Fox Valley RTAC Core Requirements for Level III Trauma
Centers Applying to Function as Level II Trauma Centers
1. Defined Trauma Program which includes
a. Trauma Service
b. Trauma Team
c. Trauma Program Medical Director
d. Trauma Multidisciplinary Committee
e. Trauma Coordinator
2. Defined Hospital Departments
a. Surgery
b. Neurologic Surgery with trauma liaison
c. Orthopedic Surgery with liaison
d. Emergency Medicine
e. Anesthesia
3. Clinical Capabilities
a. Published on call schedules for
i. General Surgery dedicated to single hospital with published
backup schedule, available at bedside within 15 minutes of arrival
of major trauma patient and within one hour of consultation for
non-major trauma patients. Presence of surgeon required at
operative procedures
ii. Anesthesia
iii. Emergency Medicine
b. On-call and available 24 hours a day
i. Hand Surgery- May have transfer agreement
ii. Neurologic Surgery dedicated to trauma hospital or published
backup call schedule with response time of one hour from
consultation
iii. Obstetrics/Gynecologic Surgery
iv. Ophthalmic Surgery
v. Oral/maxillofacial surgery
vi. Orthopedic Surgery dedicated to trauma hospital or published
backup call schedule with response time of one hour from
consultation
vii. Plastic Surgery
viii. Critical Care Medicine
ix. Radiology available onsite or by teleradiology 24 hours a day with
back up plan in place
x. Thoracic surgery with response time of one hour from consultation
4. Clinical Qualifications
a. General Surgery
i. Current board certification or board eligible within their specialty,
having completed an approved ACGME residency in the last 5
years
ii. Current ATLS certification
iii. 16 hours/year trauma CME from time of consultation visit
iv. Peer review committee attendance > 50%
v. Multidisciplinary committee attendance
b. Emergency Medicine
i. Board certification1. ABEM or ABOEM certified or completion of an approved
ACGME/ABOS or Royal College of Physicians and
Surgeons of Canada emergency medicine residency in the
last 5 years.
2. Physicians not either residency trained or board certified in
emergency medicine must have completed an approved
residency program, be licensed to practice medicine and
approved for emergency medicine privileges by the
hospital’s credentialing committee. The physician must
meet all established criteria by the trauma director and
emergency medicine director. The physician must have at
least 12 months experience in caring for trauma patients
which must be tracked by the PI program. The trauma
director and emergency medicine director must attest to this
physician’s experience and quality of patient care as a part
of the recurring granting of trauma privileges consistent
with the hospital’s policy.
ii. ATLS completion (current certification required for all physicians
who are boarded in a specialty other than emergency medicine)
iii. 16 hours/year trauma CME from time of consultation visit
iv. Peer review committee attendance > 50% by department
v. Multidisciplinary committee attendance by department
c. Neurosurgery
i. Current board certification or board eligible or board eligible
within their specialty, having completed an approved ACGME
residency in the last 5 years
ii. 16 hours/year trauma CME from time of consultation visit
iii. Peer review committee attendance > 50% by department
iv. Multidisciplinary committee attendance by department
d. Orthopedic Surgery
i. Current board certification or board eligible or board eligible
within their specialty, having completed an approved ACGME
residency in the last 5 years
ii. 16 hours/year trauma CME from time of consultation
iii. Peer review committee attendance > 50% by department
iv. Multidisciplinary committee attendance by department
5. Emergency Department
a. Designated physician director
b. Equipment for resuscitation of all ages
i. Airway control and ventilation equipment
ii. Pulse oximetry
iii. Suction devices
iv. Defibrillator with internal paddles
v. CVP Monitoring Equipment
vi. Standard IV fluids and administration sets
vii. Large bore IV catheters
viii. Sterile surgical sets for
1. Airway control
2. Thoracosotomy
3. Venous cut down
4. Central line insertion
5. Thoacotomy
6. Peritoneal lavage
ix. Arterial catheters
x. Drugs necessary for emergency care
xi. X-ray availability 24 hours/day
xii. Cervical Traction devices
xiii. Broselow tape
xiv. Thermal control equipment for patient and blood products
xv. Rapid infuser system
xvi. Qualitative end tidal CO2 detector
c. Established communication plan with redundancy with EMS
6. Operating Room
a. Must be a crew trained to emergently access the OR, 24 hours of every
day with OR ready for case within 30 minutes of patient arrival. This will
be monitored by PI process. This includes a scrub person/OR tech and a
circulating RN (2 Staff personnel).
b. Thermal control equipment for patient and blood products
c. X-ray equipment including c-arm
d. Endoscopes, bronchoscopes
e. Craniotomy instruments
f. Equipment for long bone and pelvic fixation
g. Rapid infuser system
h. Cardiopulmonary bypass equipment
i. Operating microscopes
7. Post-anesthesia Recovery Room
a. Registered nurses available 24 hours a day
b. Equipment for monitoring and resuscitation
c. Intracranial pressure monitoring equipment
d. Pulseoximetry
e. Thermal control
8. Intensive Care Unit
a. Registered nurses with trauma education
b. Designated surgical Director
c. Equipment for monitoring resuscitation
d. Intracranial monitoring equipment
e. Pulmonary artery monitoring equipment
f. Surgical ICU physician in house 24 hours/day or performance
improvement plan to show availability
9. Respiratory Therapy services available in-house 24 hours/ day
10. Radiological Services
a. In-house radiology technologist
b. Computed tomography with technologist response time of 30 minutes
from trauma patient arrival
c. Angiography services available within 30 minutes of consultation
d. Ultrasonography services available within 30 minutes of consultation
e. Performance improvement plan to show availability of above response
times
11. Clinical Laboratory Services available 24 hours a day
a. Standard analysis of blood, urine and other bodily fluids including
microsampling
b. Blood type and crossmatching
c. Coagulation studies
d. Comprehensive blood bank or access to community central blood bank
and adequate storage facilities
e. Blood gas and pH determination
f. Microbiology
12. Acute Hemodialysis available in house or transfer agreement in place
13. Burn Center In-house or transfer agreement with Trauma Burn Center
14. Acute Spinal Cord Management In-house or transfer agreement with Regional
Acute Spinal Cord Injury Rehabilitation Center
15. Rehabilitation Services
a. Rehabilitation services on site or transfer agreement to an approved
rehabilitation facility
b. Physical Therapy
c. Occupational Therapy
d. Speech Therapy
e. Social Services
16. Performance Improvement
a. Performance Improvement Program
b. Trauma Registry
i. In-house
ii. Participation in state, local or regional registry
c. Audit of all trauma deaths
d. Morbidity and Mortality review
e. Trauma Multidisciplinary conference
f. Medical Nursing Audit
g. Review of Prehospital Trauma Care
h. Review of times and reasons for trauma related bypass
i. Review and times and reasons for transfer of injured patients
j. Performance improvement personnel dedicated to care of injured patients
k. Monitoring of all response times in this document through PI process
17. Continuing Education/Outreach/Injury Prevention
a. Designated prevention coordinator-spokesperson for injury control
b. Programs provided by hospital for:
i. Staff/community physicians
ii. Nurses
iii. Allied health personnel
iv. Prehospital personnel
18. Adult Centers Caring for Injured Children
a. Trauma surgeons credentialed for pediatric trauma care
b. Pediatric resuscitation equipment available in all patient care areas
c. Transfer agreement with pediatric trauma center for care of multiply
injured patient that exceeds local resources
19. Consultation Visit from ACS with proof of satisfaction of above requirements
released to the Executive Committee of the Fox Valley RTAC