level i/ii application

State of ColoradoDepartment of Public Health and Environment

Health Facilities and Emergency Medical Services Division

Level I and Level IITrauma Center Designation

Colorado Pre-review ApplicationFebruary 2004

Trauma ProgramHFEMS-TRA-A24300 Cherry Creek Drive SouthDenver, CO 80246-1530303-692-2989 (Phone)303-691-7720 (Fax)

/home/pptfactory/temp/20101201095738/level-iii-application2236.doc of 24

Level I & IIPre-Review Application for Trauma Center Designation

February 2004

Please complete the entire pre-review packet. Use N/A where needed, and provide attachments as indicated.

The Colorado Department of Public Health and Environment (CDPHE) will evaluate any written requests for “special consideration” or proposed alternative to essential criteria. Convincing documentation and supporting data must accompany any request for special considerations. An acceptable alternative is one which CDPHE considers satisfactory in meeting a mandatory requirement. CDPHE, at its sole discretion, will determine if the proposed alternative meets the intent of the mandatory requirement.

The following checklist is attached for your convenience. Any attachments must be labeled and follow the questionnaire in order.

All materials submitted in response to this request become the property of the Colorado Department of Public Health and Environment, Trauma Program.

Important Notice: If the application contains information that the applicant organization considers to be trade secrets, privileged information, or confidential commercial or financial information, the pages containing that information should be identified as proprietary.

APPLICATION CHECKLIST (The references on this check list refer to the page and section in THIS application which requests the specified item.)

[ ] Signed board of director’s resolution (Item IV.A)[ ] Signed resolution from the medical staff (Item IV.B)[ ] Organizational chart for facility and trauma service (Item IV.C)

[ ] Chart 1: Bypass/divert (if applicable) (Item V.D.2.)[ ] Chart 2: Surgeons (Item V.H.)[ ] Chart 3: Neurosurgeons (Item V.I.)[ ] Chart 4: Orthopedic Surgeons (Item V.J.)[ ] Chart 5: Anesthesia (Item V.K.)[ ] Chart 6: Emergency Physicians (Item V.L.)[ ] Chart 7: Trauma QI/QA committee(s) (Item XII.B.1.)


[ ] Job description: Trauma Service Director(Item V.E.1.)[ ] Job description: Trauma Coordinator(Item V.F.1.)[ ] CV: Trauma Service Director(Item V.E.1.)[ ] CV: Trauma Coordinator(Item V.F.1.)[ ] CV: Chief Neurosurgery (Item V. I)[ ] CV: Chief of Orthopedic Surgery (Item V. J)[ ] CV: Chief of Emergency Medicine (Item V. L.)[ ] CV: Chief of Anesthesia (Item V. K.)[ ] CV: ICU Medical Director (Item IX. C.)[ ] CV: Chief of Pediatric Surgery (if applicable) (Item XI. A. 6.)[ ] CV: Pediatric ICU Medical Director (if applicable) (Item XI.A.7.)[ ] CV: Chief of Rehabilitation (if applicable) (Item XI.D.1.)

OTHER Attachments:Map illustrating primary response area and mutual aid areas (Item III.A.)Trauma team activation policies (Item V.B.1.b.)Policies for bypass and/or divert (Item V.D.1.)Copy of ED flow sheets used for the trauma patient (VI.C)Massive Blood transfusion protocol (if applicable) (X.B.4.)Protocol for Uncross-matched blood transfusion (if applicable)Pediatric Transfer policy (if applicable) (Item XI.A.9.)Transfer Agreements for acute and long-term rehab of trauma patients (if applicable) (Item XI.D.6.)Organ Procurement Policy (if applicable) (Item XI.E.3.)

