Level IV Trauma Center Application 2023

Utah Department of Health Bureau of Emergency Medical Services and Preparedness Application for Designation Level IV Trauma Center

Rev. 12/2023
***IMPORTANT***

This form has a "Save and Complete Later" function. As you save your progress and need to finish later, DO NOT CREATE A JotForm ACCOUNT!! Please continue SAVING WITHOUT CREATING AN ACCOUNT.
State of Utah Trauma Center Designation, Review, and Consultation Process

120 Days Prior to Survey:
- Submit Trauma Desgination Request Application
- First time applicants must have a minimum of 1 year of trauma registry data prior to application
90 Days Prior to Survey:
- State will provide site survey date
- Site agenda and reviewers names provided
- Details related to survey documents and details provided
30 Days Prior to Survey:
- Center must submit state required payment for site visit
- Site visits cancelled or rescheduled within 30 days of the scheduled survey date will forefit the site vist fee.
14-30 Days Following Survey:
- State will send written report citing Strengths, Deficiencies, Opportunities for Improvement, and Recommendations that were cited during the site visit.

Utah Department of Health Bureau of Emergency Medical Services and Preparedness Application for Designation Level IV Trauma Center

Rev. 02/2023
NAME OF PERSON COMPLETING THIS APPLICATION:

First NameLast Name
EMAIL OF PERSON COMPLETING THIS APPLICATION:
example@example.com
Application Date:

MonthDayYear
Type of Review:

ConsultationDesignationRe-Designation
Reporting year (12 months and should not be older than 14 months):
Reporting Date From:

MonthDayYear
Reporting Date To:

MonthDayYear
Hospital Name:
Hospital Address:

Street Address

Street Address Line 2

CityState

Zip Code
Hospital CEO/Administrator:
Date of Most Recent Designation Survey (if applicable)

MonthDayYear
Describe any program changes (Administrative) that have occurred since last review:
Number of deficiencies cited from last review (Briefly list deficiencies and how they were addressed):
Please List by Bullet or Numbered Points
Number of weaknesses cited from last review (Briefly list weaknesses and how they were addressed):
Please List by Bullet or Numbered Points
HOSPITAL INFORMATION

A. General Information:
1. Tax Status:

ProfitNon-ProfitGovernment

What is the hospital Payor Mix (Whole Numbers)

	All Patients (%)	Trauma Patients (%)
Commercial
Medicare
Medicaid
HMO/PPO
Uncompensated/Indigent

Hospital Beds (Do not Include Neonatal Beds):

	Adult	Pediatric	TOTAL
Licensed
Staffed
Average Census

I. REGIONAL TRAUMA SYSTEMS: OPTIMAL ELEMENTS, INTEGRATION, AND ASSESSMENT
1. Does the trauma center leadership participate actively in a state and regional system? (CD 1-1, 1-2, and 1-3) (If "yes", please describe)

YesNo
If ‘Yes’, please briefly describe:
2. Attendance and participation threshold at regional and State Trauma Systems meetings of 75% are required. (State Criteria) **Provide evidence of attendance (at time of survey)**

YesNo
II. DESCRIPTION / TRAUMA LEVEL AND ROLES
1. Does this trauma center have an integrated, concurrent performance improvement and patient (PIPS) program to ensure optimal care and continuous improvement in care? (CD 2-1)

YESNO
** MUST PROVIDE A WRITTEN PIPS PLAN AT TIME OF SURVEY**
2. Does the trauma center provide the necessary human and physical resources (physical plant and equipment) to properly administer acute care consistent with their level of verification? (CD 2-3)

YESNO
3. Complete the table below for the total number of emergency department (ED) visits for the reporting year with ICD-10 codes according to State Rule R426-9-700. Must include at least one of the following injury diagnostic codes: ICD10 Diagnostic Codes: S00-S00 with 7th character modifiers of A, B, or C only, T07, T14, T20-T28 with 7th character modifier of A, T30-T32, T79.A1-T79.A9 with 7th character modifier of A excluding the following isolated injuries: S00, S10, S20, S30, S40, S50, S60, S70, S80, S90. Late effect codes, which are represented using the same range of injury diagnosis codes but with the 7th digit modifier code of D through S are also excluded

a. ED Visits:

	TOTAL
Admitted ED Trauma Visits (Regardless of Service)
Blunt Trauma Percentage
Penetrating Trauma Percentage
Thermal Percentage

b. Disposition ED Trauma Visits:

	Number of Each
Discharged
Transferred Out
Admitted
DIED in the ED (Excluding DOAs)
DOAs
TOTAL

4. Are all patients reviewed timely by the TPM and TMD for appropriateness of admission and other opportunities for improvement? (CD 2-1)

YESNO
5. Is the attendance threshold of 80% met for physician or midlevel presence in the emergency department for patients with highest level of activation? (CD2-8)

YESNO
If "NO", please explain:
6. Is the physician or midlevel arrival within 30 minutes monitored by the hospital’s trauma PIPS program? (CD 2-8)

YESNO
IF "NO", PLEASE EXPLAIN:
7. Are collaborative treatment and transfer guidelines reflecting the Level IV facilities’ capabilities developed and regularly reviewed, with input from higher-level trauma centers in the region? (CD 2–13)

YESNO
** MUST PROVIDE A WRITTEN TRANSFER PLAN AT TIME OF SURVEY**
8. Does the facility have 24-hour emergency coverage by a physician or midlevel provider? (CD 2–14)

YESNO
a. Please explain ED Provider Coverage:
9. Is the emergency department continuously available for resuscitation with coverage by a registered nurse and physician or midlevel provider, and does it have a physician director? (CD 2–15)

YESNO
a. Please explain ED Provider Coverage:
10. Are all ED providers current in Advanced Trauma Life Support® certification as part of their competencies in trauma? (CD 2–16)2–16). (All Non-ED Boarded Providers in Level IV Centers)

YESNO
11. Are the trauma medical director and trauma program manager knowledgeable and involved in trauma care and work together with guidance from the trauma peer review committee to identify events, develop corrective action plans, and ensure methods of monitoring, reevaluation, and benchmarking? (CD 2-17)

YESNO
** MUST PROVIDE EXAMPLES OF MEETING CRITERIA AT TIME OF SURVEY**
12. Does the multidisciplinary trauma peer review committee meet regularly, with required attendance of medical staff active in trauma resuscitation, to review systemic and care provider issues, as well as propose improvements to the care of the injured patient? (CD 2–18)

YESNO
** MUST PROVIDE EXAMPLES OF MEETING CRITERIA TERIA AT TIME OF SURVEY**
13. Does the PIPS program have audit filters to review and improve pediatric and adult patient care (CD 2–19)?

YESNO
** MUST PROVIDE EXAMPLES OF MEETING CRITERIA AT TIME OF SURVEY**
14. Does the trauma center actively participate in regional and statewide trauma system meetings and committees that provide oversight? (CD 2–20)

YESNO
** MUST PROVIDE EXAMPLES OF MEETING CIRTERIA AT TIME OF SURVEY**
15. Is the trauma center the local trauma authority and assume the responsibility for providing training for prehospital and hospital based providers? (CD 2–21)

YESNO
** MUST PROVIDE EXAMPLES OF MEETING CRITERIA AT TIME OF SURVEY**
16. Does the facility participate in regional disaster management plans and exercises? (CD 2-22)

