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and 1216 )>>endobj1020 0 obj<</Dest[78 0 R/XYZ 30 400 null]/Next 1019 0 R/Parent 999 0 R/Prev 1021 0 R/SE 962 0 R/Title( 1214 )>>endobj1021 0 obj<</Dest[78 0 R/XYZ 30 428 null]/Next 1020 0 R/Parent 999 0 R/Prev 1022 0 R/SE 961 0 R/Title(\(C\) have direct experience in the preparation for and successful 1212 completion of trauma facility designation for no fewer than 2 successful designation cycles; 1213 )>>endobj1022 0 obj<</Dest[78 0 R/XYZ 30 441 null]/Next 1021 0 R/Parent 999 0 R/Prev 1023 0 R/SE 960 0 R/Title( 1211 )>>endobj1023 0 obj<</Dest[78 0 R/XYZ 30 469 null]/Next 1022 0 R/Parent 999 0 R/Prev 1024 0 R/SE 959 0 R/Title(\(B\) be currently employed in the management of or providing direct 1209 care services to trauma patients; 1210 )>>endobj1024 0 obj<</Dest[78 0 R/XYZ 30 483 null]/Next 1023 0 R/Parent 999 0 R/Prev 1025 0 R/SE 958 0 R/Title( 1208 )>>endobj1025 0 obj<</Dest[78 0 R/XYZ 30 497 null]/Next 1024 0 R/Parent 999 0 R/Prev 1026 0 R/SE 957 0 R/Title(\(A\) have at least 5 years experience in the care of trauma patients; 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and 1198 )>>endobj1034 0 obj<</Dest[78 0 R/XYZ 30 648 null]/Next 1033 0 R/Parent 999 0 R/Prev 1035 0 R/SE 948 0 R/Title( 1196 )>>endobj1035 0 obj<</Dest[78 0 R/XYZ 30 676 null]/Next 1034 0 R/Parent 999 0 R/Prev 1036 0 R/SE 947 0 R/Title(\(D\) not be employed at a facility that is a primary transfer facility with 1194 the facility being surveyed, with the exception of a burn facility; 1195 )>>endobj1036 0 obj<</Dest[78 0 R/XYZ 30 690 null]/Next 1035 0 R/Parent 999 0 R/Prev 1037 0 R/SE 946 0 R/Title( 1193 )>>endobj1037 0 obj<</Dest[78 0 R/XYZ 30 717 null]/Next 1036 0 R/Parent 999 0 R/Prev 1038 0 R/SE 944 0 R/Title(\(C\) not be a current or former employee of the facility that is the 1191 subject of the survey or of an affiliated facility; 1192 )>>endobj1038 0 obj<</Dest[76 0 R/XYZ 30 110 null]/Next 1037 0 R/Parent 999 0 R/Prev 1039 0 R/SE 943 0 R/Title( 1190 )>>endobj1039 0 obj<</Dest[76 0 R/XYZ 30 124 null]/Next 1038 0 R/Parent 999 0 R/Prev 1040 0 R/SE 942 0 R/Title(\(B\) not be employed in the same TSA as the designating facility; 1189 )>>endobj1040 0 obj<</Dest[76 0 R/XYZ 30 138 null]/Next 1039 0 R/Parent 999 0 R/Prev 1041 0 R/SE 941 0 R/Title( 1188 )>>endobj1041 0 obj<</Dest[76 0 R/XYZ 30 165 null]/Next 1040 0 R/Parent 999 0 R/Prev 1042 0 R/SE 940 0 R/Title(\(A\) be currently employed at a designated trauma facility that is greater 1186 than 100 miles from the requesting facility; 1187 )>>endobj1042 0 obj<</Dest[76 0 R/XYZ 30 179 null]/Next 1041 0 R/Parent 999 0 R/Prev 1043 0 R/SE 939 0 R/Title( 1185 )>>endobj1043 0 obj<</Dest[76 0 R/XYZ 30 193 null]/Next 1042 0 R/Parent 999 0 R/Prev 1044 0 R/SE 938 0 R/Title(\(2\) Each member of the survey teams described above shall: 1184 )>>endobj1044 0 obj<</Dest[76 0 R/XYZ 30 207 null]/Next 1043 0 R/Parent 999 0 R/Prev 1045 0 R/SE 937 0 R/Title( 1183 )>>endobj1045 0 obj<</Dest[76 0 R/XYZ 30 290 null]/Next 1044 0 R/Parent 999 0 R/Prev 1046 0 R/SE 936 0 R/Title(\(C\) Level IV facilities shall be surveyed by an office-approved 1177 organization by a surveyor that is either at a minimum: a registered nurse or a licensed physician, 1178 currently active in the management of trauma patients. Pediatric facilities sha\ll be surveyed by an 1179 office-approved organization by a surveyor that is either a pediatric trauma surgeon, or a 1180 pediatric trauma nurse, or a Trauma Program Manager with pediatric experience. An additional 1181 surveyor may be requested by the fa\cili)>>endobj1046 0 obj<</Dest[76 0 R/XYZ 30 303 null]/Next 1045 0 R/Parent 999 0 R/Prev 1047 0 R/SE 935 0 R/Title( 1176 )>>endobj1047 0 obj<</Dest[76 0 R/XYZ 30 400 null]/Next 1046 0 R/Parent 999 0 R/Prev 1048 0 R/SE 934 0 R/Title(\(B\) Level III facilities shall be surveyed by the ACS or other office-1169 approved organization, with a multi-disciplinary team that includes at a minimum: a trauma 1170 surgeon and a trauma nurse, both currently active in the management of trauma pati\ents. 1171 Pediatric facilities shall be surveyed by the ACS, or an office-approved equivalent organization 1172 with a multi-disciplinary team that includes at a minimum: a pediatric trauma surgeon, a 1173 pediatric trauma nurse with pediatric experience\. An)>>endobj1048 0 obj<</Dest[76 0 R/XYZ 30 414 null]/Next 1047 0 R/Parent 999 0 R/Prev 1049 0 R/SE 933 0 R/Title( 1168 )>>endobj1049 0 obj<</Dest[76 0 R/XYZ 30 497 null]/Next 1048 0 R/Parent 999 0 R/Prev 1050 0 R/SE 932 0 R/Title(\(A\) Level I or Level II facilities shall be surveyed by The American 1162 College of Surgeons \(ACS\) with a multi-disciplinary team that includes at a minimum: 2 general 1163 surgeons, and a trauma nurse all currently active in the management of trauma\ patients. 1164 Pediatric facilities shall be surveyed by the ACS with a multi-disciplinary team that includes at a 1165 minimum: \(2\) pediatric trauma surgeons, and a Pediatric Trauma Program Manager all active in 1166 the management of pediatric trau\ma patie)>>endobj1050 0 obj<</Dest[76 0 R/XYZ 30 510 null]/Next 1049 0 R/Parent 999 0 R/Prev 1051 0 R/SE 931 0 R/Title( 1161 )>>endobj1051 0 obj<</Count 2/Dest[76 0 R/XYZ 30 525 null]/First 1052 0 R/Last 1052 0 R/Next 1050 0 R/Parent 999 0 R/Prev 1053 0 R/SE 928 0 R/Title(\(1\) The multi-disciplinary survey team shall consist of the following members: 1160 )>>endobj1052 0 obj<</Count 1/Dest[76 0 R/XYZ 30 525 null]/First 1865 0 R/Last 1865 0 R/Parent 1051 0 R/SE 929 0 R/Title(\(1\) The multidisciplinary survey team shall consist of the following members: 1160 )>>endobj1053 0 obj<</Dest[76 0 R/XYZ 30 538 null]/Next 1051 0 R/Parent 999 0 R/Prev 1054 0 R/SE 927 0 R/Title( 1159 )>>endobj1054 0 obj<</Dest[76 0 R/XYZ 30 552 null]/Next 1053 0 R/Parent 999 0 R/Prev 1055 0 R/SE 926 0 R/Title(\(o\) Survey Team. 1158 )>>endobj1055 0 obj<</Dest[76 0 R/XYZ 30 566 null]/Next 1054 0 R/Parent 999 0 R/Prev 1056 0 R/SE 925 0 R/Title( 1157 )>>endobj1056 0 obj<</Count 2/Dest[76 0 R/XYZ 30 594 null]/First 1057 0 R/Last 1057 0 R/Next 1055 0 R/Parent 999 0 R/Prev 1058 0 R/SE 922 0 R/Title(\(ii\) In circumstances where a moderate to severe head injury 1155 center exists in the region, transfer plan must be in effect. 1156 )>>endobj1057 0 obj<</Count 1/Dest[76 0 R/XYZ 30 594 null]/First 1864 0 R/Last 1864 0 R/Parent 1056 0 R/SE 923 0 R/Title(\(ii\) In circumstances where a moderate to severe head injury 1155 center exists in the region, transfer plan must be in effect. 1156 )>>endobj1058 0 obj<</Dest[76 0 R/XYZ 30 607 null]/Next 1056 0 R/Parent 999 0 R/Prev 1059 0 R/SE 921 0 R/Title( 1154 )>>endobj1059 0 obj<</Count 2/Dest[76 0 R/XYZ 30 649 null]/First 1060 0 R/Last 1060 0 R/Next 1058 0 R/Parent 999 0 R/Prev 1061 0 R/SE 918 0 R/Title(\(i\) In circumstances where a designated spinal cord injury 1151 rehabilitation center exists in the region, transfer plan must 1152 be in effect. 1153 )>>endobj1060 0 obj<</Count 1/Dest[76 0 R/XYZ 30 649 null]/First 1863 0 R/Last 1863 0 R/Parent 1059 0 R/SE 919 0 R/Title(\(i\) In circumstances where a designated spinal cord injury 1151 rehabilitation center exists in the region, transfer plan must 1152 be in effect. 1153 )>>endobj1061 0 obj<</Dest[76 0 R/XYZ 30 662 null]/Next 1059 0 R/Parent 999 0 R/Prev 1062 0 R/SE 917 0 R/Title( 1150 )>>endobj1062 0 obj<</Count 2/Dest[76 0 R/XYZ 30 677 null]/First 1063 0 R/Last 1063 0 R/Next 1061 0 R/Parent 999 0 R/Prev 1064 0 R/SE 914 0 R/Title(\(B\) Spinal cord/head injury rehabilitation management capability. 1149 )>>endobj1063 0 obj<</Count 1/Dest[76 0 R/XYZ 30 677 null]/First 1862 0 R/Last 1862 0 R/Parent 1062 0 R/SE 915 0 R/Title(\(B\) Spinal cord/head injury rehabilitation management capability. 1149 )>>endobj1064 0 obj<</Dest[76 0 R/XYZ 30 690 null]/Next 1062 0 R/Parent 999 0 R/Prev 1065 0 R/SE 913 0 R/Title( 1148 )>>endobj1065 0 obj<</Count 2/Dest[76 0 R/XYZ 30 717 null]/First 1066 0 R/Last 1066 0 R/Next 1064 0 R/Parent 999 0 R/Prev 1067 0 R/SE 909 0 R/Title(a written transfer plan for patients requiring a higher level of care or 1146 specialty services. 1147 )>>endobj1066 0 obj<</Count 1/Dest[76 0 R/XYZ 30 717 null]/First 1861 0 R/Last 1861 0 R/Parent 1065 0 R/SE 910 0 R/Title(a written transfer plan for patients requiring a higher level of care or 1146 specialty services. 1147 )>>endobj1067 0 obj<</Count 2/Dest[74 0 R/XYZ 30 138 null]/First 1068 0 R/Last 1068 0 R/Next 1065 0 R/Parent 999 0 R/Prev 1069 0 R/SE 906 0 R/Title(\(A\) Organized Burn Care. 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In-house Computerized Tomography 1136 technician 24-hours per day or on-call and promptly available on-site within 30 1137 minutes of request. This system shall be continuously monitored by the trauma PI 1138 program\; 1139 )>>endobj1074 0 obj<</Dest[74 0 R/XYZ 30 248 null]/Next 1073 0 R/Parent 999 0 R/Prev 1075 0 R/SE 899 0 R/Title( 1135 )>>endobj1075 0 obj<</Dest[74 0 R/XYZ 30 290 null]/Next 1074 0 R/Parent 999 0 R/Prev 1076 0 R/SE 898 0 R/Title(\(C\) Standard Radiological Capability/Services. An in-house 1132 technician shall be available 24hours a day or be on-call and promptly 1133 available on-site within 30 minutes of request. 1134 )>>endobj1076 0 obj<</Dest[74 0 R/XYZ 30 303 null]/Next 1075 0 R/Parent 999 0 R/Prev 1077 0 R/SE 897 0 R/Title( 1131 )>>endobj1077 0 obj<</Dest[74 0 R/XYZ 30 331 null]/Next 1076 0 R/Parent 999 0 R/Prev 1078 0 R/SE 896 0 R/Title(\(B\) Clinical Laboratory Service. 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Respiratory services shall be in-house and 1126 available 24 hours per day. 1127 )>>endobj1080 0 obj<</Dest[74 0 R/XYZ 30 386 null]/Next 1079 0 R/Parent 999 0 R/Prev 1081 0 R/SE 893 0 R/Title( 1125 )>>endobj1081 0 obj<</Dest[74 0 R/XYZ 30 400 null]/Next 1080 0 R/Parent 999 0 R/Prev 1082 0 R/SE 892 0 R/Title(\(11\)Clinical Support Services. 1124 )>>endobj1082 0 obj<</Dest[74 0 R/XYZ 30 414 null]/Next 1081 0 R/Parent 999 0 R/Prev 1083 0 R/SE 891 0 R/Title( 1123 )>>endobj1083 0 obj<</Dest[74 0 R/XYZ 30 441 null]/Next 1082 0 R/Parent 999 0 R/Prev 1084 0 R/SE 890 0 R/Title(\(xi\) Thermal control equipment for patients and a rapid 1121 warming device for blood and fluids; 1122 )>>endobj1084 0 obj<</Dest[74 0 R/XYZ 30 455 null]/Next 1083 0 R/Parent 999 0 R/Prev 1085 0 R/SE 889 0 R/Title( 1120 )>>endobj1085 0 obj<</Dest[74 0 R/XYZ 30 469 null]/Next 1084 0 R/Parent 999 0 R/Prev 1086 0 R/SE 888 0 R/Title(\(x\) Pelvic stabilization capability; 1119 )>>endobj1086 0 obj<</Dest[74 0 R/XYZ 30 483 null]/Next 1085 0 R/Parent 999 0 R/Prev 1087 0 R/SE 887 0 R/Title( 1118 )>>endobj1087 0 obj<</Dest[74 0 R/XYZ 30 497 null]/Next 1086 0 R/Parent 999 0 R/Prev 1088 0 R/SE 886 0 R/Title(\(ix\) Long bone stabilization capability; 1117 )>>endobj1088 0 obj<</Dest[74 0 R/XYZ 30 510 null]/Next 1087 0 R/Parent 999 0 R/Prev 1089 0 R/SE 885 0 R/Title( 1116 )>>endobj1089 0 obj<</Dest[74 0 R/XYZ 30 552 null]/Next 1088 0 R/Parent 999 0 R/Prev 1090 0 R/SE 884 0 R/Title(\(viii\) Current length-based pediatric body weight & tracheal tube 1113 size evaluation system, resuscitation medications and equipment that are 1114 dose-appropriate for all ages; 1115 )>>endobj1090 0 obj<</Dest[74 0 R/XYZ 30 566 null]/Next 1089 0 R/Parent 999 0 R/Prev 1091 0 R/SE 883 0 R/Title( 1112 )>>endobj1091 0 obj<</Dest[74 0 R/XYZ 30 607 null]/Next 1090 0 R/Parent 999 0 R/Prev 1092 0 R/SE 882 0 R/Title(\(vii\) Sterile surgical sets for procedures standard for emergency 1109 care including but not limited to: thoracostomy, central line insertion, and 1110 airway control/cricothyrotomy; 1111 )>>endobj1092 0 obj<</Dest[74 0 R/XYZ 30 621 null]/Next 1091 0 R/Parent 999 0 R/Prev 1093 0 R/SE 881 0 R/Title( 1108 )>>endobj1093 0 obj<</Dest[74 0 R/XYZ 30 648 null]/Next 1092 0 R/Parent 999 0 R/Prev 1094 0 R/SE 880 0 R/Title(\(vi\) Standard intravenous fluids and administration devices, 1106 including large-bore intravenous catheters and a rapid infuser system; 1107 )>>endobj1094 0 obj<</Dest[74 0 R/XYZ 30 662 null]/Next 1093 0 R/Parent 999 0 R/Prev 1095 0 R/SE 879 0 R/Title( 1105 )>>endobj1095 0 obj<</Dest[74 0 R/XYZ 30 690 null]/Next 1094 0 R/Parent 999 0 R/Prev 1096 0 R/SE 878 0 R/Title(\(v\) Apparatus to establish central venous pressure monitoring 1103 equipment; 1104 )>>endobj1096 0 obj<</Dest[74 0 R/XYZ 30 704 null]/Next 1095 0 R/Parent 999 0 R/Prev 1097 0 R/SE 877 0 R/Title( 1102 )>>endobj1097 0 obj<</Dest[74 0 R/XYZ 30 717 null]/Next 1096 0 R/Parent 999 0 R/Prev 1098 0 R/SE 875 0 R/Title(\(iv\) Quantitative end tidal CO2 monitor; 1101 )>>endobj1098 0 obj<</Dest[72 0 R/XYZ 30 96 null]/Next 1097 0 R/Parent 999 0 R/Prev 1099 0 R/SE 874 0 R/Title( 1100 )>>endobj1099 0 obj<</Dest[72 0 R/XYZ 30 110 null]/Next 1098 0 R/Parent 999 0 R/Prev 1100 0 R/SE 873 0 R/Title(\(iii\) Supraglottic airway management device \(e.g. LMA\); 1099 )>>endobj1100 0 obj<</Dest[72 0 R/XYZ 30 124 null]/Next 1099 0 R/Parent 999 0 R/Prev 1101 0 R/SE 872 0 R/Title( 1098 )>>endobj1101 0 obj<</Dest[72 0 R/XYZ 30 138 null]/Next 1100 0 R/Parent 999 0 R/Prev 1102 0 R/SE 871 0 R/Title(\(ii\) Mechanical ventilator; 1097 )>>endobj1102 0 obj<</Dest[72 0 R/XYZ 30 152 null]/Next 1101 0 R/Parent 999 0 R/Prev 1103 0 R/SE 870 0 R/Title( 1096 )>>endobj1103 0 obj<</Dest[72 0 R/XYZ 30 179 null]/Next 1102 0 R/Parent 999 0 R/Prev 1104 0 R/SE 869 0 R/Title(\(i\) Airway control and ventilation equipment including 1094 laryngoscope and endotracheal tubes of all sizes; 1095 )>>endobj1104 0 obj<</Dest[72 0 R/XYZ 30 193 null]/Next 1103 0 R/Parent 999 0 R/Prev 1105 0 R/SE 868 0 R/Title( 1093 )>>endobj1105 0 obj<</Dest[72 0 R/XYZ 30 207 null]/Next 1104 0 R/Parent 999 0 R/Prev 1106 0 R/SE 867 0 R/Title(\(B\)Additional Required Emergency Department Equipment. 1092 )>>endobj1106 0 obj<</Dest[72 0 R/XYZ 30 221 null]/Next 1105 0 R/Parent 999 0 R/Prev 1107 0 R/SE 866 0 R/Title( 1091 )>>endobj1107 0 obj<</Dest[72 0 R/XYZ 30 248 null]/Next 1106 0 R/Parent 999 0 R/Prev 1108 0 R/SE 865 0 R/Title(\(A\) Equipment. The facility shall provide equipment and supplies in 1089 compliance with 25 TAC 133.41 Hospital Functions and Services \(e\)\(3\)\(4\). 1090 )>>endobj1108 0 obj<</Dest[72 0 R/XYZ 30 262 null]/Next 1107 0 R/Parent 999 0 R/Prev 1109 0 R/SE 864 0 R/Title( 1088 )>>endobj1109 0 obj<</Dest[72 0 R/XYZ 30 317 null]/Next 1108 0 R/Parent 999 0 R/Prev 1110 0 R/SE 863 0 R/Title(\(10\) Emergency Department Equipment and Services. Equipment and services 1084 for the evaluation, resuscitation, and life support for critically or seriously injured patients of all 1085 ages shall be available for resuscitation, temperature warming an\d cooling management, 1086 hemorrhage control, hemodynamic monitoring and orthopedic splinting. 1087 )>>endobj1110 0 obj<</Dest[72 0 R/XYZ 30 331 null]/Next 1109 0 R/Parent 999 0 R/Prev 1111 0 R/SE 862 0 R/Title( 1083 )>>endobj1111 0 obj<</Dest[72 0 R/XYZ 30 359 null]/Next 1110 0 R/Parent 999 0 R/Prev 1112 0 R/SE 861 0 R/Title(\(9\) Pre-hospital EMS Communication. There shall be two-way 1081 communication with all pre-hospital emergency medical services vehicles. 1082 )>>endobj1112 0 obj<</Dest[72 0 R/XYZ 30 372 null]/Next 1111 0 R/Parent 999 0 R/Prev 1113 0 R/SE 860 0 R/Title( 1080 )>>endobj1113 0 obj<</Dest[72 0 R/XYZ 30 400 null]/Next 1112 0 R/Parent 999 0 R/Prev 1114 0 R/SE 859 0 R/Title(\(C\) Data validation. The Trauma Registrar must participate in ongoing 1078 data validation through the department and/or the RAC PI committee. 1079 )>>endobj1114 0 obj<</Dest[72 0 R/XYZ 30 414 null]/Next 1113 0 R/Parent 999 0 R/Prev 1115 0 R/SE 858 0 R/Title( 1077 )>>endobj1115 0 obj<</Count 2/Dest[72 0 R/XYZ 30 442 null]/First 1116 0 R/Last 1116 0 R/Next 1114 0 R/Parent 999 0 R/Prev 1117 0 R/SE 855 0 R/Title(\(V\) four hours of continuing education annually specific 1075 to trauma data quality. 1076 )>>endobj1116 0 obj<</Count 1/Dest[72 0 R/XYZ 30 442 null]/First 1858 0 R/Last 1858 0 R/Parent 1115 0 R/SE 856 0 R/Title(\(V\) four hours of continuing education annually specific 1075 to trauma data quality. 