Items to have available at the time of the site review:Formal transfer agreements into your facility (if applicable) (Item V.C.8.c)Format transfer agreements out of your facility (if applicable) (Item V.C.8.d)Formal transfer agreements for any or all of the following: pediatric trauma, burns, spinal cord injuries, and rehabilitation (if applicable) (Item V.C.8.e)Formal policy or procedure for QI/QA process for appropriateness of transfer (if applicable) (Item V.C.8.g.4)A policy and procedure manual for trauma (if applicable) (Item V.G)Documentation of surgeon availability, response and arrival times (Item XII.C.2)Reprints and/or documentation of trauma-related publications, research, presentations, etc. (Item XIV.A)

You will need seven (7) copies of this application. Please forward six (6) copies along with your ACSCOT pre-review questionnaire to ACS. Please submit one copy of this application and all attachments to:

Trauma ProgramColorado Department of Public Health and EnvironmentHFEMS-TRA-A24300 Cherry Creek Drive SouthDenver, CO 80246-1530

Please DO NOT send us a copy of your ACSCOT application.

For information or guidance in responding to this application contact:

Trauma Program Director303-692-2983


Colorado Department of Public Health and EnvironmentEmergency Medical Services and Prevention Division

APPLICATION FOR DESIGNATION

Facility Name __________________________________________________________

Facility Address ________________________________________________________

________________________________________________________city State Zip Code

Contact Person ____________________________________________________Name Title

__________________________________________________________________Phone FAX

Please check the designation level requested (check all that apply):

Level I _____

Level II ____

Regional Pediatric Trauma Center ________

Burn specialty designation ______________

Other specialty designation ______________

Application prepared by: ___________________________________________________________

Title: ___________________________________________________________________________

Signature: ______________________________________________________________________

Name: __________________________________________________________________________Administrator/Chief Executive Officer

Signature: ______________________________________________________________________

The following amount for the level requested reflects the initial 1/3 due with this application:

Level I - $8,867 Specialty independent – $5,800Level II- $8,634 Specialty concurrent – $2,800


I. PREVIOUS REVIEW

A. Has this facility undergone any previous reviews for trauma certification?Yes ______No _______If yes, date(s): _______________ Level: _______If no, proceed to item II.

1. Briefly describe strengths identified in previous reviews, and any changes occurring to impact those strengths.

2. Briefly describe weaknesses identified in previous state reviews and the improvements implemented to correct those weaknesses.

3. Identify any administrative changes at the facility since the last review? What has been the impact to the trauma program?

4. What assistance has this facility provided to surrounding non-designated facilities in your RETAC?

II. PARTICIPATION IN THE STATEWIDE TRAUMA SYSTEM

A. Why or how does this facility view itself as a necessary component of the state-wide trauma system?

B. How does this facility's designation or re-designation fit into its Regional Emergency Medical Area Trauma Advisory Council (RETAC) plans, organization and geography?

C. Describe the involvement of your facility in the RETAC planning and QI development.

III. PREHOSPITAL

A. Describe your EMS catchments area. Provide a map illustrating primary response area and mutual aid areas.

B. Describe the geo-political boundaries and issues as they relate to trauma care.

C. Describe the medical leadership and participation.

1. Who is the EMS medical director?

2. Provide documentation from the medical director regarding his/her participation, responsibility and involvement in the pre-hospital care system.


3. Describe interaction between first responders, law enforcement, fire rescue and ambulance personnel.

D. Which categories of EMS providers exist in your EMS catchments area? Check all that apply.

[ ] Volunteer [ ] Paid [ ] Public agency [ ] Private [ ] Other

E. What percent of EMS providers are:

First Responder _____%EMT-B _____ %EMT-I _____%EMT-Paramedic _____%

F. Describe the participation of your facility both locally and regionally for the following.

1. QI/QA activities for prehospital personnel.

2. Continuing education for prehospital providers.

3. Disaster planning.

G. Is a 911 present in your community? Yes ______ No ______If no, describe how citizens access EMS.

H. Is an E-911 present in your community? Yes ______ No ______

I. How are EMS personnel notified and dispatched to an injury scene?

J. What types of agencies are dispatched to an injury scene?

K. Describe any specialty emergency services provided in your area: i.e., dive team; hazardous material management; search/rescue.

