Maine EMS Trauma System Plan

OCTOBER 31, 1996

 Maine EMS Trauma System Plan
Table of Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Trauma Center Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Trauma System Hospital Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
What is in this Package? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Maine EMS, Trauma Advisory Committee Members, 1996 . . . . . . . . . . . . . . . . . . . . . . . 4
Introduction to the Hospital Resource Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Hospital Resource Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Introduction - Prehospital Triage Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Prehospital Triage Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Prehospital Trauma Triage Schematic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Introduction - Site survey process for Trauma Centers . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Designation Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Site Survey Process for Trauma Centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
The pre-survey questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
The Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
If a hospital applies to be a trauma system hospital: . . . . . . . . . . . . . . . . . . . . . . . 20
If a hospital applies to be a trauma center: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
The Survey Team for Trauma Center Applicants: . . . . . . . . . . . . . . . . . . . . . . . . 20
System Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
On-Site Survey Agenda for Trauma Centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Educational Outreach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Mission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Introduction - Interfacility Transfer Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Interfacility Transfer Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Procedure for Interhospital Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Decision to Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Decision to Receive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Once the Decision to Transfer is Made . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
After Arrival at the Trauma Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Maine State Trauma System Transfer Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
The Quality Improvement Program - Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Responsibilities of Trauma Centers and System Hospitals . . . . . . . . . . . . . . . . . . 33
Trauma System Goals and Responsibilities - Tree Diagram . . . . . . . . . . . . . . . . . 34
Quality Improvement for Trauma Centers - Provide Institutional Support . . . . . 36
Quality Improvement for Trauma Centers - Education . . . . . . . . . . . . . . . . . . . . 39
Quality Improvement for Trauma Centers - Monitor the Process & Outcomes of
Trauma Care to Ensure Quality, Efficacy, Cost Effectiveness, & Timeliness
44

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Quality Improvement for Trauma Centers - Have a "Public Voice" & Support the
Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Quality Improvement for System Hospitals - Provide Institutional Support,
Structure, & Organization to Promote Quality & Future Growth . . . . . 48
Quality Improvement for System Hospitals - Education . . . . . . . . . . . . . . . . . . . 50
Quality Improvement for System Hospitals - Data Management, . . . . . . . . . . . 52
Pre-survey Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Surveyor’s Guide to the Hospital Resource Table . . . . . . . . . . . . . . . . . . . . . . . . 77

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This document contains the Trauma Plan for the State of Maine. Also contained within is an
application to participate in the State of Maine Trauma System.

Introduction
By the end of the Vietnam War, it had become apparent that war casualties were significantly
reduced by the military’s organized system of trauma care. Soon these principles were adapted
for civilian trauma care systems. Organized regional trauma systems in Maryland and Orange
County California demonstrated significantly lower morbidity and mortality for trauma victims.
These successes led to the first round of Federal Trauma grants in the late 1970's and early 1980's.
The trauma systems that developed relied on designated regional trauma centers. However,
trauma centers became overburdened with minor trauma cases that could also be cared for at local
hospitals. Because of these and other difficulties, trauma system development stagnated.
Preventable death and morbidity did not abate. Rural areas in particular had higher morbidity and
mortality due to long transport times, and lack of organized trauma care. In the early 1990's
Congress began to appreciate that rural areas could also benefit from organized trauma systems.
In 1992, Congress funded trauma system planning grants. Special consideration was given to
rural areas that lacked organized trauma systems.

In early 1992, Maine Emergency Medical Services, (MEMS), established a Trauma Advisory
Committee, (TAC), to create a statewide trauma plan. In September 1992, MEMS received a
Federal Trauma Planning grant to assist in that effort. The TAC, which was then formalized by
Maine Statute (5 MSRA §12004-I, sub-§49-B), has assisted MEMS in the establishment,
implementation and management of a comprehensive trauma care system for the state.

TAC members have been drawn from around the state. Membership includes surgeons,
emergency physicians, nurses, prehospital care providers, hospital administrators representing the
Maine Hospital Association, and concerned citizens. Leaders of the American College of
Surgeons Maine Committee on Trauma, Maine Chapter of the American College of Emergency
Physicians, and nursing organizations have all been actively involved. The TAC worked very hard
to build a comprehensive, state-wide trauma system for Maine.

Every hospital in the state is important to the functioning of the system and every hospital is
indeed a Trauma System Hospital. The responsibility and the challenge for every hospital is to
provide excellent clinical services. The reward for participation will be inclusion in a coordinated,
approved system of care, CQI based continuing education, outcome analysis, and community
recognition as a Center of Excellence in trauma care.

The resulting system of care will be known as the Maine Trauma System. Hospitals will
participate in the System in one of two ways, as a Trauma Center or as a System Hospital.

Trauma Center Responsibilities

1
A few system hospitals may elect to take on the responsibilities of being a Trauma Center. A
major requirement is institutional and medical staff commitment to trauma management, with a
surgeon-led Trauma Service.

Specific features of this commitment include:

• A Trauma Service with defined surgeon leadership;

• A functioning multi-disciplinary, multi-specialty Trauma Committee;
• A funded Trauma Nurse Coordinator to provide clinical, educational, and data/analytic
services;
• Continuous availability of critical support and diagnostic services;
• A broad-based educational program with a regional and hospital focus;
• A willingness to fund the development and maintenance of the Trauma System, locally
regionally, and statewide;
• The Trauma Nurse Coordinators will work with Maine EMS to support the statewide
Trauma System.

Trauma System Hospital Responsibilities

Requirements include commitment to trauma system development and data sharing. Little, if any,
additional cost or personnel will be necessary.

Specific requirements include:

• A functioning Emergency Department, staffed with physicians or physician-extenders who

regularly participate in trauma care continuing education;
• A Medical Information system/department;
• Communication technology;
• A person designated to work with the regional Trauma Nurse Coordinator; and
• A commitment to Trauma System integration, participation in educational programs and
allowing quality improvement review of process and outcome of patient clinical
interactions.

What is in this Package?

This package contains the Trauma System Plan. Maine EMS, in conjunction with the Maine
Hospital Association, trauma physicians, and nurses from around the state, have agreed to
participate in this voluntary trauma plan.

Most trauma patients in Maine can receive excellent care in their local community hospitals.
However, one goal is to identify those patients who will benefit most from the specialized
resources of a trauma center. It is not the TAC’s intention to mandate a change in a physician’s
or hospital’s pre-existing specialty referral patterns.
This manual contains the following sections:

2
• A list of resources needed by trauma system hospitals and trauma centers;
• Trauma field triage protocols;
• A description of the site survey process for trauma centers and trauma system hospitals;
• An application to participate;
• A quality improvement program to measure and improve the quality of trauma care in
Maine;
• An educational outreach program for participating trauma system hospitals; and
• Interfacility transfer guidelines to ensure the smooth transfer of seriously traumatized
patients to trauma centers for specialized care.

Maine hospitals that participate in this program benefit in several ways:

• They will have access to on-site educational programs and case reviews provided by
trauma centers;
• They will get timely feedback from trauma centers about transferred patients;
• They will get trauma registry software and participate in a statewide registry of trauma
care;
• They will serve their communities better by participating in an organized system of trauma
care. A large body of research has shown marked improvement in patient outcomes from
serious trauma in areas of the country where such plans have been established. Universal,
voluntary participation in this trauma plan will bring these outcome improvements to all
the citizens of Maine.

Executive Summary
The Trauma Advisory Committee, (TAC), intends that Maine’s trauma system will be inclusive.
The TAC hopes that every hospital in the state will choose to participate. This plan was
developed by physicians, nurses, hospital administrators from small, medium, and large hospitals,
prehospital care providers, and representatives from the Maine Hospital Association.

The plan identifies two types of trauma facilities. All hospitals are expected to participate as
Trauma System Hospitals Virtually every acute care hospital in Maine meets the qualifications
needed to become a trauma system hospital. Some hospitals may make a special commitment to
become Trauma Centers. Maine EMS will actively promote each hospital as a participating
Trauma System Hospital in this comprehensive trauma system. Hospitals are encouraged to
publicize their participation as a system hospital. Trauma centers may not advertise their
designation to the public.

Inside you will find the documents describing the requirements of each type of hospital, and
instructions for application.

Thank you very much for your participation in this important patient care initiative in Maine!

3
Maine EMS, Trauma Advisory Committee Members, 1996
Altaf Ahmed, M.D. Meredith Beals, R.N.
Mid-Maine Medical Center 229 Vaughn Street
North Street Portland, ME 04102
Waterville, ME 04901
Pret Bjorn, R.N. David Brown, M.D.
Eastern Maine Medical Center Central Maine Orthopedics
489 State Street 2 Great Falls Plaza
Bangor, ME 04401 Auburn, ME 04210
Allen Browne, M.D. David Clark, M.D.
7 Bramhall Street 229 Vaughn Street
Portland, ME 04102 Portland, ME 04102
Roy Cobean, M.D. Dwight Corning, EMT-P
229 Vaughn Street Pace Paramedic Service
Portland, ME 04102 80 Main Street
Norway, ME 04268
James Curtis, M.D. Mary Day
Emergency Department Eastern Maine Medical Center
Penobscot Bay Medical Center 489 State Street
Rockland, ME 04841 Bangor, ME 04401
Norman Dinerman, M.D. Harold Gerrish, D.D.S.
Director, Emergency Medicine P.O. Box 345
Eastern Maine Medical Center Dover-Foxcroft, ME 04426
489 State Street
Bangor, ME 04401
Carol Grant Harry Grimmnitz, M.D.
Houlton Regional Hospital Director, Emergency Medicine
20 Hartford Street Kennebec Valley Medical Center
Houlton, ME 04730 6 E. Chestnut Street
Augusta, ME 04330
George Higgins, M.D. Barbara Hildbreth, R.N.
Director, Emergency St. Joseph's Hospital
Maine Medical Center 360 Broadway
22 Bramhall Street Bangor, ME 04401
Portland, ME 04102
Larry Hopperstead, M.D. George Hutchins, M.D.
Director, Trauma Surgery Southern Maine Medical Center
Central Maine Medical Center One Medical Center Drive
300 Main Street Biddeford, ME 04005
Lewiston, ME 04240
James Jordan Thomas Judge, EMT-P
Box 893, RR #1 315 Harlow Street
Hampden, ME 04444 Bangor, ME 04401
Clarence LaLiberty Vice President of Operations
4
Maine Medical Center Joanne LeBrun
22 Bramhall Street EMS Regional Coordinator
Portland, ME 04102 Tri-County EMS, Inc.
300 Main Street
Lewiston, ME 04240
Peter Levasseur, M.D. Laura Lounder
Director, Emergency Medicine Emergency Department
Kennebec Valley Medical Center St. Joseph's Hospital
6 East Chestnut Street 360 Broadway
Augusta, ME 04330 Bangor, ME 04401
Jack McCormack, CEO Kevin McGinnis
Cary Medical Center Director of Maine EMS
Van Buren Road 16 Edison Drive
Box 37 Augusta, ME 04330
Caribou, ME 04736
James McKenney, EMT-P Cathy Moss, R.N.
151 Academy Street 229 Vaughn Street
Presque Isle, ME 04769 Portland, ME 04102
Lee Myles Susan O'Connor, M.D.
Chief Operating Officer Eastern Maine Medical Center
St. Mary's Regional Medical Center 489 State Street
45 Golder Street Bangor, ME 04401
Lewiston, ME 04240
Vicki Purgavie Maryann Russell, R.N.
Maine Hospital Association 12 Powder Horn Avenue
150 Capitol Street Scarborough, ME 04074
Augusta, ME 04330
Sid Salvatore, R.N. Cindy Scribner, R.N.
Mount Desert Island Hospital Trauma Nurse Coordinator
P.O. Box 8 Central Maine Medical Center
Bar Harbor, ME 04609 300 Main Street
Lewiston, ME 04240
Peter Siviski, M.D. David Stuchiner, M.D.
10 High Street Chair, Maine EMS Trauma Advisory
Lewiston, ME 04240 Committee
Director, Emergency Medicine
Central Maine Medical Center
300 Main Street
Lewiston, ME 04240
John Weisendanger, CEO
Northern Cumberland Memorial Hospital
P.O. Box 230
So. High Street
Bridgton, ME 04009
Introduction to the Hospital Resource Table
Maine EMS in conjunction with the Maine Hospital Association, trauma physicians, nurses, and
EMS providers have established two categories, Trauma Centers and Trauma System Hospitals.
The goal is to make the system voluntary and universal. It is our hope that all Maine hospitals
will participate in this plan.

This chapter consists of a table that lists the components needed for Trauma Centers and Trauma
System Hospitals. It is our belief that all Maine hospitals have the necessary components to
participate as Trauma System Hospitals. A smaller number of institutions may choose to
participate as Trauma Centers. Trauma Centers are expected to make a larger commitment to the
care of seriously injured patients. This includes dedicated resources for trauma education,
outreach, and injury prevention programs.

Please keep in mind that hospitals may advertise only their participation in the Trauma System.
They cannot publicize their individual status.
 Maine Trauma System
Hospital Resource Table
last revision 17 July 1995

This table shows levels of categorization as Trauma Center and Trauma System Participating Hospital and their
essential (E) or desirable (D) characteristics.

* Denotes Quality Improvement indicators that should be monitored when compromise of the optimal, stricter standards
is allowed.

Divisions

Trauma Center System Hospital

A. HOSPITAL ORGANIZATION

1. Trauma Service E --
a. An obligation on the part of the institution and medical staff to care
for trauma patients. Specified delineation of privileges for the
Trauma Service by the medical staff Credentialing Committee
may be desirable. The Trauma Service Director will be a board
certified general surgeon with specific commitment to trauma
care.

b. Trauma Coordinator (Under direct supervision of Trauma Service Director) E --

c. Trauma Contact Person (responsible for communicating with regional trauma E E

coordinators, coordinating trauma transfer feedback and trauma tracking forms, and
periodic resource assessments. May also be a Trauma Coordinator)

2. Multidisciplinary Trauma Committee (Trauma Service Director, Trauma E --

Coordinator, with representation from Anesthesiology, Critical Care, Emergency Medicine,
General Surgery, Neurologic Surgery, Orthopedic Surgery, Radiology)

3. Hospital Departments/Divisions/Services/Sections

Anesthesiology E --

Emergency Medicine E --

General Surgery E --

Neurologic Surgery E --

Orthopedic Surgery E --

Radiology E --

4. Specialty Availability

In-house 24 hours a day

 Trauma Center System Hospital

Anesthesiology (May be satisfied by senior resident, CRNA, or by Anesthesiologist E --

able to arrive in OR within 15 minutes of notification*)

Critical Care Physician (May be satisfied by senior resident or by ICU physician E --

able to arrive within 30 minutes of notification, time of first call and ICU arrival to be
routinely recorded*)

Emergency Medicine Physician E --

General Surgery (May be satisfied by senior surgical resident or by surgeon able to E --

arrive in ED within 30 minutes of notification, time of first call and ED arrival to be
routinely recorded*)

Neurologic Surgery (May be satisfied by physician with special competence in E --

neurotrauma, determined by local neurosurgeon who will be able to arrive in ED
within 30 minutes of notification, time of first call and ED arrival to be routinely
recorded*)

On-call and available within 30 minutes

Anesthesiology See Page 8 --

Cardiac Surgery D --

Cardiology E --

Critical Care See Page 8 --

Emergency Medicine See Page 8 --

General Surgery See Page 8 --

Hand Surgery E --

Infectious Disease D --

Internal Medicine E --

Microvascular Surgery D --

Nephrology E --

Neurologic Surgery See Page 8 --

Obstetrics/Gynecologic Surgery E --

Ophthalmic Surgery E --

Oral/Maxillofacial Surgery E --

Orthopedic Surgery E --

Pediatrics E --

Pediatric Surgery (May be satisfied by general surgeon credentialed by hospital to E --

provide surgical trauma care to pediatric patients)

Reconstructive/Plastic Surgery E --

Pulmonary Medicine E --

Radiology E --

Thoracic Surgery (May be satisfied by general surgeon credentialed by hospital to E --

 Trauma Center System Hospital

provide thoracic surgical trauma care)

Urologic Surgery E --

B. FACILITIES/RESOURCES/CAPABILITIES

1. Emergency Department (ED)

a. Personnel

1. Designated physician director E --

2. Physician with special competence in care of the critically injured E --

who is a designated member of the trauma team and
physically present in the ED 24 hours a day

3. Nurses with special capability in trauma care E --

b. Equipment for resuscitation shall include but not be limited to:

1. Airway control and ventilation equipment including E E

laryngoscopes and endotracheal tubes of all sizes, bag-mask
resuscitator, pocket masks, oxygen, and mechanical
ventilator

2. Suction devices E E

3. Electrocardiograph-oscilloscope-defibrillator E E

4. Apparatus to establish central venous pressure monitoring E --

5. All standard intravenous fluids and administration devices, E E

including intravenous catheters

6. Sterile surgical sets for standard ED procedures (thoracostomy, E E

venous cut-down, thoracotomy, cricothyroidotomy, etc.)

