
Acute Hemodialysis
E
E
E
In-house (staff not required in-house for green
							 status)
E
-
-
Burn Care - Organized
In house
D
Acute Spinal Cord Management
In-house
E
D
REHABILITATION SERVICES
Physical therapy
E
E
D
Occupational therapy
E
D
D
Speech therapy
E
D
-
Social Service
E
E
D
PERFORMANCE IMPROVEMENT
Performance improvement
							 programs14
E
E
E
Trauma registry
Participate in state registry
E
E
E
Audit of all trauma deaths
E
E
E
Morbidity and mortality review
E
E
E
Trauma conference-multidisciplinary
E
E
D
Medical nursing audit
E
E
E
Review of pre-hospital trauma
							 care9
E
E
E
CONTINUING EDUCATION/OUTREACH
General Surgery residency program
D
-
-
ATLS provide/ participate
E
D
D
Programs provided by hospital for:
Staff/community physicians (CME)
E
E
D
Nurses
E
E
D
Allied health personnel
E
E
-
Feedback provided to pre-hospital
							 personnel10
E
E
E
PREVENTION
Collaboration with other institutions for injury
							 control and prevention
E
D
D
Designated prevention coordinator-spokesman for
							 injury control
E
D
-
Outreach activities (some component to be
							 pediatrics)
E
D
D
Information resources for public
E
D
-
Collaboration with existing national, regional and
							 state programs
E
E
E
Coordination and/or participation in community
							 prevention activities
E
E
E
RESEARCH
Trauma registry performance improvement
							 activities
E
E
E
Research committee
D
-
-
Identifiable IRB process
D
-
-
Extramural educational presentations
D
D
-
Number of scientific publications
D
-
-
1 In both Level I and Level II
				facilities 24-hour in-house availability is the most direct method for the
				attending surgeon to provide care. In hospitals with residency programs, a team
				of physicians and surgeons that can include the Emergency Department
				Physicians, Surgical Residents, or Trauma Residents may start evaluation and
				treatment allowing the attending surgeon to take call outside the hospital if
				he/she can arrive. For hospitals without residency programs, the attending
				surgeon may take call from outside the hospital but should be promptly
				available. Promptly available for Level I facilities will be 15 minutes
				response time for 80 percent of trauma system patients except for EMT
				Discretion. Levels II and III response time will be 30 minutes. Compliance with
				these requirements will be monitored by the hospital's quality improvement
				program and the ATS Trauma Registry.
2 If there is no published back-up
				call schedule there must be a written procedure of how to identify or locate
				another surgeon when needed and this should be monitored by the quality
				improvement plan.
3 Anesthesiologist will be available
				in-house 24 hours a day for Level I trauma centers. In Level II and III trauma
				centers, anesthesiologist or CRNA will be available within 30 minutes response
				time. In Pediatric Level I trauma centers, anesthesiologist will be available
				in-house 24-hours a day. Requirements may be fulfilled by a Pediatric Emergency
				Attending Physician, Pediatric Emergency Fellow, or a Senior Anesthesia
				Resident CA-2/CA-3(PGY-3/PGY-4).
4 AL licensed specialty pediatric
				facilities, which are PPS exempt under Title
				42 USC
				Section 1395ww(d)(1)(B)(iii)
				and receive funding under Title
				42
				USC 256e shall not be required to have an
				obstetric/gynecologic surgery service but should have a transfer agreement for
				OB-GYN surgery services.
5 An average of 18 hours of trauma
				CME every three years is acceptable. An average of 3 of the 18 hours should
				focus on pediatrics.
6 Physicians may be board certified
				in Emergency Medicine or Pediatric Emergency Medicine by an ABMS- or
				AOA-recognized board, or may be board certified in a primary care specialty if
				they have extensive experience in management of trauma patients. *Level I and
				II trauma facilities may have an affiliation with pediatric hospitals to
				fulfill added pediatric requirements.
7 Physicians not board certified in
				Emergency Medicine or Pediatric Emergency Medicine by an ABMS- or
				AOA-recognized board must maintain their ATLS certification. There will be a
				three year grace period for emergency department staff to become compliant with
				this requirement
8 An operating room must be
				adequately staffed and immediately available in a Level I trauma center to
				remain available (green) to the trauma system. This is met by having a complete
				operating room team in the hospital at all times, so if an injured patient
				requires operative care, the patient can receive it in the most expeditious
				manner. These criteria cannot be met by individuals who are also dedicated to
				other functions within the institution. Their primary function must be the
				operating room.