1076 )>>endobj1117 0 obj<</Dest[72 0 R/XYZ 30 455 null]/Next 1115 0 R/Parent 999 0 R/Prev 1118 0 R/SE 854 0 R/Title( 1074 )>>endobj1118 0 obj<</Dest[72 0 R/XYZ 30 469 null]/Next 1117 0 R/Parent 999 0 R/Prev 1119 0 R/SE 853 0 R/Title(\(ii\) other office approved equivalent course; and 1073 )>>endobj1119 0 obj<</Dest[72 0 R/XYZ 30 483 null]/Next 1118 0 R/Parent 999 0 R/Prev 1120 0 R/SE 852 0 R/Title( 1072 )>>endobj1120 0 obj<</Dest[72 0 R/XYZ 30 510 null]/Next 1119 0 R/Parent 999 0 R/Prev 1121 0 R/SE 851 0 R/Title(\(i\) the Association for the Advancement of Automotive 1070 Medicine \(AAAM\) course, or 1071 )>>endobj1121 0 obj<</Dest[72 0 R/XYZ 30 524 null]/Next 1120 0 R/Parent 999 0 R/Prev 1122 0 R/SE 850 0 R/Title( 1069 )>>endobj1122 0 obj<</Dest[72 0 R/XYZ 30 552 null]/Next 1121 0 R/Parent 999 0 R/Prev 1123 0 R/SE 849 0 R/Title(\(B\) Identified Trauma Registrar who has had appropriate training 1067 within 24 months of hire into the position of trauma registrar which includes: 1068 )>>endobj1123 0 obj<</Dest[72 0 R/XYZ 30 566 null]/Next 1122 0 R/Parent 999 0 R/Prev 1124 0 R/SE 848 0 R/Title( 1066 )>>endobj1124 0 obj<</Dest[72 0 R/XYZ 30 607 null]/Next 1123 0 R/Parent 999 0 R/Prev 1125 0 R/SE 847 0 R/Title(\(ii\) Re-designation. Data shall be uploaded to the Texas 1063 EMS/Trauma Registry as indicated in Chapter 103, Injury Prevention and Control of this title 1064 within 45 days of patient discharge with a 90% acceptance rate. 1065 )>>endobj1125 0 obj<</Dest[72 0 R/XYZ 30 621 null]/Next 1124 0 R/Parent 999 0 R/Prev 1126 0 R/SE 846 0 R/Title( 1062 )>>endobj1126 0 obj<</Dest[72 0 R/XYZ 30 690 null]/Next 1125 0 R/Parent 999 0 R/Prev 1127 0 R/SE 845 0 R/Title(\(i\) Initial designation. Six months of data prior to the initial 1057 designation survey must be uploaded to the Texas EMS/Trauma System Registry. Subsequent to 1058 initial designation, data shall be uploaded to the Texas EMS/Trauma Registry as indicat\ed in 1059 Chapter 103, Injury Prevention and Control of this title within 45 days of discharge with a 90% 1060 acceptance or accuracy rate. 1061 )>>endobj1127 0 obj<</Dest[72 0 R/XYZ 30 704 null]/Next 1126 0 R/Parent 999 0 R/Prev 1128 0 R/SE 844 0 R/Title( 1056 )>>endobj1128 0 obj<</Dest[72 0 R/XYZ 30 717 null]/Next 1127 0 R/Parent 999 0 R/Prev 1129 0 R/SE 842 0 R/Title(\(A\) Data submission for designation purposes. 1055 )>>endobj1129 0 obj<</Dest[70 0 R/XYZ 30 96 null]/Next 1128 0 R/Parent 999 0 R/Prev 1130 0 R/SE 841 0 R/Title( 1054 )>>endobj1130 0 obj<</Dest[70 0 R/XYZ 30 124 null]/Next 1129 0 R/Parent 999 0 R/Prev 1131 0 R/SE 840 0 R/Title(\(8\) Texas EMS/Trauma Registry Requirements. Any designated trauma facility 1052 must participate in the Texas EMS/Trauma Registry. Participation shall include: 1053 )>>endobj1131 0 obj<</Dest[70 0 R/XYZ 30 138 null]/Next 1130 0 R/Parent 999 0 R/Prev 1132 0 R/SE 839 0 R/Title( 1051 )>>endobj1132 0 obj<</Dest[70 0 R/XYZ 30 207 null]/Next 1131 0 R/Parent 999 0 R/Prev 1133 0 R/SE 838 0 R/Title(\(H\) A stand-alone children•s facility shall have documentation that 1046 100% of nursing staff who care for trauma patients have successfully completed 1047 and hold current credentials in a nationally recognized pediatric advanced life 1048 support cou\rse \(e.g. PALS or ENPC\) and TNCC or ATCN or a DSHS-approved 1049 equivalent, within 18 months of date of employment in the ED. 1050 )>>endobj1133 0 obj<</Dest[70 0 R/XYZ 30 221 null]/Next 1132 0 R/Parent 999 0 R/Prev 1134 0 R/SE 837 0 R/Title( 1045 )>>endobj1134 0 obj<</Dest[70 0 R/XYZ 311 306 null]/Next 1133 0 R/Parent 999 0 R/Prev 1135 0 R/SE 836 0 R/Title(\(G\) documentation that 100% of nursing staff working in the 1039 Emergency Department \(ED\) and responding to trauma activations or caring for trauma patients 1040 have successfully completed and hold current credentials in an advanced cardiac life sup\port 1041 course \(e.g. ACLS or hospital equivalent\), a nationally recognized pediatric advanced life 1042 support course \(e.g. PALS or ENPC\) and TNCC or ATCN or a DSHS-approved equivalent, 1043 within 18 months of date of employment in the ED. 1044 )>>endobj1135 0 obj<</Dest[70 0 R/XYZ 30 317 null]/Next 1134 0 R/Parent 999 0 R/Prev 1136 0 R/SE 835 0 R/Title( 1038 )>>endobj1136 0 obj<</Dest[70 0 R/XYZ 30 386 null]/Next 1135 0 R/Parent 999 0 R/Prev 1137 0 R/SE 834 0 R/Title(\(F\) nursing documentation for trauma patients is systematic and meets 1033 the trauma registry guidelines, includes at a minimum:: the sequence of care, primary and 1034 secondary survey with interventions, outcomes, serial vital signs, GCS, consulting \services 1035 assessment, plan of care with disposition and documents the response time of all trauma team 1036 members. 1037 )>>endobj1137 0 obj<</Dest[70 0 R/XYZ 30 400 null]/Next 1136 0 R/Parent 999 0 R/Prev 1138 0 R/SE 833 0 R/Title( 1032 )>>endobj1138 0 obj<</Dest[70 0 R/XYZ 30 469 null]/Next 1137 0 R/Parent 999 0 R/Prev 1139 0 R/SE 832 0 R/Title(\(E\) a minimum of two registered nurses shall participate in initial 1027 resuscitations for full and limited or trauma activations, have successfully completed and hold 1028 current credentials in an advanced cardiac life support course \(ACLS\); a nati\onally 1029 recognized pediatric advanced life support course \( PALS or ENPC\); and TNCC or ATCN; or an 1030 office approved equivalent for each course; 1031 )>>endobj1139 0 obj<</Dest[70 0 R/XYZ 30 483 null]/Next 1138 0 R/Parent 999 0 R/Prev 1140 0 R/SE 831 0 R/Title( 1026 )>>endobj1140 0 obj<</Dest[70 0 R/XYZ 30 524 null]/Next 1139 0 R/Parent 999 0 R/Prev 1141 0 R/SE 830 0 R/Title(\(D\) a written plan, developed by the hospital, for acquisition of 1023 additional staff on a 24 hour basis to support units with increased patient acuity, multiple 1024 emergency procedures and admissions \(i.e. written surge plan.\); 1025 )>>endobj1141 0 obj<</Dest[70 0 R/XYZ 30 538 null]/Next 1140 0 R/Parent 999 0 R/Prev 1142 0 R/SE 829 0 R/Title( 1022 )>>endobj1142 0 obj<</Dest[70 0 R/XYZ 30 579 null]/Next 1141 0 R/Parent 999 0 R/Prev 1143 0 R/SE 828 0 R/Title(\(C\) a facility approved acuity-based patient classification system is 1019 utilized to define workload and number of nursing staff to provide safe patient care for all trauma 1020 patients throughout their hospitalization; 1021 )>>endobj1143 0 obj<</Dest[70 0 R/XYZ 30 593 null]/Next 1142 0 R/Parent 999 0 R/Prev 1144 0 R/SE 827 0 R/Title( 1018 )>>endobj1144 0 obj<</Dest[70 0 R/XYZ 30 621 null]/Next 1143 0 R/Parent 999 0 R/Prev 1145 0 R/SE 826 0 R/Title(\(B\) written standards on nursing care for trauma patients for all units 1016 \(i.e. ED, ICU, OR, PACU, general inpatient\) in the trauma facility shall be implemented; 1017 )>>endobj1145 0 obj<</Dest[70 0 R/XYZ 30 635 null]/Next 1144 0 R/Parent 999 0 R/Prev 1146 0 R/SE 825 0 R/Title( 1015 )>>endobj1146 0 obj<</Dest[70 0 R/XYZ 30 676 null]/Next 1145 0 R/Parent 999 0 R/Prev 1147 0 R/SE 824 0 R/Title(\(A\) all nurses caring for trauma patients throughout the continuum of 1012 care have ongoing documented knowledge and skills in trauma nursing for patients of all ages to 1013 include trauma specific orientation, annual clinical competencies, and contin\uing education; 1014 )>>endobj1147 0 obj<</Dest[70 0 R/XYZ 30 690 null]/Next 1146 0 R/Parent 999 0 R/Prev 1148 0 R/SE 823 0 R/Title( 1011 )>>endobj1148 0 obj<</Dest[70 0 R/XYZ 30 717 null]/Next 1147 0 R/Parent 999 0 R/Prev 1149 0 R/SE 821 0 R/Title(\(6\) Nursing Services for all critical care and patient care areas shall provide 1009 evidence of the following: 1010 )>>endobj1149 0 obj<</Dest[68 0 R/XYZ 30 110 null]/Next 1148 0 R/Parent 999 0 R/Prev 1150 0 R/SE 820 0 R/Title( 1008 )>>endobj1150 0 obj<</Dest[68 0 R/XYZ 30 179 null]/Next 1149 0 R/Parent 999 0 R/Prev 1151 0 R/SE 819 0 R/Title( \(5\) Nursing Staff. As part of the facility•s trauma program approved by the 1003 governing body, the program will have an identified Trauma Program Manager with equivalent 1004 authority and responsibility as granted to other department or nurse manage\rs. There shall be a 1005 demonstrated commitment by the facility for furthering the education and understanding of 1006 trauma standards of care for all nursing staff caring for the trauma patient. 1007 )>>endobj1151 0 obj<</Dest[68 0 R/XYZ 30 193 null]/Next 1150 0 R/Parent 999 0 R/Prev 1152 0 R/SE 818 0 R/Title( 1002 )>>endobj1152 0 obj<</Dest[68 0 R/XYZ 30 276 null]/Next 1151 0 R/Parent 999 0 R/Prev 1153 0 R/SE 817 0 R/Title(\(4\)Advanced Practice clinicians \(advanced practice registered nurses or physician 996 assistants\) utilized in the care of major and/or severe trauma patients, shall not be 997 a substitute for the required physician response, in patient care planning\ nor in 998 QAPI activities. Any Advanced Practice clinician who provides care to trauma 999 patients shall be current in ATLS and be appropriately credentialed by the Texas 1000 Board of Nursing \(TBON\) or the Texas Medical Board \(TMB\) respectively. \1001 )>>endobj1153 0 obj<</Dest[68 0 R/XYZ 36 290 null]/Next 1152 0 R/Parent 999 0 R/Prev 1154 0 R/SE 816 0 R/Title( 995 )>>endobj1154 0 obj<</Count 2/Dest[68 0 R/XYZ 36 359 null]/First 1155 0 R/Last 1155 0 R/Next 1153 0 R/Parent 999 0 R/Prev 1156 0 R/SE 813 0 R/Title(\(B\) The rate of change in interpretation of radiologic studies must be 990 routinely monitored and reviewed with the radiology department. 991 Identified cases should be reviewed to determine the reason for 992 misinterpretation, adverse outcomes, and \opportunities for 993 improvement. 994 )>>endobj1155 0 obj<</Count 1/Dest[68 0 R/XYZ 36 359 null]/First 1857 0 R/Last 1857 0 R/Parent 1154 0 R/SE 814 0 R/Title(\(B\) The rate of change in interpretation of radiologic studies must be 990 routinely monitored and reviewed with the radiology department. 991 Identified cases should be reviewed to determine the reason for 992 misinterpretation, adverse outcomes, and \opportunities for 993 improvement. 994 )>>endobj1156 0 obj<</Dest[68 0 R/XYZ 36 372 null]/Next 1154 0 R/Parent 999 0 R/Prev 1157 0 R/SE 812 0 R/Title( 989 )>>endobj1157 0 obj<</Count 2/Dest[68 0 R/XYZ 36 414 null]/First 1158 0 R/Last 1158 0 R/Next 1156 0 R/Parent 999 0 R/Prev 1159 0 R/SE 809 0 R/Title(\(A\) A radiologist shall be on-call and promptly available within 30 986 minutes of request from inside or outside the hospital. This system 987 shall be continuously monitored by the trauma PI program. 988 )>>endobj1158 0 obj<</Count 1/Dest[68 0 R/XYZ 36 414 null]/First 1856 0 R/Last 1856 0 R/Parent 1157 0 R/SE 810 0 R/Title(\(A\) A radiologist shall be on-call and promptly available within 30 986 minutes of request from inside or outside the hospital. This system 987 shall be continuously monitored by the trauma PI program. 988 )>>endobj1159 0 obj<</Dest[68 0 R/XYZ 36 428 null]/Next 1157 0 R/Parent 999 0 R/Prev 1160 0 R/SE 808 0 R/Title( 985 )>>endobj1160 0 obj<</Dest[68 0 R/XYZ 36 441 null]/Next 1159 0 R/Parent 999 0 R/Prev 1161 0 R/SE 807 0 R/Title(\(3\) Radiology Services. 984 )>>endobj1161 0 obj<</Dest[68 0 R/XYZ 36 455 null]/Next 1160 0 R/Parent 999 0 R/Prev 1162 0 R/SE 806 0 R/Title( 983 )>>endobj1162 0 obj<</Dest[68 0 R/XYZ 36 497 null]/Next 1161 0 R/Parent 999 0 R/Prev 1163 0 R/SE 805 0 R/Title(\(H\) participate in the trauma QAPI/multidisciplinary PI program and a 980 designated liaison shall attend at least 50% of the trauma multidisciplinary PI and peer review 981 committee meetings. 982 )>>endobj1163 0 obj<</Dest[68 0 R/XYZ 36 510 null]/Next 1162 0 R/Parent 999 0 R/Prev 1164 0 R/SE 804 0 R/Title( 979 )>>endobj1164 0 obj<</Dest[68 0 R/XYZ 36 524 null]/Next 1163 0 R/Parent 999 0 R/Prev 1165 0 R/SE 803 0 R/Title(\(G\) maintain compliance with trauma protocols; and 978 )>>endobj1165 0 obj<</Dest[68 0 R/XYZ 36 538 null]/Next 1164 0 R/Parent 999 0 R/Prev 1166 0 R/SE 802 0 R/Title( 977 )>>endobj1166 0 obj<</Dest[68 0 R/XYZ 36 566 null]/Next 1165 0 R/Parent 999 0 R/Prev 1167 0 R/SE 801 0 R/Title(\(F\) average at least 9 hours of trauma-related continuing medical 975 education annually; 976 )>>endobj1167 0 obj<</Dest[68 0 R/XYZ 36 579 null]/Next 1166 0 R/Parent 999 0 R/Prev 1168 0 R/SE 800 0 R/Title( 974 )>>endobj1168 0 obj<</Dest[68 0 R/XYZ 36 593 null]/Next 1167 0 R/Parent 999 0 R/Prev 1169 0 R/SE 799 0 R/Title(\(E\) be appropriately credentialed through the trauma program; 973 )>>endobj1169 0 obj<</Dest[68 0 R/XYZ 36 607 null]/Next 1168 0 R/Parent 999 0 R/Prev 1170 0 R/SE 798 0 R/Title( 972 )>>endobj1170 0 obj<</Dest[68 0 R/XYZ 36 648 null]/Next 1169 0 R/Parent 999 0 R/Prev 1171 0 R/SE 797 0 R/Title(\(D\) be board eligible in their applicable specialty and currently 969 credentialed in Advanced Trauma Life Support \(ATLS\) or an equivalent course approved by the 970 office; and 971 )>>endobj1171 0 obj<</Dest[68 0 R/XYZ 36 662 null]/Next 1170 0 R/Parent 999 0 R/Prev 1172 0 R/SE 796 0 R/Title( 968 )>>endobj1172 0 obj<</Dest[68 0 R/XYZ 36 704 null]/Next 1171 0 R/Parent 999 0 R/Prev 1173 0 R/SE 795 0 R/Title(\(C\) prior to \(the effective date of this rule\) have continuously provided 965 trauma coverage in the emergency department at the designated facility for the last consecutive 966 five years and be currently credentialed in Advanced Trauma Life Support \\(ATLS\); or 967 )>>endobj1173 0 obj<</Dest[68 0 R/XYZ 36 717 null]/Next 1172 0 R/Parent 999 0 R/Prev 1174 0 R/SE 793 0 R/Title( 964 )>>endobj1174 0 obj<</Dest[66 0 R/XYZ 36 110 null]/Next 1173 0 R/Parent 999 0 R/Prev 1175 0 R/SE 792 0 R/Title(\(B\) be board eligible in emergency medicine and currently credentialed 962 in Advanced Trauma Life Support \(ATLS\) or an equivalent course approved by the office; or 963 )>>endobj1175 0 obj<</Dest[66 0 R/XYZ 36 124 null]/Next 1174 0 R/Parent 999 0 R/Prev 1176 0 R/SE 791 0 R/Title( 961 )>>endobj1176 0 obj<</Dest[66 0 R/XYZ 36 152 null]/Next 1175 0 R/Parent 999 0 R/Prev 1177 0 R/SE 790 0 R/Title(\(A\) be board certified in emergency medicine and have successfully 959 completed ATLS; or 960 )>>endobj1177 0 obj<</Dest[66 0 R/XYZ 36 165 null]/Next 1176 0 R/Parent 999 0 R/Prev 1178 0 R/SE 789 0 R/Title( 958 )>>endobj1178 0 obj<</Dest[66 0 R/XYZ 36 207 null]/Next 1177 0 R/Parent 999 0 R/Prev 1179 0 R/SE 788 0 R/Title(\(2\) Emergency Medicine. A physician providing trauma coverage shall be 955 on-call \(if not in-house 24/7\), promptly available onsite within 30 minutes of request 956 from inside or outside the hospital and shall: 957 )>>endobj1179 0 obj<</Dest[66 0 R/XYZ 36 221 null]/Next 1178 0 R/Parent 999 0 R/Prev 1180 0 R/SE 787 0 R/Title( 954 )>>endobj1180 0 obj<</Count 2/Dest[66 0 R/XYZ 36 262 null]/First 1181 0 R/Last 1181 0 R/Next 1179 0 R/Parent 999 0 R/Prev 1182 0 R/SE 784 0 R/Title(\(D\) has continuously served as the Trauma Medical Director at the 951 designated facility for the last consecutive five years and is currently 952 credentialed in Advanced Trauma Life Support \(ATLS\). 953 )>>endobj1181 0 obj<</Count 1/Dest[66 0 R/XYZ 36 262 null]/First 1855 0 R/Last 1855 0 R/Parent 1180 0 R/SE 785 0 R/Title(\(D\) has continuously served as the Trauma Medical Director at the 951 designated facility for the last consecutive five years and is currently 952 credentialed in Advanced Trauma Life Support \(ATLS\). 953 )>>endobj1182 0 obj<</Dest[66 0 R/XYZ 36 276 null]/Next 1180 0 R/Parent 999 0 R/Prev 1183 0 R/SE 783 0 R/Title( 950 )>>endobj1183 0 obj<</Dest[66 0 R/XYZ 36 317 null]/Next 1182 0 R/Parent 999 0 R/Prev 1184 0 R/SE 782 0 R/Title(\(B\) board certified or board eligible in their applicable medical or 947 surgical specialty and currently credentialed in Advanced Trauma Life 948 Support \(ATLS\) or an equivalent course approved by the office; or 949 )>>endobj1184 0 obj<</Dest[66 0 R/XYZ 36 331 null]/Next 1183 0 R/Parent 999 0 R/Prev 1185 0 R/SE 781 0 R/Title( 946 )>>endobj1185 0 obj<</Dest[66 0 R/XYZ 36 386 null]/Next 1184 0 R/Parent 999 0 R/Prev 1186 0 R/SE 780 0 R/Title(\(A\) board certified in emergency medicine by the American Board of 942 Emergency Medicine \(ABMS or AOBEM\), or eligible for board certification in 943 emergency medicine and currently credentialed in Advanced Trauma Life 944 Support \(ATLS\) or an equi\valent course approved by the office; or 945 )>>endobj1186 0 obj<</Dest[66 0 R/XYZ 36 400 null]/Next 1185 0 R/Parent 999 0 R/Prev 1187 0 R/SE 779 0 R/Title( 941 )>>endobj1187 0 obj<</Dest[66 0 R/XYZ 36 414 null]/Next 1186 0 R/Parent 999 0 R/Prev 1188 0 R/SE 778 0 R/Title( \(1\) The Trauma Medical Director shall be a physician who is: 940 )>>endobj1188 0 obj<</Dest[66 0 R/XYZ 36 428 null]/Next 1187 0 R/Parent 999 0 R/Prev 1189 0 R/SE 777 0 R/Title( 939 )>>endobj1189 0 obj<</Dest[66 0 R/XYZ 36 455 null]/Next 1188 0 R/Parent 999 0 R/Prev 1190 0 R/SE 776 0 R/Title(\(n\) Trauma Designation Level IV \(Basic\). The Level IV trauma designated facility 937 will meet the following requirements: 938 )>>endobj1190 0 obj<</Dest[66 0 R/XYZ 36 469 null]/Next 1189 0 R/Parent 999 0 R/Prev 1191 0 R/SE 775 0 R/Title( 936 )>>endobj1191 0 obj<</Count 2/Dest[66 0 R/XYZ 36 483 null]/First 1192 0 R/Last 1192 0 R/Next 1190 0 R/Parent 999 0 R/Prev 1193 0 R/SE 772 0 R/Title(\(IV\) Social services. 