7. Gastric decompression equipment E E

8. Drugs and supplies necessary for emergency care E E

9. X-ray capability, 24 hour coverage by in-house technician E --

10. Two-way radio linked with vehicles of emergency transport E E

system

11. Skeletal traction device for cervical spine injuries E --

12. Thermal control devices for:

a. Patient (e.g.. circulating water or air blanket, radiant heater) E D

b. Blood and fluids (including rapid volume infuser) E D

13. Pulse oximetry E D

14. End-tidal CO2 determination E --

15. Pneumatic Anti-Shock Garment (PASG) E D

2. Intensive Care Units (ICUs) for trauma patients

 Trauma Center System Hospital

a. Designated physician director E --

b. Critical Care physician on duty in ICU 24 hours a day or immediately E --

available from in-house (May be satisfied by senior resident or by ICU
physician able to arrive within 30 minutes of notification)

c. Immediate access to clinical laboratory services (including Hb/Hct, ABG, E --

CXR within 30 mins. of request)

d. Equipment:

1. Airway control and ventilation devices E --

2. Oxygen source with concentration controls E --

3. Cardiopulmonary resuscitation cart E --

4. Temporary transvenous pacemaker E --

5. Electrocardiograph-oscilloscope-defibrillator E --

6. Cardiac output monitoring E --

7. Electronic pressure monitoring E --

8. Mechanical ventilator-respirators E --

9. Patient weighing devices E --

10. Pulmonary function measuring devices E --

11. Thermal control devices for: --

a. Patient (e.g.. circulating water or air blanket, radiant heater) E --

b. Blood and fluids (including rapid volume infuser) E --

12. Inotropic drugs, fluids, supplies E --

13. Intracranial pressure monitoring devices E --

14. Pulse oximetry E --

15. Skeletal traction devices E --

16. Peritoneal lavage equipment E --

3. Postanesthetic Recovery Room (ICU is acceptable)

a. Registered nurses and other essential personnel 24 hours a day E --

b. Equipment for continuous monitoring of hemodynamics E --

c. Intracranial pressure monitoring devices E --

d. Pulse oximetry E --

e. End-tidal CO2 determination E --

f. Thermal control devices for:

1. Patient (e.g.. circulating water or air blanket, radiant heater) E --

 Trauma Center System Hospital

2. Blood and fluids (including rapid volume infuser) E --

4. Acute Hemodialysis Capability E --

5. Organized Burn Care

a. Physician-directed burn center staffed by nursing personnel trained in E E

burn care and equipped properly for care of the extensively
burned patient

OR

b. Transfer agreement with a burn center

6. Acute Spinal Cord/Head Injury Management Capability

a. In circumstances where a designated spinal cord injury rehabilitation E E

center exists in the region, early transfer should be considered;
transfer agreements should be in effect

b. In circumstances where a head injury center exists in the region, E E

transfer should be considered in selected patients; transfer
agreements should be in effect

7. Radiological Special Capabilities

a. In-house radiology technician 24 hours a day E --

b. Angiography of all types E --

c. Sonography E --

d. Nuclear scanning D --

e. In-house computed tomography (CT) E --

f. In-house CT technician 24 hours a day (May be satisfied by technician able to E --

respond within 30 minutes of notification, time of first call and arrival to be recorded
routinely*)

g. Neuroradiology D --

8. Rehabilitation Medicine

a. Physician-directed rehabilitation service staffed by nursing personnel E E

trained in rehabilitation care and equipped properly for care of
the critically injured patient

OR

b. Transfer agreement with a rehabilitation service

9. Operating Suite Special Requirements

a. Personnel - Operating room adequately staffed and immediately E --

available 24 hours a day before patient arrives

b. Equipment shall include, but not be limited to:

1. Cardiopulmonary bypass capability D --

 Trauma Center System Hospital

2. Operating microscope D --

3. Thermal control devices for:

a. Patient (e.g. circulating water or air blanket, radiant heater) E D

b. Blood and fluids (including rapid volume infuser) E D

4. X-ray capability (including C-arm image intensifier) E --

5. Endoscopy (bronchoscopy, esophagoscopy) E --

6. Craniotomy instruments E --

7. Fixation equipment for long bone and pelvic fractures E --

10. Clinical Laboratory Services available 24 hours a day

a. Standard analyses of blood, urine, and other body fluids E D

b. Blood antigen matching E --

c. Coagulation studies E --

d. Comprehensive blood bank or access to a community central blood E --

bank and adequate hospital storage facilities

e. Blood gases and pH determinations E D

f. Microbiology E --

g. Serum alcohol determination E D

h. Drug screening E --

11. Organ Transplantation/Donation

Procedures should be in place through which brain death can be E E

declared, a family approached regarding organ donation, a potential
donor supported, and organ procurement coordinated with the
regional organ procurement center..

C. QUALITY IMPROVEMENT

1. Organized Quality Improvement Program E E

2. Special audit for all trauma deaths E D

3. Morbidity and mortality review E D

4. Multi disciplinary trauma conference (Regular and periodic conferences that include E D
all members of the trauma team. This conference will be for the purpose of quality
assurance through critiques of individual cases)

5. Medical nursing audit, utilization review, tissue review E D

6. Hospital-based trauma registry

a. Trauma registry review (Documentation of severity of injury and outcome by trauma E E

score, age, injury severity score, survival, length of stay, ICU length of stay with
monthly review of statistics)
 Trauma Center System Hospital

b. Trauma Registrar (responsible for data entry, report generation, and maintenance of E --
hospital-based trauma registry)

7. Review of prehospital and regional systems of trauma care E E

8. Published on-call schedule for general surgeons, neurologic surgeons, E D

orthopedic surgeons, thoracic surgeons

9. Reasons for trauma-related hospital destination decision documented E E

and reviewed by quality improvement program

D. OUTREACH PROGRAM

Telephone and on-site consultations with physicians of the community and E D

outlying areas

E. PUBLIC EDUCATION

Injury prevention in the home and industry, and on the highways and athletic E --
fields; standard first-aid; problems confronting public, medical profession,
and hospitals regarding optimal care for the injured

F. TRAUMA RESEARCH PROGRAM D --

G. TRAINING PROGRAM - Formal program of continuing education in

trauma provided by hospital for:
1. Staff physicians E D

2. Nurses E D

3. Allied health personnel E D

4. Community physicians E D

5. Prehospital personnel E D

H. INTERFACILITY TRANSFERS - Will accept the transfer of all patients

who:
a. Have activated the trauma system by field triage protocols or whom E --
have been directed by Medical Control

b. Have had their transfers requested appropriately through established E --

interhospital transfer procedures
Introduction - Prehospital Triage Procedures
These trauma triage protocols will help identify those patients who are most likely to benefit from specialized
trauma care. This protocol was designed by the Maine EMS Medical Direction and Practice Board (MDPB), in
conjunction with several trauma surgeons from the Trauma Advisory Committee.

Field EMS providers arriving at a trauma scene will communicate with their “On Line Medical Control” (OLMC)
physician or PA. In our current EMS system, OLMC is located at the local hospital. It is the OLMC that
provides medical control for the EMS field providers. It was the feeling of the MDPB and the Trauma Advisory
Committee that OLMC had the best knowledge of the capabilities of their facility at the moment a trauma occurs.
For example, a patient with major orthopedic injuries may be appropriately brought to a hospital with an
orthopedic surgeon on staff, but should bypass that facility if that surgeon is on vacation or is not available.

The decision to transport directly to a Trauma Center must be made by OLMC.

Prehospital Triage Procedures

last revision 17 July 1995

The current Prehospital Trauma Triage Procedure is on page 17. It is a quick reference for prehospital triage,
consultation with On-Line Medical Control (OLMC), and possible bypass of the closest hospital. A few specific
points regarding these procedures are noted:

1. Any qualified first responder can identify a Major Trauma Victim from these prehospital criteria. Any
subsequent decision to bypass the closest available hospital in favor of direct transport to a Trauma
Center will then be made by the On-Line Medical Control Officer in communication with the prehospital
care providers. Other procedures available through On-Line Medical Control include notification of
advanced life support units, activation of transport services, and activation of the receiving hospital's
trauma resource team.

2. The initial step of the prehospital provider is to assess vital signs and level of consciousness. The three
physiologic parameters listed in Assessment #1 constitute the Revised Trauma Score (RTS). Any noted
abnormality in these physiologic scores, or a RTS < 11 or Pediatric Trauma Score (PTS) < 8, indicates a
Major Trauma Victim and requires notification of the On-Line Medical Control.

3. Assessment #2, the second step of the prehospital provider, is to evaluate the anatomy of injury. The specific
anatomical injuries noted require notification of On-Line Medical Control.

4. Assessment #3, the third step of the prehospital provider, is to determine the mechanism of injury. High
energy injury biomechanics by themselves have a reasonably high likelihood of causing significant patient
injury. These are indications for consulting On-Line Medical Control for further transport
recommendations.

5. Identification of a major trauma victim by the prehospital EMS unit implies that the patient should be taken
to a Trauma Center if one is within 30 minutes by either ground or air. If transport time to a Trauma
Center exceeds 30 minutes, but the difference in transport times between the Trauma Center and closest
facility is less than ten minutes, then initial transport to the Trauma Center should still be considered.
However, if transport time to a Trauma Center exceeds 30 minutes and the difference in transport times
between the Trauma Center and closest hospital is greater than ten minutes, then initial transport of the
patient to the closest hospital should be undertaken unless directed otherwise by On-Line Medical
Control.
6. If the airway is in jeopardy and cannot be managed effectively by the on-scene prehospital providers, the
patient should be brought to the most accessible medical facility capable of immediate definitive airway
management. Alternatively, consideration should be given to coordinating a prompt rendezvous with an
Advanced Life Support, (ALS) prehospital unit. A patient directed to the most accessible facility for
urgent airway control should continue promptly on to a Trauma Center according to prehospital triage
criteria unless the Emergency Department Physician judges the clinical situation not to warrant such
action.

1 O.L.M.C. Confirms RTS/PTS

2. O.L.M.C. Considers patient transport to Regional
Trauma. Center (R.T.C.) using following
guidelines:
a) If transport time by ground or air to R.T.C. is
less than 30 min., patient should go to
R.T.C. directly;
b) If transport time to R.T.C. is greater than 30
min., determine the difference in transport
time between the R.T.C. and the most
accessible hospital:
1) If difference is less than 10 min., consider
transport to R.T.C.;
2) If difference is greater than 10 min.,
consider transport to most accessible
hospital;
3. If upon arrival in E.D.
a) Facility is not a R.T.C. and;
b) Patient continues to satisfy criteria of
Assessments One and Two, and;
c) Patient can be stabilized for further
transport, then receiving E.D. clinician
should provide only life-saving procedures
(avoiding unnecessary diagnostics) prior to
transport to R.T.C. unless he/she judges
clinical situation to not warrant such
transfer.

Transport to Trauma System Participating Hospital

7. After arrival at any facility, all patients should be evaluated for transfer to a higher level trauma facility based
upon the Maine Interfacility Triage Criteria.

8. All patients for whom either the trauma system is activated or On Line Medical Control is consulted will
undergo case review.
Introduction - Site survey process for Trauma Centers
Every hospital that wishes to be considered a Trauma Center will undergo a site survey process. This is designed
to review the medical capabilities and staff policies, facilities, policies and procedures of the hospital to ensure
they are in compliance with Maine EMS Trauma Center requirements. This survey process is also designed to be
interactive and educational.

The TAC chose to design this survey and designation process. Using a customized process will afford the most
flexibility and control over the process.

Trauma Center and Trauma System Hospital

Designation Procedures
Last Revision Date: 16 May 1994

1. All hospitals in Maine and selected hospitals in bordering New Hampshire communities will be asked to
join the Maine Trauma System. Once the initial request to join the system is sent to a hospital, a response
will be required within 90 days. Thereafter, hospitals may request to join the System by contacting Maine
EMS.

2. The request will contain:

a. The Trauma System Plan (this document);

b. An application form; and
c. A Trauma Resource Checklist, (derived from Trauma Center Resource Document), to be
completed and submitted prior to consideration for site visit).

3. An application fee of $50.00 will be required to cover the costs of processing.

4. Two or more hospitals may submit a joint proposal and be approved as a single trauma center provided
the single-institution criteria are satisfied.

5. All application material will be reviewed by the Maine EMS Trauma Advisory Committee, (TAC). The
applying hospital will be notified of any deviations from the minimum standards defined in the Trauma
Center Resource Document and will be permitted to resubmit the application for review within 90 days.

6. Applicants who document compliance with the standards as Trauma System Hospitals will be certified by
the TAC without the need for an on-site review. System hospitals may request an on-site review at their
own expense, which may include an educational session at a regularly scheduled conference.

7. Once a Trauma Center applicant has documented compliance with minimum Trauma Center standards, an
on-site review by members of the TAC shall be scheduled, (see pages 20 and 22). Reviewing members
shall not work in the service area of the applicant hospital. At least one reviewer shall be an experienced
site reviewer from out of state agreeable to both the institution and the TAC.

8. A portion of the on-site review shall consist of:

a. inspecting the hospital for compliance with minimum standards of equipment, personnel, and
organization;
b. reviewing medical records, and interviewing appropriate individuals; and
c. an exit interview will be provided on the day of the review.
The on-site survey review agenda is further described on page 22.
9. For a hospital requesting designation as a Trauma Center, a written report will be prepared for review by
the TAC within 90 days. A hospital which is found not to fulfill requirements for Trauma Center
designation will be notified in writing and allowed a second on-site review within one year without
reapplication. The applicant will be required to cover the expense of a second on-site review.