YESNO
** MUST PROVIDE EXAMPLES OF MEETING CRITERIA AT TIME OF SURVEY**
III. PREHOSPITAL TRAUMA CARE
1. How does the trauma program participate in the training of prehospital personnel, the development and improvement of prehospital care protocols, and performance improvement and patient safety programs (CD 3-1)?
Please Provide Details (HAVE EMS OUTREACH EXAMPLES AT TIME OF SURVEY)
2. Describe how protocols that guide prehospital trauma care are established by the trauma health care team, including surgeons, emergency physicians, medical directors for EMS agencies, and basic and advanced prehospital personnel (CD 3-2):
Please Provide Details (HAVE EXAMPLES AVAILABLE AT TIME OF SURVEY)
3. Briefly describe the air medical support services available for your trauma program, including rotor wing and fixed wing services:
Please Provide Details
4. Does your hospital provide online medical control for prehospital trauma patients?
IF YES, Please Provide Details
5. When the trauma center is required to go on bypass or to divert, what is your process? (CD 3–7)
Please Provide Details
IV. INTERHOSPITAL TRANSFER
1. Is there direct physician/midlevel-to-physician contact when patients are transferred out of your facility? (CD 4–1)
IF YES, Please Provide Details
2. Does your trauma service routinely evaluate all transfers through the PIPS program, including transport activities? (CD 4–3)
IF YES, PLEASE DESCRIBE PROCESS OF HOW TRANSFERS ARE REVIEWED
3. Total number of transfers:
PROVIDE TOTAL # HERE
V. HOSPITAL ORGANIZATION AND THE TRAUMA PROGRAM
1. Does the hospital have the commitment of the institutional governing body and medical staff to become a trauma center? (CD 5–1)

YESNO
2. TRAUMA PROGRAM MANAGER (TPM)

First NameLast Name
Education:

Associate in NursingBachelor in NursingMasters in NursingOther Degree (Please describe)
Describe Other:
a. TPM reporting status. (Please describe structure)
Describe reporting structure
b. How many years has the TPM been at that position or date of appointment to this position?
c. Total number of FTE's:
Hour Many Hours is TPM given
d. List the number of support personnel including names, titles, and FTEs:
3. Trauma Medical Director (TMD)

First NameLast Name
a. TMD reporting status. (Please describe structure)
Describe reporting structure
4. Are the criteria for graded activation clearly defined by the trauma center, including the highest level of activation including the six required criteria listed in the ACS BOOK OF OPTIMAL CARE? (CD 5–13)

YESNO
** HAVE ACTIVATION CRITERIA AVAILABLE AT TIME OF SURVEY**
5. Are the activation criteria reviewed annually? (CD 5-13)

YESNO
6. Does the facility have a multi-level response?

YESNO
7. Do you have geriatric-trauma activation criteria?

YESNO
8. Is the team fully assembled within 30 minutes? (CD 5-15)

YESNO
9. Is the activation criteria evaluated on an ongoing basis in the PIPS process to determine their positive predictive value in identifying patients who require the resources of the full trauma team? (CD 5-16)

YESNO
10. Number of trauma activations :

a. Statistics for level of response (CD 5-14. CD 5-15. Chapter 16):

	Number of Activations	Percent of total activations (=%100)
Highest Level
Intermediate Level
Lowest Level (Consult)
Total:

11. Which trauma team members respond to each level of activation?
a. Please provide additional details of activation as needed:
Please upload file showing Level of activation team members responding to each level of activation:

PDF FILE
Cancelof
VI. GENERAL SURGERY
1. Briefly describe how the TMD oversees all aspects of the multi-disciplinary care, from the time of injury through discharge:
2. If applicable, is is there an on-call Surgical Coverage for Trauma Patients and is the maximum response time criteria of 30 minutes or less achieved? (CD 2-8)

YESNO
3. Is response time tracked from patient arrival rather than from notification or activation time? (CD 2-8)

YESNO
** HAVE PROCESS AVAILABLE AT TIME OF SURVEY**
4. Does the PIPS Program demonstrate the surgeon’s (if available) attendance for the highest-level at least 80 percent of the time? (CD 2-8)

YESNO
** HAVE PROCESS AVAILABLE AT TIME OF SURVEY**
5. Is there a published schedule of general surgical coverage (where applicable)?