935 )>>endobj1192 0 obj<</Count 1/Dest[66 0 R/XYZ 36 483 null]/First 1854 0 R/Last 1854 0 R/Parent 1191 0 R/SE 773 0 R/Title(\(IV\) Social services. 935 )>>endobj1193 0 obj<</Dest[66 0 R/XYZ 36 497 null]/Next 1191 0 R/Parent 999 0 R/Prev 1194 0 R/SE 771 0 R/Title( 934 )>>endobj1194 0 obj<</Count 2/Dest[66 0 R/XYZ 36 511 null]/First 1195 0 R/Last 1195 0 R/Next 1193 0 R/Parent 999 0 R/Prev 1196 0 R/SE 768 0 R/Title(\(III\) Speech therapy; and 933 )>>endobj1195 0 obj<</Count 1/Dest[66 0 R/XYZ 36 511 null]/First 1853 0 R/Last 1853 0 R/Parent 1194 0 R/SE 769 0 R/Title(\(III\) Speech therapy; and 933 )>>endobj1196 0 obj<</Dest[66 0 R/XYZ 36 524 null]/Next 1194 0 R/Parent 999 0 R/Prev 1197 0 R/SE 767 0 R/Title( 932 )>>endobj1197 0 obj<</Count 2/Dest[66 0 R/XYZ 36 538 null]/First 1198 0 R/Last 1198 0 R/Next 1196 0 R/Parent 999 0 R/Prev 1199 0 R/SE 764 0 R/Title(\(II\) Occupational therapy; 931 )>>endobj1198 0 obj<</Count 1/Dest[66 0 R/XYZ 36 538 null]/First 1852 0 R/Last 1852 0 R/Parent 1197 0 R/SE 765 0 R/Title(\(II\) Occupational therapy; 931 )>>endobj1199 0 obj<</Dest[66 0 R/XYZ 36 552 null]/Next 1197 0 R/Parent 999 0 R/Prev 1200 0 R/SE 763 0 R/Title( 930 )>>endobj1200 0 obj<</Count 2/Dest[66 0 R/XYZ 36 566 null]/First 1201 0 R/Last 1201 0 R/Next 1199 0 R/Parent 999 0 R/Prev 1202 0 R/SE 760 0 R/Title(\(I\) Physical therapy; 929 )>>endobj1201 0 obj<</Count 1/Dest[66 0 R/XYZ 36 566 null]/First 1851 0 R/Last 1851 0 R/Parent 1200 0 R/SE 761 0 R/Title(\(I\) Physical therapy; 929 )>>endobj1202 0 obj<</Dest[66 0 R/XYZ 36 579 null]/Next 1200 0 R/Parent 999 0 R/Prev 1203 0 R/SE 759 0 R/Title( 928 )>>endobj1203 0 obj<</Count 2/Dest[66 0 R/XYZ 36 608 null]/First 1204 0 R/Last 1204 0 R/Next 1202 0 R/Parent 999 0 R/Prev 1205 0 R/SE 756 0 R/Title(\(ii\) The facility shall have the following services available for a 926 critically injured patient: 927 )>>endobj1204 0 obj<</Count 1/Dest[66 0 R/XYZ 36 608 null]/First 1850 0 R/Last 1850 0 R/Parent 1203 0 R/SE 757 0 R/Title(\(ii\) The facility shall have the following services available for a 926 critically injured patient: 927 )>>endobj1205 0 obj<</Dest[66 0 R/XYZ 36 621 null]/Next 1203 0 R/Parent 999 0 R/Prev 1206 0 R/SE 755 0 R/Title( 925 )>>endobj1206 0 obj<</Dest[66 0 R/XYZ 36 704 null]/Next 1205 0 R/Parent 999 0 R/Prev 1207 0 R/SE 754 0 R/Title(\(i\) A physiciandirected rehabilitation service, staffed by 919 personnel trained in rehabilitation care and equipped properly for care of 920 the critically injured patient, or transfer plan when medically feasible to a 921 rehabilitation facility and \a process to expedite the transfer of 922 rehabilitation patients to include written protocols, or a written transfer 923 plan. 924 )>>endobj1207 0 obj<</Dest[66 0 R/XYZ 36 717 null]/Next 1206 0 R/Parent 999 0 R/Prev 1208 0 R/SE 752 0 R/Title( 918 )>>endobj1208 0 obj<</Dest[64 0 R/XYZ 36 96 null]/Next 1207 0 R/Parent 999 0 R/Prev 1209 0 R/SE 751 0 R/Title(\(D\) Rehabilitation Medicine. 917 )>>endobj1209 0 obj<</Dest[64 0 R/XYZ 36 110 null]/Next 1208 0 R/Parent 999 0 R/Prev 1210 0 R/SE 750 0 R/Title( 916 )>>endobj1210 0 obj<</Dest[64 0 R/XYZ 36 138 null]/Next 1209 0 R/Parent 999 0 R/Prev 1211 0 R/SE 749 0 R/Title(\(ii\) In circumstances where a moderate to severe head injury 914 center exists in the region, a transfer plan must be in effect. 915 )>>endobj1211 0 obj<</Dest[64 0 R/XYZ 36 152 null]/Next 1210 0 R/Parent 999 0 R/Prev 1212 0 R/SE 748 0 R/Title( 913 )>>endobj1212 0 obj<</Dest[64 0 R/XYZ 36 179 null]/Next 1211 0 R/Parent 999 0 R/Prev 1213 0 R/SE 747 0 R/Title(\(i\) In circumstances where a designated spinal cord injury 911 rehabilitation center exists in the region, a transfer plan must be in effect. 912 )>>endobj1213 0 obj<</Dest[64 0 R/XYZ 36 193 null]/Next 1212 0 R/Parent 999 0 R/Prev 1214 0 R/SE 746 0 R/Title( 910 )>>endobj1214 0 obj<</Count 2/Dest[64 0 R/XYZ 36 207 null]/First 1215 0 R/Last 1215 0 R/Next 1213 0 R/Parent 999 0 R/Prev 1216 0 R/SE 743 0 R/Title(\(C\) Spinal cord/head injury rehabilitation management capability. 909 )>>endobj1215 0 obj<</Count 1/Dest[64 0 R/XYZ 36 207 null]/First 1849 0 R/Last 1849 0 R/Parent 1214 0 R/SE 744 0 R/Title(\(C\) Spinal cord/head injury rehabilitation management capability. 909 )>>endobj1216 0 obj<</Dest[64 0 R/XYZ 36 221 null]/Next 1214 0 R/Parent 999 0 R/Prev 1217 0 R/SE 742 0 R/Title( 908 )>>endobj1217 0 obj<</Dest[64 0 R/XYZ 36 276 null]/Next 1216 0 R/Parent 999 0 R/Prev 1218 0 R/SE 741 0 R/Title(\(B\) Organized Burn Care. Established criteria for care of major or 904 severe burn patients and/or a process to expedite the transfer of burn patients to a 905 burn center or higher level of care to include written protocols and written transfer 906 pla\n. 907 )>>endobj1218 0 obj<</Dest[64 0 R/XYZ 36 290 null]/Next 1217 0 R/Parent 999 0 R/Prev 1219 0 R/SE 740 0 R/Title( 903 )>>endobj1219 0 obj<</Dest[64 0 R/XYZ 36 317 null]/Next 1218 0 R/Parent 999 0 R/Prev 1220 0 R/SE 739 0 R/Title(\(A\) Acute hemodialysis capability. A Transfer plan shall be 901 implemented if there is no capability for this standard. 902 )>>endobj1220 0 obj<</Dest[64 0 R/XYZ 36 331 null]/Next 1219 0 R/Parent 999 0 R/Prev 1221 0 R/SE 738 0 R/Title( 900 )>>endobj1221 0 obj<</Dest[64 0 R/XYZ 36 345 null]/Next 1220 0 R/Parent 999 0 R/Prev 1222 0 R/SE 737 0 R/Title(\(18\) Specialized Capabilities/Services/Units. 899 )>>endobj1222 0 obj<</Dest[64 0 R/XYZ 36 359 null]/Next 1221 0 R/Parent 999 0 R/Prev 1223 0 R/SE 736 0 R/Title( 898 )>>endobj1223 0 obj<</Dest[64 0 R/XYZ 36 372 null]/Next 1222 0 R/Parent 999 0 R/Prev 1224 0 R/SE 735 0 R/Title(\(iv\) Nuclear scanning. 897 )>>endobj1224 0 obj<</Dest[64 0 R/XYZ 36 386 null]/Next 1223 0 R/Parent 999 0 R/Prev 1225 0 R/SE 734 0 R/Title( 896 )>>endobj1225 0 obj<</Dest[64 0 R/XYZ 36 400 null]/Next 1224 0 R/Parent 999 0 R/Prev 1226 0 R/SE 733 0 R/Title(\(iii\) Angiography of all types; and 895 )>>endobj1226 0 obj<</Dest[64 0 R/XYZ 36 414 null]/Next 1225 0 R/Parent 999 0 R/Prev 1227 0 R/SE 732 0 R/Title( 894 )>>endobj1227 0 obj<</Dest[64 0 R/XYZ 36 469 null]/Next 1226 0 R/Parent 999 0 R/Prev 1228 0 R/SE 731 0 R/Title(\(ii\) Computerized Tomography. In-house CT technician 24-890 hours per day or on-call and promptly available on-site within 30 minutes 891 of request. This system shall be continuously monitored by the trauma PI 892 program; 893 )>>endobj1228 0 obj<</Dest[64 0 R/XYZ 36 483 null]/Next 1227 0 R/Parent 999 0 R/Prev 1229 0 R/SE 730 0 R/Title( 889 )>>endobj1229 0 obj<</Dest[64 0 R/XYZ 36 497 null]/Next 1228 0 R/Parent 999 0 R/Prev 1230 0 R/SE 729 0 R/Title(\(i\) Sonography; 888 )>>endobj1230 0 obj<</Dest[64 0 R/XYZ 36 510 null]/Next 1229 0 R/Parent 999 0 R/Prev 1231 0 R/SE 728 0 R/Title( 887 )>>endobj1231 0 obj<</Dest[64 0 R/XYZ 36 538 null]/Next 1230 0 R/Parent 999 0 R/Prev 1232 0 R/SE 727 0 R/Title(\(D\) Special Radiological Capabilities shall be available for the trauma 885 patient as defined by the facility•s trauma plan to include: 886 )>>endobj1232 0 obj<</Dest[64 0 R/XYZ 36 552 null]/Next 1231 0 R/Parent 999 0 R/Prev 1233 0 R/SE 726 0 R/Title( 884 )>>endobj1233 0 obj<</Dest[64 0 R/XYZ 36 607 null]/Next 1232 0 R/Parent 999 0 R/Prev 1234 0 R/SE 725 0 R/Title(\(C\) Standard Radiological Services. An in-house technician 880 shall be available 24-hours a day or be on-call and promptly available on-881 site within 30 minutes of request. . This system shall be continuously 882 monitored by the trauma PI program; \883 )>>endobj1234 0 obj<</Dest[64 0 R/XYZ 36 621 null]/Next 1233 0 R/Parent 999 0 R/Prev 1235 0 R/SE 724 0 R/Title( 879 )>>endobj1235 0 obj<</Dest[64 0 R/XYZ 36 648 null]/Next 1234 0 R/Parent 999 0 R/Prev 1236 0 R/SE 723 0 R/Title(\(B\) Clinical Laboratory Service. Laboratory services shall be in-house 877 and available 24 hours per day; 878 )>>endobj1236 0 obj<</Dest[64 0 R/XYZ 36 662 null]/Next 1235 0 R/Parent 999 0 R/Prev 1237 0 R/SE 722 0 R/Title( 876 )>>endobj1237 0 obj<</Dest[64 0 R/XYZ 36 690 null]/Next 1236 0 R/Parent 999 0 R/Prev 1238 0 R/SE 721 0 R/Title(\(A\) Respiratory Services. Respiratory services shall be inhouse and 874 available 24 hours per day. 875 )>>endobj1238 0 obj<</Dest[64 0 R/XYZ 36 704 null]/Next 1237 0 R/Parent 999 0 R/Prev 1239 0 R/SE 720 0 R/Title( 873 )>>endobj1239 0 obj<</Dest[64 0 R/XYZ 36 717 null]/Next 1238 0 R/Parent 999 0 R/Prev 1240 0 R/SE 718 0 R/Title( \(17\) Clinical Support Services. 872 )>>endobj1240 0 obj<</Dest[62 0 R/XYZ 36 96 null]/Next 1239 0 R/Parent 999 0 R/Prev 1241 0 R/SE 717 0 R/Title( 871 )>>endobj1241 0 obj<</Count 2/Dest[62 0 R/XYZ 36 138 null]/First 1242 0 R/Last 1242 0 R/Next 1240 0 R/Parent 999 0 R/Prev 1243 0 R/SE 714 0 R/Title(\(C\) Arrangements for 24-hour surgical coverage of all trauma patients 868 shall be provided for emergencies and routine care. 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This system shall 869 be continuously monitored by the trauma PI program; 870 )>>endobj1243 0 obj<</Dest[62 0 R/XYZ 36 179 null]/Next 1241 0 R/Parent 999 0 R/Prev 1244 0 R/SE 713 0 R/Title(\(B\) A physician credentialed in critical care on duty in the ICU 24 865 hours a day or immediately available from inhospital and meets the 866 credentialing requirements as defined in the facility trauma program plan. 867 )>>endobj1244 0 obj<</Dest[62 0 R/XYZ 36 193 null]/Next 1243 0 R/Parent 999 0 R/Prev 1245 0 R/SE 712 0 R/Title( 864 )>>endobj1245 0 obj<</Dest[62 0 R/XYZ 36 262 null]/Next 1244 0 R/Parent 999 0 R/Prev 1246 0 R/SE 711 0 R/Title(\(A\) Designated physician surgical director or surgical co-director 859 responsible for setting policies, developing protocols and management guidelines 860 related to trauma ICU patients. A physician providing this coverage must be a 861 board certified\ or board-eligible surgeon and meets the credentialing requirements 862 as defined in the facility trauma program plan; or 863 )>>endobj1246 0 obj<</Dest[62 0 R/XYZ 36 276 null]/Next 1245 0 R/Parent 999 0 R/Prev 1247 0 R/SE 710 0 R/Title( 858 )>>endobj1247 0 obj<</Dest[62 0 R/XYZ 36 345 null]/Next 1246 0 R/Parent 999 0 R/Prev 1248 0 R/SE 709 0 R/Title(\(16\) Intensive Care Capability. Intensive care capability shall be available for 853 the trauma critical care patient and interventions as defined by the facility•s trauma plan 854 to include resuscitation, temperature warming and cooling management, h\emorrhage 855 control, hemodynamic monitoring and orthopedic splinting to ensure that trauma 856 standards of care are met. 857 )>>endobj1248 0 obj<</Dest[62 0 R/XYZ 36 359 null]/Next 1247 0 R/Parent 999 0 R/Prev 1249 0 R/SE 708 0 R/Title( 852 )>>endobj1249 0 obj<</Dest[62 0 R/XYZ 36 400 null]/Next 1248 0 R/Parent 999 0 R/Prev 1250 0 R/SE 707 0 R/Title(\(ii\) Post-Anesthesia Care Unit. A post-anesthesia care unit or 849 surgical intensive care unit shall have registered nurses and other essential 850 personnel available 24 hours a day. 851 )>>endobj1250 0 obj<</Dest[62 0 R/XYZ 36 414 null]/Next 1249 0 R/Parent 999 0 R/Prev 1251 0 R/SE 706 0 R/Title( 848 )>>endobj1251 0 obj<</Dest[62 0 R/XYZ 36 455 null]/Next 1250 0 R/Parent 999 0 R/Prev 1252 0 R/SE 705 0 R/Title(\(i\) Operating Suite. Operating room services shall be 845 available 24 hours a day. With advanced notice, the Operating Room shall 846 be opened and ready to accept a patient within 30 minutes. 847 )>>endobj1252 0 obj<</Dest[62 0 R/XYZ 36 469 null]/Next 1251 0 R/Parent 999 0 R/Prev 1253 0 R/SE 704 0 R/Title( 844 )>>endobj1253 0 obj<</Count 2/Dest[62 0 R/XYZ 36 483 null]/First 1254 0 R/Last 1254 0 R/Next 1252 0 R/Parent 999 0 R/Prev 1255 0 R/SE 701 0 R/Title(\(B\) Services. 843 )>>endobj1254 0 obj<</Count 1/Dest[62 0 R/XYZ 36 483 null]/First 1847 0 R/Last 1847 0 R/Parent 1253 0 R/SE 702 0 R/Title(\(B\) Services. 843 )>>endobj1255 0 obj<</Dest[62 0 R/XYZ 36 497 null]/Next 1253 0 R/Parent 999 0 R/Prev 1256 0 R/SE 700 0 R/Title( 842 )>>endobj1256 0 obj<</Dest[62 0 R/XYZ 36 524 null]/Next 1255 0 R/Parent 999 0 R/Prev 1257 0 R/SE 699 0 R/Title( \(A\) Equipment. 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825 )>>endobj1270 0 obj<</Count 1/Dest[60 0 R/XYZ 36 124 null]/First 1843 0 R/Last 1843 0 R/Parent 1269 0 R/SE 681 0 R/Title(\(viii\) Current lengthbased pediatric body weight & tracheal tube 823 size evaluation system, resuscitation medications and 824 equipment that are dose-appropriate for all ages; 825 )>>endobj1271 0 obj<</Dest[60 0 R/XYZ 36 138 null]/Next 1269 0 R/Parent 999 0 R/Prev 1272 0 R/SE 679 0 R/Title( 822 )>>endobj1272 0 obj<</Count 2/Dest[60 0 R/XYZ 36 207 null]/First 1273 0 R/Last 1273 0 R/Next 1271 0 R/Parent 999 0 R/Prev 1274 0 R/SE 676 0 R/Title(\(vii\) Sterile surgical sets for procedures standard for emergency 817 care including but not limited to: thoracostomy, 818 thoracotomy, diagnostic peritoneal lavage, venous 819 cutdown, central line insertion, airway 820 control/cricothyrotomy; 821 )>>endobj1273 0 obj<</Count 1/Dest[60 0 R/XYZ 36 207 null]/First 1842 0 R/Last 1842 0 R/Parent 1272 0 R/SE 677 0 R/Title(\(vii\) Sterile surgical sets for procedures standard for emergency 817 care including but not limited to: thoracostomy, 818 thoracotomy, diagnostic peritoneal lavage, venous 819 cutdown, central line insertion, airway 820 control/cricothyrotomy; 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Equipment for the evaluation, 793 resuscitation, and life support for critically or seriously injured patients of all ages shall be 794 available for resuscitation, temperature warming and cooling management, hemorr\hage control, 795 hemodynamic monitoring and orthopedic splinting. 796 )>>endobj1299 0 obj<</Dest[60 0 R/XYZ 36 552 null]/Next 1298 0 R/Parent 999 0 R/Prev 1300 0 R/SE 643 0 R/Title( 792 )>>endobj1300 0 obj<</Dest[60 0 R/XYZ 36 579 null]/Next 1299 0 R/Parent 999 0 R/Prev 1301 0 R/SE 642 0 R/Title(\(13\) Pre-hospital EMS Communication. There shall be two-way 790 communication with all prehospital emergency medical services vehicles. 791 )>>endobj1301 0 obj<</Dest[60 0 R/XYZ 36 593 null]/Next 1300 0 R/Parent 999 0 R/Prev 1302 0 R/SE 641 0 R/Title( 789 )>>endobj1302 0 obj<</Dest[60 0 R/XYZ 36 621 null]/Next 1301 0 R/Parent 999 0 R/Prev 1303 0 R/SE 640 0 R/Title(\(B\) the American Trauma Society \(ATS\) Trauma Registrar Course or an 787 office approved equivalent. 788 )>>endobj1303 0 obj<</Dest[60 0 R/XYZ 36 635 null]/Next 1302 0 R/Parent 999 0 R/Prev 1304 0 R/SE 639 0 R/Title( 786 )>>endobj1304 0 obj<</Dest[60 0 R/XYZ 36 662 null]/Next 1303 0 R/Parent 999 0 R/Prev 1305 0 R/SE 638 0 R/Title(\(A\) the Association for the Advancement of Automotive Medicine 784 \(AAAM\) course or a an office approved equivalent; and 785 )>>endobj1305 0 obj<</Dest[60 0 R/XYZ 36 676 null]/Next 1304 0 R/Parent 999 0 R/Prev 1306 0 R/SE 637 0 R/Title( 783 )>>endobj1306 0 obj<</Dest[60 0 R/XYZ 36 717 null]/Next 1305 0 R/Parent 999 0 R/Prev 1307 0 R/SE 635 0 R/Title(\(12\) Trauma Registrar. There shall be an identified Trauma Registrar, who is 780 separate from but supervised by the TPM, who has had appropriate training within 24 months of 781 hire into the position of trauma registrar which includes: 782 )>>endobj1307 0 obj<</Dest[58 0 R/XYZ 36 96 null]/Next 1306 0 R/Parent 999 0 R/Prev 1308 0 R/SE 634 0 R/Title( 779 )>>endobj1308 0 obj<</Dest[58 0 R/XYZ 36 124 null]/Next 1307 0 R/Parent 999 0 R/Prev 1309 0 R/SE 633 0 R/Title(\(C\) Data validation. The Trauma Registrar must participate in ongoing 777 data validation through the department and/or the RAC PI committee. 778 )>>endobj1309 0 obj<</Dest[58 0 R/XYZ 36 138 null]/Next 1308 0 R/Parent 999 0 R/Prev 1310 0 R/SE 632 0 R/Title( 776 )>>endobj1310 0 obj<</Dest[58 0 R/XYZ 36 179 null]/Next 1309 0 R/Parent 999 0 R/Prev 1311 0 R/SE 631 0 R/Title(\(B\) Identified Trauma Registrar who has appropriate education, 773 training in injury severity scaling, and four hours of continuing education annually specific to 774 trauma data quality. 