10. After designation as either a Trauma System Hospital or a Trauma Center, the hospital will enter into a
contractual agreement with Maine EMS for a period of three years. However, the TAC may suspend a
hospital’s designation at any time if it determines that the hospital has failed to comply with its obligations.
The hospital will receive notification of the deficiencies by the TAC. Failure to correct deficiencies in a
reasonable period of time will result in revocation or suspension of the designation.

11. All participating hospitals will submit data for inclusion in the state trauma registry for all trauma patients
who die, are transferred to hospitals other than Trauma Centers, or who are hospitalized longer than three
days (some exclusion criteria likely to be added). In addition, hospital discharge summaries will be
provided to the TAC for quality improvement purposes for all patients who die (including DOA) or are
admitted to an intensive care unit.

12. All participating hospitals will permit upon request of the TAC review of the medical records and
radiology tests of any patient admitted for trauma.

13. Trauma Centers shall not announce the level of their EMS designation for the purposes of public
advertising or influencing the flow of trauma patients transported privately outside of the Maine EMS.
However, all participating hospitals are encouraged to publicize their involvement in the State Trauma
System.
 Last revision March 27, 1995

Site Survey Process for Trauma Centers

The pre-survey questionnaire
The site survey process will begin with an information packet and questionnaire sent to all Maine hospitals.
These materials will include the Maine criteria for trauma system hospitals and trauma centers, the Maine
prehospital triage protocols, the interhospital transfer guidelines, and the quality improvement and education and
outreach plans.
The questionnaire will be used to determine a hospital’s interest in becoming a Trauma System Hospital or a
Trauma Center.

The Application
The application will be sent to all Maine hospitals. Only Trauma Center applicants will be surveyed. However,
any hospital that wishes to be surveyed can request a site survey of their trauma program. The details for these
system hospital surveys will be developed as interest develops.

If a hospital applies to be a trauma system hospital:

A trauma system questionnaire is sent. If a hospital chooses to become a trauma system hospital, they will
answer a few demographic questions and pay a small processing fee. The application is reviewed by MEMS
staff.

If a hospital applies to be a trauma center:

The pre-survey questionnaire is sent. The hospital must return the questionnaire to Maine EMS within 60 days.
EMS staff will review the application for completeness. If any information is missing Maine EMS will request it
from the hospital. The hospital must complete and return the finished questionnaire within 30 days of the request
for additional information.

The Survey Team for Trauma Center Applicants:

A survey team will then be assembled by Maine EMS. Survey team members must be acceptable to Maine EMS
and the hospital being surveyed. The survey date will be scheduled at a time mutually agreeable to the hospital,
Maine EMS, and the survey team. A survey is expected to last a maximum of two days. Typically the survey
team will arrive the night before, have an orientation session with the medical staff and perform the survey the
following day. The cost of the site visit, including the expenses of the survey team, will be borne by the applicant
hospital.

Using the Maine EMS criteria for trauma centers, and reasonably accepted guidelines for trauma care, the survey
team will assess the applicant’s ability to perform as a trauma center. Important aspects include: availability of
general or trauma surgeons, neurosurgeons, orthopedists and anesthesiologists who can respond to the hospital
rapidly to care for a multiply injured patient. Emergency physicians who can adequately care for the multiply
injured patient. Intensivists, radiologists, nurses, operating room availability and laboratory services.

The survey team will be especially interested in the applicant’s implementation of the Quality Improvement Plan
as outlined in this document. The Trauma Center / System Hospital QI Plan begins on page 33.

After evaluating the hospital, the survey team will produce a report. The Trauma Advisory Committee, (TAC),
will appoint a subcommittee to review the survey report. This TAC subcommittee will include:

* A Maine EMS office staffer;

* a Maine trauma surgeon not affiliated with the hospital being surveyed;
 Last revision March 27, 1995

* a Maine trauma nurse coordinator not affiliated with the hospital being surveyed;
* an emergency physician not affiliated with the hospital being surveyed;
* a hospital administrator not affiliated with the hospital being surveyed. And

This subcommittee will review the pre-survey questionnaire and survey report. The subcommittee will then
determine whether the hospital fulfills the criteria to be designated a trauma center.

If the hospital meets the criteria, a certificate is issued. If the hospital does not fulfill the criteria the
subcommittee of the TAC will set a timetable for corrective action. Based on the degree of variance from the
standards, the subcommittee will decide whether a follow-up survey or a paper report is required. The time to
perform corrective action will not exceed six months. If the hospital fails after the corrective action, they may
not apply for another year.

System Improvement
During the next two years, the Trauma Advisory Committee will review the criteria for trauma centers and
review the performance of the designated trauma centers. The TAC will propose outcome-based performance
criteria for trauma centers and assess the trauma centers against these performance criteria.
Last revision March 27, 1995

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 Last revision March 27, 1995

On-Site Survey Agenda for Trauma

Centers

For planning purposes, the review will last at least six hours.

1. Emergency Department - 30 minutes

a. Review Emergency Department facility, resuscitation area, equipment, protocols,
flow sheets, staffing, trauma call.
b. Interview emergency physicians and emergency nurses.

2. Operating Room/Recovery Room - 15 minutes

a. Interview operating room manager, nursing supervisor, and anesthesiologist
b. Check Operating Room schedule

3. ICU - 15 to 30 minutes
a. Inspect facility
b. Review flow sheets
c. Interview nurse

4. Radiology - 20 minutes
a. Inspect facility
b. Interview radiologist and technician

5. Blood Bank/Laboratories/Rehabilitation - MAY BE VISITED

a. Inspect facility
b. Interview technicians

6. Please allow 2½ - 3 hours for the following:

a. Interviews with a hospital administrator, chief of trauma service, neurosurgeon,
orthopaedic surgeons, chief of staff may also be necessary
b. Review quality assurance documents
c. Patient chart review

7. Exit Interview - 45 - 60 minutes

a. Hospital administrator, chief of trauma service, and others as desired

The following should be available at the review

1. Listing of hospital’s trauma involvement for one year

a. Education - physicians, nurses, prehospital providers, and the public
b. Research, copies of submitted articles, protocols of present studies and reprints

2. Copy of call schedule for three months prior to review

a. Trauma attending
b. Trauma residents
c. Neurosurgeon attending

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 Last revision March 27, 1995

d. Neurosurgery residents

3. Quality Assurance
a. Minutes of trauma service meetings for one year
b. Quality assurance programs relating to trauma for one year

4. Specific trauma patient charts will be requested either before the review or from the
Trauma Registry at the time of the review.

The following people should be available during the survey for interviews:

Hospital administrator, trauma director, emergency department medical director, chief of

neurosurgery, trauma nurse coordinator, chief of anesthesia, chief of staff, chief of rehabilitation,
chief of orthopedics, chief of surgery, director of critical care unit.

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 Last revision March 27, 1995

Educational Outreach
Trauma education is a major responsibility for Trauma Centers. The education and outreach
program is designed to assist participating Trauma System hospitals and their staffs. Frequent
professional dialogue will ensure that all physicians who care for trauma patients have access to
the latest medical information. The section that follows describes the educational and outreach
portions of the Trauma Plan.

Mission

¯ To provide relationships between the participants in the trauma system.

¯ To provide educational opportunities for the participants in the trauma system

The trauma system should include four areas of education and outreach to achieve the
mission. These are: 1) Exchange programs, 2) Feedback programs, 3) Conferences, 4) Lay
education.

1. EXCHANGE PROGRAMS:
a. Physician Exchange
This program would provide for physicians to go from a trauma center hospital to
a system hospital to maintain an important capability at the system hospital while
the system hospital physician was away. It would also provide coverage and an
opportunity for the system hospital physician to go to the trauma center for training
and experience. Privileging would be the responsibility of the system hospitals.
Remuneration and housing would be negotiated between the physicians involved.
The Maine Chapter of the American College of Surgeons would like to serve as a
facilitator in such a program when the involved physician was a surgeon.

b. Other Personnel Exchanges

This program would provide for visits by system hospital personnel such as R.N.’s,
N.P.’s and P.A.’s to a trauma center for educational purposes. The visitor would
be exclusively an observer / student and provide no service. There would be no
remuneration. Housing and meals should be provided by the trauma center.

2. FEEDBACK PROGRAMS:
a. System Hospitals
Each system hospital will be responsible for feedback to personnel involved in
prehospital care and inter hospital transfers in their geographic area. This can be
accomplished in a written form utilizing mail, E-mail, or fax services. It can be
done verbally by telephone or with conferencing. Every effort should be made to
get the information to the individuals involved in the specific incident. The
information should include at least 1) review of prehospital assessment and
treatment, 2) review of the communications involved, 3) the hospital diagnosis and
therapy, 4) the outcome of the patient. Arrangements and agreements will need to
be developed between the hospital and the ambulance units to be consistent with
the confidentiality of the patient.

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 Last revision March 27, 1995

Discussion: This is a very important activity which will be amongst the most
difficult to implement. It will be very effective in terms of education and
development of close relationships between the system hospital and the ambulance
units. The verbal feedback is very time and personnel consuming but is by far the
most effective. Written feedback systems can be developed using computer.

b. Trauma Centers
Each trauma center will be responsible for both written and verbal feedback to the
system hospital personnel on a patient by patient basis. The written feedback will
involve at least the "initial arrival form" and the hospital discharge summary. A
quarterly summary should go to the ED director and each involved staff physician.
Verbal feedback will involve at least a call back to the transferring physician from
the trauma center and a visit once per year by trauma center hospital physicians to
the system hospital to review patients.

Discussion: Some of the trauma centers are already active in this in some aspects.
The efforts need to be more comprehensive and uniform throughout the state. The
“initial arrival form” is important because of the lag until discharge and then a
discharge summary. The quarterly summary will be facilitated by the trauma
registry. The visit once a year by a physician from the trauma center to the system
hospital is ambitious, but important. The trauma hospitals need to help to provide
support to the physicians to carry out this charge.

3. CONFERENCES:
a. Trauma Centers
Each trauma center should provide a conference once a year for the local
catchment area. The conference should include local problems and issues and
general educational topics. The conferences should be open and applicable to all
the participants in the trauma system in that area including prehospital, system
hospital, and trauma center personnel.

Discussion: This is another version of feedback, but it also allows for

individualization of conference materials to meet the needs in each geographic area
and for each group of personnel. Care needs to be taken to see that the conferences
are truly open and truly applicable in some respects to all of the participants in the
trauma system.

b. National
The Trauma Advisory Committee and the trauma centers should facilitate the
availability of recognized trauma courses such as ATLS, PHTLS or TNCC. These
courses should be held in all parts of the state on a regular basis. Assistance should
be provided in scheduling and obtaining faculty for these courses.

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 Last revision March 27, 1995

Discussion: Currently there is an imbalance where these conferences are available.

Typically they are held where the faculty is available. A look should be taken at
needs and resources statewide, and establish a better match.

4. LAY EDUCATION:
a. Each member hospital in the trauma system will be involved locally in education to
the public. The trauma centers will serve as resources to the system hospitals in
these efforts.

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 Last revision March 27, 1995

Introduction - Interfacility Transfer Guidelines

Given the rural character of Maine, it is anticipated that some major trauma patients will arrive at
Trauma System Hospitals and will need transfer to a higher level of care. The inter-facility
transfer guidelines are designed to ensure smooth and efficient transfer of seriously traumatized
patients.

Interfacility Transfer Criteria

last revision 22 March 1995

Patients identified by interhospital transfer criteria may have increased risk of dying from
multiple or severe injuries and their subsequent complications. These patients may be more
appropriately treated at a Trauma Center, where multidisciplinary teams accustomed to
such patients afford the best outcome. These criteria, while not totally inclusive, have been
designed to help identify patients for consideration of transfer early in their Emergency
Department or hospital stay, during or after initial resuscitation, but prior to completing a
full evaluation and obtaining time-consuming diagnostic tests.

Central Nervous System

Head Injury - Penetrating injury or depressed skull fracture

- Open injury with or without cerebrospinal fluid leak
- Altered or diminishing level of consciousness related to trauma (not
obviously a result of alcohol or drug intoxication, alone)
- Lateralizing signs

Spinal cord injury or major vertebral injury

Chest

Wide or suspicious mediastinum (if Trauma Center has appropriate personnel/facilities)

Major chest wall injury (e.g. flail chest, open pneumothorax)
Cardiac injury (if Trauma Center has appropriate personnel/facilities)
Patients who may require prolonged ventilation

Pelvis

Unstable pelvic ring disruption

Pelvic ring disruption with shock or evidence of continuing hemorrhage
Open pelvic fracture

Major Extremity Injury

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 Last revision March 27, 1995

Fracture/dislocation with loss of distal pulses

Open proximal long-bone fractures
Extremity ischemia

Multiple System Injury

Head injury combined with face, chest, abdominal, or pelvic injury
Burns with associated injuries
Multiple long-bone fractures
Significant injury to more than two body regions

Coexisting Conditions (which may complicate care)

Elderly or children
Known cardiac, pulmonary, renal, or metabolic disorders (e.g. diabetes)
Pregnancy
Morbid obesity
Immunosuppression

Secondary Deterioration (Late Sequelae)

Mechanical ventilation required

Sepsis
Single or multiple organ system failure (deterioration in central nervous, cardiac,
pulmonary, hepatic, renal, or coagulation systems)
Major tissue necrosis

Any Other Specific Situations Referring and Receiving Hospitals Want to Define

e.g. Burns, Hand Injuries, Complex Plastic/Reconstructive, Facial Fractures

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 Last revision March 27, 1995

Procedure for Interhospital Transfer

last revision 22 March 1995

Decision to Transfer

1. The decision to transfer should be made as early in the patient's evaluation and
stabilization as possible, prior to performing an extensive diagnostic evaluation. This
decision will be based upon:

a. the presence of injuries or illnesses defined in the transferring and receiving

hospitals' existing transfer agreement and
b. the physician’s or PA’s assessment of the patient's clinical condition and
anticipated clinical course and the appropriateness of the transferring hospital's
available personnel and other resources for providing complete care.

2. The decision to transfer will not be influenced by a patient's ability to pay medical
expenses.

3. The decision to transfer for urgent advanced level trauma care will not be influenced by a
patient's participation in a specific health care provider network (PPO, HMO, etc.).

Decision to Receive

1. A Trauma Center will not refuse the transfer of any trauma patient
a. who satisfies the clinical criteria defined in the Trauma Center's existing transfer
agreement with the transferring hospital or
b. who the primary acute care provider believes requires urgent advanced level
trauma care which cannot be provided with the available resources at the
transferring hospital.

An exception to this agreement may occur when the Trauma Center has at the time of transfer
request a critical shortage in either personnel or other resources which would jeopardize the care
of the transferring patient. In such a case the transferring care provider should follow his/her
hospital's backup plan to arrange prompt transfer to another qualified Trauma Center.

2. The decision to receive a trauma patient will not be influenced by demands placed upon
personnel and other resources at the Trauma Center by scheduled elective or
non-emergent operations

3. The decision to receive will not be influenced by a patient's ability to pay medical
expenses.

4. The decision to receive for urgent advanced level trauma care will not be influenced by a
patient's participation in a specific health care provider network (PPO, HMO, etc.).