YESNO
** HAVE PROCESS AVAILABLE AT TIME OF SURVEY**
VII. EMERGENCY MEDICINE
**Have a copy of the ED trauma flow sheet available at the time of the site visit.**
1. Briefly describe the initial credentialing requirements for nurses who treat trauma patients in the ED:

a. NURSING EDUCATION

	% COMPLETED
ATCN
ENPC
TNCC
PALS
ACLS
TCAR

b. ADVANCED CERTIFICATIONS NURSING EDUCATION

	% COMPLETED
CCRN
CEN
PCEN
TCRN
OTHER

2. Briefly describe continuing education for the nurses working in ED:
3. Do emergency physicians ever respond to in-house emergencies? If yes, briefly describe how the ED is covered in their absence and how this is incorporated in your PI process:
4. Is there a representative from the emergency department participating in the pre-hospital PIPS program?

YESNO
5. Does the emergency medicine liaison on the multidisciplinary trauma peer review committee attend a minimum of 50% of the committee meetings?

YESNO
6. Have all of the physicians who are board certified/eligible in emergency medicine successfully completed the ATLS course at least once?

YESNO
7. Do the other physicians who are board certified/eligible other than emergency medicine have current ATLS status? (Working in the ED and taking care of Trauma Patients)

YESNO
VIII. NEUROSURGERY (N/A)
IX. ORTHOPAEDIC SURGERY (IF APPLICABLE)
1. Describe the orthopedic surgery coverage at your facility:
2. Is there an orthopedic surgeon who is identified as the liaison to the trauma program?

YESNO
3. Does the PIPS process review the appropriateness of the decision to transfer or retain major orthopaedic trauma patients? (Yes/No)

YESNO
4. Average time to first antibiotic administration for open fractures secondary to a blunt mechanism:
5. Percent of femoral shaft fractures (defined as intramedullary rod, external fixation or ORIF) stabilized within 24 hours of admission:
6. Does the orthopaedic service actively participate in the overall trauma PIPS program and the multidisciplinary trauma peer review committee? (Yes/No)

YESNO
X. PEDIATRIC TRAUMA CARE:
1. Trauma care provided to pediatric patients must have a pediatric specific PI program that reviews trauma care for all pediatric trauma patients. Do you have this process in place?

YESNO
2. Appropriate equipment, policies and PI must be in place for pediatric patients. Please have evidence available during survey. Please explain your pediatric PI process below.
XI. COLLABORATIVE CLINICAL SERVICES:
1. ANESTHESIOLOGY (if available):
a. Describe details os how anesthesia services are used in your trauma program:
2. OPERATING ROOM (if available):
a. Is the operating room adequately staffed and available within 30 minutes?

YESNO
Number of operating rooms:
b. Describe details of your PIPS program related to operating room service related to availability, schedule and response to trauma:
3. POST - ANESTHESIA CARE UNIT (if available):
a. Describe details of your PIPS program related to PACU service related to availability, schedule and response to trauma. Please include levels of nursing care and staffing:
4. RADIOLOGY:
a. Is conventional Radiology and CT services available 24 hours per day either in house or on call. (CD 11-29)

YESNO
b. Does the trauma center have policies designed to ensure that appropriately trained providers accompany trauma patients who may require resuscitation and monitoring during transportation to and while in the radiology department?

YESNO
c. When the CT technologist responds from outside the hospital, the PI program documents response time and any delays to patient care. Please describe details of your PI process related to your radiology services to the trauma program:
d. Who provides FAST for trauma patients? (Check all that apply)

RadiologyED Physician/MidlevelFAST studies not performedOther
e. Describe your institution’s policy for obtaining FAST exams for injured patients:
f. Are radiologists available within 30 minutes in person or by tele-radiology, when requested for the interpretation of radiographs? Please describe your radiologist coverage and process for read-results:
g. Is critical information deemed to immediately affect patient care verbally communicated to the trauma team in a timely manner?

YESNO
h. PIPS program should document the response times when the CT technologist responds? If 'Yes', briefly describe:
5. INTENSIVE CARE UNIT (ICU) (IF AVAILABLE):
a. Does your facility have an ICU?