775 )>>endobj1311 0 obj<</Dest[58 0 R/XYZ 36 193 null]/Next 1310 0 R/Parent 999 0 R/Prev 1312 0 R/SE 630 0 R/Title( 772 )>>endobj1312 0 obj<</Dest[58 0 R/XYZ 36 234 null]/Next 1311 0 R/Parent 999 0 R/Prev 1313 0 R/SE 629 0 R/Title(\(ii\) Re-designation. Data shall be uploaded to the Texas 769 EMS/Trauma Registry as indicated in Chapter 103, Injury Prevention and Control of this title 770 within 45 days of patient discharge with a 90% acceptance rate. 771 )>>endobj1313 0 obj<</Dest[58 0 R/XYZ 36 248 null]/Next 1312 0 R/Parent 999 0 R/Prev 1314 0 R/SE 628 0 R/Title( 768 )>>endobj1314 0 obj<</Dest[58 0 R/XYZ 36 317 null]/Next 1313 0 R/Parent 999 0 R/Prev 1315 0 R/SE 627 0 R/Title(\(i\) Initial designation. Six months of data prior to the initial 763 designation survey must be uploaded to the Texas EMS/Trauma System Registry. Subsequent to 764 initial designation, data shall be uploaded to the Texas EMS/Trauma Registry as indicated\ in 765 Chapter 103, Injury Prevention and Control of this title within 45 days of discharge with a 90% 766 acceptance or accuracy rate. 767 )>>endobj1315 0 obj<</Dest[58 0 R/XYZ 36 331 null]/Next 1314 0 R/Parent 999 0 R/Prev 1316 0 R/SE 626 0 R/Title( 762 )>>endobj1316 0 obj<</Dest[58 0 R/XYZ 36 345 null]/Next 1315 0 R/Parent 999 0 R/Prev 1317 0 R/SE 625 0 R/Title(\(A\) Data submission for designation purposes. 761 )>>endobj1317 0 obj<</Dest[58 0 R/XYZ 36 359 null]/Next 1316 0 R/Parent 999 0 R/Prev 1318 0 R/SE 624 0 R/Title( 760 )>>endobj1318 0 obj<</Count 2/Dest[58 0 R/XYZ 36 400 null]/First 1319 0 R/Last 1319 0 R/Next 1317 0 R/Parent 999 0 R/Prev 1320 0 R/SE 621 0 R/Title(\(11\) Texas EMS/Trauma Registry Requirements. Any designated trauma 757 facility must participate in the Texas EMS/Trauma Registry. Participation 758 shall include: 759 )>>endobj1319 0 obj<</Count 1/Dest[58 0 R/XYZ 36 400 null]/First 1834 0 R/Last 1834 0 R/Parent 1318 0 R/SE 622 0 R/Title(\(11\) Texas EMS/Trauma Registry Requirements. Any designated trauma 757 facility must participate in the Texas EMS/Trauma Registry. Participation 758 shall include: 759 )>>endobj1320 0 obj<</Dest[58 0 R/XYZ 36 414 null]/Next 1318 0 R/Parent 999 0 R/Prev 1321 0 R/SE 620 0 R/Title( 756 )>>endobj1321 0 obj<</Dest[58 0 R/XYZ 36 483 null]/Next 1320 0 R/Parent 999 0 R/Prev 1322 0 R/SE 619 0 R/Title(\(H\) A stand-alone children•s facility shall have documentation that 751 100% of nursing staff who care for trauma patients have successfully completed 752 and hold current credentials in a nationally recognized pediatric advanced life 753 support course\ \(e.g. PALS or ENPC\) and TNCC or ATCN or a DSHS-approved 754 equivalent, within 18 months of date of employment in the ED. 755 )>>endobj1322 0 obj<</Dest[58 0 R/XYZ 36 497 null]/Next 1321 0 R/Parent 999 0 R/Prev 1323 0 R/SE 618 0 R/Title( 750 )>>endobj1323 0 obj<</Dest[58 0 R/XYZ 36 593 null]/Next 1322 0 R/Parent 999 0 R/Prev 1324 0 R/SE 617 0 R/Title(\(G\) documentation that 100% of nursing staff working in the 743 Emergency Department \(ED\) and responding to trauma activations or caring for 744 trauma patients have successfully completed and hold current credentials in an 745 advanced cardiac life s\upport course \(e.g. ACLS or hospital equivalent\), a 746 nationally recognized pediatric advanced life support course \(e.g. PALS or 747 ENPC\) and TNCC or ATCN or a DSHS-approved equivalent, within 18 months 748 of date of employment in the ED. 749 )>>endobj1324 0 obj<</Dest[58 0 R/XYZ 36 607 null]/Next 1323 0 R/Parent 999 0 R/Prev 1325 0 R/SE 616 0 R/Title( 742 )>>endobj1325 0 obj<</Dest[58 0 R/XYZ 36 676 null]/Next 1324 0 R/Parent 999 0 R/Prev 1326 0 R/SE 615 0 R/Title(\(F\) nursing documentation for trauma patients is systematic, meets the 737 trauma registry guidelines, and includes at a minimum: the sequence of care, 738 primary and secondary survey with interventions, outcomes, serial vital signs, 739 Glasgow Coma S\core \(GCS\), consulting services assessment, plan of care with 740 disposition and documents the response time of all trauma team members. 741 )>>endobj1326 0 obj<</Dest[58 0 R/XYZ 36 690 null]/Next 1325 0 R/Parent 999 0 R/Prev 1327 0 R/SE 614 0 R/Title( 736 )>>endobj1327 0 obj<</Dest[58 0 R/XYZ 36 717 null]/Next 1326 0 R/Parent 999 0 R/Prev 1328 0 R/SE 612 0 R/Title(\(ACLS\); a nationally recognized pediatric advanced life support course \( PALS or 734 ENPC\); and TNCC or ATCN; or an office approved equivalent for each course; 735 )>>endobj1328 0 obj<</Dest[56 0 R/XYZ 36 138 null]/Next 1327 0 R/Parent 999 0 R/Prev 1329 0 R/SE 611 0 R/Title(\(E\) a minimum of two registered nurses shall participate in initial 731 resuscitations for full and limited or trauma activations, have successfully 732 completed and hold current credentials in an advanced cardiac life support course 733 )>>endobj1329 0 obj<</Dest[56 0 R/XYZ 36 152 null]/Next 1328 0 R/Parent 999 0 R/Prev 1330 0 R/SE 610 0 R/Title( 730 )>>endobj1330 0 obj<</Dest[56 0 R/XYZ 36 193 null]/Next 1329 0 R/Parent 999 0 R/Prev 1331 0 R/SE 609 0 R/Title(\(D\) a written plan, developed by the hospital, for acquisition of 727 additional staff on a 24 hour basis to support units with increased patient acuity, 728 multiple emergency procedures and admissions \(i.e. written surge plan.\); 729 )>>endobj1331 0 obj<</Dest[56 0 R/XYZ 36 207 null]/Next 1330 0 R/Parent 999 0 R/Prev 1332 0 R/SE 608 0 R/Title( 726 )>>endobj1332 0 obj<</Dest[56 0 R/XYZ 36 248 null]/Next 1331 0 R/Parent 999 0 R/Prev 1333 0 R/SE 607 0 R/Title(\(C\) a facility approved acuity-based patient classification system is 723 utilized to define workload and number of nursing staff to provide safe patient 724 care for all trauma patients throughout their hospitalization; 725 )>>endobj1333 0 obj<</Dest[56 0 R/XYZ 36 262 null]/Next 1332 0 R/Parent 999 0 R/Prev 1334 0 R/SE 606 0 R/Title( 722 )>>endobj1334 0 obj<</Dest[56 0 R/XYZ 36 303 null]/Next 1333 0 R/Parent 999 0 R/Prev 1335 0 R/SE 604 0 R/Title(\(B\) written standards on nursing care for trauma patients for all units 719 \(i.e. ED, ICU, OR, PACU, general inpatient\) in the trauma facility shall be 720 implemented; 721 )>>endobj1335 0 obj<</Dest[56 0 R/XYZ 36 317 null]/Next 1334 0 R/Parent 999 0 R/Prev 1336 0 R/SE 603 0 R/Title( 718 )>>endobj1336 0 obj<</Dest[56 0 R/XYZ 36 372 null]/Next 1335 0 R/Parent 999 0 R/Prev 1337 0 R/SE 602 0 R/Title(\(A\) all nurses caring for trauma patients throughout the continuum of 714 care have ongoing documented knowledge and skills in trauma nursing for 715 patients of all ages to include trauma specific orientation, annual clinical 716 competencies, and cont\inuing education; 717 )>>endobj1337 0 obj<</Dest[56 0 R/XYZ 36 386 null]/Next 1336 0 R/Parent 999 0 R/Prev 1338 0 R/SE 601 0 R/Title( 713 )>>endobj1338 0 obj<</Count 2/Dest[56 0 R/XYZ 36 414 null]/First 1339 0 R/Last 1339 0 R/Next 1337 0 R/Parent 999 0 R/Prev 1340 0 R/SE 598 0 R/Title(\(10\) Nursing Services for all critical care and patient care areas shall provide 711 evidence of the following: 712 )>>endobj1339 0 obj<</Count 1/Dest[56 0 R/XYZ 36 414 null]/First 1833 0 R/Last 1833 0 R/Parent 1338 0 R/SE 599 0 R/Title(\(10\) Nursing Services for all critical care and patient care areas shall provide 711 evidence of the following: 712 )>>endobj1340 0 obj<</Dest[56 0 R/XYZ 36 428 null]/Next 1338 0 R/Parent 999 0 R/Prev 1341 0 R/SE 597 0 R/Title( 710 )>>endobj1341 0 obj<</Count 2/Dest[56 0 R/XYZ 36 511 null]/First 1342 0 R/Last 1342 0 R/Next 1340 0 R/Parent 999 0 R/Prev 1343 0 R/SE 594 0 R/Title(\(9\) Nursing Staff. As part of the facility•s trauma program approved by the 704 governing body, the program will have an identified Trauma Program 705 Manager with equivalent authority and responsibility as granted to other 706 department or nurse manag\ers. There shall be a demonstrated commitment by 707 the facility for furthering the education and understanding of trauma standards 708 of care for all nursing staff caring for the trauma patient. 709 )>>endobj1342 0 obj<</Count 1/Dest[56 0 R/XYZ 36 511 null]/First 1832 0 R/Last 1832 0 R/Parent 1341 0 R/SE 595 0 R/Title(\(9\) Nursing Staff. As part of the facility•s trauma program approved by the 704 governing body, the program will have an identified Trauma Program 705 Manager with equivalent authority and responsibility as granted to other 706 department or nurse manag\ers. There shall be a demonstrated commitment by 707 the facility for furthering the education and understanding of trauma standards 708 of care for all nursing staff caring for the trauma patient. 709 )>>endobj1343 0 obj<</Dest[56 0 R/XYZ 36 524 null]/Next 1341 0 R/Parent 999 0 R/Prev 1344 0 R/SE 593 0 R/Title( 703 )>>endobj1344 0 obj<</Count 2/Dest[56 0 R/XYZ 36 621 null]/First 1345 0 R/Last 1345 0 R/Next 1343 0 R/Parent 999 0 R/Prev 1346 0 R/SE 590 0 R/Title(\(8\) Advanced Practice clinicians \(advanced practice registered nurses or 696 physician assistants\) utilized in the care of major and/or severe trauma 697 patients, shall not be a substitute for the required physician response, in 698 patient care pla\nning nor in QAPI activities. Any Advanced Practice clinician 699 who provides care to trauma patients shall be current in ATLS and be 700 appropriately credentialed by the Texas Board of Nursing \(TBON\) or the 701 Texas Medical Board \(TMB\) respectivel\y. 702 )>>endobj1345 0 obj<</Count 1/Dest[56 0 R/XYZ 36 621 null]/First 1831 0 R/Last 1831 0 R/Parent 1344 0 R/SE 591 0 R/Title(\(8\) Advanced Practice clinicians \(advanced practice registered nurses or 696 physician assistants\) utilized in the care of major and/or severe trauma 697 patients, shall not be a substitute for the required physician response, in 698 patient care pla\nning nor in QAPI activities. Any Advanced Practice clinician 699 who provides care to trauma patients shall be current in ATLS and be 700 appropriately credentialed by the Texas Board of Nursing \(TBON\) or the 701 Texas Medical Board \(TMB\) respectivel\y. 702 )>>endobj1346 0 obj<</Dest[56 0 R/XYZ 36 635 null]/Next 1344 0 R/Parent 999 0 R/Prev 1347 0 R/SE 589 0 R/Title( 695 )>>endobj1347 0 obj<</Count 2/Dest[56 0 R/XYZ 36 704 null]/First 1348 0 R/Last 1348 0 R/Next 1346 0 R/Parent 999 0 R/Prev 1349 0 R/SE 586 0 R/Title(\(B\) The rate of change in interpretation of radiologic studies must be 690 routinely monitored and reviewed with the radiology department. 691 Identified cases should be reviewed to determine the reason for 692 misinterpretation, adverse outcomes, and \opportunities for 693 improvement. 694 )>>endobj1348 0 obj<</Count 1/Dest[56 0 R/XYZ 36 704 null]/First 1830 0 R/Last 1830 0 R/Parent 1347 0 R/SE 587 0 R/Title(\(B\) The rate of change in interpretation of radiologic studies must be 690 routinely monitored and reviewed with the radiology department. 691 Identified cases should be reviewed to determine the reason for 692 misinterpretation, adverse outcomes, and \opportunities for 693 improvement. 694 )>>endobj1349 0 obj<</Dest[56 0 R/XYZ 36 717 null]/Next 1347 0 R/Parent 999 0 R/Prev 1350 0 R/SE 584 0 R/Title( 689 )>>endobj1350 0 obj<</Count 2/Dest[54 0 R/XYZ 36 124 null]/First 1351 0 R/Last 1351 0 R/Next 1349 0 R/Parent 999 0 R/Prev 1352 0 R/SE 581 0 R/Title(\(A\) A radiologist shall be on-call and promptly available within 30 686 minutes of request from inside or outside the hospital. This system 687 shall be continuously monitored by the trauma PI program. 688 )>>endobj1351 0 obj<</Count 1/Dest[54 0 R/XYZ 36 124 null]/First 1829 0 R/Last 1829 0 R/Parent 1350 0 R/SE 582 0 R/Title(\(A\) A radiologist shall be on-call and promptly available within 30 686 minutes of request from inside or outside the hospital. This system 687 shall be continuously monitored by the trauma PI program. 688 )>>endobj1352 0 obj<</Dest[54 0 R/XYZ 36 138 null]/Next 1350 0 R/Parent 999 0 R/Prev 1353 0 R/SE 580 0 R/Title( 685 )>>endobj1353 0 obj<</Count 2/Dest[54 0 R/XYZ 36 152 null]/First 1354 0 R/Last 1354 0 R/Next 1352 0 R/Parent 999 0 R/Prev 1355 0 R/SE 577 0 R/Title(\(7\) Radiology Services. 684 )>>endobj1354 0 obj<</Count 1/Dest[54 0 R/XYZ 36 152 null]/First 1828 0 R/Last 1828 0 R/Parent 1353 0 R/SE 578 0 R/Title(\(7\) Radiology Services. 684 )>>endobj1355 0 obj<</Dest[54 0 R/XYZ 36 165 null]/Next 1353 0 R/Parent 999 0 R/Prev 1356 0 R/SE 576 0 R/Title( 683 )>>endobj1356 0 obj<</Dest[54 0 R/XYZ 36 193 null]/Next 1355 0 R/Parent 999 0 R/Prev 1357 0 R/SE 575 0 R/Title(\(G\) a designated liaison shall attend at least 50% of the trauma 681 multidisciplinary PI and peer review committee meetings. 682 )>>endobj1357 0 obj<</Dest[54 0 R/XYZ 36 207 null]/Next 1356 0 R/Parent 999 0 R/Prev 1358 0 R/SE 574 0 R/Title( 680 )>>endobj1358 0 obj<</Dest[54 0 R/XYZ 36 221 null]/Next 1357 0 R/Parent 999 0 R/Prev 1359 0 R/SE 573 0 R/Title(\(F\) participate in the trauma QAPI/Multidisciplinary PI program; and 679 )>>endobj1359 0 obj<</Dest[54 0 R/XYZ 36 234 null]/Next 1358 0 R/Parent 999 0 R/Prev 1360 0 R/SE 572 0 R/Title( 678 )>>endobj1360 0 obj<</Dest[54 0 R/XYZ 36 248 null]/Next 1359 0 R/Parent 999 0 R/Prev 1361 0 R/SE 571 0 R/Title(\(E\) maintain compliance with trauma protocols; 677 )>>endobj1361 0 obj<</Dest[54 0 R/XYZ 36 262 null]/Next 1360 0 R/Parent 999 0 R/Prev 1362 0 R/SE 570 0 R/Title( 676 )>>endobj1362 0 obj<</Dest[54 0 R/XYZ 36 276 null]/Next 1361 0 R/Parent 999 0 R/Prev 1363 0 R/SE 569 0 R/Title(\(D\) be appropriately credentialed through the trauma program; 675 )>>endobj1363 0 obj<</Dest[54 0 R/XYZ 36 290 null]/Next 1362 0 R/Parent 999 0 R/Prev 1364 0 R/SE 568 0 R/Title( 674 )>>endobj1364 0 obj<</Dest[54 0 R/XYZ 36 331 null]/Next 1363 0 R/Parent 999 0 R/Prev 1365 0 R/SE 567 0 R/Title(\(C\) prior to \(the effective date of this rule\) have continuously provided 671 anesthesia coverage at the designated facility for the last consecutive five years; 672 average at least 9 hours of continuing medical education annually; and 673 )>>endobj1365 0 obj<</Dest[54 0 R/XYZ 36 345 null]/Next 1364 0 R/Parent 999 0 R/Prev 1366 0 R/SE 566 0 R/Title( 670 )>>endobj1366 0 obj<</Dest[54 0 R/XYZ 36 372 null]/Next 1365 0 R/Parent 999 0 R/Prev 1367 0 R/SE 565 0 R/Title(\(B\) be a candidate in the American Board of Anesthesiology 668 examination system; or 669 )>>endobj1367 0 obj<</Dest[54 0 R/XYZ 36 386 null]/Next 1366 0 R/Parent 999 0 R/Prev 1368 0 R/SE 564 0 R/Title( 667 )>>endobj1368 0 obj<</Dest[54 0 R/XYZ 36 400 null]/Next 1367 0 R/Parent 999 0 R/Prev 1369 0 R/SE 563 0 R/Title(\(A\) be a board certified anesthesiologist; or 666 )>>endobj1369 0 obj<</Dest[54 0 R/XYZ 36 414 null]/Next 1368 0 R/Parent 999 0 R/Prev 1370 0 R/SE 562 0 R/Title( 665 )>>endobj1370 0 obj<</Count 2/Dest[54 0 R/XYZ 36 456 null]/First 1371 0 R/Last 1371 0 R/Next 1369 0 R/Parent 999 0 R/Prev 1372 0 R/SE 559 0 R/Title(\(6\) Anesthesia Services. If the facility furnishes anesthesia services, it shall do so 662 in compliance with 25 TAC 133.41 Hospital Functions and Services. The 663 anesthesiologist providing trauma coverage shall: 664 )>>endobj1371 0 obj<</Count 1/Dest[54 0 R/XYZ 36 456 null]/First 1827 0 R/Last 1827 0 R/Parent 1370 0 R/SE 560 0 R/Title(\(6\) Anesthesia Services. If the facility furnishes anesthesia services, it shall do so 662 in compliance with 25 TAC 133.41 Hospital Functions and Services. The 663 anesthesiologist providing trauma coverage shall: 664 )>>endobj1372 0 obj<</Dest[54 0 R/XYZ 36 469 null]/Next 1370 0 R/Parent 999 0 R/Prev 1373 0 R/SE 558 0 R/Title( 661 )>>endobj1373 0 obj<</Dest[54 0 R/XYZ 36 510 null]/Next 1372 0 R/Parent 999 0 R/Prev 1374 0 R/SE 557 0 R/Title(\(H\) participate in the trauma QAPI/Multidisciplinary PI program and a 658 designated liaison shall attend at least 50% of the trauma multidisciplinary PI and peer review 659 committee meetings. 