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 Last revision March 27, 1995

Once the Decision to Transfer is Made

1. The transferring provider should obtain permission for transfer from the patient or family
if this can be accomplished without delaying transfer. Ideally, the patient will be clinically
stabilized prior to transfer. However, in the situation where delay for further attempts at
stabilization are deemed by the primary acute care provider and the trauma center
physician to be a greater risk than urgent transfer to a higher level of trauma care, the
primary provider should document this fact and not delay transfer.
2. Notify EMS to arrange prompt transport

3. The transferring primary acute care provider will complete a thorough primary and
secondary survey but should not delay interhospital transfer in order to obtain further
diagnostic tests which will not significantly influence the initial resuscitation (e.g. CT scan,
extremity radiographs, complete C-spine series).

4. The transferring care provider will call a single specified telephone number at the Trauma
Center. This number will be clearly posted in the Emergency Department resuscitation
area.

5. At the Trauma Center the call will be directed to the Trauma Officer. A standardized log
of the conversation will be recorded, including at least the name of the conversants, date,
and time.

6. The transferring care provider will present the patient in a standard format:

a. Care provider's name, title, hospital, and telephone number

b. Patient's name, age, gender
c. History/mechanism of injury including date and time
d. Condition reported at the scene and en route to ED
e. Condition upon ED arrival including BP, P, RR, Temp, RTS, GCS
f. Current condition
g. Initial diagnoses
h. Diagnostic tests if available:
i. Hct/Hb, ABG, urinalysis or urine dipstick
ii. CXR, lateral C-spine, pelvis
iii. other pertinent
i. Treatment rendered:
i. IVS - size and location
ii. IV fluids - type and amount, current IV rate
iii. Status/quality of airway/breathing
iv. Tubes - ETT, chest tube, Foley, nasogastric, etc.
j. Pertinent medical history, medications, allergies
k. Anticipated time of departure
l. Estimated time en route

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 Last revision March 27, 1995

7. The Trauma Center trauma officer will ensure that the above information has been
accurately received and will clarify the report if necessary. The trauma officer should
provide advice regarding options for transportation, timing of transfer, further pre-transfer
stabilization, and the need for any additional diagnostic tests.

8. The Trauma Center physician will notify and assemble in a timely manner the personnel
and other resources necessary to optimally receive the transferred patient. (Each Trauma
Center should define its own criteria for what situations warrant trauma team
mobilization i.e. general surgeon, respiratory therapist, radiology, blood bank, etc.)

9. The following minimum material will be provided in a timely manner to the Trauma
Center (this may accompany the patient or be sent by FAX but should never delay
transport):

a. A completed trauma transfer summary, which will become part of the medical
record at the Trauma Center
b. A copy of the initial EMS prehospital run sheet
c. A copy of the complete or pertinent medical record
d. A list of all medications given - dose and time
e. I+O, vital sign flow-sheet with total IV fluids
f. All available laboratory test results and ECG
g. All radiographs (transfer should not be delayed to make copies)
h. Appropriate patient transfer forms as required under COBRA/EMTALA

Any test results not available at the time of transfer should be forwarded to the Trauma
Center within 24 hours.

10. When the patient leaves its facility the transferring hospital will call the Trauma Center to
report the time of departure, mode of transportation, and estimated time en route. The
trauma transfer form will then be sent by FAX to the Trauma Center.

After Arrival at the Trauma Center

1. After the patient's disposition from the emergency department has been determined, the
trauma physician or their designee, will call the transferring primary acute care provider at
the previously recorded telephone number and provide the following information:

a. Patient status, current diagnoses, initial evaluation/therapy

b. Name and telephone number for the admitting attending physician

2. The transferring care provider should be welcome to contact the attending trauma
physician or the trauma nurse coordinator at any time for further discussion.

3. The transferring care provider listed on the trauma transfer form will receive a copy of the
patient's discharge summary.

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 Last revision March 27, 1995

Maine State Trauma System Transfer Summary

last revision 30 January 1995

Date:

Transferring Hospital:
Primary Provider: Phone:
Receiving Hospital:
Receiving Physician:

Patient Name:
Age: Gender: M or F
Date/Time of Injury:
Mechanism of Injury:

Condition at Scene and En-route to ED (VS, level of consciousness):

Time of ED Arrival:
Condition upon ED arrival (including VS, GCS):

Condition at transfer (including VS, Temp, GCS):

Preliminary Diagnoses:

Test Results
Hematocrit:
ABGs:
Grossly bloody urine?: Yes or No
X-rays
AP Chest:
Others:

Other Pertinent Data:

Treatment Rendered
IVS (size, location):

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 Last revision March 27, 1995

Total Fluids
Intake
Crystalloid:
Blood:
Other:
Output
Urine:
Other:
Current IV rate and composition:
Airway (quality or airway/breathing, O2 setting):
Tubes (ETT, chest tubes, Foley, nasogastric, etc.):

Pertinent Medical History:

Medications:
Allergies:

COBRA Forms Completed: Yes or No

Accompanying Patient

9 A copy of the initial EMS prehospital run sheet

9 A copy of the complete or pertinent medical record
9 A list of all medications given - dose and time
9 A copy of I+O, VS Flow-sheet
9 All available laboratory test results and ECG
9 All radiographs (transfer should not be delayed to make copies)

Person to whom feedback should be directed:

Department: Phone:

Time of Departure:

Summary completed by:

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 Last revision March 27, 1995

The Quality Improvement Program - Introduction

The quality improvement program is designed to measure and improve the quality of trauma care
in Maine. Using a Total Quality approach, the QI program is designed to stimulate continual
improvements in trauma care throughout the system.

Responsibilities of Trauma Centers and System Hospitals

This section is background material for the attached Tree Diagram (page 35), which represents in
graphic form the responsibilities of both a Trauma Center and Trauma System Hospital. This
effort, begun in March, 1995, is an evolving work produced by the State Trauma Quality Team of
the Trauma Advisory Committee.

Team members included:

Marideth Beals, R.N., Maine Medical Center
Team Leader - Larry Hopperstead, M.D.
Central Maine Medical Center.
Pret Bjorn, R.N., Eastern Maine Medical Center Jay Bradshaw, EMT-P, Maine EMS
Mary Day, Eastern Maine Medical Center Cathy Moss, R.N.,Maine Medical Center
Rick Petrie, EMT-P, Maine EMS Cindy Scribner, R.N.,Central Maine Medical Center
Lance N. Tucker, Tri-County EMS

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 Last revision March 27, 1995

Trauma System Goals and Responsibilities - Tree Diagram

This is a graphical depiction of the interrelationship of Trauma System goals and responsibilities. See Figure 2
page 35.

The “Responsibilities” are outlined in what is known as a Tree Diagram. The diagram works outward
(horizontally) from major broad branches (Strategic Goals) to ever smaller branches defining relational aspects of
those goals at a level of ever-increasing specificity. (See Figure 2, page 35, for an example.) Careful evaluation
defines categorical relationships within those strategic goals, and will describe specific responsibilities, tasks, or
operations necessary to fulfill or achieve those goals.

In reflecting upon what aspects of the Trauma System would have direct impact on your institution or on what
would be expected of you as an institution, consider which of the “tree diagrams” is applicable to your hospital.
Then, for any Strategic Goal, follow the breakdown into “strategies”, and then “tasks” or “work efforts”, out to
the right. A good example of the different levels of responsibility and work can be seen by looking at Strategic
Goal #3 : DATA Management on the two tree diagrams:

• Look at Strategy 3.1 ---”Develop a Central DATA Maintenance System”

Trauma System Hospitals are expected to show commitment, have trained personnel, and
submit data via state-provided forms and/or software.
Trauma Centers, on the other hand, are expected to train the data personnel of the region
and to provide Trauma Nurse Coordinator back-up to the region, in addition to
maintaining their own institution’s data.
• Look at Strategy 3.2 — “Conduct DATA Analysis on Process and Outcomes”
Here, there is no direct responsibility of the Trauma System Hospitals. The Trauma Centers, on
the other hand, have the enormous and all-important responsibilities of identifying criteria for data
collection regionally, identifying data sets and fields, collecting and analyzing the data, and finally,
disseminating the analysis / information back to the system via feedback mechanisms. These
responsibilities are consumptive of both time and personnel, which is why they fall exclusively
within the domain of Trauma Center.

In Summary:

Similar comparisons or analyses of the “tree diagrams” follow the same approach, and deserve your scrutiny.
The approach is very straightforward. These “Tree Diagrams” are documents-in-evolution, but they define for
now what the Quality Team of the Maine Trauma Advisory Committee feel are the best delineation of the
responsibility commitments of the two broad categories of hospitals to the developing statewide Trauma
System. Sections that follow detail each item or entry in the Tree Diagrams.
 Last revision March 27, 1995

1.1.1Acute care based on national

standards and use of data

1.1 Comprehensive care 1.1.2 Develop critical pathways /

system using critical pathways trauma case management

1.2 Leverage emerging technology

1.1.3 Provide psychosocial -
for system development
economic support

1.3 Fund the system

1.1.4 Rehabilitation
1.4 Promote trauma system / EMS
integration

1.5 Develop team architecture and

support structure

1.6 Promote trauma system

alignment

Responsibilities of a Trauma Center -T ree Diagram

 Last revision March 27, 1995

1 Quality Improvement for Trauma Centers - Provide Institutional Support, Structure,

& Organization to Promote Quality & Future Growth

1.1 Comprehensive Care System Using Critical Pathways

The delivery of trauma care requires an organized systematic approach to effect optimal
outcomes. Trauma Centers must have the following key criteria in place to meet this objective.

1.1.1 Acute Care Based on National Standards and Use of Data

National standards have been incorporated into the criteria for Trauma Centers and Trauma
System Hospital requirements and responsibilities. In addition, ongoing data analysis will drive
further refinements in the care system.

1.1.2 Develop Critical Pathways / Trauma Case Management

Trauma Nurse Coordinators are required at all Trauma Centers and provide Case Management
for trauma patients. Critical pathways describe the expected care outcomes.

1.1.3 Provide Psycho-Social-Economic Support

Trauma centers have an obligation to provide initial and ongoing support for trauma patients and
their families.

1.1.4 Rehabilitation
Relationships and/or transfer agreements with rehabilitation facilities are in the continuum of
trauma care.

1.2 Leverage Emerging Technology for System Development

The sharing of information regarding issues is a requirement for continued system development.
Technology is critical to supporting this objective.

1.2.1 Clinical Technology

Minimum required technology for clinical services is detailed in the resource document. The
sharing of information regarding clinical issues is a requirement for continued system
development. Technology is critical to supporting this objective.

1.2.2 Technology for Communication

Trauma Centers must have uninterrupted telephone and/or radio access to support direct medical
control. Fax capability is also required. A centralized communication center, although not
required, would also enhance the coordination of patient movement through the system.

1.2.3 Technology for Education

Trauma Centers should make every effort to share educational presentations with system
hospitals. This may be done real time with an interactive video network or on a delayed basis via
video taping.

1.3 Fund the System

Trauma Centers make a commitment to provide a minimum level of service to the surrounding
community and the state. The commitment has financial implications as follows:
 Last revision March 27, 1995

1.3.1 Funding for Clinicians

Trauma Centers must provide funding for positions, i.e. Trauma Director, Trauma Coordinator,
Trauma Registrar, education of all providers of trauma care, and essential equipment as outlined
in the Resource Document.

1.3.2 Funding for Data Collectors

Additionally, Trauma Centers must maintain the computer hardware and software to support the
Trauma Registry. Trauma System Hospitals are obligated to provide data and as such must fund
the position for data collection.

1.4 Promote Trauma System / EMS Integration

Each Trauma Center shares equal responsibility with other EMS organizations to promote total
system integration. State trauma and EMS systems must be seen as one seamless web, each a part
of the same continuum that exists to provide national gold standard trauma and emergency
medical care to our communities.

1.4.1 Develop Medical Control

Trauma Centers will be responsible for ongoing quality improvement of On-line Medical Control.
Protocols for Medical Control have been described by Maine EMS on a statewide basis. It will be
required of Trauma Centers to demonstrate compliance with these protocols. Trauma Centers
will be required to provide 24-hour availability of a licensed Maine physician able to
immediately participate in On-Line Medical Control.

1.4.2 Implement Triage & Interfacility Transfer Protocols

Each Trauma Center will be responsible for implementation and ongoing quality improvement of
Triage Protocols. Prehospital Triage Protocols have been developed by the Maine EMS Physician
Advisory Board..

1.4.3 Support the Pre-Hospital System

It is the responsibility of the Trauma Center to take an active role in developing and cultivating
the prehospital emergency medical system within their service area. There should be a
comprehensive disaster management program (1.4.3.1) in place utilizing the New England
Council for Emergency Medical Services (NECEMS) blueprint. Initial pre-hospital education is
necessarily very generic in order to cover the many topics in a reasonable period of time. A strong
effort should be made to increase the trauma capabilities of the pre-hospital personnel through
continuing education, clinical site availability, development of peer support programs,
and allocation of Trauma Center personnel for educational purposes (1.4.3.2). The Center should
recognize the importance of crisis intervention for all pre-hospital and in-hospital staff (1.4.3.3)
and should support the regional CISD team with educational, financial, and administrative
assistance.

1.4.4 Develop Transportation Systems

Each Trauma Center should assure adequate air transportation service by either establishing a
service where there is none or setting up agreements with an existing service (1.4.4.1). It is
important to recognize that the primary area of training and education for pre-hospital personnel
is in the emergency response arena. Trauma Centers should work to augment existing pre-hospital
education in order to develop better interfacility transport teams (1.4.4.2).
 Last revision March 27, 1995

1.5 Develop Team Architecture and Support Structure

Trauma Centers as leaders in trauma care within their geographic area have a unique responsibility to
promote a team environment based on trust, sharing of data, and collaboration of all members of the
trauma multidisciplinary team. To assist the work of teams within each area, the Trauma Centers need to
promote the support structure and resources needed for the team architecture.

1.5.1 Appropriate Resources (Coverage & Services)

Trauma Centers need to provide trauma care providers with the appropriate resources, including
real time consultation, specialty coverage, and coverage of providers.

1.5.2 Develop Active Trauma Committee

Each Trauma Center will have an active Trauma Committee in accordance with ACS guidelines.
This multidisciplinary team should be the focus of trauma leadership within each geographic area.

1.5.3 Promote Team Skills/Tools/Organizational Learning

All multidisciplinary trauma teams should display the characteristics of, and practice the required
skills of effective teams. This includes, but is not limited to, team tools for problem solving,
process improvement, project management, and organizational development. The goal should be
organizational learning so that no one organization or team members be "left behind" in the
process. In order for an entire system to mature and develop, all members of the team must
contribute and be involved.

1.6 Promote Trauma System Alignment

As leaders of trauma care within their respective geographic area, trauma centers have an obligation to
promote total system alignment, both vertically and horizontally. Major efforts in attaining system
alignment should be the development and deployment of a comprehensive strategic and quality
improvement plan, development of systems for provider feedback, and a sharing of resources for
education.

1.6.1 Develop and Deploy a Plan with Maximum Involvement

Trauma Centers should develop and deploy a plan for long term system development and quality
improvement. This plan should be developed within the context of the trauma team architecture
so that it reflects the needs and contributions of all multi-disciplinary team members.

1.6.2 Willingness to Accept All Patients

Trauma Centers provide around the clock trauma services to all patients without regard to race,
gender, age, mechanism of injury, or ability to pay.

1.6.3 Develop Feedback Programs

Trauma Centers will assist in the development of provider feedback mechanisms. This should
include immediate telephone calls and eventual written feedback. Feedback is recognized as the
sine qua non for system-wide quality improvement.