An operating room must be adequately staffed in 30 minutes or
				readily available in a Level II trauma center to remain available (green) to
				the trauma system. The need to have an in-house OR team will depend on a number
				of things, including patient population served, ability to share responsibility
				for OR coverage with other hospital staff, prehospital communication, and the
				size of the community served by the institution. If an out-of-house OR team is
				used, then this aspect of care must be monitored by the performance improvement
				program.
9 All levels of Trauma Centers
				should monitor prehospital trauma care. This includes the qualify of patient
				care provided, patients brought by EMS and not entered into the trauma system
				but had to be entered into the trauma system by the hospital (under triage),
				and patients entered into the trauma system by EMS that did not meet criteria
				(over triage).
10 Hospitals must complete and
				return to the RTAC the initial patient findings, treatment provided and outcome
				at the end of the first 24 hours. This should be noted on the ATCC patient
				record.
11 Level III X-ray services will be
				available promptly after hours and on weekends.
12 Level I director of surgical
				critical care team will be surgical critical care board certified except for
				pediatric facilities that have 24 hours in- house pediatric intensivist.
13 Some portion of education should
				be pediatric based.
14 Includes adults and
				pediatrics.
ALABAMA TRAUMA SYSTEM (ATS) INSTITUTIONAL
				ORGANIZATION
Click to
				view image
The purpose of this document is to primarily assist Level I,
				Level II, and Level III trauma hospitals with suggestions of composition,
				organization, and process for the institutional and organizational aspects of
				trauma care. It is recognized that the institutional organization for each
				level ATS hospital differs. A suggestion of use of the American College of
				Surgeons (ACS) Resources for the Optimal Care of Trauma Patients is made for
				all ATS Level hospitals.
The Trauma Program
The trauma program involves multiple care disciplines and
				departments within the hospital that transcend normal departmental hierarchies.
				Because the best trauma care begins at the scene of an injury through the acute
				care setting to discharge from a rehabilitation center, the trauma program
				should have appropriate representation from all phases of care. Representatives
				of all disciplines and hospital departments involved in trauma patient care
				provide the appropriate skills, as team members working in concert, to
				implement treatment based on a prioritized plan of care. To ensure optimal and
				timely care, a multidisciplinary trauma program must continuously evaluate its
				processes and outcomes.
The Trauma Medical
				Director
The trauma medical director is the surgeon who leads the
				multidisciplinary activities of the trauma program. The trauma medical director
				must be a board-certified surgeon (usually a general surgeon) or an American
				College of Surgeons Fellow with special interest in trauma care and must
				participate in trauma call and be current in Advanced Trauma Life Support
				(ATLS).
Membership and active participation in regional or national
				trauma organizations is essential for the trauma director in Level I trauma
				centers.
The trauma medical director's responsibility extends beyond the
				technical skills of surgery. The trauma medical director must have the
				authority to manage all aspects of trauma care. The trauma medical director
				authorizes trauma service privileges of the on-call panel, works in cooperation
				with nursing administration to support the nursing needs of trauma patients,
				develops treatment protocols along with the trauma team, and coordinates the
				performance improvement and peer review processes. The trauma medical director
				must have the authority to correct deficiencies in trauma care and exclude from
				trauma call the trauma team members who do not meet specified criteria. With
				the assistance of the hospital administrator and the trauma program manager,
				the trauma medical director is responsible for coordinating the budgetary
				process for the trauma program. The trauma medical director will identify
				representatives from neurosurgery, orthopedic surgery, anesthesiology,
				emergency medicine, and other appropriate disciplines to determine which
				physicians from their disciplines are qualified to be members of the trauma
				program and on-call panel.
The Trauma Team
The trauma team consists of physicians, nurses, and allied
				health personnel. The size and composition of the team will vary with hospital
				size, the severity of the injury, and the corresponding level of trauma team
				activation. A high-level response to a severely injured patient must include
				the following:
(1) a general surgeon;
(2) surgical and emergency residents, as available;
(3) emergency department nurses, including a scribe
				nurse;
(4) laboratory technician;
(5) a radiology technologist;
(6) a critical care nurse;
(7) an anesthesiologist or a certified registered nurse
				anesthetist;
(8) an operating room nurse;
(9) security officers, if needed; and
(10) a chaplain or social worker.
In contrast, the trauma team's response to a less severely
				injured patient may initially consist of only an emergency physician and the
				emergency department nurses until the general surgeon arrives. The team leader
				must be a trauma surgeon. The criteria for trauma activation must be clearly
				defined by the trauma center and continuously evaluated by the Quality
				Assurance (QA) program and patient safety program.