660 )>>endobj1374 0 obj<</Dest[54 0 R/XYZ 36 524 null]/Next 1373 0 R/Parent 999 0 R/Prev 1375 0 R/SE 556 0 R/Title( 657 )>>endobj1375 0 obj<</Dest[54 0 R/XYZ 36 538 null]/Next 1374 0 R/Parent 999 0 R/Prev 1376 0 R/SE 555 0 R/Title(\(G\) maintain compliance with trauma protocols; and 656 )>>endobj1376 0 obj<</Dest[54 0 R/XYZ 36 552 null]/Next 1375 0 R/Parent 999 0 R/Prev 1377 0 R/SE 554 0 R/Title( 655 )>>endobj1377 0 obj<</Dest[54 0 R/XYZ 36 579 null]/Next 1376 0 R/Parent 999 0 R/Prev 1378 0 R/SE 553 0 R/Title(\(F\) average at least 9 hours of trauma-related continuing medical 653 education annually; 654 )>>endobj1378 0 obj<</Dest[54 0 R/XYZ 36 593 null]/Next 1377 0 R/Parent 999 0 R/Prev 1379 0 R/SE 552 0 R/Title( 652 )>>endobj1379 0 obj<</Dest[54 0 R/XYZ 36 607 null]/Next 1378 0 R/Parent 999 0 R/Prev 1380 0 R/SE 551 0 R/Title(\(E\) be appropriately credentialed through the trauma program; 651 )>>endobj1380 0 obj<</Dest[54 0 R/XYZ 36 621 null]/Next 1379 0 R/Parent 999 0 R/Prev 1381 0 R/SE 550 0 R/Title( 650 )>>endobj1381 0 obj<</Dest[54 0 R/XYZ 36 662 null]/Next 1380 0 R/Parent 999 0 R/Prev 1382 0 R/SE 549 0 R/Title(\(D\) be board eligible in their applicable specialty and currently 647 credentialed in Advanced Trauma Life Support \(ATLS\) or an equivalent course approved by the 648 office; and 649 )>>endobj1382 0 obj<</Dest[54 0 R/XYZ 36 676 null]/Next 1381 0 R/Parent 999 0 R/Prev 1383 0 R/SE 548 0 R/Title( 646 )>>endobj1383 0 obj<</Dest[54 0 R/XYZ 36 717 null]/Next 1382 0 R/Parent 999 0 R/Prev 1384 0 R/SE 546 0 R/Title(\(C\) prior to \(the effective date of this rule\) have continuously provided 643 trauma coverage in the emergency department at the designated facility for the last consecutive 644 five years and be currently credentialed in Advanced Trauma Life Support \\(ATLS\); or 645 )>>endobj1384 0 obj<</Dest[52 0 R/XYZ 36 96 null]/Next 1383 0 R/Parent 999 0 R/Prev 1385 0 R/SE 545 0 R/Title( 642 )>>endobj1385 0 obj<</Dest[52 0 R/XYZ 36 124 null]/Next 1384 0 R/Parent 999 0 R/Prev 1386 0 R/SE 544 0 R/Title(\(B\) be board eligible in emergency medicine and currently credentialed 640 in Advanced Trauma Life Support \(ATLS\) or an equivalent course approved by the office; or 641 )>>endobj1386 0 obj<</Dest[52 0 R/XYZ 36 138 null]/Next 1385 0 R/Parent 999 0 R/Prev 1387 0 R/SE 543 0 R/Title( 639 )>>endobj1387 0 obj<</Dest[52 0 R/XYZ 36 165 null]/Next 1386 0 R/Parent 999 0 R/Prev 1388 0 R/SE 542 0 R/Title(\(A\) be board certified in emergency medicine and have successfully 637 completed ATLS; or 638 )>>endobj1388 0 obj<</Dest[52 0 R/XYZ 36 179 null]/Next 1387 0 R/Parent 999 0 R/Prev 1389 0 R/SE 541 0 R/Title( 636 )>>endobj1389 0 obj<</Dest[52 0 R/XYZ 36 207 null]/Next 1388 0 R/Parent 999 0 R/Prev 1390 0 R/SE 540 0 R/Title(\(5\) Emergency Medicine. Any emergency medicine physician who is 634 providing trauma coverage shall be in-house 24 hours a day and shall: 635 )>>endobj1390 0 obj<</Dest[52 0 R/XYZ 36 221 null]/Next 1389 0 R/Parent 999 0 R/Prev 1391 0 R/SE 539 0 R/Title( 633 )>>endobj1391 0 obj<</Count 2/Dest[52 0 R/XYZ 36 276 null]/First 1392 0 R/Last 1392 0 R/Next 1390 0 R/Parent 999 0 R/Prev 1393 0 R/SE 536 0 R/Title(\(vii\) at a minimum, orthopedic surgeons and neurosurgeons, 629 participate in the published, on-call schedule and backup 630 on-call schedule or plan readily available to all staff to 631 obtain specialty surgical care. 632 )>>endobj1392 0 obj<</Count 1/Dest[52 0 R/XYZ 36 276 null]/First 1826 0 R/Last 1826 0 R/Parent 1391 0 R/SE 537 0 R/Title(\(vii\) at a minimum, orthopedic surgeons and neurosurgeons, 629 participate in the published, on-call schedule and backup 630 on-call schedule or plan readily available to all staff to 631 obtain specialty surgical care. 632 )>>endobj1393 0 obj<</Dest[52 0 R/XYZ 36 290 null]/Next 1391 0 R/Parent 999 0 R/Prev 1394 0 R/SE 535 0 R/Title( 628 )>>endobj1394 0 obj<</Count 2/Dest[52 0 R/XYZ 36 345 null]/First 1395 0 R/Last 1395 0 R/Next 1393 0 R/Parent 999 0 R/Prev 1396 0 R/SE 532 0 R/Title(\(vi\) participate in the trauma QAPI/Multidisciplinary PI 624 program and a designated liaison shall attend at least 50% 625 of the trauma multidisciplinary and peer review trauma 626 committee meetings; and 627 )>>endobj1395 0 obj<</Count 1/Dest[52 0 R/XYZ 36 345 null]/First 1825 0 R/Last 1825 0 R/Parent 1394 0 R/SE 533 0 R/Title(\(vi\) participate in the trauma QAPI/Multidisciplinary PI 624 program and a designated liaison shall attend at least 50% 625 of the trauma multidisciplinary and peer review trauma 626 committee meetings; and 627 )>>endobj1396 0 obj<</Dest[52 0 R/XYZ 36 359 null]/Next 1394 0 R/Parent 999 0 R/Prev 1397 0 R/SE 531 0 R/Title( 623 )>>endobj1397 0 obj<</Count 2/Dest[52 0 R/XYZ 36 373 null]/First 1398 0 R/Last 1398 0 R/Next 1396 0 R/Parent 999 0 R/Prev 1399 0 R/SE 528 0 R/Title(\(v\) maintain compliance with trauma protocols; 622 )>>endobj1398 0 obj<</Count 1/Dest[52 0 R/XYZ 36 373 null]/First 1824 0 R/Last 1824 0 R/Parent 1397 0 R/SE 529 0 R/Title(\(v\) maintain compliance with trauma protocols; 622 )>>endobj1399 0 obj<</Dest[52 0 R/XYZ 36 386 null]/Next 1397 0 R/Parent 999 0 R/Prev 1400 0 R/SE 527 0 R/Title( 621 )>>endobj1400 0 obj<</Count 2/Dest[52 0 R/XYZ 36 414 null]/First 1401 0 R/Last 1401 0 R/Next 1399 0 R/Parent 999 0 R/Prev 1402 0 R/SE 524 0 R/Title(\(iv\) average at least 9 hours of trauma-related continuing 619 medical education annually; 620 )>>endobj1401 0 obj<</Count 1/Dest[52 0 R/XYZ 36 414 null]/First 1823 0 R/Last 1823 0 R/Parent 1400 0 R/SE 525 0 R/Title(\(iv\) average at least 9 hours of trauma-related continuing 619 medical education annually; 620 )>>endobj1402 0 obj<</Dest[52 0 R/XYZ 36 428 null]/Next 1400 0 R/Parent 999 0 R/Prev 1403 0 R/SE 523 0 R/Title( 618 )>>endobj1403 0 obj<</Count 2/Dest[52 0 R/XYZ 36 442 null]/First 1404 0 R/Last 1404 0 R/Next 1402 0 R/Parent 999 0 R/Prev 1405 0 R/SE 520 0 R/Title(\(iii\) be appropriately credentialed through the trauma service; 617 )>>endobj1404 0 obj<</Count 1/Dest[52 0 R/XYZ 36 442 null]/First 1822 0 R/Last 1822 0 R/Parent 1403 0 R/SE 521 0 R/Title(\(iii\) be appropriately credentialed through the trauma service; 617 )>>endobj1405 0 obj<</Dest[52 0 R/XYZ 36 455 null]/Next 1403 0 R/Parent 999 0 R/Prev 1406 0 R/SE 519 0 R/Title( 616 )>>endobj1406 0 obj<</Dest[52 0 R/XYZ 36 497 null]/Next 1405 0 R/Parent 999 0 R/Prev 1407 0 R/SE 518 0 R/Title(\(ii\) prior to \(the effective date of this rule\) have continuously 613 provided trauma coverage and participated in trauma call at the 614 designated facility for the last consecutive five years; and 615 )>>endobj1407 0 obj<</Dest[52 0 R/XYZ 36 510 null]/Next 1406 0 R/Parent 999 0 R/Prev 1408 0 R/SE 517 0 R/Title( 612 )>>endobj1408 0 obj<</Count 2/Dest[52 0 R/XYZ 36 538 null]/First 1409 0 R/Last 1409 0 R/Next 1407 0 R/Parent 999 0 R/Prev 1410 0 R/SE 514 0 R/Title(\(i\) be board certified or board eligible in the applicable 610 surgical specialty; or 611 )>>endobj1409 0 obj<</Count 1/Dest[52 0 R/XYZ 36 538 null]/First 1821 0 R/Last 1821 0 R/Parent 1408 0 R/SE 515 0 R/Title(\(i\) be board certified or board eligible in the applicable 610 surgical specialty; or 611 )>>endobj1410 0 obj<</Dest[52 0 R/XYZ 36 552 null]/Next 1408 0 R/Parent 999 0 R/Prev 1411 0 R/SE 513 0 R/Title( 609 )>>endobj1411 0 obj<</Count 2/Dest[52 0 R/XYZ 36 566 null]/First 1412 0 R/Last 1412 0 R/Next 1410 0 R/Parent 999 0 R/Prev 1413 0 R/SE 510 0 R/Title(\(A\) Orthopedic and Neurosurgery surgeons shall: 608 )>>endobj1412 0 obj<</Count 1/Dest[52 0 R/XYZ 36 566 null]/First 1820 0 R/Last 1820 0 R/Parent 1411 0 R/SE 511 0 R/Title(\(A\) Orthopedic and Neurosurgery surgeons shall: 608 )>>endobj1413 0 obj<</Dest[52 0 R/XYZ 36 579 null]/Next 1411 0 R/Parent 999 0 R/Prev 1414 0 R/SE 509 0 R/Title( 607 )>>endobj1414 0 obj<</Dest[52 0 R/XYZ 36 593 null]/Next 1413 0 R/Parent 999 0 R/Prev 1415 0 R/SE 508 0 R/Title(\(4\) Trauma Surgical Specialties. 606 )>>endobj1415 0 obj<</Dest[52 0 R/XYZ 36 607 null]/Next 1414 0 R/Parent 999 0 R/Prev 1416 0 R/SE 507 0 R/Title( 605 )>>endobj1416 0 obj<</Dest[52 0 R/XYZ 36 635 null]/Next 1415 0 R/Parent 999 0 R/Prev 1417 0 R/SE 506 0 R/Title(\(3\) In addition to continuous general surgery coverage the facility shall have 603 continuous orthopedic surgical coverage. 604 )>>endobj1417 0 obj<</Dest[52 0 R/XYZ 36 648 null]/Next 1416 0 R/Parent 999 0 R/Prev 1418 0 R/SE 505 0 R/Title( 602 )>>endobj1418 0 obj<</Dest[52 0 R/XYZ 36 717 null]/Next 1417 0 R/Parent 999 0 R/Prev 1419 0 R/SE 503 0 R/Title(\(C\) If the facility has a surgical residency program and a team of 597 surgical residents start the evaluation and treatment of the trauma patient, the 598 attending surgeon shall participate in all major therapeutic decisions, be present in 599 the eme\rgency department for major resuscitations, and be present during all 600 phases of operative procedures. 601 )>>endobj1419 0 obj<</Dest[50 0 R/XYZ 36 96 null]/Next 1418 0 R/Parent 999 0 R/Prev 1420 0 R/SE 502 0 R/Title( 596 )>>endobj1420 0 obj<</Dest[50 0 R/XYZ 36 179 null]/Next 1419 0 R/Parent 999 0 R/Prev 1421 0 R/SE 501 0 R/Title(\(B\) If a facility has a surgical residency program, and a team of 590 surgical residents start the evaluation and treatment of the trauma patient, the 591 team shall have, at a minimum, a postgraduate year 4 \(PGY-4\) or more senior 592 surgical residen\t who is a member of the facility•s residency program. The 593 presence of a surgical resident does not take the place of the attending physician. 594 The attending physician must be compliant with all response times. 595 )>>endobj1421 0 obj<</Dest[50 0 R/XYZ 36 193 null]/Next 1420 0 R/Parent 999 0 R/Prev 1422 0 R/SE 500 0 R/Title( 589 )>>endobj1422 0 obj<</Dest[50 0 R/XYZ 36 221 null]/Next 1421 0 R/Parent 999 0 R/Prev 1423 0 R/SE 499 0 R/Title(\(x\) be the admitting physician on all multi-system trauma 587 patients requiring the consultation of one or more specialty services; 588 )>>endobj1423 0 obj<</Dest[50 0 R/XYZ 36 234 null]/Next 1422 0 R/Parent 999 0 R/Prev 1424 0 R/SE 498 0 R/Title( 586 )>>endobj1424 0 obj<</Dest[50 0 R/XYZ 36 262 null]/Next 1423 0 R/Parent 999 0 R/Prev 1425 0 R/SE 497 0 R/Title(\(ix\) be present in the ED within 60 minutes or less when called 584 for a limited trauma team activation; and 585 )>>endobj1425 0 obj<</Dest[50 0 R/XYZ 36 276 null]/Next 1424 0 R/Parent 999 0 R/Prev 1426 0 R/SE 496 0 R/Title( 583 )>>endobj1426 0 obj<</Dest[50 0 R/XYZ 36 317 null]/Next 1425 0 R/Parent 999 0 R/Prev 1427 0 R/SE 495 0 R/Title(\(viii\) be present in the ED at the time of arrival for a full trauma 580 team activation of a trauma patient; maximum response time 30 minutes 581 from trauma team activation; 582 )>>endobj1427 0 obj<</Dest[50 0 R/XYZ 36 331 null]/Next 1426 0 R/Parent 999 0 R/Prev 1428 0 R/SE 494 0 R/Title( 579 )>>endobj1428 0 obj<</Dest[50 0 R/XYZ 36 372 null]/Next 1427 0 R/Parent 999 0 R/Prev 1429 0 R/SE 493 0 R/Title(\(vii\) participate in the trauma QAPI program and attend at least 576 50% of the trauma multidisciplinary and peer review trauma committee 577 meetings; 578 )>>endobj1429 0 obj<</Dest[50 0 R/XYZ 36 386 null]/Next 1428 0 R/Parent 999 0 R/Prev 1430 0 R/SE 492 0 R/Title( 575 )>>endobj1430 0 obj<</Dest[50 0 R/XYZ 36 400 null]/Next 1429 0 R/Parent 999 0 R/Prev 1431 0 R/SE 491 0 R/Title(\(vi\) maintain compliance with trauma protocols; 574 )>>endobj1431 0 obj<</Dest[50 0 R/XYZ 36 414 null]/Next 1430 0 R/Parent 999 0 R/Prev 1432 0 R/SE 490 0 R/Title( 573 )>>endobj1432 0 obj<</Dest[50 0 R/XYZ 36 441 null]/Next 1431 0 R/Parent 999 0 R/Prev 1433 0 R/SE 489 0 R/Title(\(v\) average at least 9 hours of trauma-related continuing 571 medical education annually; 572 )>>endobj1433 0 obj<</Dest[50 0 R/XYZ 36 455 null]/Next 1432 0 R/Parent 999 0 R/Prev 1434 0 R/SE 488 0 R/Title( 570 )>>endobj1434 0 obj<</Dest[50 0 R/XYZ 36 469 null]/Next 1433 0 R/Parent 999 0 R/Prev 1435 0 R/SE 487 0 R/Title(\(iv\) be appropriately credentialed through the trauma program; 569 )>>endobj1435 0 obj<</Dest[50 0 R/XYZ 36 483 null]/Next 1434 0 R/Parent 999 0 R/Prev 1436 0 R/SE 486 0 R/Title( 568 )>>endobj1436 0 obj<</Dest[50 0 R/XYZ 36 538 null]/Next 1435 0 R/Parent 999 0 R/Prev 1437 0 R/SE 485 0 R/Title( \(iii\) prior to \(the effective date of this rule\) have continuously 564 provided trauma coverage and participated in trauma call at the designated facility for the 565 last consecutive five years and be currently credentialed in Advanced Trauma Life \566 Support \(ATLS\); and 567 )>>endobj1437 0 obj<</Dest[50 0 R/XYZ 36 552 null]/Next 1436 0 R/Parent 999 0 R/Prev 1438 0 R/SE 484 0 R/Title( 563 )>>endobj1438 0 obj<</Dest[50 0 R/XYZ 36 593 null]/Next 1437 0 R/Parent 999 0 R/Prev 1439 0 R/SE 483 0 R/Title(\(ii\) be board eligible in general surgery and currently 560 credentialed in Advanced Trauma Life Support \(ATLS\) or an equivalent 561 course approved by the office; or 562 )>>endobj1439 0 obj<</Dest[50 0 R/XYZ 36 607 null]/Next 1438 0 R/Parent 999 0 R/Prev 1440 0 R/SE 482 0 R/Title( 559 )>>endobj1440 0 obj<</Dest[50 0 R/XYZ 36 635 null]/Next 1439 0 R/Parent 999 0 R/Prev 1441 0 R/SE 481 0 R/Title(\(i\) be board certified in general surgery and successfully 557 completed ATLS; or 558 )>>endobj1441 0 obj<</Dest[50 0 R/XYZ 36 648 null]/Next 1440 0 R/Parent 999 0 R/Prev 1442 0 R/SE 480 0 R/Title( 556 )>>endobj1442 0 obj<</Dest[50 0 R/XYZ 36 676 null]/Next 1441 0 R/Parent 999 0 R/Prev 1443 0 R/SE 479 0 R/Title(\(A\) All surgeons who provide trauma coverage or participates in 554 trauma call coverage shall: 555 )>>endobj1443 0 obj<</Dest[50 0 R/XYZ 36 690 null]/Next 1442 0 R/Parent 999 0 R/Prev 1444 0 R/SE 478 0 R/Title( 553 )>>endobj1444 0 obj<</Count 2/Dest[50 0 R/XYZ 36 704 null]/First 1445 0 R/Last 1445 0 R/Next 1443 0 R/Parent 999 0 R/Prev 1446 0 R/SE 475 0 R/Title(\(2\) General Surgery. 552 )>>endobj1445 0 obj<</Count 1/Dest[50 0 R/XYZ 36 704 null]/First 1819 0 R/Last 1819 0 R/Parent 1444 0 R/SE 476 0 R/Title(\(2\) General Surgery. 552 )>>endobj1446 0 obj<</Dest[50 0 R/XYZ 36 717 null]/Next 1444 0 R/Parent 999 0 R/Prev 1447 0 R/SE 473 0 R/Title( 551 )>>endobj1447 0 obj<</Count 2/Dest[48 0 R/XYZ 36 138 null]/First 1448 0 R/Last 1448 0 R/Next 1446 0 R/Parent 999 0 R/Prev 1449 0 R/SE 470 0 R/Title(\(B\) a general surgeon who has continuously served as the Trauma Medical 547 Director at the designated facility for the last consecutive five years 548 and is currently credentialed in Advanced Trauma Life Support 549 \(ATLS\). 550 )>>endobj1448 0 obj<</Count 1/Dest[48 0 R/XYZ 36 138 null]/First 1818 0 R/Last 1818 0 R/Parent 1447 0 R/SE 471 0 R/Title(\(B\) a general surgeon who has continuously served as the Trauma Medical 547 Director at the designated facility for the last consecutive five years 548 and is currently credentialed in Advanced Trauma Life Support 549 \(ATLS\). 550 )>>endobj1449 0 obj<</Dest[48 0 R/XYZ 36 152 null]/Next 1447 0 R/Parent 999 0 R/Prev 1450 0 R/SE 469 0 R/Title( 546 )>>endobj1450 0 obj<</Dest[48 0 R/XYZ 36 193 null]/Next 1449 0 R/Parent 999 0 R/Prev 1451 0 R/SE 468 0 R/Title(\(A\) a board certified general surgeon or a general surgeon eligible for 543 certification by the American Board of Surgery according to current requirements 544 or an equivalent course approved by the office; or 545 )>>endobj1451 0 obj<</Dest[48 0 R/XYZ 36 207 null]/Next 1450 0 R/Parent 999 0 R/Prev 1452 0 R/SE 467 0 R/Title( 542 )>>endobj1452 0 obj<</Count 2/Dest[48 0 R/XYZ 36 221 null]/First 1453 0 R/Last 1453 0 R/Next 1451 0 R/Parent 999 0 R/Prev 1454 0 R/SE 464 0 R/Title(\(1\) The Trauma Medical Director shall be a physician who is: 541 )>>endobj1453 0 obj<</Count 1/Dest[48 0 R/XYZ 36 221 null]/First 1817 0 R/Last 1817 0 R/Parent 1452 0 R/SE 465 0 R/Title(\(1\) The Trauma Medical Director shall be a physician who is: 541 )>>endobj1454 0 obj<</Dest[48 0 R/XYZ 36 234 null]/Next 1452 0 R/Parent 999 0 R/Prev 1455 0 R/SE 463 0 R/Title( 540 )>>endobj1455 0 obj<</Dest[48 0 R/XYZ 36 262 null]/Next 1454 0 R/Parent 999 0 R/Prev 1456 0 R/SE 462 0 R/Title(\(m\) Trauma Designation Level III \(Advanced\). The Level III trauma designated 538 facility will meet the following requirements: 539 )>>endobj1456 0 obj<</Dest[48 0 R/XYZ 36 276 null]/Next 1455 0 R/Parent 999 0 R/Prev 1457 0 R/SE 461 0 R/Title( 537 )>>endobj1457 0 obj<</Dest[48 0 R/XYZ 36 303 null]/Next 1456 0 R/Parent 999 0 R/Prev 1458 0 R/SE 460 0 R/Title(\(l\) Trauma Designation Level II \(Major\). The facility shall meet the current ACS 535 essential criteria for a verified Level II trauma center. 536 )>>endobj1458 0 obj<</Dest[48 0 R/XYZ 36 317 null]/Next 1457 0 R/Parent 999 0 R/Prev 1459 0 R/SE 459 0 R/Title( 534 )>>endobj1459 0 obj<</Dest[48 0 R/XYZ 36 345 null]/Next 1458 0 R/Parent 999 0 R/Prev 1460 0 R/SE 458 0 R/Title( \(k\) Trauma Designation Level I \(Comprehensive\). The facility shall meet the current 532 American College of Surgeons \(ACS\) essential criteria for a verified Level I trauma center. 