1.6.4 Share Resources/Promote Research & Education

Trauma Centers will share resources both system wide and within their respective geographic
areas for trauma research and education. The education part of trauma system development is so
 Last revision March 27, 1995

crucial that it warrants special emphasis as a major responsibility in its own right; please see
Strategic Goal 2.0 series in this manual.
 Last revision March 27, 1995

2 Quality Improvement for Trauma Centers - Education

2.1 Create an Environment of Openly Shared Clinical Learning for Education and Training
The complexity of trauma management demands an on-going commitment to education and
training specifically directed at trauma issues. Equally as important, is a willingness to share
clinical experiences and understandings across the entire fabric of the trauma care system. Such a
willingness can lead to optimization of the educational opportunities inherent in clinical events,
and can evolve only in an environment of mutual trust and respect.

2.1.1 Meetings to Discuss Issues/Concerns/Needs

A trauma care system plan must include the ability of the system to monitor its own performance
and to access its impact on trauma morbidity and mortality. Therefore, regularly scheduled
meetings should occur between Maine EMS (lead agency) and representatives assigned by the
Trauma Advisory Committee to discuss issues identified through the Quality Improvement
process: monitoring of state identified audit filters, patient needs and outcomes and system
resources etc. In this way trauma care management deficits can be identified and appropriate
changes can be made to allow for the continual development and improvement of the system.

2.1.1.1 Care Standards

The Maine Trauma System plan has established standards of care according to ACS and
ACEP guidelines for trauma centers and trauma system hospitals including resources and
equipment.

2.1.1.2 Regularly Scheduled Education

Regularly scheduled meetings between trauma directors, trauma nurse coordinators,
trauma surgeons, ED nurses, and pre-hospital providers should occur monthly to discuss
quality patient care.

2.1.1.3 Informal Meetings

Impromptu meetings between trauma director and other trauma personnel should occur on
an as needed basis depending on severity of the issue.

2.1.2 Conduct Clinically-Related Training as needed (Just-In-Time)

Collaborative practice rounds should occur weekly and on an as needed basis.

2.1.2.1 Pre-hospital Providers

Involvement of Pre-hospital Providers in case review presentations should occur as
appropriate on a regular basis.

2.1.2.2 Nurses
Involvement of Nurses in case review presentations should occur as appropriate on a
regular basis.

2.1.2.3 Physicians
Involvement of Physicians in case review presentations should occur as appropriate on a
regular basis.

2.1.2.4 Ancillary Personnel

 Last revision March 27, 1995

Involvement of Ancillary Personnel in case review presentations should occur as

appropriate on a regular basis.

2.1.3 Conduct Case Reviews

Quality improvement activities should include prospective and retrospective case reviews that
may be injury specific, triggered by audit filters, randomly selected, or based on monthly
morbidity/mortality conferences. These reviews should involve all appropriate disciplines and are
necessary to monitor and assess the facility's ability to comply with pre-established standards.

2.1.4 Conduct Trauma Conferences

Trauma conferences should be open to all trauma disciplines for educational purposes to prepare
personnel for the delivery of quality patient care based on ACS guidelines.

2.2 Support Formal Trauma Education Courses

The Trauma Centers have unique responsibility in providing formal trauma education and
consequently must facilitate the availability of national courses such as ATLS, PHTLS, ABLS,
PALS, and TNCC. These courses should be held in all parts of the state on a regular basis.
Assistance should be provided in scheduling and obtaining faculty for these courses.

2.2.1 Establish Regional Education Programs

Each trauma center should provide a conference once a year for the local service area. The
conference should include local problems and issues as well as general educational topics. The
conference should be open and applicable to all trauma care providers including pre-hospital,
system hospital, and trauma center personnel. Other programs should be established within the
region. For example, a physician exchange program. This program would provide for physicians
to go from a trauma center to a system hospital to maintain an important capability at the system
hospital while the system hospital physician was away. It would also provide coverage and an
opportunity for the system hospital to go to the trauma center for training and experience.
Privileging would be the responsibility of the system hospitals. Remuneration and housing would
be negotiated between the physicians involved. The Maine Chapter of the American College of
Surgeons would like to serve as a facilitator in such a program when the involved physician was a
surgeon. Other personnel exchanges would include visits by system hospital personnel such as
RN’s, NP’s, and PA’s to the trauma center for educational purposes. The visitor would be
exclusively an observer and student and provide no service. There would be no remuneration.
Housing and meals should be provided by the trauma center.

2.2.2 Provide TNCC Courses

TNCC is a verification course providing core-level trauma knowledge and psychomotor skills
associated with the delivery of professional nursing care to the trauma patient. This program was
developed and sponsored by the E.N.A. and should be made available to nurses throughout the
state.

2.2.3 Support and Participate in ATLS Courses

ATLS is a course developed and sponsored by the American College of Surgeons for physicians
which covers trauma knowledge and skills. It is considered an optimum standard for trauma care
physicians and physician extenders directly involved in the resuscitation of the injured patient. The
Trauma Advisory Committee and the trauma centers should facilitate the availability of this course
throughout the state.
 Last revision March 27, 1995

2.2.4 Support and Participate in Pre-Hospital Education

Trauma Centers must provide leadership in EMS Provider trauma education and training. Some
courses available to EMS providers include:
PHTLS a course for prehospital care providers that teaches concepts of basic and advanced
trauma life support.
PALS Pediatric Advanced Life Support is a national level course that teaches the concepts of
advanced life support for infants and children
PABLS Prehospital Advanced Burn Life Support

2.2.5 Annual Trauma Symposium

Each trauma hospital will support trauma personnel to attend annual trauma symposium in order
to complete CME or CEU/CEH requirements.

2.2.6 MCOT
The Maine Committee on Trauma meets semiannually and is an excellent forum for the discussion
of trauma care issues..

2.2.7 Network with other organizations such as ACEP, ACS, ENA, AACN, and the Maine
Paramedic Association
All trauma care providers share a responsibility to be involved with their peers.

2.3 Support Informal Education and Training

Trauma Centers are expected to provide and support ongoing informal education for
all professionals involved in care of injured patients.
2.3.1 Encourage Inter-Provider Discourse
The Trauma Center should provide for regular and inclusive discussions of clinical and Trauma
System topics. Such forums should focus on improving communication and collaboration among
various services and disciplines in order to achieve maximum quality and efficiency along the
continuum of trauma care. Inclusion of hospital staff in EMS Quality Improvement updates
related to trauma care, is one example of compliance with this condition. Participants in these
reviews should be reminded of the confidential nature of the material discussed as it relates to
specific individuals. While it may be useful to the Trauma Centers or their affiliates to record
minutes at these sessions, the Trauma System Quality Improvement team requests only that
Trauma Center keep a comprehensive log listing the date, time, topic, and list of participants for
each session.

2.3.2 Conduct Informal Talks About Specific Runs / Events

Trauma Centers must be able to demonstrate a willingness and ability to discuss clinically
important cases and events with pertinent personnel as the opportunity arises. Compliance with
this requirement includes impromptu case discussions in real time, such as a brief review or
critique of an Emergency Department case with the transferring or transporting crew.
Participants in these reviews should be reminded of the confidential nature of the material
discussed as it relates to specific individuals. These sessions may be logged with events described
in Section 2.3.1, provided the informal nature of the discussion is noted.

2.3.3 Identify Specific Contact Nurses for Trauma Education

 Last revision March 27, 1995

Each Trauma Center must identify one or more members of the nursing staff possessing adequate
experience and interpersonal skills to ensure optimum inter-provider education as described
throughout this section. It will be the responsibility of this nurse to maintain a list of contacts at
all referring hospitals and EMS units, and to act as a resource to these providers for the purposes
of ad hoc education and follow-up.

2.3.4 Establish Training Mentorships

Trauma Centers, individually or cooperatively, construct, promote, and provide clinical
mentorships for Physician and Nursing staff of other Trauma System Hospitals. Reasonable
goals and objectives of these Mentorships, as well as minimum qualifications and fees for
participants, may be devised by the Trauma Center, provided that the resulting program
demonstrates usefulness to the region.

2.4 Conduct Simulation Training

Trauma Centers must conduct simulation training commensurate with the needs of the region to
ensure adequate preparation for a variety of volume, acuity, and types of cases. The format and
frequency of such programs is at the discretion of the Trauma Center, provided that each of the following
is adequately documented and demonstrated:

• Participation of multiple providers and services within the region;

• Exercise of a reasonable variety of Hospital, Regional, and State Trauma Care Protocols;
• Case simulation reflecting high-risk, high-volume, or problem-prone patient types;
• Varying selection of dates and times to ensure maximum exposure of staff to the simulations.
Frequency of simulations sufficient to suggest participation of all Trauma Center staff in at least one
simulation annually. In addition, the simulation training program must include the following, each at a
minimum of one simulation annually. Simulations listed in 2.4.1 and 2.4.2 may be combined with 2.4.3 or
2.4.4 as needed to fulfill the requirement. These simulations may be simultaneous with those required by
other hospital functions, such as disaster planning. Regardless of the primary purpose of any simulation,
each exercise must be documented and reviewed by the Trauma Center*s Trauma Committee (see
Section 1.5.2) in order to meet the requirements of Section 2.4.

2.4.1 Planned Simulations

In planned simulations, it is permissible for participants to be advised in advance of the nature and
timing of the simulation. Such simulations are encouraged to permit inclusion of specific
personnel (e.g. a desired staff member) with advanced notice. They may also be useful to teach
new or infrequently-utilized processes and protocols to staff. For the purposes of fulfilling the
Trauma Center requirement for this section, a Planned Simulation may be replaced by an
additional No- Notice Simulation (see Section 2.4.2).

2.4.2 No-Notice Simulations

No-notice simulations may be useful in testing the true preparedness of the Trauma Care Team in
a given region. This simulation is planned and implemented as a surprise exercise, and is used to
measure the functional and educational needs of the Trauma Center as well as to train the staff
involved.

2.4.3 Full-System Simulations

While any trauma simulation may be devised specifically for the needs of a given unit or service
(e.g., the Emergency Department), it is important that at least one simulation annually test the
 Last revision March 27, 1995

integration of the full Trauma Care System of the region, from the scene to the Trauma Center by
way of a Trauma System Hospital. The purpose of this exercise should be to examine the
implementation of Medical Control, Triage, Transfer, and Communication Practices among
regional facilities and services. Full-System Simulations should be designed to include a different
TSH for each exercise, except as indicated for correction of problems identified.

2.4.4 Mass-Casualty Simulations

Mass-Casualty Simulations may be organized in concert with local Emergency Management
Agencies. The purpose of such exercises should be to test the operation of existing regional
systems in the event of excessive volume of high-acuity cases. In the event that Mass-Casualty
Simulations are required by the Trauma Center for other clinical or regulatory needs, the
simulations may be used to fulfill both requirements simultaneously.

2.5 Documentation of Meetings and Educational Experiences

In order to maintain, review, promote, and improve the educational functions of the Trauma Center, it
is necessary to document and demonstrated the following in addition to those requirements previously
described.

2.5.1 Educational Administrative Support Team

The Trauma Center should enlist its Education and Training Staff to assist in the design and
updating of all educational programs previously described. These personnel are especially needed
to ensure comprehensive Quality Improvement and accreditation of the educational services of the
Trauma Center, and their participation in such efforts should be explicit.

2.5.2 Organizational Learning

Each Trauma Center should be able to provide, annually and on request, a listing of major
institutional needs identified as necessary to the mission of the Trauma Center in the region. This
itemized document should also include a problem analysis, list of actions taken, and plan for
future reassessment and intervention. This requirement may be met, for example, by a satisfactory
institutional Quality Improvement plan. This section is included to emphasize aggressive
Continuing Quality Improvement as a foundation for the Maine Trauma Care System at each
level.

2.5.3 Needs-Based Education

Each formal educational offering undertaken by the Trauma Center should include a needs
assessment. Such documentation should be sufficient to justify the purpose of the program
beyond its requirement under the Maine Trauma Care System Plan. Examples would include
topics identified by institutional or system Quality Improvement, new products, services, or
protocols adopted by the Trauma Center; or personnel updates.

2.5.4 Follow-Up
 Last revision March 27, 1995

3 Quality Improvement for Trauma Centers - Monitor the Process & Outcomes of
Trauma Care to Ensure Quality, Efficacy, Cost Effectiveness, & Timeliness
3.1 Develop a Central Data Maintenance System
Each Trauma Center will maintain a trauma registry. A subset of the data collected will be downloaded to
Maine Emergency Medical Services for inclusion it its System Trauma Registry.

3.1.1 Institutional Commitment & Support for the Trauma Registry

A successful data system must have the support of the trauma center's administration and staff.
The facility needs to have trained personnel, computer resources, and access and ability to collect
the necessary data.

3.1.2 Identify and Train the People to Support the System

Each Trauma Center will identify individuals who will be trained in gathering data and entering
same into the hospital trauma registry, and generating standard reports and responding to ad hoc
queries and reports.

3.1.3 Acquire and Maintain the Hardware to Support the System

The trauma registry requires a personal computer (IBM or true compatible). Minimum
recommended system requirements: 386 or 386SX (486 or 486SX highly recommended) with 4
MB RAM 40 - 110 mb available on Hard Disk Floppy disk drive (5 1/4" or 3 ½")VGA resolution
(color highly recommended) DOS 5.0 or 6.0 (preferred)

3.1.4 Acquire and Maintain the Software to Support the System

Maine Emergency Medical Services will provide, at no charge, a copy of Hospital Trauma
Register (HTR). All trauma centers will use HTR, or an acceptable substitute as approved by
Maine EMS for their trauma registry. Maine EMS will maintain the license for HTR. Trauma
centers will also be provided with one copy of dBASE IV for their own use. Upgrades of dBASE
will be the responsibility of the trauma center.

3.2 Conduct Data Analysis on Processes and Outcomes

Using hospital oriented criteria equivalent to those defined by the Centers for Disease Control,
retrospective analysis of trauma cases will be conducted on process and outcomes to determine
compliance with or deviation from National Standards.

3.2.1 Identify Criteria for Data Collection

Any patient whose injuries are described by ICD-9-CM N-codes 800.00 through 959.9 plus any
of the following:

• Transfer from another facility;

• Admission to intensive care;
• Hospitalization for three or more days; or
• Death.

3.2.23.2.2. Identify the Data Set and Fields

Required data for the Registry would include Social Security number, law enforcement record number,
Prehospital record number, Hospital Medical Record number and Emergency Department
 Last revision March 27, 1995

admission date. Fields would include prehospital scene to hospital run times, vital signs, place and
mechanism of injury.
3.2.3 Collect and Analyze the Data
In addition to Prehospital data as described in 3.2.2, response times of physicians, vital signs and
length of stay in the Emergency Department, admitting physician, diagnoses codes, procedures
performed, injury severity scores, outcomes, and disposition will be collected. Analysis will be
conducted to determine if length of stay, outcomes, and response times are appropriate.

3.2.4 Communicate the Analysis/Information throughout the System

Report at regular intervals or as requested to Hospital Administrators, Trauma Service
Administration/Clinicians, Hospital Quality Assurance Committees, and Systems Trauma
Registry.

3.3 Conduct Data Analysis of Individual Cases on a Routine Basis

Trauma centers will routinely conduct data analysis of individual cases to determine compliance with or
deviation from National Standards.