L. Do you utilize helicopter or fixed wing service to transport trauma patients? Yes _____ No_____ If yes, describe the location of helipad or landing site and proximity to facility.

M. What percentage of trauma charts includes prehospital trip sheets? ______%

IV. HOSPITAL INFORMATION

A. Please attach a signed Board of Director’s resolution supporting your continuation as a trauma center.

B. Please attach a signed resolution from your medical staff supporting your continuation as a trauma center.

C. Describe your facility, including governance and affiliations, and role in the community, including regional trauma activities. Include applicable organizational chart for the trauma service and how it fits into the facility's organization.


D. Describe any multi-facility trauma affiliations and activities.

E. Hospital physical description:

1. Total number of licensed hospital beds: ______

2. Number of beds staffed and operational: _______ a. adult _____b. pediatric ______

3. Average daily census for the past calendar year: a. adult ______

b. pediatric _____

4. Average daily census for the year previous to question #3:

5. Do you anticipate any changes in the number of beds, organization or affiliations overthe next several years? If so, explain.

6. Explain any volume changes over the past three years.

7. What effect does/will trauma designation has on your current census?

F. Describe the commitment of your administration to the trauma program.

1. Is there a line item budget for trauma? Yes ______ No ______

V. TRAUMA SERVICE

A. Describe the trauma service at your facility including all disciplines participating in the care of the trauma patient from injury through rehabilitation.

B. Trauma response

1. What criteria do you use to activate the trauma team?a.k Are there multi-levels of response? Yes ______ No ______

If yes, please describe.

b. Attach activation policy(ies).

2. Describe the personnel included on the trauma team for each level of activation.

3. Who has the authority to activate the trauma team?

C. Statistical Data (use same one year period for all statistical questions/responses)

1. Indicate the reporting year used for this application: (mo/yr to mo/yr)______/______ ______/______

2. Percentage of overall trauma volume that is blunt trauma? _____%penetrating trauma ______%


3. Total number of ED visits for reporting year: ______

4. Total number of trauma related ED visits: ______

5. Number of hospital trauma admissions for reporting year: ______ a. Number admitted to trauma service: ______b. Number admitted to neurosurgical service: ______c. Number admitted to orthopedic service: ______d. Number admitted to non-surgical service: ______

6. Total number of trauma admissions from the ED: ______

a. Number of trauma admissions from ED to ICU: ______(1) Number admitted to trauma service: ______

b. Number of trauma admissions from ED to OR: ______(1) Number admitted to trauma service: ______

c.l Number of trauma admissions from ED to floor: _______(1) Number admitted to trauma service: ________

7. Number of trauma patients admitted to hospital by ISS. a. ISS <9: ______ %mortality ______b. ISS 10-15:_____ %mortality ______c. ISS 16-24:_____ %mortality ______d. ISS >25:_____ %mortality ______e. If ISS scores are not used to categorize severity of injury, please define what

method is used.

8. Trauma transfers a. Number of trauma transfers IN from other facilities: _____b. Number of trauma transfers OUT to other facilities: _____

(1) Number transferred to designated trauma centers: _____(2) Number transferred to non-designated trauma centers: _____

(a) Number transported by private vehicle:. _____(b) Number transported by ambulance: ______(c) Number transported by helicopter/fixed wing: _____

c. Are there formal transfer agreements for patients INTO your facility? _____Yes ______ No______ If yes, have agreements available at time of review.

d. Are there formal transfer agreements for transfer OUT of your facility? ______Yes _____ No _____ If yes, have agreements available at time of review?

e. Are there specific formal transfer agreements for the following?If yes, please have agreements available at time of review.

(1) Pediatric trauma: Yes ______ No ______(2) Burn patients: Yes ______ No _______(3) Spinal cord injuries: Yes ______ No ______(4) Rehabilitation: Yes ______ No ______

f. Describe your facility's criteria for transfer of the following traumapatients:

(1) Multiple trauma(2) Isolated extremity trauma(3) Pediatric trauma(4) Burns(5) Spinal cord injuries

g. Is there a QI/QA process for appropriateness of transfer?