A preplanned and coordinated approach defining which patients
				need to be seen in consultation by or admitted to the trauma service or other
				specialty services should be in place. Programs that admit more than 10 percent
				of injured patients to nonsurgical services must demonstrate the
				appropriateness of that practice through the QA program and patient safety
				program.
The Trauma Coordinator
				(TC)
The TC is fundamental to the development, implementation, and
				evaluation of the trauma program. In addition to administrative ability, the TC
				must show evidence of educational preparation and clinical experience in the
				care of injured patients. The TC works in close collaboration with the trauma
				medical director and complements the director's efforts. A constructive,
				mutually supportive relationship between these key leaders is important to the
				success of the program.
The TC may be a full-time registered nurse and is responsible
				for the organization of services and systems necessary for the
				multidisciplinary approach to providing care to trauma patients. The TC, in
				particular, assumes day-to-day responsibility for process and performance
				improvement activities as they relate to nursing and ancillary personnel and
				assists the trauma medical director in carrying out the same functions for the
				physicians. Ultimate accountability for all activities of the trauma program
				resides with the trauma medical director. The role of the TC in the
				educational, clinical, research, administrative, and outreach activities of the
				trauma program is determined by the needs of the trauma medical director and
				the institution.
Administrative and budgetary support will be provided for the
				TC. Secretarial and clinical nursing personnel help fulfill needs for outreach,
				concurrent case review, and discharge planning. The registrar, secretary, and
				nurse clinician(s) must be supervised by the TC.
The Trauma Service
				(TS)
A trauma service must represent a structure of care for injured
				patients. The service includes personnel and other resources necessary to
				ensure appropriate and efficient provision of care. In a Level I trauma center,
				seriously injured patients must be admitted to or evaluated by an identifiable
				surgical service staffed by credentialed trauma providers. Sufficient
				infrastructure and support to ensure adequate provision of care must be
				provided for this service. To be sufficient, the infrastructure and support
				must require additional qualified physicians, residents, nurse practitioners,
				physician's assistants, or other physician extenders. The number and type of
				individuals required for a trauma service should be determined by the volume of
				patients requiring care and the complexity of their conditions. In teaching
				facilities, the requirements of the Residency Review Committee must also be
				met.
The trauma service and individual surgeons who make up the TS
				must admit trauma patients to the floor and Trauma Intensive Care Unit (TICU)
				as well as be the primary physician for the patient until discharge. The
				director of the surgical critical care team must be a board certified or board
				eligible surgeon. The director of the TICU must also be board certified in
				critical care.
The Trauma Registrar
				(TR)
The trauma registrar is an important member of the trauma team.
				Trauma registrars may be from diverse backgrounds such as nursing, medical
				records, computer science, medical informatics, and other fields. They must
				work directly with the trauma team and report to the TC. The TR should also
				complete four hours of registry-specific continuing education each year which
				the Alabama Department of Public Health/Office of EMS and Trauma
				(ADPH/OEMS&T) will provide. Technical support, locally and from the
				ADPH/OEMS&T, is available to assist with these training requirements. It is
				the TR's responsibility to complete the ATS LifeTrac Form on each patient and
				e-mail or fax each patient's completed form to the Birmingham Regional
				Emergency Medical Services System.
The trauma medical director and the trauma coordinator must
				ensure and document dissemination of information and findings from the peer
				review meetings to the noncore surgeons on the trauma call panel.
Trauma Multidisciplinary Committee or Peer
				Review
There must be a multidisciplinary committee or peer review
				committee with the trauma medical director, along with representatives from
				emergency medicine, anesthesia, the trauma coordinator, and hospital
				administration. A purpose of the committee is to improve trauma care along with
				other medical care by reviewing all deaths, complications, and sentinel events
				with objective identification of issues and appropriate responses. The
				aforementioned representatives must attend at least 50 percent of these
				multidisciplinary or peer-review committee meetings. This meeting may be held
				monthly, however, the frequency is to be determined by the medical director
				based on the needs of the performance improvement and patient safety
				programs.
ALABAMA TRAUMA SYSTEM (ATS) INSTITUTIONAL
				ORGANIZATION
Click to
				view image
The purpose of this document is to primarily assist Level I,
				Level II, and Level III trauma hospitals with suggestions of composition,
				organization, and process for the institutional and organizational aspects of
				trauma care. It is recognized that the institutional organization for each
				level ATS hospital differs. A suggestion of use of the American College of
				Surgeons (ACS) Resources for the Optimal Care of Trauma Patients is made for
				all ATS Level hospitals.