533 )>>endobj1460 0 obj<</Dest[48 0 R/XYZ 36 359 null]/Next 1459 0 R/Parent 999 0 R/Prev 1461 0 R/SE 457 0 R/Title( 531 )>>endobj1461 0 obj<</Count 2/Dest[48 0 R/XYZ 36 400 null]/First 1462 0 R/Last 1462 0 R/Next 1460 0 R/Parent 999 0 R/Prev 1463 0 R/SE 454 0 R/Title(\(viii\) participates in a leadership role in the facility including the 528 facility-wide QAPI Committee, community, and regional 529 emergency management \(disaster\) response committee; and 530 )>>endobj1462 0 obj<</Count 1/Dest[48 0 R/XYZ 36 400 null]/First 1816 0 R/Last 1816 0 R/Parent 1461 0 R/SE 455 0 R/Title(\(viii\) participates in a leadership role in the facility including the 528 facility-wide QAPI Committee, community, and regional 529 emergency management \(disaster\) response committee; and 530 )>>endobj1463 0 obj<</Dest[48 0 R/XYZ 36 414 null]/Next 1461 0 R/Parent 999 0 R/Prev 1464 0 R/SE 453 0 R/Title( 527 )>>endobj1464 0 obj<</Count 2/Dest[48 0 R/XYZ 36 483 null]/First 1465 0 R/Last 1465 0 R/Next 1463 0 R/Parent 999 0 R/Prev 1466 0 R/SE 450 0 R/Title(\(II\) monitor trauma patient care from ED 522 arrival through operative intervention\(s\), 523 ICU care, stabilization, rehabilitation care, 524 and discharge, including the trauma 525 performance improvement \(PI\) program; 526 )>>endobj1465 0 obj<</Count 1/Dest[48 0 R/XYZ 36 483 null]/First 1815 0 R/Last 1815 0 R/Parent 1464 0 R/SE 451 0 R/Title(\(II\) monitor trauma patient care from ED 522 arrival through operative intervention\(s\), 523 ICU care, stabilization, rehabilitation care, 524 and discharge, including the trauma 525 performance improvement \(PI\) program; 526 )>>endobj1466 0 obj<</Dest[48 0 R/XYZ 36 497 null]/Next 1464 0 R/Parent 999 0 R/Prev 1467 0 R/SE 449 0 R/Title( 521 )>>endobj1467 0 obj<</Count 2/Dest[48 0 R/XYZ 36 525 null]/First 1468 0 R/Last 1468 0 R/Next 1466 0 R/Parent 999 0 R/Prev 1469 0 R/SE 446 0 R/Title(\(I\) monitor the clinical outcomes, direction 519 and oversight of the trauma program. 520 )>>endobj1468 0 obj<</Count 1/Dest[48 0 R/XYZ 36 525 null]/First 1814 0 R/Last 1814 0 R/Parent 1467 0 R/SE 447 0 R/Title(\(I\) monitor the clinical outcomes, direction 519 and oversight of the trauma program. 520 )>>endobj1469 0 obj<</Dest[48 0 R/XYZ 36 538 null]/Next 1467 0 R/Parent 999 0 R/Prev 1470 0 R/SE 445 0 R/Title( 518 )>>endobj1470 0 obj<</Count 2/Dest[48 0 R/XYZ 36 552 null]/First 1471 0 R/Last 1471 0 R/Next 1469 0 R/Parent 999 0 R/Prev 1472 0 R/SE 442 0 R/Title(\(vii\) has the responsibility and authority to: 517 )>>endobj1471 0 obj<</Count 1/Dest[48 0 R/XYZ 36 552 null]/First 1813 0 R/Last 1813 0 R/Parent 1470 0 R/SE 443 0 R/Title(\(vii\) has the responsibility and authority to: 517 )>>endobj1472 0 obj<</Dest[48 0 R/XYZ 36 566 null]/Next 1470 0 R/Parent 999 0 R/Prev 1473 0 R/SE 441 0 R/Title( 516 )>>endobj1473 0 obj<</Count 2/Dest[48 0 R/XYZ 36 594 null]/First 1474 0 R/Last 1474 0 R/Next 1472 0 R/Parent 999 0 R/Prev 1475 0 R/SE 438 0 R/Title(\(vi\) is responsible for the integration of trauma nursing 514 standards of care; 515 )>>endobj1474 0 obj<</Count 1/Dest[48 0 R/XYZ 36 594 null]/First 1812 0 R/Last 1812 0 R/Parent 1473 0 R/SE 439 0 R/Title(\(vi\) is responsible for the integration of trauma nursing 514 standards of care; 515 )>>endobj1475 0 obj<</Dest[48 0 R/XYZ 36 607 null]/Next 1473 0 R/Parent 999 0 R/Prev 1476 0 R/SE 437 0 R/Title( 513 )>>endobj1476 0 obj<</Count 2/Dest[48 0 R/XYZ 36 677 null]/First 1477 0 R/Last 1477 0 R/Next 1475 0 R/Parent 999 0 R/Prev 1478 0 R/SE 434 0 R/Title(\(v\) has completed a course designed for his/her role which 508 provides essential information of a trauma PI program to 509 include trauma outcomes and performance improvement 510 \(e.g. Trauma Outcomes Performance Improvement Course 511 \(TOPIC\) or an\ office approved equivalent course\); 512 )>>endobj1477 0 obj<</Count 1/Dest[48 0 R/XYZ 36 677 null]/First 1811 0 R/Last 1811 0 R/Parent 1476 0 R/SE 435 0 R/Title(\(v\) has completed a course designed for his/her role which 508 provides essential information of a trauma PI program to 509 include trauma outcomes and performance improvement 510 \(e.g. Trauma Outcomes Performance Improvement Course 511 \(TOPIC\) or an\ office approved equivalent course\); 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500 )>>endobj1485 0 obj<</Count 1/Dest[46 0 R/XYZ 36 207 null]/First 1808 0 R/Last 1808 0 R/Parent 1484 0 R/SE 423 0 R/Title(\(iii\) is current in a nationally recognized pediatric advanced life 497 support course \(\(e.g. Pediatric Advanced Life Support 498 \(PALS\) or the Emergency Nurse Pediatric Course 499 \(ENPC\)\); 500 )>>endobj1486 0 obj<</Dest[46 0 R/XYZ 36 221 null]/Next 1484 0 R/Parent 999 0 R/Prev 1487 0 R/SE 421 0 R/Title( 496 )>>endobj1487 0 obj<</Count 2/Dest[46 0 R/XYZ 36 262 null]/First 1488 0 R/Last 1488 0 R/Next 1486 0 R/Parent 999 0 R/Prev 1489 0 R/SE 418 0 R/Title(\(ii\) is current in the Trauma Nurse Core Course \(TNCC\) or 493 Advanced Trauma Course for Nurses \(ATCN\) or a DSHS-494 approved equivalent; 495 )>>endobj1488 0 obj<</Count 1/Dest[46 0 R/XYZ 36 262 null]/First 1807 0 R/Last 1807 0 R/Parent 1487 0 R/SE 419 0 R/Title(\(ii\) is current in the Trauma Nurse Core Course \(TNCC\) or 493 Advanced Trauma Course for Nurses \(ATCN\) or a DSHS-494 approved equivalent; 495 )>>endobj1489 0 obj<</Dest[46 0 R/XYZ 36 276 null]/Next 1487 0 R/Parent 999 0 R/Prev 1490 0 R/SE 417 0 R/Title( 492 )>>endobj1490 0 obj<</Count 4/Dest[46 0 R/XYZ 36 304 null]/First 1491 0 R/Last 1492 0 R/Next 1489 0 R/Parent 999 0 R/Prev 1493 0 R/SE 412 0 R/Title(\(A\) The TPM: 490 )>>endobj1491 0 obj<</Count 1/Dest[46 0 R/XYZ 36 304 null]/First 1806 0 R/Last 1806 0 R/Next 1492 0 R/Parent 1490 0 R/SE 413 0 R/Title(\(A\) The TPM: 490 )>>endobj1492 0 obj<</Count 1/Dest[46 0 R/XYZ 36 290 null]/First 1805 0 R/Last 1805 0 R/Parent 1490 0 R/Prev 1491 0 R/SE 415 0 R/Title(\(i\) shall be a registered nurse; 491 )>>endobj1493 0 obj<</Dest[46 0 R/XYZ 36 317 null]/Next 1490 0 R/Parent 999 0 R/Prev 1494 0 R/SE 411 0 R/Title( 489 )>>endobj1494 0 obj<</Dest[46 0 R/XYZ 36 359 null]/Next 1493 0 R/Parent 999 0 R/Prev 1495 0 R/SE 410 0 R/Title( \(8\) Trauma Program Manager \(TPM\). There shall be an identified Trauma 486 Program Manager responsible for monitoring trauma patient care throughout the continuum of 487 care and through discharge. 488 )>>endobj1495 0 obj<</Dest[46 0 R/XYZ 36 372 null]/Next 1494 0 R/Parent 999 0 R/Prev 1496 0 R/SE 409 0 R/Title( 485 )>>endobj1496 0 obj<</Dest[46 0 R/XYZ 36 400 null]/Next 1495 0 R/Parent 999 0 R/Prev 1497 0 R/SE 408 0 R/Title(\(XIV\) maintains active staff privileges as defined in the 483 facility•s medical staff bylaws; 484 )>>endobj1497 0 obj<</Dest[46 0 R/XYZ 36 414 null]/Next 1496 0 R/Parent 999 0 R/Prev 1498 0 R/SE 407 0 R/Title( 482 )>>endobj1498 0 obj<</Dest[46 0 R/XYZ 36 441 null]/Next 1497 0 R/Parent 999 0 R/Prev 1499 0 R/SE 406 0 R/Title( \(XIII\) averaging 9 hours of continuing trauma medical 480 education \(CME\) annually; 481 )>>endobj1499 0 obj<</Dest[46 0 R/XYZ 36 455 null]/Next 1498 0 R/Parent 999 0 R/Prev 1500 0 R/SE 405 0 R/Title( 479 )>>endobj1500 0 obj<</Dest[46 0 R/XYZ 36 483 null]/Next 1499 0 R/Parent 999 0 R/Prev 1501 0 R/SE 404 0 R/Title(\(XII\) evidence that the TMD is aware of the 477 multidisciplinary team findings on all trauma patients; 478 )>>endobj1501 0 obj<</Dest[46 0 R/XYZ 36 497 null]/Next 1500 0 R/Parent 999 0 R/Prev 1502 0 R/SE 403 0 R/Title( 476 )>>endobj1502 0 obj<</Dest[46 0 R/XYZ 36 524 null]/Next 1501 0 R/Parent 999 0 R/Prev 1503 0 R/SE 402 0 R/Title(\(XI\) participates in the facility, community, and regional 474 disaster preparedness activities. 475 )>>endobj1503 0 obj<</Dest[46 0 R/XYZ 36 538 null]/Next 1502 0 R/Parent 999 0 R/Prev 1504 0 R/SE 401 0 R/Title( 473 )>>endobj1504 0 obj<</Dest[46 0 R/XYZ 36 566 null]/Next 1503 0 R/Parent 999 0 R/Prev 1505 0 R/SE 400 0 R/Title(\(VIX\) participation in the applicable RAC\(s\) and 471 reviewing the RAC\(s\) trauma system plan; 472 )>>endobj1505 0 obj<</Dest[46 0 R/XYZ 36 579 null]/Next 1504 0 R/Parent 999 0 R/Prev 1506 0 R/SE 399 0 R/Title( 470 )>>endobj1506 0 obj<</Dest[46 0 R/XYZ 36 621 null]/Next 1505 0 R/Parent 999 0 R/Prev 1507 0 R/SE 398 0 R/Title(\(VIII\) ensuring that the trauma QAPI/Multidisciplinary PI 467 and peer review meeting is specific to trauma care, is ongoing, is data driven and effective; TMD 468 serves as chair of trauma QAPI committee meetings; 469 )>>endobj1507 0 obj<</Dest[46 0 R/XYZ 36 635 null]/Next 1506 0 R/Parent 999 0 R/Prev 1508 0 R/SE 397 0 R/Title( 466 )>>endobj1508 0 obj<</Dest[46 0 R/XYZ 36 662 null]/Next 1507 0 R/Parent 999 0 R/Prev 1509 0 R/SE 396 0 R/Title(\(VII\) participating in the ongoing education of the 464 medical and nursing staff in the care of the trauma patient; 465 )>>endobj1509 0 obj<</Dest[46 0 R/XYZ 36 676 null]/Next 1508 0 R/Parent 999 0 R/Prev 1510 0 R/SE 395 0 R/Title( 463 )>>endobj1510 0 obj<</Dest[46 0 R/XYZ 36 704 null]/Next 1509 0 R/Parent 999 0 R/Prev 1511 0 R/SE 394 0 R/Title(\(VI\) developing and providing ongoing maintenance of 461 treatment protocols based on current standards of trauma care; 462 )>>endobj1511 0 obj<</Dest[46 0 R/XYZ 36 717 null]/Next 1510 0 R/Parent 999 0 R/Prev 1512 0 R/SE 392 0 R/Title( 460 )>>endobj1512 0 obj<</Dest[44 0 R/XYZ 36 138 null]/Next 1511 0 R/Parent 999 0 R/Prev 1513 0 R/SE 391 0 R/Title(\(V\) ensuring the use of medical staff peer review 456 outcomes, including deviations from trauma standards of care trending, when considering re457 credentialing members of the trauma team. All follow-up and feedback from peer review activity 458 must \be made available to the reviewers at the time of the onsite survey; 459 )>>endobj1513 0 obj<</Dest[44 0 R/XYZ 36 152 null]/Next 1512 0 R/Parent 999 0 R/Prev 1514 0 R/SE 390 0 R/Title( 455 )>>endobj1514 0 obj<</Dest[44 0 R/XYZ 36 179 null]/Next 1513 0 R/Parent 999 0 R/Prev 1515 0 R/SE 389 0 R/Title(\(IV\) the authority to exclude those trauma team members 453 from trauma call who do not maintain trauma program requirements; 454 )>>endobj1515 0 obj<</Dest[44 0 R/XYZ 36 193 null]/Next 1514 0 R/Parent 999 0 R/Prev 1516 0 R/SE 388 0 R/Title( 452 )>>endobj1516 0 obj<</Dest[44 0 R/XYZ 36 221 null]/Next 1515 0 R/Parent 999 0 R/Prev 1517 0 R/SE 387 0 R/Title(\(III\) regularly and actively participating in or on the 450 trauma call panel; 451 )>>endobj1517 0 obj<</Dest[44 0 R/XYZ 36 234 null]/Next 1516 0 R/Parent 999 0 R/Prev 1518 0 R/SE 386 0 R/Title( 449 )>>endobj1518 0 obj<</Dest[44 0 R/XYZ 36 276 null]/Next 1517 0 R/Parent 999 0 R/Prev 1519 0 R/SE 385 0 R/Title(\(II\) ensuring that a published, on-call schedule and a 446 backup on-call schedule is readily available to all staff in the emergency department, for 447 obtaining surgical care for all surgical specialties; 448 )>>endobj1519 0 obj<</Dest[44 0 R/XYZ 36 290 null]/Next 1518 0 R/Parent 999 0 R/Prev 1520 0 R/SE 384 0 R/Title( 445 )>>endobj1520 0 obj<</Dest[44 0 R/XYZ 36 331 null]/Next 1519 0 R/Parent 999 0 R/Prev 1521 0 R/SE 383 0 R/Title(\(I\) reviewing credentials of medical staff requesting 442 privileges on the trauma team and making recommendations to the MEC for either approval or 443 denial of such privileges; 444 )>>endobj1521 0 obj<</Dest[44 0 R/XYZ 36 345 null]/Next 1520 0 R/Parent 999 0 R/Prev 1522 0 R/SE 382 0 R/Title( 441 )>>endobj1522 0 obj<</Dest[44 0 R/XYZ 36 372 null]/Next 1521 0 R/Parent 999 0 R/Prev 1523 0 R/SE 381 0 R/Title(\(iii\) The responsibilities and authority of the TMD shall include 439 but are not limited to: 440 )>>endobj1523 0 obj<</Dest[44 0 R/XYZ 36 386 null]/Next 1522 0 R/Parent 999 0 R/Prev 1524 0 R/SE 380 0 R/Title( 438 )>>endobj1524 0 obj<</Dest[44 0 R/XYZ 36 414 null]/Next 1523 0 R/Parent 999 0 R/Prev 1525 0 R/SE 379 0 R/Title(\(ii\) The TMD shall have responsibility for the overall clinical 436 direction and oversight of the trauma service; 437 )>>endobj1525 0 obj<</Dest[44 0 R/XYZ 36 428 null]/Next 1524 0 R/Parent 999 0 R/Prev 1526 0 R/SE 378 0 R/Title( 435 )>>endobj1526 0 obj<</Dest[44 0 R/XYZ 36 455 null]/Next 1525 0 R/Parent 999 0 R/Prev 1527 0 R/SE 377 0 R/Title(\(i\) The TMD shall be a member of the Medical Executive 433 Committee \(MEC\); 434 )>>endobj1527 0 obj<</Dest[44 0 R/XYZ 36 469 null]/Next 1526 0 R/Parent 999 0 R/Prev 1528 0 R/SE 376 0 R/Title( 432 )>>endobj1528 0 obj<</Dest[44 0 R/XYZ 36 510 null]/Next 1527 0 R/Parent 999 0 R/Prev 1529 0 R/SE 375 0 R/Title(\(7\) Medical Director. There shall be an identified Trauma Medical Director 429 \(TMD\) responsible for the provision of trauma care and credentialed by the 430 facility for the treatment of trauma patients. 431 )>>endobj1529 0 obj<</Dest[44 0 R/XYZ 36 524 null]/Next 1528 0 R/Parent 999 0 R/Prev 1530 0 R/SE 374 0 R/Title( 428 )>>endobj1530 0 obj<</Dest[44 0 R/XYZ 36 579 null]/Next 1529 0 R/Parent 999 0 R/Prev 1531 0 R/SE 373 0 R/Title(\(6\) Medical Staff. The facility must have an organized, effective trauma 424 program that is recognized in the medical staff bylaws and approved by the governing body. 425 Medical staff credentialing shall include a process for requesting and granting d\elineation of 426 privileges for trauma care. 427 )>>endobj1531 0 obj<</Dest[44 0 R/XYZ 36 593 null]/Next 1530 0 R/Parent 999 0 R/Prev 1532 0 R/SE 372 0 R/Title( 423 )>>endobj1532 0 obj<</Count 2/Dest[44 0 R/XYZ 36 621 null]/First 1533 0 R/Last 1533 0 R/Next 1531 0 R/Parent 999 0 R/Prev 1534 0 R/SE 369 0 R/Title(\(B\) Coordination and/or participation in community and/or RAC injury 421 prevention activities. 422 )>>endobj1533 0 obj<</Count 1/Dest[44 0 R/XYZ 36 621 null]/First 1804 0 R/Last 1804 0 R/Parent 1532 0 R/SE 370 0 R/Title(\(B\) Coordination and/or participation in community and/or RAC injury 421 prevention activities. 422 )>>endobj1534 0 obj<</Dest[44 0 R/XYZ 36 635 null]/Next 1532 0 R/Parent 999 0 R/Prev 1535 0 R/SE 368 0 R/Title( 420 )>>endobj1535 0 obj<</Count 2/Dest[44 0 R/XYZ 36 663 null]/First 1536 0 R/Last 1536 0 R/Next 1534 0 R/Parent 999 0 R/Prev 1537 0 R/SE 365 0 R/Title(\(A\) A public education program to address the major injury problems 418 identified within the facility•s service area; and 419 )>>endobj1536 0 obj<</Count 1/Dest[44 0 R/XYZ 36 663 null]/First 1803 0 R/Last 1803 0 R/Parent 1535 0 R/SE 366 0 R/Title(\(A\) A public education program to address the major injury problems 418 identified within the facility•s service area; and 419 )>>endobj1537 0 obj<</Dest[44 0 R/XYZ 36 676 null]/Next 1535 0 R/Parent 999 0 R/Prev 1538 0 R/SE 364 0 R/Title( 417 )>>endobj1538 0 obj<</Dest[44 0 R/XYZ 36 690 null]/Next 1537 0 R/Parent 999 0 R/Prev 1539 0 R/SE 363 0 R/Title(\(5\) Injury Prevention and Public Education. 416 )>>endobj1539 0 obj<</Dest[44 0 R/XYZ 36 704 null]/Next 1538 0 R/Parent 999 0 R/Prev 1540 0 R/SE 362 0 R/Title( 415 )>>endobj1540 0 obj<</Count 2/Dest[44 0 R/XYZ 36 718 null]/First 1541 0 R/Last 1541 0 R/Next 1539 0 R/Parent 999 0 R/Prev 1542 0 R/SE 358 0 R/Title(\(vii\) other appropriate personnel involved in trauma care 414 )>>endobj1541 0 obj<</Count 1/Dest[44 0 R/XYZ 36 718 null]/First 1802 0 R/Last 1802 0 R/Parent 1540 0 R/SE 359 0 R/Title(\(vii\) other appropriate personnel involved in trauma care 414 )>>endobj1542 0 obj<</Count 14/Dest[35 0 R/XYZ 36 221 null]/First 1543 0 R/Last 1544 0 R/Next 1540 0 R/Parent 999 0 R/Prev 1545 0 R/SE 343 0 R/Title(\(C\) Training programs in trauma continuing education provided by facility 404 for staff and community members involved in trauma care based on 405 needs identified from the QAPI program for: 406 )>>endobj1543 0 obj<</Count 1/Dest[35 0 R/XYZ 36 221 null]/First 1801 0 R/Last 1801 0 R/Next 1799 0 R/Parent 1542 0 R/SE 344 0 R/Title(\(C\) Training programs in trauma continuing education provided by facility 404 for staff and community members involved in trauma care based on 405 needs identified from the QAPI program for: 406 )>>endobj1544 0 obj<</Count 1/Dest[35 0 R/XYZ 36 97 null]/First 1790 0 R/Last 1790 0 R/Parent 1542 0 R/Prev 1791 0 R/SE 356 0 R/Title(\(vi\) prehospital personnel; and 413 )>>endobj1545 0 obj<</Dest[35 0 R/XYZ 36 234 null]/Next 1542 0 R/Parent 999 0 R/Prev 1546 0 R/SE 342 0 R/Title( 403 )>>endobj1546 0 obj<</Count 2/Dest[35 0 R/XYZ 36 262 null]/First 1547 0 R/Last 1547 0 R/Next 1545 0 R/Parent 999 0 R/Prev 1548 0 R/SE 339 0 R/Title(\(B\) Provide education to and consultations with physicians of the 401 community and outlying areas; and 402 )>>endobj1547 0 obj<</Count 1/Dest[35 0 R/XYZ 36 262 null]/First 1789 0 R/Last 1789 0 R/Parent 1546 0 R/SE 340 0 R/Title(\(B\) Provide education to and consultations with physicians of the 401 community and outlying areas; and 402 )>>endobj1548 0 obj<</Dest[35 0 R/XYZ 36 276 null]/Next 1546 0 R/Parent 999 0 R/Prev 1549 0 R/SE 338 0 R/Title( 400 )>>endobj1549 0 obj<</Count 2/Dest[35 0 R/XYZ 36 304 null]/First 1550 0 R/Last 1550 0 R/Next 1548 0 R/Parent 999 0 R/Prev 1551 0 R/SE 335 0 R/Title(\(A\) A defined individual to coordinate the facility•s community outreach 398 and education programs for the public and professionals is evident; 399 )>>endobj1550 0 obj<</Count 1/Dest[35 0 R/XYZ 36 304 null]/First 1788 0 R/Last 1788 0 R/Parent 1549 0 R/SE 336 0 R/Title(\(A\) A defined individual to coordinate the facility•s community outreach 398 and education programs for the public and professionals is evident; 399 )>>endobj1551 0 obj<</Dest[35 0 R/XYZ 36 317 null]/Next 1549 0 R/Parent 999 0 R/Prev 1552 0 R/SE 334 0 R/Title( 397 )>>endobj1552 0 obj<</Dest[35 0 R/XYZ 36 331 null]/Next 1551 0 R/Parent 999 0 R/Prev 1553 0 R/SE 333 0 R/Title(\(4\) Outreach and Education. 