***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.

Reporting year (12 months and should not be older than 14 months):

HOSPITAL INFORMATION

A. General Information:

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

***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.

1  Institutional Administrative Commitment

1.1 - Administrative Commitment (Type I):

A. Upload attestation of commitment to trauma program from Hospital Board of Directors (or other administrative governing authority). This attestation must include the following:

• Approval of the establishment of the trauma center at the level specified and of the application for verification

• Commitment to adherence to the standards required for the level of verification throughout the verification cycle

• Commitment to ensuring that the necessary personnel, facilities, and equipment are made available to support adherence to the standards

2 Program Scope and Governance

2.1 - State and Regional Involvement (Type II):

2.2 - Hospital Regional Disaster Committee (Type II):

2.3 - Disaster Management Planning (Type II):

Have the following documents available at time of survey:

• Hospital’s disaster plan that includes a surgical response and the following elements of orthopaedic trauma care: definition of critical personnel requirements and means of contact, initial triage of orthopaedic patients, and coordination of secondary procedures.
• The completed ‘Drills and Activations’ during reporting period

2.6 - Adult Trauma Centers Admitting Pediatric Patients (Type I):

2.7 - Trauma Multidisciplinary PIPS Committee (Type I):

2.8 - Trauma Medical Director Requirements (Type II):

A - Have the following documents available at time of survey:

 

1. Evidence of board certification or board eligibility for the TMD.
2. The roles and responsibilities document for the TMD’s position. (This question is shared between Standards 2.8 and Standard 2.9).
3. The TMD’s credentialing letter.
4. Evidence of ATLS certification for the TMD.
5. Call schedules over the course of the Reporting Period.
6. The TMD’s trauma CME certificates and Maintenance of Certification transcripts obtained during the Reporting Period/Designation Cycle (3 years).
7. Appointment letter and attendance records from national or regional trauma organization during the Reporting Period/Designation Cycle (3 years).

2.9 - Trauma Medical Director Responsibility and Authority (Type II):

2.10 - Trauma Program Manager Requirements (Type II):

2.11 - Trauma Program Manager Responsibilities and Reporting Structure
(Type II)

2.12 - Injury Prevention Program (Type II):

2.13 - Organ Procurement Program (Type II):

3 Facilities and Equipment Resources

3.1 - Operating Room Availability (Type I):

3.3 - Operating Room for Orthopaedic Trauma Care (Type II):

3.4 - Blood Products (Type I):

3.5 - Medical Imaging (Type I):

3.7 - Cerebral Monitoring Equipment (Type I) ** NEURO CAPABLE ONLY **

4 Personnel and Services

4.1 - Trauma Surgeon Requirements (Type II):

4.2 - Trauma Surgeon Coverage (Type I):

4.3 - Trauma Surgery Backup Call Schedule (Type II):

4.4 - Trauma Surgeon Presence in Operating Room (Type II):

4.5 - Specialty Liaisons to the Trauma Service (Type II):

COMPLETE THE FOLLOWING:

1. Trauma Surgeons: APPENDIX #2
2. Ortho Liaison: APPENDIX #3
3. Ortho Sugeon List: APPENDIX #4
4. ED Liaison: APPENDIX #5
5. ED MD LIST: APPENDIX # 6
6. Anethisia Liaison: APPENDIX #7
7. Radiology Liaison: APPENDIX #10
8. Griatric Provider Liaison: APPENDIX #14 (if applicable)

4.6 - Emergency Department Director (Type I):

4.7 - Emergency Department Physician Requirements (Type II):

4.11 - Orthopaedic Trauma Care (Type I):

4.13 - Anesthesia Services (Type I):

4.14 - Radiologist Access (Type I):

4.16 - ICU Director (Type II):

4.19 - ICU Provider Coverage for Level III Trauma Centers (Type I):

4.20 - ICU Nursing Staffing Requirement (Type II):

4.26 - Medical Specialists (Type II):

4.28 - Allied Health Services (Type II):

4.29 - Renal Replacement Therapy Services (Type II):

4.30 - Advanced Practice Providers (Type II):

4.31 - Trauma Registry Staffing Requirements (Type II):

4.32 - Trauma Registry Staffing Requirements (Type II):

4.33 - Trauma Registry Courses (Type II):

4.34 - Trauma Registrar Continuing Education (Type II):

4.35 - Performance Improvement Staffing Requirements (Type II):

5 Patient Care: Expectations and Protocols

5.1 - Clinical Practice Guidelines (Type II):