The Trauma Program
The trauma program involves multiple care disciplines and
				departments within the hospital that transcend normal departmental hierarchies.
				Because the best trauma care begins at the scene of an injury through the acute
				care setting to discharge from a rehabilitation center, the trauma program
				should have appropriate representation from all phases of care. Representatives
				of all disciplines and hospital departments involved in trauma patient care
				provide the appropriate skills, as team members working in concert, to
				implement treatment based on a prioritized plan of care. To ensure optimal and
				timely care, a multidisciplinary trauma program must continuously evaluate its
				processes and outcomes.
The Trauma Medical
				Director
The trauma medical director is the surgeon who leads the
				multidisciplinary activities of the trauma program. The trauma medical director
				must be a board-certified surgeon (usually a general surgeon). The trauma
				medical director must have had Advanced Trauma Life Support (ATLS), but it does
				not have to be current.
The trauma medical director's responsibility extends far beyond
				the technical skills of surgery. The trauma medical director will have the
				authority to manage all aspects of trauma care. The trauma medical director
				authorizes trauma service privileges of the on-call panel, works in cooperation
				with nursing administration to support the nursing needs of trauma patients,
				develops treatment protocols along with the trauma team, and coordinates the
				performance improvement and peer review processes. The trauma medical director
				will have the authority to correct deficiencies in trauma care and exclude from
				trauma call the trauma team members who do not meet specified criteria. With
				the assistance of the hospital administrator, the trauma medical director is
				responsible for coordinating the budgetary process for the trauma program. The
				trauma medical director should identify representatives from neurosurgery,
				orthopedic surgery, anesthesiology, emergency medicine, and other appropriate
				disciplines to determine which physicians from their disciplines are qualified
				to be members of the trauma program and on-call panel.
The Trauma Team
The trauma team consists of physicians, nurses, and allied
				health personnel. The size and composition of the team will vary with hospital
				size, the severity of the injury, and the corresponding level of trauma team
				activation. It is anticipated that primarily physiologically stable patients
				will be routed to a Level II ATS hospital. However, patient choice, a trauma
				patient with an airway unable to be secured, hemodynamically unstable patient
				with no IV secured, or uncontrolled hemorrhage in a patient, an unstable
				patient beyond a reasonable transport time to an ATS Level I hospital, or a
				non-EMS delivered patient may arrive at a Level II ATS hospital. Thus, there is
				a need for a graded response by the Level II hospital to meet the potential
				varied patient arrivals. The determination of the level of response should be
				made by the emergency medical doctor receiving the information in the emergency
				department.
A high-level response to a severely injured unstable patient
				must include the following:
(1) a general surgeon;
(2) an emergency physician;
(3) emergency department nurses, including a scribe
				nurse;
(4) a laboratory technician;
(5) a radiology technologist;
(6) a critical care nurse;
(7) an anesthesiologist or a certified registered nurse
				anesthetist; and
(8) security officers.
The trauma team's response to a less severely injured stable
				patient may consist of an emergency medicine physician and the emergency
				department nurses (Level III) until the general surgeon arrives, if needed. The
				criteria for trauma activation should be clearly defined by the trauma center
				and continuously evaluated by the Quality Assurance (QA) program and patient
				safety program.
The Trauma Coordinator
				(TC)
The TC is fundamental to the development, implementation, and
				evaluation of the trauma program. In addition to administrative ability, the TC
				must show evidence of educational preparation and clinical experience in the
				care of injured patients. The TC works in close collaboration with the trauma
				medical director and complements the director's efforts. A constructive,
				mutually supportive relationship between these key leaders is important to the
				success of the program.
The TC may be a full-time registered nurse and is responsible
				for the organization of services and systems necessary for the
				multidisciplinary approach to providing care to trauma patients. The TC, in
				particular, assumes day-to-day responsibility for process and performance
				improvement activities, as they relate to nursing and ancillary personnel, and
				assists the trauma medical director in carrying out the same functions for the
				physicians. Ultimate accountability for all activities of the trauma program
				resides with the trauma medical director. The role of the TC in the
				educational, clinical, research, administrative, and outreach activities of the
				trauma program is determined by the needs of the trauma medical director and
				the institution.