Yes ______ No ______ If yes, have policy or procedure available at time of review.

D. Trauma Bypass and Divert

1. Do you have policies in place for bypass and/or divert? Yes ______ No _______If yes, please attach.

2. Have you gone on trauma bypass and/or divert during the previous year? Yes _____ No _____ If yes, complete Chart I "Bypass/Divert"

E. Trauma Service Director

1. Attach a job description and Curriculum Vitae.

2. Describe the authority to direct the trauma service.

F. Trauma Coordinator

1. Attach a job description and Curriculum Vitae.

2. Describe the administrative reporting structure.

3. List support staff along with duties/responsibilities.

G. Is there a policy and procedure manual for trauma? Yes ______ No ______If yes, have manual available at time of review.

H. List all surgeons taking trauma call on Chart 2 "Surgeons" and attach.

I. List all neurosurgeons taking trauma call on Chart 3 "Neurosurgeons" and attach.Also attach a Curriculum Vitae for your Chief of Neurosurgery.

J. List all orthopedic surgeons taking trauma call on Chart 4 "Orthopedic Surgeons" and attach. Also attach a Curriculum Vitae for your chief of Orthopedic Surgery.

K. List all anesthesiologists on Chart 5 " Anesthesia " and attach. Also attach a Curriculum Vitae for your Chief of Anesthesiology.

L. List all emergency physicians taking trauma call on Chart 6 " Emergency Physicians " and attach. Also attach a Curriculum Vitae for your Chief of Emergency Medicine.

M. Describe the facility's trauma call roster for each applicable trauma specialty above, including primary and back-up call schedules.

N. Are any of the trauma surgeons, orthopedic surgeons, neurosurgeons, or anesthesiologists taking trauma call at more than one facility simultaneously? Yes ______ No ______ 1. If yes, please explain.


2. If neurosurgeon, please provide the criteria for neurosurgical attending and resident activation, the neurosurgeon (attending and residents) response time requirement and combined volume of trauma related emergency neurosurigical operative procedures for the past three years.

O. List any specific credentialing procedures for participation in trauma call.

VI. EMERGENCY DEPARTMENTA. Describe the role and relationship of emergency medicine to the trauma service.

B. What are the criteria used by the ED staff to activate the trauma team for those patients not meeting pre-hospital trauma team activation?

C. Attach a copy of the emergency department flow sheet(s) used for the trauma patient.

D. Describe the staffing patterns and qualification requirements for the emergency department coverage for RNs, LPNs, EDTs, and other emergency department personnel.

1. Percent of total staff with the following credentials: a. TNCC _____%b. ACLS ______%c. CEN ______%d. ENPC______%e. PALS ______%

2. If any other equivalent program is utilized, please describe the program.

VII. RADIOLOGY

A. Is an x-ray technician in-house 24-hours/day? Yes ______ No ______

B. Are there CT technicians in-house 24-hours/day? Yes ______ No ______If no to either question, is there a QI process to evaluate response times?Please describe.

C. What type of monitoring equipment is available for resuscitation in theradiology department?

D. Who accompanies and monitors the trauma patient while in radiology?

E. Is there a radiologist available 24 hours per day? Yes ______ No ______

F. Is interventional radiology available? Yes ______ No ______

G. Are teleradiology capabilities utilized? Yes______No ______


VIII. OPERATING ROOM

A. Is there 24-hour in-house anesthesia coverage? Yes ______ No ______If no, describe the coverage available.

B. Number of operating rooms:_________

C. What are the staff qualifications and requirements related to trauma?

D. Are there specific educational requirements for staff taking care of trauma patients? Yes ______ No ______. If yes, please describe.