3.3.1 Screen all Trauma Patients

Audit filters are used by trauma systems to examine the timeliness, appropriateness and
effectiveness of care delivered to an individual patient. We are currently using ACS suggested
filters and morbidity complications for our review process.

3.3.2 Conduct Informal Reviews

All patients that meet inclusive criteria are followed prospectively until discharge and monitored
for complications, timeliness of therapies, and appropriateness of care.

3.3.3 Conduct Formal Case Reviews

Each month a quality improvement summary is obtained by trauma coordinators and all patients
with variances are flagged and formally reviewed by the trauma care providers. An action plan is
developed and information is shared with the appropriate personnel.

3.3.4 Conduct Trauma Conferences

When there is a variation from the standard of care, or when trends appear, a corrective action
plan is developed and shared in a trauma conference where resolution of the issue is accomplished
by education and/or a change in policy. Minutes of the conference should be taken.

3.4 Develop Provider & Referral Feedback Mechanisms

Each trauma center will develop and maintain provider and referral feedback mechanisms for quality
improvement.

3.4.1 Establish Minimum Information for Feedback

Each System Hospital will be responsible for feedback to personnel involved in prehospital care
and interhospital transfers in their geographic area. This can be accomplished in a written form
utilizing mail, e-mail or fax services. It can be done verbally or with conferencing. The information
should include at least the following:

• Review of prehospital assessment and treatment;

• Review of communications involved;
 Last revision March 27, 1995

• The hospital diagnosis and therapy; and

• Outcome.

Every attempt should be made to contact the individual involved in the incident or a specified contact person.

3.4.2 Identify Communication Flow for Feedback Information

Once the patient has been settled, the receiving physician or a designated individual will call the
transferring primary acute care provider at the previously recorded telephone number and provide
the following information:

• Patient status;
• Current diagnosis; and
• Initial evaluation / therapy.

The transferring care provider should be welcomed to contact the attending physician or trauma coordinator at
any time for further discussion. The transfer physician will receive a copy of the patient's discharge summary.

3.4.3 Identify Protocols & People to Provide the Feedback

Trauma Centers are responsible for developing and maintaining appropriate mechanisms for
providing feedback to trauma providers.
 Last revision March 27, 1995

4 Quality Improvement for Trauma Centers - Have a "Public Voice" & Support the
Community
4.1 Support and Involvement in Public Education
Trauma centers will support and be involved with public education not only within the geographic
area but also on a state and national level.

4.1.1 Injury Prevention Education

Trauma Centers should be in the forefront of injury prevention education with the State.

4.1.2 Group Discussion of Issues

Trauma Centers should lead the clinical discussions as appropriate for public education.

4.2 Input for Public Policy

Trauma Centers should play an active role in shaping public policy.

4.2.1 Prevention / Safety Issues

Trauma Centers should promote prevention and public safety issues. For example:

• A mandatory Seatbelt Law;

• A mandatory Motorcycle Helmet Law.

4.2.2 Mandatory Autopsy

Trauma Centers should actively promote the development of mandatory autopsy within the State.

4.2.3 Emerging Issues (support for the system)

Trauma Centers should be aware of emerging trauma issues and actively organize for influence
within the public debate.
 Last revision March 27, 1995

1 Quality Improvement for System Hospitals - Provide Institutional Support,

Structure, & Organization to Promote Quality & Future Growth
1.1 Develop a Comprehensive Care System
National standards have been incorporated into the criteria for Trauma Centers and Trauma System
Hospital and requirements and responsibilities. Trauma Nurse Coordinators are required at all Trauma
Centers and provide Case Management for trauma patients. Critical pathways are guidelines for the care
of trauma patients and are being developed. Relationships with rehabilitation services are in place and are
critical in the continuum of trauma care.
1.1.1 Acute Care Based on National Standards and Use of Data

1.1.2 Develop Critical Pathways / Trauma Case Management

1.1.3 Provide Psycho-Social-Economic Support

1.2 Leverage Emerging Technology for System Development

Minimum required technology for clinical services is detailed in the resource document. Technology for
communication and education may involve interactive video network and centralized communication
center, but must at the minimum provide direct telephone and/or radio access and fax capability.
1.2.1 Clinical Technology

1.2.2 Communication Technology

1.2.3 Education Technology

1.3 Support the Trauma System

Trauma System Hospitals should encourage the education of all trauma care providers. They should also
ensure that essential equipment as outlined in the Resource Document is available..
1.3.1 Funding for Clinicians

1.4 Promote Trauma System / EMS Integration

1.4.1 Support Medical Control
Each Trauma Center will be responsible for development, implementation, and ongoing quality
improvement of Medical Control in support of Emergency Medical Services Providers. Medical
Control activities include the provision of contemporaneous medical direction to out-of-hospital
EMS via on-line and off-line services. Protocols for On-line Medical Control have been
previously described by Maine EMS on a regional basis. It will be required of Trauma Center*s
to demonstrate compliance with these protocols. Training for Medical Control Officers is
provided by the National Association of Emergency Medical Services Providers. Trauma Centers
will be required to provide 24-hour availability of a licensed Maine physician able to immediately
participate in On-line Medical Control. In regions and circumstances where technologies and
personnel exist to provide centralized Medical Control, such will be adequate to fulfill the
requirement of this section, provided that a) it is accomplished with consensus among all Maine
Trauma System Hospitals and EMS Providers served, and b) coverage is adequate to provide
immediate 24-hour coverage to all requesting agencies by a licensed Maine physician. In the event
that Aeromedical or other services are developed to provide transport for trauma patients over
extended routes, it will be the responsibility of those services to provide Centralized Medical
Control as previously described.
 Last revision March 27, 1995

1.4.2 Support Triage Protocols

Each Trauma System Hospital will be responsible for supporting Triage Protocols. Pre-Hospital
Triage Protocols have been developed by the Maine EMS Physician Advisory Board.

1.4.3 Support Pre-Hospital System

Each Trauma System Hospital has a responsibility to assist EMS organizations in the development
of pre-hospital systems within their geographic area. Specifically, this responsibility consists of
three major areas:
• Comprehensive Disaster Management;
• Develop Diagnostic Tools; and
• Crisis Intervention.

1.4.4 Support Transportation Systems

Trauma System Hospitals should support appropriate agencies and organizations in the
development of EMS transportation systems that reflect the rural nature, geography, and special
needs of the state. This includes the potential for more rapid systems of transportation such as
aviation and the special needs of EMS providers.

1.5 Support Trauma System Alignment

Trauma System Hospitals should support system alignment, both vertically and horizontally. Major
efforts in attaining system alignment should be the development and deployment of a comprehensive
strategic and quality improvement plan, development of systems for provider feedback, and a sharing of
resources for education.
1.5.1 Support a Plan with Maximum Involvement
Trauma System Hospitals should support the Trauma System plan for long term system
development and quality improvement. This plan should be developed within the context of the
trauma team architecture so that it reflects the needs and contributions of all multi-disciplinary
team members.

1.5.2 Participate and Support Feedback Programs

Trauma System Hospitals will assist in the development of provider feedback mechanisms. This
should include immediate telephone calls and eventual written feedback. Feedback is recognized
as the sine qua non for system wide quality improvement.

1.5.3 Share Resources/Promote Research & Education

Trauma System Hospitals will share resources both system wide and within their respective
geographic areas for trauma research and education. The education part of trauma system
development is so crucial that it warrants special emphasis as a major responsibility in its own
right, (please see Strategic Goal 2.0 series in this manual).
 Last revision March 27, 1995

2 Quality Improvement for System Hospitals - Education

2.1 Create an Environment of Openly Shared Clinical Learning for Education and Training
2.1.1 Meetings to Discuss Issues/Concerns/Needs
A trauma care system plan must include the ability of the system to monitor its own performance
and to access its impact on trauma morbidity and mortality. Therefore, regularly scheduled
meetings should occur between Maine EMS (lead agency) and representatives assigned by the
TAC to discuss issues identified through the QI process: monitoring of state identified audit
filters, patient needs and outcomes and system resources etc. In this way trauma care management
deficits can be identified and appropriate changes can be made to allow for the continual
development and improvement of the system.
2.1.1.1 Care Standards
The Maine Trauma System plan has established standards of care according to ACS and
ACEP guidelines for trauma centers and trauma system hospitals including resources
and equipment.
2.1.1.2 Regularly Scheduled Education
Regularly scheduled meetings between trauma directors, trauma nurse coordinators,
trauma surgeons, ED nurses, and pre-hospital providers should occur monthly to discuss
quality patient care.
2.1.1.3 Informal Meetings
Impromptu meetings between trauma director and other trauma personnel should occur on
an as needed basis depending on severity of the issue.

2.1.2 Conduct Clinically-Related Training as needed (Just-In-Time)

Collaborative practice rounds should occur weekly and on an as needed basis.
2.1.3 Pre-hospital Providers
Involvement of Pre-hospital Providers in case review presentations should occur as
appropriate on a regular basis.
2.1.3.1 Nurses
Involvement of Nurses in case review presentations should occur as appropriate on a
regular basis.
2.1.3.2 Physicians
Involvement of Physicians in case review presentations should occur as appropriate on a
regular basis.
2.1.3.3 Ancillary Personnel
Involvement of Ancillary Personnel in case review presentations should occur as
appropriate on a regular basis.
2.1.4 Conduct Case Reviews
Quality improvement activities should include prospective and retrospective case reviews that
may by injury specific triggered by audit filters, randomly selected or based on monthly morbidity
mortality conferences. These reviews should involve all appropriate disciplines and are necessary
to monitor and access the facilities's ability to comply with pre-established standards.
2.1.5 Participate in Simulation

2.2 Participate in & Document Formal Trauma Education Courses

The Trauma Centers have unique responsibility in providing formal trauma education and consequently
must facilitate the availability of national courses such as ATLS, PHTLS, ABLS, PALS, and TNCC.
 Last revision March 27, 1995

These courses should be held in all parts of the state on a regular basis. Assistance should be provided in
scheduling and obtaining faculty for these courses.
2.2.1 Support and Participate in ATLS Courses
ATLS is a course developed and sponsored by the A.C.S. for physicians which covers trauma
knowledge and skills. It is considered an optimum standard for trauma care physicians and
physician extenders directly involved in the resuscitation of the injured patient. The TAC and the
trauma centers should facilitate the availability of this course throughout the state. A physicians
education program made and options to facility.
2.2.2 Support and Participate in Pre-Hospital Education
Trauma Centers in general, and physicians in particular, must provide leadership in the
development of triage, trauma protocols, and EMS Provider trauma education and training.
PHTLS
PHTLS is a verification course for pre-hospital care providers that teaches concepts of basic and
advanced trauma life support.
PALS
Pediatric Advanced Life Support (PALS) is a national level course that should be available for
pre- hospital personnel.
PABLS
Pre-Hospital Advanced Burn Life Support (PABLS) is national level course that should be
available for pre-hospital personnel.
Air Ambulance
Each system should support established guidelines for land/air transportation subject to legislative
regulation, geographic boundaries, and topography etc.

2.3 Support & Document Informal Education and Training

Trauma Centers are expected to provide, support, and chronicle ongoing informal education for all
professionals involved in care of injured patients. To this end, the expressed mission of the Trauma
Center must include, but is not limited to, the following:
2.3.1 Conduct Informal Talks About Specific Runs / Events
Trauma Center*s must be able to demonstrate a willingness and ability to discuss clinically
important cases and events with pertinent personnel as the opportunity arises. Compliance with
this requirement includes impromptu case discussions in real time, such as a brief review or
critique of an Emergency Department case with the transferring or transporting crew.
Participants in these reviews should be reminded of the confidential nature of the material
discussed as it relates to specific individuals. These sessions may be logged with events described
in Section 2.3.1, provided the informal nature of the discussion is noted.
2.3.2 Identify Specific “Point of Contact” Nurses for Trauma Education
Each Trauma Center must identify one or more members of the nursing staff possessing adequate
experience and interpersonal skills to ensure optimum inter-provider education as described
throughout this section. It will be the responsibility of this nurse to maintain a list of contacts at
all referring hospitals and EMS units, and to act as a resource to these providers for the purposes
of ad hoc education and follow-up.

2.4 Support Public Education

Each Trauma System Hospital has a responsibility for supporting public education within their local area.
 Last revision March 27, 1995

3 Quality Improvement for System Hospitals - Data Management, Trauma System

Hospitals have a responsibility to manage data

3.1 Participate in a Central Data Maintenance System and Submit Data

Trauma System Hospitals have a responsibility to participate in the regional and state data management
system by submitting data. Data submission leads to analysis and input for Education and Quality
Improvement.
3.1.1 Institutional Commitment & Support for the Data System
Trauma System Hospitals will support the data management system.
3.1.2 Identify and Train the People to Support the System
Trauma System Hospitals will support the data management system by providing the requisite
trained personnel.
3.2 Submit Data
Trauma System Hospitals will submit data to support Education and Quality Improvement.

3.3 Conduct Data Analysis of Individual Cases on a Routine Basis

Trauma System Hospitals will routinely conduct data analysis of individual cases to determine
compliance with or deviation from National Standards.

3.4 Participate in Provider & Referral Feedback Mechanisms

Each trauma system hospital will participate in provider and referral feedback mechanisms for Quality
Improvement.
 Last revision March 27, 1995

Appendix
 Last revision March 27, 1995

MAINE EMS TRAUMA ADVISORY COMMITTEE

Application for Trauma Centers

Site Survey Process

Pre-survey Questionnaire

Please Complete the Attached Questionnaire and Hospital Resources Table

and Return To:

Maine EMS
16 Edison Drive
Augusta, ME 04330
(207) 287-3953
 Last revision March 27, 1995

Pre-survey Questionnaire

Please complete this questionnaire and return it to Maine EMS

IV. GENERAL INFORMATION - For Trauma System Hospitals or Trauma Center Applicants

A. Name of Hospital
B. Number of hospital beds__________.
C. Number of ICU beds_____________.
D. Number of surgical ICU beds_____________.
E. Number of ED visits last year_______________.
F. Number of ED Trauma related visits last year_________.
G. Number of trauma admissions in the last 12 months _________.
H. For Trauma Centers Only : Is there a resolution supporting the trauma center by the hospital’s
governing body?_______Yes _____No. If yes, provide documentation.
I. For Trauma Centers Only : Is there a medical staff resolution supporting the trauma center?
______ Yes ______ No. If yes, provide documentation.

This completes the Trauma System Hospital Application.

If you are submitting a Trauma Center Application, you must complete the pages that
follow.
 Last revision March 27, 1995

V. PREHOSPITAL SYSTEM

A. Describe how the commitment to education, medical control, and interactions with base station
medical control. Please describe the hospital’s participation in the EMS region. Also describe
problems along with proposed solutions relating to pre-hospital care and medical control. Include
details about 911, radio communications, management protocols, and interaction with EMS.
Include any pre-hospital QA activities.

B. Have you had to divert transfer patients? ______ Yes ______ No.

If so where?
 Last revision March 27, 1995

VI. HOSPITAL

In order to assist the reviewing team, please describe your hospital, its governance, its role in the community,
applicable organizational charts, regional trauma activities, etc. Are all trauma activities within one facility? If
not, describe multi-facility relationships.
 Last revision March 27, 1995

VII. TRAUMA SERVICES

Please describe the members of the Trauma Service, i.e. all general surgeons, specific trauma
surgeons, etc.