396 )>>endobj1553 0 obj<</Dest[35 0 R/XYZ 36 345 null]/Next 1552 0 R/Parent 999 0 R/Prev 1554 0 R/SE 332 0 R/Title( 395 )>>endobj1554 0 obj<</Dest[35 0 R/XYZ 36 359 null]/Next 1553 0 R/Parent 999 0 R/Prev 1555 0 R/SE 331 0 R/Title( 394 )>>endobj1555 0 obj<</Count 2/Dest[35 0 R/XYZ 36 400 null]/First 1556 0 R/Last 1556 0 R/Next 1554 0 R/Parent 999 0 R/Prev 1557 0 R/SE 328 0 R/Title(\(iv\) Committee meeting documentation of the attendance, 391 activities, actions, and follow-up with ongoing monthly 392 review of key elements of trauma care. 393 )>>endobj1556 0 obj<</Count 1/Dest[35 0 R/XYZ 36 400 null]/First 1787 0 R/Last 1787 0 R/Parent 1555 0 R/SE 329 0 R/Title(\(iv\) Committee meeting documentation of the attendance, 391 activities, actions, and follow-up with ongoing monthly 392 review of key elements of trauma care. 393 )>>endobj1557 0 obj<</Dest[35 0 R/XYZ 36 414 null]/Next 1555 0 R/Parent 999 0 R/Prev 1558 0 R/SE 327 0 R/Title( 390 )>>endobj1558 0 obj<</Count 2/Dest[35 0 R/XYZ 36 538 null]/First 1559 0 R/Last 1559 0 R/Next 1557 0 R/Parent 999 0 R/Prev 1560 0 R/SE 324 0 R/Title(\(iii\) Composition of the Trauma Multidisciplinary QAPI 381 committee to include the trauma medical director \(TMD\), 382 the trauma program manager \(TPM\), an executive officer 383 of the facility, a trauma nurse active in the management of 384 trauma \patients, a trauma nurse active in the management 385 of pediatric trauma patients as applicable, and physicians 386 and surgeons that provide coverage or care to trauma 387 patients, and other healthcare professionals participating in 388 the care of maj\or or se)>>endobj1559 0 obj<</Count 1/Dest[35 0 R/XYZ 36 538 null]/First 1786 0 R/Last 1786 0 R/Parent 1558 0 R/SE 325 0 R/Title(\(iii\) Composition of the Trauma Multidisciplinary QAPI 381 committee to include the trauma medical director \(TMD\), 382 the trauma program manager \(TPM\), an executive officer 383 of the facility, a trauma nurse active in the management of 384 trauma \patients, a trauma nurse active in the management 385 of pediatric trauma patients as applicable, and physicians 386 and surgeons that provide coverage or care to trauma 387 patients, and other healthcare professionals participating in 388 the care of maj\or or se)>>endobj1560 0 obj<</Dest[35 0 R/XYZ 36 552 null]/Next 1558 0 R/Parent 999 0 R/Prev 1561 0 R/SE 323 0 R/Title( 380 )>>endobj1561 0 obj<</Count 2/Dest[35 0 R/XYZ 36 677 null]/First 1562 0 R/Last 1562 0 R/Next 1560 0 R/Parent 999 0 R/Prev 1563 0 R/SE 320 0 R/Title(\(ii\) Demonstrate how the staff evaluate the provision of trauma 371 care and patient services, identify opportunities for 372 improvement, develop and implement improvement plans, 373 and evaluate the implementation of those plans until 374 resolution i\s achieved. Evidence shall support that 375 aggregate patient data, including identification and tracking 376 of trauma patient complications or variances from 377 standards of care, is continuously reviewed for trends by 378 the trauma multidisciplinary \QAPI)>>endobj1562 0 obj<</Count 1/Dest[35 0 R/XYZ 36 677 null]/First 1785 0 R/Last 1785 0 R/Parent 1561 0 R/SE 321 0 R/Title(\(ii\) Demonstrate how the staff evaluate the provision of trauma 371 care and patient services, identify opportunities for 372 improvement, develop and implement improvement plans, 373 and evaluate the implementation of those plans until 374 resolution i\s achieved. Evidence shall support that 375 aggregate patient data, including identification and tracking 376 of trauma patient complications or variances from 377 standards of care, is continuously reviewed for trends by 378 the trauma multidisciplinary \QAPI)>>endobj1563 0 obj<</Dest[35 0 R/XYZ 36 690 null]/Next 1561 0 R/Parent 999 0 R/Prev 1564 0 R/SE 319 0 R/Title( 370 )>>endobj1564 0 obj<</Count 2/Dest[35 0 R/XYZ 36 717 null]/First 1565 0 R/Last 1565 0 R/Next 1563 0 R/Parent 999 0 R/Prev 1566 0 R/SE 315 0 R/Title(of care to ensure achievement of optimal trauma outcomes, 368 patient safety standards and cost effective care. 369 )>>endobj1565 0 obj<</Count 1/Dest[35 0 R/XYZ 36 717 null]/First 1784 0 R/Last 1784 0 R/Parent 1564 0 R/SE 316 0 R/Title(of care to ensure achievement of optimal trauma outcomes, 368 patient safety standards and cost effective care. 369 )>>endobj1566 0 obj<</Count 2/Dest[33 0 R/XYZ 36 152 null]/First 1567 0 R/Last 1567 0 R/Next 1564 0 R/Parent 999 0 R/Prev 1568 0 R/SE 312 0 R/Title(\(i\) A description of the facility's trauma program and the 364 services provided. All facility services \(including those 365 services furnished under contract or arrangement\) shall 366 focus on decreasing deviations from the trauma standards 367 )>>endobj1567 0 obj<</Count 1/Dest[33 0 R/XYZ 36 152 null]/First 1783 0 R/Last 1783 0 R/Parent 1566 0 R/SE 313 0 R/Title(\(i\) A description of the facility's trauma program and the 364 services provided. All facility services \(including those 365 services furnished under contract or arrangement\) shall 366 focus on decreasing deviations from the trauma standards 367 )>>endobj1568 0 obj<</Dest[33 0 R/XYZ 36 165 null]/Next 1566 0 R/Parent 999 0 R/Prev 1569 0 R/SE 311 0 R/Title( 363 )>>endobj1569 0 obj<</Dest[33 0 R/XYZ 36 179 null]/Next 1568 0 R/Parent 999 0 R/Prev 1570 0 R/SE 310 0 R/Title(\(B\) The trauma QAPI plan shall include, at a minimum: 362 )>>endobj1570 0 obj<</Dest[33 0 R/XYZ 36 193 null]/Next 1569 0 R/Parent 999 0 R/Prev 1571 0 R/SE 309 0 R/Title( 361 )>>endobj1571 0 obj<</Count 2/Dest[33 0 R/XYZ 36 235 null]/First 1572 0 R/Last 1572 0 R/Next 1570 0 R/Parent 999 0 R/Prev 1573 0 R/SE 306 0 R/Title(\(A\) The Trauma QAPI plan shall be reviewed and approved by the 358 facility•s governing body. The governing body shall ensure that the 359 requirements of this section are implemented and enforced. 360 )>>endobj1572 0 obj<</Count 1/Dest[33 0 R/XYZ 36 235 null]/First 1782 0 R/Last 1782 0 R/Parent 1571 0 R/SE 307 0 R/Title(\(A\) The Trauma QAPI plan shall be reviewed and approved by the 358 facility•s governing body. The governing body shall ensure that the 359 requirements of this section are implemented and enforced. 360 )>>endobj1573 0 obj<</Dest[33 0 R/XYZ 36 248 null]/Next 1571 0 R/Parent 999 0 R/Prev 1574 0 R/SE 305 0 R/Title( 357 )>>endobj1574 0 obj<</Dest[33 0 R/XYZ 36 317 null]/Next 1573 0 R/Parent 999 0 R/Prev 1575 0 R/SE 304 0 R/Title(\(3\) Quality Assessment and Performance Improvement Plan. The facility 352 shall develop, implement, maintain, and evaluate an effective, ongoing, facility-wide, 353 data-driven, outcomes based multidisciplinary quality assessment and performance 354 im\provement \(QAPI\) plan. The plan shall be individualized to the facility and meet the 355 requirements described in this section. 356 )>>endobj1575 0 obj<</Dest[33 0 R/XYZ 36 331 null]/Next 1574 0 R/Parent 999 0 R/Prev 1576 0 R/SE 303 0 R/Title( 351 )>>endobj1576 0 obj<</Dest[33 0 R/XYZ 36 359 null]/Next 1575 0 R/Parent 999 0 R/Prev 1577 0 R/SE 302 0 R/Title(\(iii\) Daily physician notes by the admitting physician and all 349 sub-speciality physicians participating in the patient•s care; 350 )>>endobj1577 0 obj<</Dest[33 0 R/XYZ 36 372 null]/Next 1576 0 R/Parent 999 0 R/Prev 1578 0 R/SE 301 0 R/Title( 348 )>>endobj1578 0 obj<</Dest[33 0 R/XYZ 36 400 null]/Next 1577 0 R/Parent 999 0 R/Prev 1579 0 R/SE 300 0 R/Title(\(ii\) Vital signs and other information necessary for ongoing 346 monitoring of the patient•s condition; and 347 )>>endobj1579 0 obj<</Dest[33 0 R/XYZ 36 414 null]/Next 1578 0 R/Parent 999 0 R/Prev 1580 0 R/SE 299 0 R/Title( 345 )>>endobj1580 0 obj<</Dest[33 0 R/XYZ 36 441 null]/Next 1579 0 R/Parent 999 0 R/Prev 1581 0 R/SE 298 0 R/Title( \(i\) Trauma team response times, mechanism of injury, 343 assessments, interventions, and response to interventions; 344 )>>endobj1581 0 obj<</Dest[33 0 R/XYZ 36 510 null]/Next 1580 0 R/Parent 999 0 R/Prev 1582 0 R/SE 297 0 R/Title(\(2\) Medical Records. Maintain medical records that contain information to 338 justify and support the immediate evaluation, activation, resuscitation, diagnosis, treatment, and 339 describe the patient•s progress and response to medication and interven\tions from arrival in the 340 Emergency Department through discharge. Records include evidence of documentation of the 341 following as appropriate: 342 )>>endobj1582 0 obj<</Dest[33 0 R/XYZ 36 524 null]/Next 1581 0 R/Parent 999 0 R/Prev 1583 0 R/SE 296 0 R/Title( 337 )>>endobj1583 0 obj<</Dest[33 0 R/XYZ 36 566 null]/Next 1582 0 R/Parent 999 0 R/Prev 1584 0 R/SE 295 0 R/Title(\(xiii\) contingency plans to ensure the immediate continuation of 334 an active trauma program in the event that the Trauma Medical Director or 335 the Trauma Program Manager position becomes vacant; 336 )>>endobj1584 0 obj<</Dest[33 0 R/XYZ 36 579 null]/Next 1583 0 R/Parent 999 0 R/Prev 1585 0 R/SE 294 0 R/Title( 333 )>>endobj1585 0 obj<</Dest[33 0 R/XYZ 36 607 null]/Next 1584 0 R/Parent 999 0 R/Prev 1586 0 R/SE 293 0 R/Title(\(xii\) identify a program sponsor who is a member of the 331 executive leadership at the facility; 332 )>>endobj1586 0 obj<</Dest[33 0 R/XYZ 36 621 null]/Next 1585 0 R/Parent 999 0 R/Prev 1587 0 R/SE 292 0 R/Title( 330 )>>endobj1587 0 obj<</Dest[33 0 R/XYZ 36 662 null]/Next 1586 0 R/Parent 999 0 R/Prev 1588 0 R/SE 291 0 R/Title(\(xi\) a trauma staff registered nurse as a representative on the 327 nurse staffing committee as established in accordance with TAC 328 §§133.41\(o\)\(2\)\(F\); 329 )>>endobj1588 0 obj<</Dest[33 0 R/XYZ 36 676 null]/Next 1587 0 R/Parent 999 0 R/Prev 1589 0 R/SE 290 0 R/Title( 326 )>>endobj1589 0 obj<</Dest[33 0 R/XYZ 36 717 null]/Next 1588 0 R/Parent 999 0 R/Prev 1590 0 R/SE 288 0 R/Title(\(x\) provisions for consistent participation by the TMD, TPM, 323 TR, or other members of the trauma program in the regional advisory 324 council \(RAC\); 325 )>>endobj1590 0 obj<</Dest[31 0 R/XYZ 36 96 null]/Next 1589 0 R/Parent 999 0 R/Prev 1591 0 R/SE 287 0 R/Title( 322 )>>endobj1591 0 obj<</Dest[31 0 R/XYZ 36 110 null]/Next 1590 0 R/Parent 999 0 R/Prev 1592 0 R/SE 286 0 R/Title(\(ix\) the role of the hospitalists in the care of the trauma patient; 321 )>>endobj1592 0 obj<</Dest[31 0 R/XYZ 36 124 null]/Next 1591 0 R/Parent 999 0 R/Prev 1593 0 R/SE 285 0 R/Title( 320 )>>endobj1593 0 obj<</Dest[31 0 R/XYZ 36 152 null]/Next 1592 0 R/Parent 999 0 R/Prev 1594 0 R/SE 284 0 R/Title(\(viii\) telemedicine utilization in the Emergency Department 318 \(ED\); 319 )>>endobj1594 0 obj<</Dest[31 0 R/XYZ 36 165 null]/Next 1593 0 R/Parent 999 0 R/Prev 1595 0 R/SE 283 0 R/Title( 317 )>>endobj1595 0 obj<</Dest[31 0 R/XYZ 36 193 null]/Next 1594 0 R/Parent 999 0 R/Prev 1596 0 R/SE 282 0 R/Title( \(vii\) provisions for staff education; including annual 315 competency and skills assessment that is appropriate for the patient population served; 316 )>>endobj1596 0 obj<</Dest[31 0 R/XYZ 36 207 null]/Next 1595 0 R/Parent 999 0 R/Prev 1597 0 R/SE 281 0 R/Title( 314 )>>endobj1597 0 obj<</Dest[31 0 R/XYZ 36 234 null]/Next 1596 0 R/Parent 999 0 R/Prev 1598 0 R/SE 280 0 R/Title(\(vi\) requirements for minimal credentials for all staff 312 participating in the care of trauma patients; 313 )>>endobj1598 0 obj<</Dest[31 0 R/XYZ 36 248 null]/Next 1597 0 R/Parent 999 0 R/Prev 1599 0 R/SE 279 0 R/Title( 311 )>>endobj1599 0 obj<</Count 2/Dest[31 0 R/XYZ 36 304 null]/First 1600 0 R/Last 1600 0 R/Next 1598 0 R/Parent 999 0 R/Prev 1601 0 R/SE 276 0 R/Title(\(v\) a written policy and procedure for massive transfusion 307 developed collaboratively between the trauma service and 308 the blood bank and appropriate resources for 309 implementation; 310 )>>endobj1600 0 obj<</Count 1/Dest[31 0 R/XYZ 36 304 null]/First 1781 0 R/Last 1781 0 R/Parent 1599 0 R/SE 277 0 R/Title(\(v\) a written policy and procedure for massive transfusion 307 developed collaboratively between the trauma service and 308 the blood bank and appropriate resources for 309 implementation; 310 )>>endobj1601 0 obj<</Dest[31 0 R/XYZ 36 317 null]/Next 1599 0 R/Parent 999 0 R/Prev 1602 0 R/SE 275 0 R/Title( 306 )>>endobj1602 0 obj<</Count 2/Dest[31 0 R/XYZ 36 359 null]/First 1603 0 R/Last 1603 0 R/Next 1601 0 R/Parent 999 0 R/Prev 1604 0 R/SE 272 0 R/Title(\(iv\) the availability of all necessary equipment and services to 303 provide the appropriate level of care and support of the 304 patient population served; 305 )>>endobj1603 0 obj<</Count 1/Dest[31 0 R/XYZ 36 359 null]/First 1780 0 R/Last 1780 0 R/Parent 1602 0 R/SE 273 0 R/Title(\(iv\) the availability of all necessary equipment and services to 303 provide the appropriate level of care and support of the 304 patient population served; 305 )>>endobj1604 0 obj<</Dest[31 0 R/XYZ 36 372 null]/Next 1602 0 R/Parent 999 0 R/Prev 1605 0 R/SE 271 0 R/Title( 302 )>>endobj1605 0 obj<</Dest[31 0 R/XYZ 36 400 null]/Next 1604 0 R/Parent 999 0 R/Prev 1606 0 R/SE 270 0 R/Title( \(iii\) written triage, stabilization and transfer guidelines for the 300 trauma patient that include consultation and transport services; 301 )>>endobj1606 0 obj<</Dest[31 0 R/XYZ 36 414 null]/Next 1605 0 R/Parent 999 0 R/Prev 1607 0 R/SE 269 0 R/Title( 299 )>>endobj1607 0 obj<</Dest[31 0 R/XYZ 36 441 null]/Next 1606 0 R/Parent 999 0 R/Prev 1608 0 R/SE 268 0 R/Title(\(ii\) A periodic review and revision schedule for all trauma care 297 policies and procedures; 298 )>>endobj1608 0 obj<</Dest[31 0 R/XYZ 36 455 null]/Next 1607 0 R/Parent 999 0 R/Prev 1609 0 R/SE 267 0 R/Title( 296 )>>endobj1609 0 obj<</Dest[31 0 R/XYZ 36 510 null]/Next 1608 0 R/Parent 999 0 R/Prev 1610 0 R/SE 266 0 R/Title(\(i\) policies and procedures based on national evidence-based 292 standards of practice of trauma care, that are adopted, implemented, and 293 enforced for compliance by the facility, that governs the trauma program 294 through all phases of care for a\ll patient populations; 295 )>>endobj1610 0 obj<</Dest[31 0 R/XYZ 36 524 null]/Next 1609 0 R/Parent 999 0 R/Prev 1611 0 R/SE 265 0 R/Title( 291 )>>endobj1611 0 obj<</Dest[31 0 R/XYZ 36 538 null]/Next 1610 0 R/Parent 999 0 R/Prev 1612 0 R/SE 264 0 R/Title(\(B\) The written program plan shall include, at a minimum: 290 )>>endobj1612 0 obj<</Dest[31 0 R/XYZ 36 552 null]/Next 1611 0 R/Parent 999 0 R/Prev 1613 0 R/SE 263 0 R/Title( 289 )>>endobj1613 0 obj<</Dest[31 0 R/XYZ 36 593 null]/Next 1612 0 R/Parent 999 0 R/Prev 1614 0 R/SE 262 0 R/Title(\(A\) The written plan and the program policies and procedures shall be 286 reviewed and approved by the facility•s governing body. The governing body shall ensure that 287 the requirements of this chapter are implemented and enforced. 288 )>>endobj1614 0 obj<</Dest[31 0 R/XYZ 36 607 null]/Next 1613 0 R/Parent 999 0 R/Prev 1615 0 R/SE 261 0 R/Title( 285 )>>endobj1615 0 obj<</Dest[31 0 R/XYZ 36 676 null]/Next 1614 0 R/Parent 999 0 R/Prev 1616 0 R/SE 260 0 R/Title(\(1\) Program Plan. The facility shall develop a written plan of the trauma 280 program that includes a detailed description of the scope of services available to all trauma 281 patients, defines the trauma patient population evaluated and/or treated by \the facility, 282 transferred, or transported by the facility, that is consistent with accepted professional standards 283 of practice for trauma care, and ensures the health and safety of patients. 