E. Describe the OR trauma staffing and back-up call for all shifts including weekends and holidays.

F. Is there an OR dedicated to trauma? Yes ______ No _______

G. Is there OR staff dedicated to trauma? Yes ______ No______

1. Describe the procedure for STAT access to OR.

H. What are the hours of operation and staffing for PACU (post-anesthesia care unit) recovery?

IX. INTENSIVE CARE UNITS

A. Number of ICU beds:

1. Number of adult ICU beds:

2. Number of pediatric ICU beds:

3. Number of surgical ICU beds:

4. Number of neurosurgical ICU beds:

B. Are there any ICU beds dedicated to trauma patients? Yes ______ No _______If so, how many? ______ If not, describe the procedure for opening beds for trauma patients.

C. Describe the physician coverage for trauma patients in the ICU. Also attach a Curriculum Vitae for your ICU Medical Director.

D. Is there a credential process for ICU privileges? Yes ______ No ______

E. Who is the surgical director of ICU? Provide a CV.

F. Describe the authority for the trauma patient in the ICU.

G. What are the staff qualification requirements for ICU?

1. What is the staffing ratio for the trauma patients?2. Are there specific trauma related educational requirements for ICU staff? Explain.


a. Percentages of staff with the following certifications:

(1) TNCC ______%(2) CCRN ______%(3) ACLS ______%(4) PALS ______%

b. If any other equivalent program is provided for traumaeducation, please describe.

X. LABORATORY AND BLOOD BANK

A. Laboratory

1. Is there 24 hour staffing in-house? Yes ______ No ______ If no, describe the procedure for assuring availability and method for monitoring timeliness of response.

2. What is the estimated response time for STAT orders in the ED?

3. What is the estimated response time for STAT orders in the ICU?

4. Do you have any satellite sites for blood gas determination? Yes ______ No ______If yes, where?

B. Blood Bank

1. List your source of blood products.

2. Describe the quantities of blood immediately available.

3. Describe the procedure for obtaining blood products and estimated timefor access.

4. Is there a massive blood transfusion protocol? Yes ______No_______If yes, attach.

5. Is there a protocol for uncross- matched blood transfusion?Yes______ No______ If yes, attach.

6. Where is blood stored in your facility? If more than one location,explain.

XI. SPECIALTY SERVICES

A. Pediatric Trauma

1. What is the upper and lower age limit for pediatric trauma in your facility?

2. How many pediatric trauma admissions occurred during the reportingyear? ______

3. How many pediatric trauma transfers into facility? ______ out? ______


4. Are there any variations in the trauma team activation protocol for thepediatric trauma patient? Yes ______ No ______If yes, describe.

5. Is there a separate pediatric ICU? Yes ______ No ______ If yes, number of beds: ______If yes, are any of the beds dedicated to trauma patients? Yes ______ No ______

6. What services admit pediatric trauma patients to ICU?

7. Is there a pediatric ICU medical director? Yes ______ No ______ If yes, provide CV.Also attach a Curriculum Vitae for your Chief of Pediatric Surgery, if applicable.

8. What medical specialty maintains primary responsibility for directionof pediatric trauma patient care in the ICU?

9. Are there policies regarding the transfer of the injured pediatric patient?Yes______ No______ If yes, attach.

10. Describe the credential and experience requirements for staff caringfor pediatric ICU trauma patients.

11. Total number of pediatric trauma admissions for reporting year: ______

a. Number admitted to trauma service ______b. Number admitted to neurosurgical service ______c. Number admitted to orthopedic service ______d. Number admitted to non-surgical service ______

12. Pediatric trauma admissions from the ED:c. Number of pediatric trauma admissions from ED to ICU ______d. Number of pediatric trauma admissions from ED to OR ______e. Number of pediatric trauma admissions from ED to floor ______

13. Pediatric trauma patients admitted to hospital by ISS and age:0-5years 6-12 years > 13 years

a. ISS 1-9: _______ ________ _________b. ISS 10-15: _______ ________ _________c. ISS 16-24: _______ ________ _________d. ISS >25 _______ ________ _________