YESNO
Number of ICU beds:
b. Please describe how the PIPS program reviews ICU admissions and transfers to ensure appropriate patients are selected to remain at a Level IV center vs. being transferred to a higher level of care. (CD 11-60)
6. RESPIRATORY SERVICES:
a. Describe respiratory therapy coverage:
7. CLINICAL LABORATORY AND BLOOD BANK:
a. Are laboratory services available 24 hours per day for the standard analysis of blood, urine, and other body fluids, including micro-sampling when appropriate? (CD 11-80)

YESNO
b. Is the blood bank capable of blood typing and cross matching? (CD 11-81)

YESNO
c. What is the average turnaround time for typespecific blood (minutes)
d. What is the average turnaround time for full crossmatched blood (minutes)?
e. Describe the availability, including quantity, of the blood products available at your facility:
f. Does the facility have a massive transfusion protocol developed collaboratively between the trauma service and the blood bank? (CD 11-84)

YESNO
MTP PROCESS:

Upload MTP files here
Cancelof
g. Describe your PIPS process, if any, for MTP activation:
h. Do you have an anticoagulation reversal protocol?

YESNO
i. Please describe reversal protocol:
8. ADVANCED PRACTITIONERS:
a. Does the trauma or ED utilize APs in the initial evaluation of trauma patients during the activation phase?

YESNO
b. If yes, are the APPs current in ATLS? (CD 11-86)

YESNO
c. Which advanced practitioners participate in the initial evaluation of trauma patients? (choose all that apply)

TraumaEmergency MedicineAnesthesiology
d. Does the trauma program demonstrate appropriate orientation, credentialing processes, and skill maintenance for advanced practitioners, as witnessed by an annual review by the TMD? (CD 11-87)

YESNO
e. Describe APP orientation and annual skills review:
XII. REHABILITATION (IF AVAILABLE):
1. Describe services if available:
XIII. RURAL TRAUMA CARE:
THE FOLLOWING CRITERIA MUST BE MET (Please Check ALL):

Direct communication of the physician or midlevel provider with a physician at thereceiving hospital is required. (CD 4-1)All transfers must be evaluated as part of the PIPS program. (CD 4-3).The foundation for evaluation of a trauma system is the establishment and maintenance of a trauma registry (CD 15–1).Issues that must be reviewed will revolve predominately around (1) system and process issues such as documentation and communication; (2) clinical car, including identification and treatment of immediate life-threatening injuries (ATLS); and (3) transfer decisionsThe best possible care for patients must be achieved with a cooperative and inclusive program that clearly defines the role of each facility within the system (CD 1–1).
XIV. BURN CARE:
1. Trauma centers that refer burn patients to a designated burn center must have in place written transfer agreements with the referral burn center (CD 14–1)

Transfer Agreement in place
XV: TRAUMA REGISTRY:
1. What registry program does the hospital use?
2. Are trauma registry data collected and analyzed? (CD 15-1)

YESNO
3. Is this data collected and submitted in a timely fashion so it can be aggregated and analyzed at the state level? (Rule 426-9-700)

YESNO
4. Does the trauma registry support the PIPS process? (CD 15–3)( 15-4)

YESNO
a. Describe how the registry is used in the PIPS process to identify and track opportunities for improvement:
b. Describe how registry findings are used to identify injury prevention priorities that are appropriate for local implementation:
5. Are at least 80% of the trauma cases entered into the trauma registry within 60 days of discharge? (CD 15-6)

YESNO
6. Has the registrar attended or previously attended two courses within 12 months of being hired? (check all that apply)

The American Trauma Society’s Trauma Registrar CourseThe Association of the Advancement of Automotive Medicine’s Injury Scaling CourseIf Other, please briefly describe:
EXPLAIN "OTHER":
7. Does the trauma program ensure that trauma registry confidentiality measures are in place? (CD 15-8)

YESNO
a. EXPLAIN THESE MEASURES:
8. Are there strategies for monitoring data validity for the trauma registry? (CD 15-10)

YESNO
a. DESCRIBE VALIDITY PROCESS:
XVI: PERFORMANCE IMPROVEMENT AND PATIENT SAFETY:
1. Is the PIPS program supported by a reliable method of data collection that consistently obtains the necessary information to identify opportunities for improvement? (CD 15-1)