Administrative and budgetary support will be provided for the
				TC. Secretarial and clinical nursing personnel help fulfill needs for outreach,
				concurrent case review, and discharge planning. The registrar, secretary, and
				nurse clinician(s) must be supervised by the TC.
The Trauma Service
				(TS)
A trauma service represents a structure of care for injured
				patients. The service includes personnel and other resources necessary to
				ensure appropriate and efficient provision of care. The precise nature of a
				trauma service may vary based on specific needs of the medical facility,
				available personnel, and the quantity of resources. In a Level II trauma
				center, seriously injured patients must be admitted to or evaluated by an
				identifiable surgical service staffed by credentialed trauma providers.
				Sufficient infrastructure and support to ensure adequate provision of care must
				be provided for this service. To be sufficient, the infrastructure and support
				must require additional qualified physicians, residents, nurse practitioners,
				physician's assistants, or other physician extenders. In teaching facilities,
				the requirements of the Residency Review Committee must also be met.
The Trauma Registrar
				(TR)
The trauma registrar is an important member of the trauma team.
				Trauma registrars may be from diverse backgrounds such as nursing, medical
				records, computer science, medical informatics, and other fields. They must
				work directly with the trauma team and report to the TC. The TR also should
				complete four hours of registry-specific continuing education each year which
				the Alabama Department of Public Health/Office of EMS and Trauma
				(ADPH/OEMS&T) will provide. Technical support, locally and from the
				ADPH/OEMS&T, is available to assist with these training requirements. It is
				the TR's responsibility to complete the ATS LifeTrac Form on each patient and
				e-mail or fax each patient's completed form to the Birmingham Regional
				Emergency Medical Services System.
Trauma Multidisciplinary Committee or Peer
				Review
There is a multidisciplinary/peer review committee chaired by a
				medical director or designee, with representatives from orthopedic surgery,
				emergency medicine, anesthesia, and hospital administration. The purpose of the
				committee is to improve trauma care along with other types of medical care by
				reviewing deaths, complications, and sentinel events with objective
				identification of issues and appropriate responses. The aforementioned
				representatives must attend at least 50 percent of these multidisciplinary or
				peer-review committee meetings. Although this meeting is usually held monthly,
				the frequency is to be determined by the trauma medical director based on the
				needs of the performance improvement and patient safety programs.
General surgery attendance at the committee or peer review
				meetings is essential. The general surgeon is the foundation of care in the
				trauma program in a Level II hospital. All general surgeons on the trauma call
				panel should attend meetings if possible. At a minimum, the surgeons who
				constitute the core of trauma call coverage must each attend at least 50
				percent of these meetings. This core group must be defined by the trauma
				medical director. This core group must take at least 60 percent of the total
				trauma call hours each month. Evidence for appropriate participation and
				acceptable attendance must be documented. The trauma medical director must
				ensure and document dissemination of information and findings from the peer
				review meetings to the noncore surgeons on the trauma call panel.
ALABAMA TRAUMA SYSTEM (ATS) INSTITUTIONAL
				ORGANIZATION
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				view image
The purpose of this document is to primarily assist Level I,
				Level II, and Level III trauma hospitals with suggestions of composition,
				organization, and process for the institutional and organizational aspects of
				trauma care. It is recognized that the institutional organization for each
				level ATS hospital differs. A suggestion of use of the ACS Resources for the
				Optimal Care of Trauma Patients is made for all ATS Level hospitals.
The Trauma Program
The trauma program involves multiple care disciplines and
				departments within the hospital that transcend normal departmental hierarchies.
				Because the best trauma care begins at the scene of an injury through the acute
				care setting to discharge from a rehabilitation center, the trauma program
				should have appropriate representation from all phases of care. Representatives
				of all disciplines and hospital departments involved in trauma patient care
				should provide team members working in concert to give care based on a
				prioritized plan. Optimal and timely care, in a multidisciplinary trauma
				program, is continuously evaluated by processes and outcomes.
The Trauma Medical
				Director
The trauma medical director is the surgeon or emergency medical
				doctor who leads the multidisciplinary activities of the trauma program.
The trauma medical director's responsibility extends far beyond
				the technical skills of trauma care. The trauma medical director should have
				the authority to manage trauma care. The trauma medical director coordinates
				trauma service privileges of the on-call panel, works in cooperation with
				nursing administration to support the nursing needs of trauma patients,
				develops treatment protocols along with the trauma team, and coordinates the
				performance improvement and peer review processes. The trauma medical director
				must have the authority to correct deficiencies in trauma care. With the
				assistance of the hospital administrator and the trauma coordinator, the trauma
				medical director is responsible for coordinating the budgetary process for the
				trauma program. The trauma medical director should identify representatives
				from surgery, anesthesiology, emergency medicine, and other appropriate
				disciplines to determine which physicians from their disciplines are qualified
				to be members of the trauma program and on-call panel.