14. Describe any specialty acute and long-term rehabilitation servicesprovided for the pediatric trauma patient.

B. Burn Services

1. Is there a separate burn team? Yes ______ No ______

2. Is your facility a verified or recognized burn center? Yes ______ No ______ (ACS page 15, VI.C.3)

3. Number of patients admitted to burn center in reporting year: ______ a. Number of patients with burns and/or inhalations injuries: ______ b. Number of patients with concomitant trauma and burns: ______c. Number of patients meeting physiologic criteria for burn center transfer: ______


d. Number of burn patients transferred IN from other facilities: ______ e. Number of burn patients transferred OUT to other facilities: ______

4. Briefly describe indications or criteria for transferring a burn patientout of facility.

5. Describe any acute and long-term rehabilitation services providedspecific to the burn patient.

6. Do these services differ from other rehabilitation services in the facility? Yes______ No ______ If yes, explain.

C. Spinal Cord Injuries

1. Number of spinal cord injuries for reporting year: ______

2. Number of spinal cord injury transfers: in ______ out ______

3. Describe protocols for care of the patient with spinal cord injuries, both acute and long-term.

D. Rehabilitation Services

1. Is there a designated Chief of Rehabilitation? Yes _____ No ______If yes, provide a CV.

2. Describe the relationship between the trauma service and the rehabilitation services. When do trauma patients begin to receive rehabilitative care?

3. Are rehabilitative consultations routinely obtained while in ICU? Yes ______ No _______ If yes, what services are provided?

a. Physical therapy: Yes ______ No ______b. Occupational therapy: Yes ______ No ______c. Speech therapy: Yes ______ No ______d. Other: ________________________________

4. Are these services provided seven days per week? Yes ______No ______If no, explain.

5. Describe, if applicable, pediatric rehabilitation services

6. Are there transfer agreements for acute and long-term rehabilitation of trauma patients? Yes ______ No ______ If yes, attach.

E. Organ Procurement

1. Do you have an organ procurement program? Yes ______ No ______ If yes, how many referrals were there to the regional organprocurement organization in the reporting year? _______

2. How many patient donors were there in the reporting year? ______


3. Describe the organ procurement procedures for your facility.Attach policy if applicable.

F. Social Services

1. Is there a dedicated social worker for the trauma service? Yes ______ No______ If no, what is the commitment from social services to the trauma patient?

XII. QUALITY IMPROVEMENT and/or QUALITY ASSURANCEQI/QA documents will be reviewed at time of site visit. No documents or minutesshould accompany this application.

A. Quality Improvement program

1. Describe the QI program for the trauma services.

2. How are issues identified and tracked?

3. List all QI filters used for trauma.

4. Who is responsible for loop closure relating to trauma issues?

5. How has QI affected the care of the trauma patient?

6. Who participates in the trauma QI review?

7. Describe how the compliance with standards and protocols is monitored on the specific nursing care units.

8. Describe how compliance with activation and response time standard for neurosurgical coverage are monitored and reviewed.

B. Trauma Committee(s)

1. Provide a description of all committees that are involved in trauma QI on Chart 7 "Trauma QI Committee(s)". Include applicable multi disciplinary, morbidity and mortality review, peer review, medical nursing audit, utilization review, tissue review, prehospital trauma care review, and other committee(s) as indicated.

2. Are there QI personnel dedicated to and specific for the trauma program?

C. Trauma Registry

1. Do you have a trauma registry? Yes ______ No ______ f. How many months are complete for review? g. Are you downloading data to the State Registry. Yes ______No ______

If no, explain.c. Are you participating in RETAC data collection? Yes ______ No ______d. Who identifies additional information to be included in the trauma

registry?e. Who enters the information?f. Describe the criteria for patient entry into the trauma registry.


g. Are there trauma patients that are not included in the registry?Yes ______ No ______ If yes, explain.

h. Are reports produced from the trauma registry? Yes ______No ______If yes, describe frequency and use of reports.

2. Do you have documentation of surgeon availability, response, and arrival times? Yes ______ No ______ If yes, have available at time of review. If no, explain.