YESNO
a. Describe your process for identification and review of all trauma patients:
2. Does the process of event identification and level of review result in development of corrective action plans, and methods of monitoring, reevaluation, and benchmarking? (CD 2-17)

YESNO
If Yes, provide an example:
3. Describe how your PI plan incorporates or assigns levels of review (primary, secondary, tertiary) for events/issues identified through the PI process:
4. Does peer review occur at regular intervals to ensure that the volume of cases is reviewed in a timely fashion? (CD 2–18)

YESNO
5. Describe your peer review process (include review process for mortality, adverse events, and problem trends):
6. List attendees and percent attendance at peer review meetings for reporting year:

Upload Attendee List Here
Cancelof
7. Is the trauma PIPS program empowered to address events that involve multiple disciplines? (CD 5-1)

YESNO
a. Is the PIPS program endorsed by the hospital governing body as part of its commitment to optimal care of injured patients? (CD 5-1) (Yes/No)

YESNO
b. Is there adequate administrative support to ensure evaluation of all aspects of trauma care? (CD 5-1)

YESNO
c. Do the TMD and TPM have authority and are they empowered by the hospital governing body to lead the program? (CD 5-1)

YESNO
8. Is the TMD the chair of the peer review committee? (Yes/No)

YESNO
9. Is there a multidisciplinary performance improvement process to evaluate over triage and under triage rates to attain the optimal goal of less than 5 percent undertriage?

YESNO
a. Describe how your center defines over and undertriage and your PI process for each:
10. The trauma PIPS program must be supported by a registry and a reliable method of concurrent data collection that consistently obtains information necessary to identify opportunities for improvement (CD 15–3). Please describe this process in detail:
11. All process and outcome measures must be documented within the trauma PIPS program’s written plan and reviewed and updated at least annually (CD 16–5). Describe this process in detail:
12. What is your PI process for identifying delays in completion of radiologic studies or interpretation of results? Describe in detail:
13. If applicable, describe your PI process for reviewing transfers to a higher level of care within your institution to determine the rationale for transfer, adverse outcomes, and opportunities for improvement. (CD 16-8)
14. Describe the mechanisms used to identify events for review by the trauma PIPS program (CD 16-10):
15. Describe the process used by the PIPS program for verification and validation of identified events (CD 16-11):
16. Does your trauma program have a written PI plan outlining your PIPS process? (CD 16-5) (HAVE A COPY AVAILABLE AT SURVEY)

YESNO
17. List 2 examples of loop closure involving peer review issues during the reporting year:
18. List 2 examples of loop closure involving system issues during the reporting year:
19. How is PI integrated with the overall hospital PIPS program?
XVII: OUTREACH and EDUCATION:
1. Is the trauma center engaged in public and professional education? (CD 17-1)

YESNO
2. Describe the hospitals mechanism for trauma-related education for nurses involved in trauma care?
3. The successful completion of the ATLS® course, at least once, is required in all levels of trauma centers for all general surgeons (CD 6-9), emergency medicine physicians (CD 7-14) and midlevel providers (CD 11-86) on the trauma team. PLEASE PROVIDE DETAILS OF THIS CRITERIA.
XVIII: PREVENTION
1. Does the trauma center demonstrate the presence of injury prevention activities that centers on priorities based on local data? (CD 18–1)

YESNO
2. Does your trauma center have someone in a leadership position that has injury prevention as part of his or her job description? (CD 18-2) (Yes/No) Please provide documentation along with job description at time of survey:

YESNO
3. What are the three leading causes of injury in your community?
Please list
4. Describe the PIPS process ensuring there is universal screening for alcohol use for all injured trauma patients? (CD 18-3)
Please list
XIX: Trauma Research and Scholoarship: N/A for level IV Centers
XX: DISASTER PLANNING:
1. Trauma center meet the disaster-related requirements of the Joint Commission? (CD 20–1).