Are you using ISS or Revised Trauma Score? ______ ISS ______ RTS

A. Number of trauma admissions for one year beginning 14 months prior to this review
1. Total trauma admissions from ED to ICU
2. Total trauma admissions from ED to ICU with ISS >15
3. Total trauma admissions from ED to OR
4. Total trauma admissions from ED to OR with ISS >15
5. Number of (a) above admitted to Trauma Service __________;
6. Number of (b) above admitted to Trauma Service___________;
7. Number of trauma patients directly admitted to Neurosurgery__________;
8. Number of trauma patients directly admitted to Orthopedics _____________;
9. Number of trauma patients admitted to non-surgical services ____________.

B. Chief of Trauma Service (See Chart A)

1. Curriculum Vitae (please submit) (Chief)
2. CME in trauma for 3 years (please submit)
3. ATLS status
a. Instructor ______ Yes ______ No
b. Provider _______ Yes ______ No
c. Describe authority to direct trauma service (provide documentation).

4. Provide a copy of job description of Trauma Director; narrative description and

organizational chart of the trauma service including its relationships to the Department of
Surgery and other major hospital departments and services.

C. Narrative description of the hospital’s trauma call roster for surgeons, neurosurgeons, and
orthopedic surgeons, including first and second call. Include any policy and procedure for
appointment to and removal from trauma call roster. Outline any additional Credentialing
process for participation in Trauma Call Roster beyond your routine Credentialing
process.

D. List all surgeons taking trauma call (complete Chart A)

1. CME in trauma for 3 years (please submit)
2. ATLS status
3. Frequency of trauma calls per month
4. Board certification
 Last revision March 27, 1995

HAVE AVAILABLE AT TIME OF REVIEW:

E. List of Neurosurgeons (complete Chart B)

1. Curriculum Vitae (please submit) (Chief)
2. List of trauma CME for 3 years
3. ATLS status
4. Frequency of trauma call per month
5. Board certification

F. List of Orthopedic Surgeons (complete Chart C)

1. Curriculum Vitae (please submit) (Chief)
2. List of trauma CME for 3 years
3. ATLS status
4. Frequency of trauma call per month
5. Board certification

G. Trauma Coordinator
1. Curriculum Vitae (please submit)
2. List of trauma CME for 3 years
2. List support personnel (names and titles)
3. Describe the Administrative reporting structure

ARE ANY OF YOUR SURGEONS TAKING TRAUMA CALL AT MORE THAN ONE
HOSPITAL? ______YES ______ NO

If yes, explain:
 Last revision March 27, 1995

VIII. HOSPITAL FACILITIES

A. Emergency Department
1. Chief Emergency Department Physician (see Chart D)
a. Complete CV
b. CME in Trauma for 3 years (please submit)
c. ATLS status
d. Board certification

2. List of Emergency Department Physicians (see Chart D)

a. Trauma CME for 3 years (please submit)
b. ATLS status
c. Credentialing process
d. Board certification

3. Define role and relationship of emergency medicine in trauma service:

ATTACH A COPY OF EMERGENCY DEPARTMENT TRAUMA FLOW SHEET AND ANY

RESUSCITATION THAT ARE APPLICABLE

B. Radiology
1. Is there, in hospital, a 24-hour X-Ray Technician available? ___Yes___No
2. Is there, in hospital, a 24-hour CT Technician available? ____Yes_____No
a. If not, is there a Quality Assurance Program showing prompt/ appropriate CT
management? ______Yes ______No
3. Is there resuscitation and monitoring equipment available in the Radiology Suite?
______Yes ______ No
4. Who accompanies the major trauma patient to the Radiology Suite?
Last revision March 27, 1995
 Last revision March 27, 1995

C. Operating Room
1. Number of Operating Rooms __________
2. Describe your trauma staffing and backup call for day, nights, weekends, and holidays in
hospital 24-hour, 7 days, for the following:
a. Anesthesiologist and CRNA
b. Circulator
c. Scrub technician

3. Do you have an OR dedicated to trauma? ______ Yes ______ No

D. Recovery Room - Hours of operation. If not open 24 hours a day, explain:

E. Clinical Lab/Blood Bank

1. Blood Bank -
a. Source of blood:
 Last revision March 27, 1995

b. Is there a massive blood transfusion? ______Yes ______No

c. Do you have any satellite blood banks in hospital?
______Yes ______No
d. Is there an uncross matched blood protocol? ______Yes ______No

2. Clinical Lab:
a. Is there 24 hour staffing? ______Yes ______No
b. Estimated ED and ICU stat order response time?
c. Do you have any satellite sites for blood gas determination?
______ Yes ______ No

Comments:
 Last revision March 27, 1995

IX. ICU

A. Number of beds

B. Are any ICU beds dedicated solely to trauma patients? ______Yes ______No

C. What is physician coverage?

D. Is the surgeon credentialed in critical care by Trauma Director on duty in ICU 24 hours a day or
immediately available? ______Yes ______No

E. Who is the director?

Complete C.V. available at time of review.

F. Who is responsible for the trauma patient?

G. Describe in narrative below the availability of beds, dedication of beds, and governance as it
relates to the trauma patient. Attach policy for and frequency of diversion of trauma patients due
to unavailability of ICU beds
 Last revision March 27, 1995

H. Also, attach a copy of the ICU flow sheet.

 Last revision March 27, 1995

X. ANESTHESIA / CRNA

A. Do you have Anesthesia in-house 24-hours a day? ______Yes ______No. If no, are you applying
under your Quality Assurance documentation?
______Yes ______No.

If yes, what are your QA Filters?

 Last revision March 27, 1995

XI. SPECIALTY/REHABILITATIVE/SOCIAL SERVICES

A. Rehabilitative Services

1. Who is your Chief of Rehabilitation?

(Have CV available during review).
a. Board Certification ______Yes ______No
If yes, what specifically?

b. Describe the role and relationship of rehabilitation services to the trauma service

2. Are rehabilitative consultations routinely obtained while trauma patient is in the ICU?
______Yes ______No. If yes, who responds

3. What services are provided in the ICU? i.e.,

Physical Therapy ______Yes ______No
Occupational Therapy ______Yes ______No
Speech Therapy ______Yes ______No
Other .... list please

4. Have available (during review) the transfer protocols for acute or long-term disabilities.

B. Pediatric Trauma

1. What is the age limit for pediatric trauma in your hospital?

2. What is the number of pediatric trauma admissions during the year?
3. Is there a separate pediatric ICU? ______Yes ______No
 Last revision March 27, 1995

4. What services admits pediatric trauma ICU patients?

5. Who is responsible for pediatric trauma patients in ICU?

6. Are there any transfer agreements for pediatric trauma patients?

______Yes ______No. If so, have available at time of review.
 Last revision March 27, 1995

C. Burn Patients

1. Number of burn patients admitted during reporting year

2. Describe your transfer policy for burn patients. (Have protocol available at time of
review)

D. Spinal Cord Injuries

1. Number of spinal cord patients treated during reporting year

2. Number of patients transferred to other facility
3. Describe your transfer policy for spinal cord injury patients. (Have available at time of
review)

E. Social Services

1. Is there support for trauma service, including family support?

______Yes ______No
2. Do you have a crisis intervention program? ______Yes ______No
3. Do you have counseling for the family (i.e., chaplain)?
______Yes ______No
4. Do you have an organ procurement program? ______Yes ______No. If yes, how many
referrals were there to Regional Organ Procurement Organization last year?

F. Are there any transfer policies for transfer INTO the hospital for specific problems?
______Yes ______No. If so, list below
 Last revision March 27, 1995

XII. DESCRIBE YOUR FACILITIES TRAUMA QUALITY ASSURANCE PROGRAM

INCLUDING:

A. Do you have a trauma register? ______Yes ______No

B. Who maintains the trauma register?

C. Describe the criteria for patient entry into the trauma register?

D. Do you have any regional or national affiliation of your trauma register?

______Yes ______No. Number of patients entered per year in your trauma register?

E. Do you have documentation and statistics of surgeons availability in the OR?

______Yes ______No; ED? ______Yes ______No; ICU? ______Yes ______No

F. How many multi-disciplinary conferences do you have a year?

G. Who attends your multi-disciplinary conferences? (Have minutes and attendance available for
past year at time of review).
 Last revision March 27, 1995

H. Trauma Death Audits

1. Who reviews Emergency Department trauma deaths?

2. Who reviews in-house trauma deaths?

a. How many trauma deaths during reporting period?

(Include DOA, ED admissions, and in-house).

b. Number of meetings?

I. How many audits filters are you using? List at least five

J. Who does the nursing audits for trauma?

Describe

K. How often does the trauma service or problem-solving committee meet?

 Last revision March 27, 1995

DO NOT SEND ANY QUALITY ASSURANCE DOCUMENTS OR MINUTES! THESE SHOULD BE

AVAILABLE AT TIME OF REVIEW!

WE WILL NEED IN QA REVIEW EVIDENCE OF “CLOSING THE LOOP”

 Last revision March 27, 1995

XIII. DESCRIBE, IN A NARRATIVE, THE COMMITMENT OF YOUR ADMINISTRATION. IS

THERE A LINE ITEM BUDGET FOR TRAUMA?
 Last revision March 27, 1995

XIV. EDUCATIONAL ACTIVITIES/OUTREACH PROGRAMS

A. Do you have a General Surgery Residency Program? ______Yes ______No. If so, how related
to Trauma Service?

B. Do you have other Specialty Residency Programs? ______Yes ______No. If so, list and define
any relationship with trauma program.
 Last revision March 27, 1995

C. Do you have Intramural Trauma education for the Medical/Nursing Staff? ______Yes ______No.
If so, have available at time or review.

D. Do you have educational activities for the public? ______Yes ______No. If so, have available at
time of review.

E. Do you provide ATLS courses? ______Yes ______No.

 Last revision March 27, 1995

F. Do you have educational programs for physicians? ______Yes ______No.

G. Do you have educational programs for prehospital providers? ______Yes ______No.

H. Is there any hospital funding for extramural physician/nursing trauma education? ______Yes
______No.

I. Do you have any outreach programs for trauma? ______Yes ______No. If so, have available at
time of review.

J. Do you have any Trauma Prevention Programs? ______Yes ______No. If so, have available at
time or review.
 Last revision March 27, 1995

XV. RESEARCH ACTIVITIES

LIST LAST THREE YEARS OF TRAUMA RELATED PUBLICATIONS, RESEARCH,

ONGOING PROJECTS.

DO NOT SEND REPRINTS!! HAVE THESE AND ANY OTHER

MATERIALS AVAILABLE AT TIME OF REVIEW.
THIS REPORT COMPLETED BY:

TITLE:
TRAUMA DIRECTOR:

DJS:cfn
ED: 3/20/95
 Last revision March 27, 1995

TRAUMA SURGEONS CHART A

1. Complete columns.
2. Have Curricula Vitae available at time of review.
3. Have list of CME credits for past three years available.

Name Residency - Where and Board ATLS Instructor, Trauma CME Frequency Number of
When Completed Certificatio n Provider Status, Number of of Trauma Trauma
Date of Expiration Hours in 3 Call Per Patients
Years Month Admitted
per Year
Last revision March 27, 1995
 Last revision March 27, 1995

NEUROSURGEONS CHART B

1. Complete columns.
2. Have Curricula Vitae available at time of review.
3. Have list of CME credits for past three years available.

Name Residency - Where Board ATLS Instructor, Trauma CME Frequency of

and When Completed Certificatio n Provider Status, Number of Hours Trauma Call Per
Date of Expiration in 3 Years Month
 Last revision March 27, 1995

ORTHOPEDIC SURGEONS CHART C

1. Complete columns.
2. Have Curricula Vitae available at time of review.
3. Have list of CME credits for past three years available.

Name Residency - Where Board ATLS Instructor, Trauma CME Frequency of

and When Completed Certificatio n Provider Status, Number of Hours Trauma Call Per
Date of Expiration in 3 Years Month
 Last revision March 27, 1995

EMERGENCY PHYSICIANS CHART D

1. Complete columns.
2. Have Curricula Vitae available at time of review.
3. Have list of CME credits for past three years available.

Name Residency - Where Board ATLS Instructor, Trauma CME Frequency of

and When Completed Certification Provider Status, Number of Hours Trauma Call Per
Date of Expiration in 3 Years Month
Last revision March 27, 1995
 Last revision March 27, 1995

Maine Trauma System Plan

Surveyor’s Guide to the Hospital Resource Table
June 17, 1996

The site survey team will consist of a Trauma surgeon, an emergency physician, a trauma nurse coordinator, an
administrator and a representative from Maine EMS. It is expected that the Trauma surgeon will be lead reviewer, and
will come from out of state. It is expected that the out of state trauma surgeon will be familiar with Maine’s standards for trauma
centers.

Requirements Met? &

Surveyor’s Guidelines Comments

A. HOSPITAL ORGANIZATION 1. This standard may be demonstrated by E .

1. Trauma Service specific statements in the hospital’s
a. 1. An obligation on the part of the mission statement, medical staff
institution and medical staff bylaws, an organizational structure
to care for trauma patients. clearly defining the trauma service
Specified delineation of with an appropriate responsible
privileges for the Trauma administrator. The institutional
Service by the medical staff bylaws or rules should contain
Credentialing Committee language specifying a commitment to
may be desirable. care for trauma patients without
2. The Trauma Service Director regard for ability to pay. Evidence of
will be a board certified compliance with this can come from
general surgeon with an examination of the hospital’s
3. specific commitment to trauma transfer logs, discussion with
care. emergency staff etc. Policies
regarding diversion should be clearly
defined.
2. There should be a specific job description
for the Trauma Surgeon. The
surgeon should demonstrate
continuing trauma education, be
ATLS certified, regularly attend the
institution’s trauma meetings.
3. A contract and or a job description would
be expected.

b. Trauma Coordinator (Under direct This role may be filled by an R.N., P.A-c or an E
supervision of Trauma Service M.D./D.O. The standards for the Trauma
Director) Surgeon above apply for this role as well.

c. Trauma Contact Person (responsible for As above E

communicating with regional trauma
coordinators, coordinating trauma
transfer feedback and trauma
tracking forms and periodic resource
assessments. May be Trauma
Coordinator)

2. Multi disciplinary Trauma Committee An assessment should be made of the meeting E

(Trauma Service Director, Trauma frequency; does the committee exist within the
Coordinator, with representation medical staff bylaws? To whom does it report?
from Anesthesiology, Critical Care,
Emergency Medicine, General
Are minutes kept. What are the issues that the
Surgery, Neurologic Surgery, committee has dealt with? Is there appropriate
Orthopedic Surgery, Radiology) administrative input and support? Does the
 Last revision March 27, 1995

Requirements Met? &

Surveyor’s Guidelines Comments

committee “leverage” the institution’s

commitment to trauma, for example is there an
assessment of resource allocation? Does the
committee “operationalize” the goals of the
trauma program? Is the role of the committee
clearly defined? Is the committee included in
issues of QA and QI?

3. Hospital For each of these specialties there should be

Departments/Divisions/Ser visible evidence that these services are being
vices/Se ctions provided on an ongoing, regular basis at the
institution. This could be demonstrated
through call schedules, OR/procedure
schedules, and discussions with nurses and
physicians.

Anesthesiology see above E

Emergency Medicine see above E

General Surgery see above E

Neurologic Surgery see above E

Orthopedic Surgery see above E

Radiology see above E

4. Specialty Availability Response times should be demonstrated by

individual chart reviews, ED logs, discussion
with staff, or summation reports from the
trauma registry.