D. Deaths

1. Who reviews both in-house and emergency department deaths?

2. How many total trauma deaths occurred in the reporting period?______

a. Number of ED trauma deaths: ______b. Number of in-house trauma deaths: ______

3. Are deaths classified as preventable, potentially preventable, and non-preventable? Yes ______No ______If no, explain review process.

E. Autopsy

1. What is the percentage of trauma deaths receiving autopsy? ______%

2. By whom and where are autopsies performed?

3. How are autopsies reported to the trauma program?

XIII. EDUCATIONAL ACTIVITIES AND OUTREACH PROGRAMS

A. Do you have a general surgery residency program? Yes ______ No ______If so, describe how this program relates to the trauma service.

B. Do you have any other specialty residency programs? Yes ______ No ______If so, list and define any interaction with the trauma program.

C. Describe any trauma educational programs for staff held at your facility.

D. Describe the facility's participation in public trauma education. If you facility sponsors trauma related public injury prevention programs, please list and describe.

E. Do you provide ATLS or TNCC courses? Yes ______ No ______ If yes, providecourse dates for the reporting year.

F. Describe your trauma education programs for prehospital providers:

G. Is there hospital funding allocated for continuing education in trauma for physician and nursing personnel? Yes ______ No ______

H. If yes, list each program with a brief description. Who coordinates the injury Prevention programs?

I. What outreach and program development assistance is provided by your facility?


J. Key Resource Facility (provide the following information if your facilityparticipates as a Key Resource Facility for any RETAC).

1. What RETACs have identified this facility as the key resource facility represented on the area council?

2. What consultation and technical assistance is being provided to each of the above in the following areas:

a. Educationb. Quality Improvementc. Trainingd. Communicationse. Data collectionf. Financial assistanceg. Other trauma related issues

3. Describe any participation or involvement in other RETACs.

4. Do you receive telephone consultations from non-designated facilities?Yes ______ No ______If yes, answer the following:

a. Who receives and responds to these consultations?b. Is there documentation of trauma consults?c. What is the evaluation process for appropriateness, timeliness,

compliance, etc?

XIV. RESEARCHA. List the trauma related publications, research, ongoing projects and trauma

presentations for the past three years. Have reprints and documents availableat time of review.

1. Which research projects did the Internal Review Board evaluate?

2. What presentations occurred at a regional or national level?

B. Do you receive any trauma related grants? Yes ______ No ______ If yes, describe.


CHART ITRAUMA BYPASS/DIVERT

Month of Occurrence Time on Bypass Number of Occurrences Reason for Bypass


CHART 2TRAUMA SURGEONS

Name

Residency -where and

when completed

BoardCertification

ATLS:Instructor/

Provider Status& Date ofExpiration

Total TraumaCME in lastthree years -number of

hoursobtained outsidefacility

Frequencyof trauma

call per month

Numberof traumapatientsadmittedper year


CHART 3NEUROSURGEONS

Name

Residency:where and when

completedBoard

Certification

ATLS:Instructor/ProviderStatus &Date of

Expiration

Total traumarelated CME in

last three years -number of hoursobtained outside

the facility

Frequencyof trauma call

per month


CHART 4ORTHOPEDIC SURGEONS

Name


completedBoard

Certification

ATLS:Instructor/ProviderStatus & Date of

Expiration



the facility


per month


CHART 5ANESTHESIA

Name


completedBoard

Certification


Expiration



the facility


per month


CHART 6EMERGENCY PHYSICIAN

Name


completedBoard

Certification


Expiration



the facility

Number ofhours worked

per month


Chart 7 Q1 Committee(s)

Name of CommitteeWhat is the purpose of the committee?Describe the membership using titlesName/Title of Chairperson

How often does the committee meet?

Are there attendance requirements? If yes, describe:

Committee reports to whom?


level i/ii application

Documents

neurosurgeons item

specified item

applicable item xi

chief of anesthesia

trauma service item

chief neurosurgery item

emergency physicians

orthopedic surgeons