YESNO
2. Are there hospital drills that test the hospital's disaster plan conducted at least twice a year, including actual plan activations that can substitute for drills? (CD 20–3) Please provide documentation that supports these drills as required (available during site survey):

YESNO
3. Does the trauma center have a hospital disaster plan described in the hospital’s policy and procedure manual or equivalent? (CD 20-4) Please have this plan available at time of survey:

YESNO
XXI. SOLID ORGAN PROCUREMENT ACTIVITES
1. Does your trauma center have written protocols defining the clinical criteria and confirmatory tests for the diagnosis of brain death (CD 21–3). (HAVE DOCUMENTS AVAILABLE AT TIME OF SURVEY)

YESNO
APPENDIX #1 Trauma Medical Director (TMD)
APPENDIX #2 TRAUMA SURGEONS (LIST ALL SURGEONS TAKING TRAUMA CALL)
APPENDIX #3 Orthopedic Liaison to the Trauma Program
APPENDIX #4 ORTHOPEDIC SURGEONS (LIST ALL SURGEONS TAKING TRAUMA CALL)
APPENDIX #5 Emergency Medicine Liaison to the Trauma Program
APPENDIX #6 Emergency Medicine (Please list all emergency department physicians on the trauma panel (those who care for trauma patients)
APPENDIX #7 Anesthesiologist Liaison to the Trauma Program
APPENDIX # 9 – PIPS Committee – Multidisciplinary Trauma Systems/Operations Committee

Attendance of specialty panel members:

	% of Attendance
TMD:
TPM:
Trauma Surgeons:
Emergency Medicine:
Orthopedics:
Anesthesiologist:
Radiologist:
LAB:

APPENDIX #8 – PIPS Committee- MULTIDISCPLINARY TRAUMA PEER REVIEW

Attendance of specialty panel members:

	% of Attendance
TMD:
TPM:
Trauma Surgeons:
Emergency Medicine Liaison or Designated Representative:
Orthopaedics Liaison or Designated Representative:
Anesthesia Liaison or Designated Representative:
Radiologist Liaison or Designated Representative:
ICU Director Liaison or Designated Representative:

APPENDIX #10 Radiologist Liaison to the Trauma Program.

Utah Department of Health Office of Emergency Medical Services and Preparedness Trauma Center & Resource Hospital Capabilities

Rev. 02/2023
Facility Administrator

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Department Medical Director

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Department Nurse Manager

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Pediatric Emergency Care Coordinator

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
EMS Agencies in Catchment Area
Dispatch Center Name:
Dispatch Center Phone Number:
Please enter a valid phone number.
Facility Helipad GPS Location:
THE RESPONSES TO THESE QUESTIONS ARE REQUIRED IN ACCORDANCE WITH STATE RULES: R426-9-500 and R426-9-1000

PLEASE RESPOND AS ACCURATELY AS POSSIBLE - USE AS MUCH SPACE AS YOU NEED

If you need clarification or assistance, please e-mail Carl Avery at carlavery@utah.gov

or call (385) 522-1685
State of Utah Trauma Center Designation, Review, and Consultation Process

120 Days Prior to Survey:
- Submit Trauma Desgination Request Application
- First time applicants must have a minimum of 1 year of trauma registry data prior to application
90 Days Prior to Survey:
- State will provide site survey date
- Site agenda and reviewers names provided
- Details related to survey documents and details provided
30 Days Prior to Survey:
- Center must submit state required payment for site visit
- Site visits cancelled or rescheduled within 30 days of the scheduled survey date will forefit the site vist fee.
14-30 Days Following Survey:
- State will send written report citing Strengths, Deficiencies, Opportunities for Improvement, and Recommendations that were cited during the site visit.
***IMPORTANT***

This form has a "Save and Complete Later" function. As you save your progress and need to finish later, DO NOT CREATE A JotForm ACCOUNT!! Please continue SAVING WITHOUT CREATING AN ACCOUNT.
Should be Empty:

Utah Department of Health Bureau of Emergency Medical Services and Preparedness Application for Designation Level IV Trauma Center

Utah Department of Health Bureau of Emergency Medical Services and Preparedness Application for Designation Level IV Trauma Center

Utah Department of Health Office of Emergency Medical Services and Preparedness Trauma Center & Resource Hospital Capabilities