The Trauma Team
The trauma team consists of physicians, nurses, and allied
				health personnel. The size and composition of the team will vary with hospital
				size, hospital trauma level, the severity of the injury, and the corresponding
				level of trauma team activation. It is anticipated that only physiologically
				stable patients will be routed to a Level III ATS hospital. However, patient
				choice, a trauma patient with an airway unable to be secured, hemodynamically
				unstable patient with no IV secured, or uncontrolled hemorrhage in a patient,
				an unstable patient beyond a reasonable transport time to an ATS Level I or II
				hospital, or a non-EMS delivered patient may arrive at a Level III ATS
				hospital. Thus, there is a need for a graded response by the Level III hospital
				to meet the potential varied patient arrivals. The determination of the level
				of response should be made by the emergency medical doctor receiving the
				information in the emergency department.
A high-level response to a severely injured unstable patient
				should include the following:
(1) a general surgeon;
(2) an emergency physician;
(3) emergency department nurses, including a scribe
				nurse;
(4) a laboratory technician;
(5) a radiology technologist;
(6) a critical care nurse;
(7) an anesthesiologist or a certified registered nurse
				anesthetist; and
(8) security officers.
The trauma team's response to a less severely injured stable
				patient usually consists of an emergency medicine physician and the emergency
				department nurses (Level III) until the general surgeon arrives, if needed. The
				criteria for trauma activation should be clearly defined by the trauma center
				and continuously evaluated by the Quality Assurance (QA) program and patient
				safety program.
The Trauma Coordinator
				(TC)
The TC is fundamental to the development, implementation, and
				evaluation of the trauma program. The TC works in close collaboration with the
				trauma medical director and complements the director's efforts. A constructive,
				mutually supportive relationship between these key leaders is important to the
				success of the program.
The TC, usually a registered nurse and most likely the
				emergency department nurse manager, is responsible for the organization of
				services and systems necessary for the multidisciplinary approach to providing
				care to trauma patients. The TC provides day-to-day responsibility for process
				and performance improvement activities, as they relate to nursing and ancillary
				personnel, and assists the trauma medical director in carrying out the same
				functions for the physicians. Accountability for all activities of the trauma
				program resides with the medical director and the TC. The role of the TC in the
				educational, clinical, research, administrative, and outreach activities of the
				trauma program is determined by the needs of the trauma medical director and
				the institution.
Administrative and budgetary support is needed for the TC. The
				registrar, secretary, and nurse clinician(s) must be supervised by the
				TC.
The Trauma Registrar
				(TR)
The trauma registrar is an important member of the trauma team.
				Trauma registrars may be from diverse backgrounds such as nursing, medical
				records, computer science, medical informatics and other fields. The TR must
				work directly with the trauma team and report to the TC or may be the TC in
				smaller Level III hospitals. Trauma registrars will receive initial training as
				the Alabama State Trauma Registry is rolled out. They also must complete four
				hours of registry-specific continuing education per year which the Alabama
				Department of Public Health/Office of EMS and Trauma (ADPH/OEMS&T) will
				provide. Technical support must be available to assist with these training
				requirements.
Trauma Multidisciplinary Committee or Peer
				Review
There may be a multidisciplinary/peer review committee chaired
				by the trauma medical director or designee, with representatives from surgery,
				emergency medicine, anesthesia, and hospital administration. The purpose of the
				committee is to improve trauma care, along with other medical care by reviewing
				all trauma deaths, complications, and sentinel events with objective
				identification of issues and appropriate responses. A monthly meeting should be
				held.
General surgery attendance at the committee/peer review
				meetings is essential. The general surgeon is the foundation of care in the
				trauma program. All general surgeons on the trauma call panel should attend
				meetings, if possible.
The trauma medical director must ensure and document
				dissemination of information and findings from the peer review meetings to the
				noncore surgeons on the trauma call panel.
The trauma multidisciplinary or peer-review committee may also
				serve other Quality Assurance/Quality Improvement (QA/QI) functions or be
				combined as a part of other QA/QI functions.
Author:
John Campbell, M.D.
Statutory Authority:
Alabama Legislature, Act
				  299, Regular Session, 2007 (Code of Ala. 1975, §
										22-11D-1, et seq.)