5.2 - Trauma Surgeon and Emergency Medicine Physician Shared
Responsibilities (Type II):

5.3 - Levels of Trauma Activation (Type II):

5.4 - Trauma Surgeon Response to Highest Level of Activation (Type I):

5.5 - Trauma Surgical Evaluation for Activations below the Highest Level
(Type II):

5.7 - Assessment of Children for Nonaccidental Trauma (Type II):

5.8 - Massive Transfusion Protocol (Type I):

5.9 - Anticoagulation Reversal Protocol (Type II):

5.10 - Pediatric Readiness (Type II):

5.11 - Emergency Airway Management (Type I):

5.12 - Transfer Protocols (Type II):

5.13 - Decision to Transfer (Type II):

5.14 - Transfer Communication (Type II):

5.15 - Trauma Diversion Protocol (Type II):

5.16 - Trauma Diversion Hours (Type II):

5.17 - Neurosurgeon Response (Type II):

5.18 - Neurotrauma Plan of Care for Level III Trauma Centers (Type II):

5.19 - Neurotrauma Contingency Plan (Type II):

5.20 - Treatment Guidelines for Orthopaedic Injuries (Type II):

5.21 - Orthopaedic Surgeon Response (Type II):

5.22 - Operating Room Scheduling Policy (Type II):

5.23 - Surgical Evaluation of ICU Patients (Type II):

5.24 - Trauma Surgeon Responsibility for ICU Patients (Type II):

5.25 - Communication of Critical Imaging Results (Type II):

5.26 - Timely Computed Tomography Scan Reporting (Type II):

5.27 - Rehabilitation Services during Acute Phase of Care (Type II):

5.28 - Rehabilitation and Discharge Planning (Type II):

5.29 - Mental Health Screening (Type II):

5.30 - Alcohol Misuse Screening (Type II):

5.31 - Alcohol Misuse Intervention (Type II):

6 Data Surveillance and Systems

6.1 - Data Quality Plan (Type II):

6.2 - Trauma Registry Patient Record Completion (Type II):

6.3 - Trauma Registry Data Collection and Submission (Type II):

7 Performance Improvement and Patient Safety (PIPS)

7.1 - Trauma PIPS Program (Type II):

7.2 - PIPS Plan (Type II):

7.3 - Documented Effectiveness of the PIPS Program (Type II):

7.4 - Participation in Risk-Adjusted Benchmarking Programs (Type II):

7.5 - Physician Participation in Prehospital Performance Improvement (Type II):

7.6 - Trauma Multidisciplinary PIPS Committee Attendance (Type II):

7.7 - Trauma Mortality Review (Type II):

A - Complete the sections below for all cases of trauma-related mortality and transfer to hospice during the Reporting Period: 

RESULTS OF MORTALITY REVIEW:

7.8 - Nonsurgical Trauma Admissions Review (Type II):

7.9 - Trauma Diversions Review (Type II):

7.10 - Prehospital Care Feedback (Type II):

8 Education: Professional and Community Outreach

8.1 - Public and Professional Trauma Education (Type II):

8.2 - Nursing Trauma Orientation and Education (Type II):

B - Complete the tables below:

Note: Please be prepared to provide CE certificates or transcripts to demonstrate compliance with this standard at the time of the site visit.

8.3 - Prehospital Provider Training (Type II):

Alternate Pathway

1. Make available the completed “Alternate Pathway Physician” information.
2. Upload the required documentation for the Alternate Pathway candidate(s) as necessary. For physicians seeking approval through the Alternate Pathway, this includes:
• Documentation of CME hours (i.e., transcripts)
• Proof of membership in and meeting attendance from a national or regional      trauma organization during
the Reporting Period
• PIPS committee meeting attendance rosters during the Reporting Period
• Credentials to provide trauma care
• Documentation evaluating the physician’s processes and outcomes of care (such as a PI report by the TMD demonstrating morbidity and mortality results for patients treated by the physician)

For physicians previously approved through the Alternate Pathway, this only includes documentation of CME
hours.

APPENDIX # 9 – PIPS Committee – Multidisciplinary Trauma Systems/Operations Committee

APPENDIX #8 – PIPS Committee- MULTIDISCPLINARY TRAUMA PEER REVIEW

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.

YOU HAVE COMPLETED YOUR LEVEL III TRAUMA APPLICATION!!!

PLEASE SELECT THE "SUBMIT" BUTTON BELOW TO FINISH THE APPLICATION PROCESS.