In-house 24 hours a day

Anesthesiology (May be satisfied by senior Appropriate response times documented? (see E

resident, CRNA, or by above)
Anesthesiologist able to arrive in OR
within 15 minutes of notification*)

Critical Care Physician (May be satisfied Appropriate response times documented? (see E
by senior resident or by ICU physician able above)
to arrive within 30 minutes of notification,
time of first call and ICU arrival to be
routinely recorded*)

Emergency Medicine Physician Appropriate response times documented? (see E

above)

General Surgery (May be satisfied by Appropriate response times documented? (see E

senior surgical resident or by surgeon able above)
to arrive in ED within 30 minutes of
notification, time of first call and ED
arrival to be routinely recorded*)

Neurologic Surgery (May be satisfied by Appropriate response times documented? (see E

physician with special competence in above)
neurotrauma, determined by local
neurosurgeon who will be able to arrive in
ED within 30 minutes of notification, time
 Last revision March 27, 1995

Requirements Met? &

Surveyor’s Guidelines Comments

of first call and ED arrival to be routinely

recorded*)

On-call and available within 30 minutes

Cardiac Surgery Appropriate response times documented? (see D

above)

Cardiology Appropriate response times documented? (see E

above)

Hand Surgery Appropriate response times documented? (see E

above)

Infectious Disease Appropriate response times documented? (see D

above)

Internal Medicine Appropriate response times documented? (see E

above)

Microvascular Surgery Appropriate response times documented? (see D

above)

Nephrology Appropriate response times documented? (see E

above)

Obstetrics/Gynecologic Surgery Appropriate response times documented? (see E

above)

Ophthalmic Surgery Appropriate response times documented? (see E

above)

Oral/Maxillofacial Surgery Appropriate response times documented? (see E

above)

Orthopedic Surgery Appropriate response times documented? (see E

above)

Pediatrics Appropriate response times documented? (see E

above)

Pediatric Surgery (May be satisfied by Appropriate response times documented? (see E

general surgeon credentialed by hospital to above)
provide surgical trauma care to pediatric
patients)

Reconstructive/Plastic Surgery Appropriate response times documented? (see E

above)

Pulmonary Medicine Appropriate response times documented? (see E

above)

Radiology Appropriate response times documented? (see E

above)

Thoracic Surgery (May be satisfied by Appropriate response times documented? (see E

general surgeon credentialed by hospital to above)
provide thoracic surgical trauma care)

Urologic Surgery Appropriate response times documented? (see E

above)
 Last revision March 27, 1995

Requirements Met? &

Surveyor’s Guidelines Comments

B. FACILITIES / RESOURCES /
CAPABILITIES
1. Emergency Department (ED)
a. Personnel Obtain evidence of a designated physician
1. Designated physician director director E

2. Physician with special Evidence of continuing education in trauma E

competence in care of care is strongly recommended. Trauma CME
the critically injured may include ATLS or other broad based CME
who is a designated activity..
member of the trauma
team and physically
present in the ED 24
hours a day

3. Nurses with special capability in Emergency physicians, and emergency nurses E

trauma care should be oriented to the trauma protocol. For
nurses, evidence of trauma training is
required. Evidence of ongoing training may
be fulfilled by TNCC, with a target of 50% of
the Emergency nurses being certified. In the
absence of the 50% target, there should be a
commitment to have at least one TNCC
certified nurse on each shift.

b. Equipment for resuscitation shall

include but not be
limited to:
1. Airway control and ventilation Is the specified equipment present? E
equipment including
laryngoscopes and
endotracheal tubes of all
sizes, bag-mask
resuscitator, pocket
masks, oxygen, and
mechanical ventilator

2. Suction devices Is the specified equipment present? E

3. Electrocardiograph- Is the specified equipment present? E

oscilloscope-defibrillato
r

4. Apparatus to establish central Is the specified equipment present? E

venous pressure
monitoring

5. All standard intravenous fluids Is the specified equipment present? E

and administration
devices, including
intravenous catheters

6. Sterile surgical sets for standard Is the specified equipment present? E

ED procedures
(thoracostomy, venous
cut-down, thoracotomy,
cricothyroidotomy, etc.)
 Last revision March 27, 1995

Requirements Met? &

Surveyor’s Guidelines Comments

7. Gastric decompression Is the specified equipment present? E

equipment

8. Drugs and supplies necessary for Is the specified equipment present? E

emergency care

9. X-ray capability, 24 hour Is the specified equipment present? E

coverage by in-house
technician

10. Two-way radio linked with Is the specified equipment present? E

vehicles of emergency
transport system

11. Skeletal traction device for Is the specified equipment present? E

cervical spine injuries

12. Thermal control devices for:

a. Patient (e.g. circulating water or Is the specified equipment present? E

air blanket, radiant heater)

b. Blood and fluids (including Is the specified equipment present? E

rapid volume infuser)

13. Pulse oximetry Is the specified equipment present? E

14. End-tidal CO2 determination Is the specified equipment present? E

15. Pneumatic Anti-Shock Garment Is the specified equipment present? E

(PASG)

2. Intensive Care Units (ICUs) for trauma Nurses should be encouraged to have
patients additional education in trauma care. This is
not a requirement at this time, but the
requirement in B.1.a.3, (Emergency nurses),
will be required at the time of recertification.

a. Designated physician director Obtain evidence of a designated physician E

director

Response times should be demonstrated by E

b. Critical Care physician on duty in individual chart reviews, ED logs, discussion
ICU 24 hours a day or with staff, or summation reports from the
immediately available trauma registry.
from in- house (May be
satisfied by senior resident or Appropriate response times documented? (see
by ICU physician able to arrive
within 30 minutes of above)
notification)

c. Immediate access to clinical Appropriate response times documented? (see E

laboratory services above)
(including Hb/Hct, ABG, CXR
within 30 mins. of request)

d. Equipment:

1. Airway control and ventilation Is the specified equipment present? E

devices
 Last revision March 27, 1995

Requirements Met? &

Surveyor’s Guidelines Comments

2. Oxygen source with Is the specified equipment present? E

concentration controls

3. Cardiopulmonary resuscitation Is the specified equipment present? E

cart

4. Temporary transvenous Is the specified equipment present? E

pacemaker

5. Electrocardiograph- Is the specified equipment present? E

oscilloscope-defibrillato
r

6. Cardiac output monitoring Is the specified equipment present? E

7. Electronic pressure monitoring Is the specified equipment present? E

8. Mechanical ventilator- Is the specified equipment present? E

respirators

9. Patient weighing devices Is the specified equipment present? E

10. Pulmonary function measuring Is the specified equipment present? E

devices

11. Thermal control devices for:

a. Patient (e.g.. circulating water or
air blanket, radiant heater) Is the specified equipment present? E

b. Blood and fluids (including Is the specified equipment present? E

rapid volume infuser)

12. Inotropic drugs, fluids, supplies Is the specified equipment present? E

13. Intracranial pressure monitoring Is the specified equipment present? E

devices

14. Pulse oximetry Is the specified equipment present? E

15. Skeletal traction devices Is the specified equipment present? E

16. Peritoneal lavage equipment Is the specified equipment present? E

3. Postanesthetic Recovery Room (ICU is

acceptable)

a. Registered nurses and other essential Nurses should be encouraged to have E

personnel 24 hours a additional education in trauma care. This si
day not a requirement at this time, but the
requirement in B.1.a.3, (Emergency nurses),
will be required at the time of recertification.

NOTE If trauma patients are recovered in ICU

this education requirement will be waived.

b. Equipment for continuous Is the specified equipment present? E

 Last revision March 27, 1995

Requirements Met? &

Surveyor’s Guidelines Comments

monitoring of
hemodynamics

c. Intracranial pressure monitoring Is the specified equipment present? E

devices

d. Pulse oximetry Is the specified equipment present? E

e. End-tidal CO2 determination Is the specified equipment present? E

f. Thermal control devices for:

1. Patient (e.g.. circulating water or air Is the specified equipment present? E

blanket, radiant heater)

2. Blood and fluids (including rapid Is the specified equipment present? E

volume infuser)

4. Acute Hemodialysis Capability Is the specified equipment present? E

5. Organized Burn Care Transfer agreements may facilitate the transfer

of patients. An understanding of COBRA
requirements should be in place. A transfer
protocol should be in place that Manages risk,
assures permission to transfer, records the
transfer and ensures the use of qualified
personnel.

a. Physician-directed burn center staffed This requirement may be fulfilled by a list of E

by nursing personnel receiving facilities have the capability of
trained in burn care and treating these patients.
equipped properly for
care of the extensively The reviewer will retrieve a copy of the
burned patient transfer agreement or list

OR

b. Transfer agreement with a burn

center

6. Acute Spinal Cord/Head Injury as above

Management Capability
a. In circumstances where a designated The reviewer will retrieve a copy of the E
spinal cord injury transfer agreement or list
rehabilitation center
exists in the region,
early transfer should be
considered; transfer
agreements should be in
effect

b. In circumstances where a head injury The reviewer will retrieve a copy of the E
center exists in the transfer agreement or list
region, transfer should
be considered in
selected patients;
 Last revision March 27, 1995

Requirements Met? &

Surveyor’s Guidelines Comments

transfer agreements
should be in effect

7. Radiological Special Capabilities

a. In-house radiology technician 24 May be assessed by examining staffing E

hours a day schedules, staff interviews etc.

b. Angiography of all types Is there evidence that these procedures are E

available?

c. Sonography Is there evidence that these procedures are E

available?

d. Nuclear scanning Is there evidence that these procedures are D

available?

e. In-house computed tomography (CT) Is there evidence that these procedures are E
available?

f. In-house CT technician 24 hours a May be assessed by examining staffing E

day (May be satisfied by schedules, staff interviews etc.
technician able to respond
within 30 minutes of
notification, time of first call
and arrival to be recorded
routinely*)

g. Neuroradiology Is there evidence that these procedures are D

available?

8. Rehabilitation Medicine

a. Physician-directed rehabilitation Obtain evidence of a designated physician E

service staffed by director
nursing personnel
trained in rehabilitation
care and equipped
properly for care of the
critically injured patient

OR

b. Transfer agreement with a

rehabilitation service

9. Operating Suite Special Requirements

a. Personnel - Operating room May be assessed by examining staffing E

adequately staffed and schedules, staff interviews etc.
immediately available
24 hours a day before
patient arrives

b. Equipment shall include but not be

limited to:
1. Cardiopulmonary bypass Is the specified equipment present? D
capability
 Last revision March 27, 1995

Requirements Met? &

Surveyor’s Guidelines Comments

2. Operating microscope Is the specified equipment present? D

3. Thermal control devices for:

a. Patient (e.g.. circulating water or Is the specified equipment present? E

air blanket, radiant
heater)

b. Blood and fluids (including Is the specified equipment present? E

rapid volume
infuser)

4. X-ray capability (including C- arm Is the specified equipment present? E

image intensifier)

5. Endoscopy (bronchoscopy, Is the specified equipment present? E

esophagoscopy)

6. Craniotomy instruments Is the specified equipment present? E

7. Fixation equipment for long Is the specified equipment present? E

bone and pelvic
fractures

10. Clinical Laboratory Services available

24 hours a day
a. Standard analyses of blood, urine, Is the specified equipment present? E
and other body fluids

b. Blood antigen matching Is the specified equipment present? E

c. Coagulation studies Is the specified equipment present? E

d. Comprehensive blood bank or access Is the specified equipment present? E

to a community central
blood bank and
adequate hospital
storage facilities

e. Blood gases and pH determinations Is the specified equipment present? E

f. Microbiology Is the specified equipment present? E

g. Serum alcohol determination Is the specified equipment present? E

h. Drug screening Is the specified equipment present? E

11. Organ Transplantation/Donation The reviewer should examine the organ

procurement policies and procedures; as well
as trauma registry reports on organ request
and recovery.

Procedures should be in place through E

which brain death can be
declared, a family
approached regarding organ
donation, a potential donor
supported, and organ
 Last revision March 27, 1995

Requirements Met? &

Surveyor’s Guidelines Comments

procurement coordinated
with the regional organ
procurement center.

C. QUALITY IMPROVEMENT The QI plan should be written, and must

identify scope, authority, and current audit
filters, review processes, corrective approaches
and follow-up.

Documentation of compliance with the QI

process should be examined by selecting one
or more audit filters and following the review
process through problem resolution.

Evaluation of QI activities should include a

review of randomly selected major trauma
patient records.

1. Organized Quality Improvement Program Minutes of trauma QI activity should be E

available for the reviewer.

2. Special audit for all trauma deaths Review all mortalities less than age 80, with E
GCS Motor Score > 3.

3. Morbidity and mortality review Is there documented evidence that the E

specified reviews occurred?

4. Multi disciplinary trauma conference There should be evidence that this conference E
(Regular and periodic conferences was held quarterly as a minimum. A more
that include all members of the frequent conference is encouraged.
trauma team. This conference will be
for the purpose of quality assurance
through critiques of individual cases)

5. Medical nursing audit, utilization review, Is there documented evidence that the E
tissue review specified reviews occurred?

6. Hospital-based trauma registry There should be evidence that the trauma

registry data Is being used as part of the QI
process. Was the registry used to select cases
for review?

a. Trauma registry review (Documentation E

of severity of injury and
outcome by trauma score, age,
injury severity score, survival,
length of stay, ICU length of
stay with monthly review of
statistics)

b. Trauma Registrar (responsible for data This position may be fulfilled by a variety of E
entry, report generation, and people, it is not necessary to be one person as
maintenance of hospital-based
long as the trauma registry is complete and up
trauma registry)
to date.

7. Review of prehospital and regional Is the specified review occurring? E

systems of trauma care

8. Published on-call schedule for general Were these consultants able to respond within E
surgeons, neurologic 30 minutes or sooner for appropriate patients?
 Last revision March 27, 1995

Requirements Met? &

Surveyor’s Guidelines Comments

surgeons, orthopedic
surgeons, thoracic surgeons

9. Reasons for trauma-related hospital Is the specified review occurring? E

destination decision
documented and reviewed by
quality improvement
program

D. OUTREACH PROGRAM

Telephone and on-site consultations with Is there evidence that this activity Is E
physicians of the community and occurring?
outlying areas

E. PUBLIC EDUCATION

Injury prevention in the home and industry, Schedule of lectures / activities should be E
and on the highways and athletic available for review.
fields; standard first-aid;
problems confronting public,
medical profession, and hospitals
regarding optimal care for the
injured

F. TRAUMA RESEARCH PROGRAM Provide copies of publications if applicable. D

G. TRAINING PROGRAM - Formal These programs may be multi-disciplinary and

program of continuing education may involve any or all of the providers listed
in trauma provided by hospital below. It is not necessary, to have separate
for: conferences for each group listed below.

1. Staff physicians E

2. Nurses Provide a list of the topics discussed. E

3. Allied health personnel Provide a list of the topics discussed. E

4. Community physicians Provide a list of the topics discussed. E

5. Prehospital personnel Provide a list of the topics discussed. E

H. INTERFACILITY TRANSFERS - Will

accept the transfer of all patients
who:
a. Have activated the trauma system by Are policies in place to ensure that acceptance E
field triage protocols or Is occurring?
whom have been
directed by Medical
Control

b. Have had their transfers requested Documentation should be available if E

appropriately through appropriate.
established interhospital
transfer procedures