284 )>>endobj1616 0 obj<</Dest[31 0 R/XYZ 36 690 null]/Next 1615 0 R/Parent 999 0 R/Prev 1617 0 R/SE 259 0 R/Title( 279 )>>endobj1617 0 obj<</Dest[31 0 R/XYZ 36 704 null]/Next 1616 0 R/Parent 999 0 R/Prev 1618 0 R/SE 258 0 R/Title(\(j\) Program Requirements. 278 )>>endobj1618 0 obj<</Dest[31 0 R/XYZ 36 717 null]/Next 1617 0 R/Parent 999 0 R/Prev 1619 0 R/SE 256 0 R/Title( 277 )>>endobj1619 0 obj<</Dest[29 0 R/XYZ 36 110 null]/Next 1618 0 R/Parent 999 0 R/Prev 1620 0 R/SE 255 0 R/Title(\(i\) The office may grant an exception to this section if it finds that compliance with 275 this section would not be in the best interests of the persons served in the affected local system. 276 )>>endobj1620 0 obj<</Dest[29 0 R/XYZ 36 124 null]/Next 1619 0 R/Parent 999 0 R/Prev 1621 0 R/SE 254 0 R/Title( 274 )>>endobj1621 0 obj<</Dest[29 0 R/XYZ 36 262 null]/Next 1620 0 R/Parent 999 0 R/Prev 1622 0 R/SE 253 0 R/Title(\(h\) The office shall have the right to review, inspect, evaluate, and audit all trauma 264 patient records, trauma QAPI/performance improvement and peer review committee minutes and 265 other documents relevant to trauma care in any designated trauma fa\cility or applicant/healthcare 266 facility at any time to verify compliance with the statute and this rule, including the designation 267 criteria. The office shall maintain confidentiality of such records to the extent authorized by the 268 Texas Public\ Inf)>>endobj1622 0 obj<</Dest[29 0 R/XYZ 36 276 null]/Next 1621 0 R/Parent 999 0 R/Prev 1623 0 R/SE 252 0 R/Title( 263 )>>endobj1623 0 obj<</Dest[29 0 R/XYZ 36 331 null]/Next 1622 0 R/Parent 999 0 R/Prev 1624 0 R/SE 251 0 R/Title(\(g\) A healthcare facility may not use the terms "trauma facility", "trauma hospital", 259 "trauma center", or similar terminology in its signs, advertisements or in printed materials and 260 information it provides to the public unless the healthcare fa\cility is currently designated as a 261 trauma facility according to the process described in this section. 262 )>>endobj1624 0 obj<</Dest[29 0 R/XYZ 36 345 null]/Next 1623 0 R/Parent 999 0 R/Prev 1625 0 R/SE 250 0 R/Title( 258 )>>endobj1625 0 obj<</Dest[29 0 R/XYZ 36 400 null]/Next 1624 0 R/Parent 999 0 R/Prev 1626 0 R/SE 249 0 R/Title(\(f\) Relinquishment of designation. If the facility chooses to relinquish its trauma 254 designation, it shall provide at least 30 day notice to the department, the applicable RAC\(s\), the 255 emergency medical services providers, and healthcare facilit\ies to which it customarily transfers-256 out and/or transfers-in trauma patients if it no longer provides trauma services. 257 )>>endobj1626 0 obj<</Dest[29 0 R/XYZ 36 414 null]/Next 1625 0 R/Parent 999 0 R/Prev 1627 0 R/SE 248 0 R/Title( 253 )>>endobj1627 0 obj<</Dest[29 0 R/XYZ 36 497 null]/Next 1626 0 R/Parent 999 0 R/Prev 1628 0 R/SE 247 0 R/Title(\(3\) A designated trauma facility that is unable to maintain compliance with 247 the level of the current designation may choose to apply for a lower level of trauma designation 248 at any time. It shall be necessary to repeat the designation process for\ the lower level. There shall 249 be a paper review by the office to determine if and when a full survey shall be required. The 250 facility must notify the office within 5 days of the date that it no longer provides trauma services 251 commensurate with \its )>>endobj1628 0 obj<</Dest[29 0 R/XYZ 36 510 null]/Next 1627 0 R/Parent 999 0 R/Prev 1629 0 R/SE 246 0 R/Title( 246 )>>endobj1629 0 obj<</Dest[29 0 R/XYZ 36 566 null]/Next 1628 0 R/Parent 999 0 R/Prev 1630 0 R/SE 245 0 R/Title(\(2\) A designated trauma facility that is increasing its trauma capabilities may 242 choose to apply for a higher level of trauma designation at any time. It shall be necessary to 243 repeat the designation process for the higher level. The facility must\ notify the RAC when the 244 facility•s trauma capabilities have changed. 245 )>>endobj1630 0 obj<</Dest[29 0 R/XYZ 36 579 null]/Next 1629 0 R/Parent 999 0 R/Prev 1631 0 R/SE 244 0 R/Title( 241 )>>endobj1631 0 obj<</Dest[29 0 R/XYZ 36 607 null]/Next 1630 0 R/Parent 999 0 R/Prev 1632 0 R/SE 243 0 R/Title(\(1\) An application for a higher or lower level designation may be submitted to 239 the office at any time. 240 )>>endobj1632 0 obj<</Dest[29 0 R/XYZ 36 621 null]/Next 1631 0 R/Parent 999 0 R/Prev 1633 0 R/SE 242 0 R/Title( 238 )>>endobj1633 0 obj<</Dest[29 0 R/XYZ 36 635 null]/Next 1632 0 R/Parent 999 0 R/Prev 1634 0 R/SE 241 0 R/Title(\(e\) Upgrade or Downgrade of designation levels. 237 )>>endobj1634 0 obj<</Dest[29 0 R/XYZ 36 648 null]/Next 1633 0 R/Parent 999 0 R/Prev 1635 0 R/SE 240 0 R/Title( 236 )>>endobj1635 0 obj<</Dest[29 0 R/XYZ 36 676 null]/Next 1634 0 R/Parent 999 0 R/Prev 1636 0 R/SE 239 0 R/Title(\(C\) suspend the facility's designation status or the facility may 234 relinquish designation status. 235 )>>endobj1636 0 obj<</Dest[29 0 R/XYZ 36 690 null]/Next 1635 0 R/Parent 999 0 R/Prev 1637 0 R/SE 238 0 R/Title( 233 )>>endobj1637 0 obj<</Dest[29 0 R/XYZ 36 717 null]/Next 1636 0 R/Parent 999 0 R/Prev 1638 0 R/SE 236 0 R/Title(\(B\) redesignate the facility at the level appropriate to its revised 231 capabilities; or 232 )>>endobj1638 0 obj<</Dest[27 0 R/XYZ 36 96 null]/Next 1637 0 R/Parent 999 0 R/Prev 1639 0 R/SE 235 0 R/Title( 230 )>>endobj1639 0 obj<</Dest[27 0 R/XYZ 36 124 null]/Next 1638 0 R/Parent 999 0 R/Prev 1640 0 R/SE 234 0 R/Title(\(A\) allow the facility to request designation at the level appropriate to 228 its revised capabilities; 229 )>>endobj1640 0 obj<</Dest[27 0 R/XYZ 36 138 null]/Next 1639 0 R/Parent 999 0 R/Prev 1641 0 R/SE 233 0 R/Title( 227 )>>endobj1641 0 obj<</Dest[27 0 R/XYZ 36 234 null]/Next 1640 0 R/Parent 999 0 R/Prev 1642 0 R/SE 232 0 R/Title(\(2\) If the healthcare facility is unable to comply with program requirements to 220 maintain the current designation status, it shall submit to the office a POC as described in \(b\)\(2\) 221 \(D\) of this section, and a request for a temporary exceptio\n to criteria. Any request for an 222 exception shall be submitted in writing from an executive officer of the facility. The office shall 223 review the request and the POC and either grant or deny the exception. If the healthcare facility 224 has not com\e into com)>>endobj1642 0 obj<</Dest[27 0 R/XYZ 36 248 null]/Next 1641 0 R/Parent 999 0 R/Prev 1643 0 R/SE 231 0 R/Title( 219 )>>endobj1643 0 obj<</Dest[27 0 R/XYZ 36 276 null]/Next 1642 0 R/Parent 999 0 R/Prev 1644 0 R/SE 230 0 R/Title(\(D\) the healthcare facilities to which it customarily transfers-out and/or 217 transfers-in trauma patients. 218 )>>endobj1644 0 obj<</Dest[27 0 R/XYZ 36 290 null]/Next 1643 0 R/Parent 999 0 R/Prev 1645 0 R/SE 229 0 R/Title(\(C\) the emergency medical services providers, and 216 )>>endobj1645 0 obj<</Dest[27 0 R/XYZ 36 303 null]/Next 1644 0 R/Parent 999 0 R/Prev 1646 0 R/SE 228 0 R/Title(\(B\) applicable RAC\(s\), 215 )>>endobj1646 0 obj<</Dest[27 0 R/XYZ 36 317 null]/Next 1645 0 R/Parent 999 0 R/Prev 1647 0 R/SE 227 0 R/Title(\(A\) the office, 214 )>>endobj1647 0 obj<</Dest[27 0 R/XYZ 36 372 null]/Next 1646 0 R/Parent 999 0 R/Prev 1648 0 R/SE 226 0 R/Title(\(1\) Any event or decision impacting the ability of a trauma facility to comply 210 with any critical elements, as defined in \(c\)\(1-2\) of this section or an increase in the trauma 211 facility•s resources that affect the region, the facility shall no\tify in writing within 5 calendar 212 days : 213 )>>endobj1648 0 obj<</Dest[27 0 R/XYZ 36 386 null]/Next 1647 0 R/Parent 999 0 R/Prev 1649 0 R/SE 225 0 R/Title( 209 )>>endobj1649 0 obj<</Dest[27 0 R/XYZ 36 400 null]/Next 1648 0 R/Parent 999 0 R/Prev 1650 0 R/SE 224 0 R/Title(\(d\) Exceptions and Notifications 208 )>>endobj1650 0 obj<</Dest[27 0 R/XYZ 36 414 null]/Next 1649 0 R/Parent 999 0 R/Prev 1651 0 R/SE 223 0 R/Title( 207 )>>endobj1651 0 obj<</Dest[27 0 R/XYZ 36 455 null]/Next 1650 0 R/Parent 999 0 R/Prev 1652 0 R/SE 222 0 R/Title(\(12\) If a facility disagrees with the office's decision regarding its designation 204 status, the facility has a right to a hearing, in accordance with the department's rules for contested 205 cases, and Government Code, Chapter 2001. 206 )>>endobj1652 0 obj<</Dest[27 0 R/XYZ 36 469 null]/Next 1651 0 R/Parent 999 0 R/Prev 1653 0 R/SE 221 0 R/Title( 203 )>>endobj1653 0 obj<</Dest[27 0 R/XYZ 36 497 null]/Next 1652 0 R/Parent 999 0 R/Prev 1654 0 R/SE 220 0 R/Title(\(11\) The office shall post the current designation status of each facility on the 201 office website. 202 )>>endobj1654 0 obj<</Dest[27 0 R/XYZ 36 510 null]/Next 1653 0 R/Parent 999 0 R/Prev 1655 0 R/SE 219 0 R/Title( 200 )>>endobj1655 0 obj<</Dest[27 0 R/XYZ 36 538 null]/Next 1654 0 R/Parent 999 0 R/Prev 1656 0 R/SE 218 0 R/Title(\(10\) It shall be necessary to repeat the designation process as described in this 198 section prior to expiration of a facility's designation or the designation expires. 199 )>>endobj1656 0 obj<</Dest[27 0 R/XYZ 36 552 null]/Next 1655 0 R/Parent 999 0 R/Prev 1657 0 R/SE 217 0 R/Title( 197 )>>endobj1657 0 obj<</Count 2/Dest[27 0 R/XYZ 36 580 null]/First 1658 0 R/Last 1658 0 R/Next 1656 0 R/Parent 999 0 R/Prev 1659 0 R/SE 214 0 R/Title(\(9\) The facility shall have the right to withdraw its application at any time prior to 195 being recommended for trauma facility designation by the office. 196 )>>endobj1658 0 obj<</Count 1/Dest[27 0 R/XYZ 36 580 null]/First 1779 0 R/Last 1779 0 R/Parent 1657 0 R/SE 215 0 R/Title(\(9\) The facility shall have the right to withdraw its application at any time prior to 195 being recommended for trauma facility designation by the office. 196 )>>endobj1659 0 obj<</Dest[27 0 R/XYZ 36 593 null]/Next 1657 0 R/Parent 999 0 R/Prev 1660 0 R/SE 213 0 R/Title( 194 )>>endobj1660 0 obj<</Dest[27 0 R/XYZ 36 635 null]/Next 1659 0 R/Parent 999 0 R/Prev 1661 0 R/SE 212 0 R/Title(\(D\) Alteration: the trauma designation certificate and the award letter 191 shall not be altered. Any alteration to either document voids trauma designation for the 192 remainder of that cycle. 193 )>>endobj1661 0 obj<</Dest[27 0 R/XYZ 36 648 null]/Next 1660 0 R/Parent 999 0 R/Prev 1662 0 R/SE 211 0 R/Title( 190 )>>endobj1662 0 obj<</Dest[27 0 R/XYZ 36 676 null]/Next 1661 0 R/Parent 999 0 R/Prev 1663 0 R/SE 210 0 R/Title(\(C\) If the facility closes or loses trauma designation, the certificate 188 shall be returned to the office. 189 )>>endobj1663 0 obj<</Dest[27 0 R/XYZ 36 690 null]/Next 1662 0 R/Parent 999 0 R/Prev 1664 0 R/SE 209 0 R/Title( 187 )>>endobj1664 0 obj<</Dest[27 0 R/XYZ 36 717 null]/Next 1663 0 R/Parent 999 0 R/Prev 1665 0 R/SE 207 0 R/Title(\(B\) The trauma designation certificate shall be valid only when 185 displayed with the current letter awarding designation. 186 )>>endobj1665 0 obj<</Dest[21 0 R/XYZ 36 102 null]/Next 1664 0 R/Parent 999 0 R/Prev 1666 0 R/SE 206 0 R/Title( 184 )>>endobj1666 0 obj<</Dest[21 0 R/XYZ 36 157 null]/Next 1665 0 R/Parent 999 0 R/Prev 1667 0 R/SE 205 0 R/Title(\(A\) Display: The hospital shall prominently and conspicuously display 180 the trauma designation certificate and the current letter awarding designation from the 181 Commissioner, in a public area of the licensed premises that is readily visible to pati\ents, 182 employees, and visitors. 183 )>>endobj1667 0 obj<</Dest[21 0 R/XYZ 36 171 null]/Next 1666 0 R/Parent 999 0 R/Prev 1668 0 R/SE 204 0 R/Title( 179 )>>endobj1668 0 obj<</Dest[21 0 R/XYZ 36 199 null]/Next 1667 0 R/Parent 999 0 R/Prev 1669 0 R/SE 203 0 R/Title( \(8\) If the commissioner concurs with the recommendation to designate, the 177 facility shall receive a letter of designation valid for 3 years and a certificate of designation. 178 )>>endobj1669 0 obj<</Dest[21 0 R/XYZ 36 211 null]/Next 1668 0 R/Parent 999 0 R/Prev 1670 0 R/SE 202 0 R/Title( 176 )>>endobj1670 0 obj<</Count 2/Dest[21 0 R/XYZ 36 235 null]/First 1671 0 R/Last 1671 0 R/Next 1669 0 R/Parent 999 0 R/Prev 1672 0 R/SE 199 0 R/Title(\(7\) A recommendation for designation will be made to the commissioner if the 174 facility meets the requirements for designation found in this section. 175 )>>endobj1671 0 obj<</Count 1/Dest[21 0 R/XYZ 36 235 null]/First 1778 0 R/Last 1778 0 R/Parent 1670 0 R/SE 200 0 R/Title(\(7\) A recommendation for designation will be made to the commissioner if the 174 facility meets the requirements for designation found in this section. 175 )>>endobj1672 0 obj<</Dest[21 0 R/XYZ 36 248 null]/Next 1670 0 R/Parent 999 0 R/Prev 1673 0 R/SE 198 0 R/Title( 173 )>>endobj1673 0 obj<</Dest[21 0 R/XYZ 36 276 null]/Next 1672 0 R/Parent 999 0 R/Prev 1674 0 R/SE 197 0 R/Title(\(6\) The office shall review the findings of the survey report, patient care 171 reviews and any POC submitted by the facility to determine compliance with the requirements. 172 )>>endobj1674 0 obj<</Dest[21 0 R/XYZ 36 290 null]/Next 1673 0 R/Parent 999 0 R/Prev 1675 0 R/SE 196 0 R/Title( 170 )>>endobj1675 0 obj<</Dest[21 0 R/XYZ 36 345 null]/Next 1674 0 R/Parent 999 0 R/Prev 1676 0 R/SE 195 0 R/Title(\(5\) The trauma designation survey report and patient care reviews in its 166 entirety shall be part of a facility's quality assessment and performance improvement 167 \(QAPI\)/Multidisciplinary Trauma PI and peer review program and subject to confidenti\ality as 168 articulated in the Health and Safety Code, §773.095. 169 )>>endobj1676 0 obj<</Dest[21 0 R/XYZ 36 359 null]/Next 1675 0 R/Parent 999 0 R/Prev 1677 0 R/SE 194 0 R/Title( 165 )>>endobj1677 0 obj<</Dest[21 0 R/XYZ 36 428 null]/Next 1676 0 R/Parent 999 0 R/Prev 1678 0 R/SE 193 0 R/Title(\(4\) The surveyor\(s\) shall provide the facility with a written, signed survey 160 report regarding their evaluation of the facility's compliance / noncompliance with §157.125. 161 This survey report shall be forwarded to the facility no later than 30 \calendar days of the 162 completion date of the survey. The facility is responsible for forwarding a copy of this report, 163 including patient care reviews, to the office if it intends to continue the designation process. 164 )>>endobj1678 0 obj<</Dest[21 0 R/XYZ 36 441 null]/Next 1677 0 R/Parent 999 0 R/Prev 1679 0 R/SE 192 0 R/Title( 159 )>>endobj1679 0 obj<</Count 8/Dest[21 0 R/XYZ 36 497 null]/First 1680 0 R/Last 1681 0 R/Next 1678 0 R/Parent 999 0 R/Prev 1682 0 R/SE 183 0 R/Title(\(i\) the Chief Executive Officer 155 )>>endobj1680 0 obj<</Count 1/Dest[21 0 R/XYZ 36 497 null]/First 1777 0 R/Last 1777 0 R/Next 1775 0 R/Parent 1679 0 R/SE 184 0 R/Title(\(i\) the Chief Executive Officer 155 )>>endobj1681 0 obj<</Count 1/Dest[21 0 R/XYZ 36 456 null]/First 1772 0 R/Last 1772 0 R/Parent 1679 0 R/Prev 1773 0 R/SE 190 0 R/Title(\(iv\) the current Executive Sponsor of the trauma program 158 )>>endobj1682 0 obj<</Dest[21 0 R/XYZ 36 510 null]/Next 1679 0 R/Parent 999 0 R/Prev 1683 0 R/SE 182 0 R/Title( 154 )>>endobj1683 0 obj<</Dest[21 0 R/XYZ 36 524 null]/Next 1682 0 R/Parent 999 0 R/Prev 1684 0 R/SE 181 0 R/Title(\(C\) staff interviews to include: 153 )>>endobj1684 0 obj<</Dest[21 0 R/XYZ 36 538 null]/Next 1683 0 R/Parent 999 0 R/Prev 1685 0 R/SE 180 0 R/Title( 152 )>>endobj1685 0 obj<</Dest[21 0 R/XYZ 36 552 null]/Next 1684 0 R/Parent 999 0 R/Prev 1686 0 R/SE 179 0 R/Title(\(B\) tour of the physical plant; and 151 )>>endobj1686 0 obj<</Dest[21 0 R/XYZ 36 579 null]/Next 1685 0 R/Parent 999 0 R/Prev 1687 0 R/SE 178 0 R/Title(\(A\) reviewing documents, including a minimum of 10 closed medical 149 records per surveyor; 150 )>>endobj1687 0 obj<</Dest[21 0 R/XYZ 36 593 null]/Next 1686 0 R/Parent 999 0 R/Prev 1688 0 R/SE 177 0 R/Title( 148 )>>endobj1688 0 obj<</Dest[21 0 R/XYZ 36 621 null]/Next 1687 0 R/Parent 999 0 R/Prev 1689 0 R/SE 176 0 R/Title(\(3\) The survey team shall evaluate the facility's compliance and document the 146 noncompliance with this section 157.125 by: 147 )>>endobj1689 0 obj<</Dest[21 0 R/XYZ 36 635 null]/Next 1688 0 R/Parent 999 0 R/Prev 1690 0 R/SE 175 0 R/Title( 145 )>>endobj1690 0 obj<</Dest[21 0 R/XYZ 36 662 null]/Next 1689 0 R/Parent 999 0 R/Prev 1691 0 R/SE 174 0 R/Title(\(B\) The office, at its discretion, may appoint an observer to accompany 143 the survey team. In this event, the cost for the observer shall be borne by the office. 144 )>>endobj1691 0 obj<</Dest[21 0 R/XYZ 36 676 null]/Next 1690 0 R/Parent 999 0 R/Prev 1692 0 R/SE 173 0 R/Title( 142 )>>endobj1692 0 obj<</Dest[21 0 R/XYZ 36 704 null]/Next 1691 0 R/Parent 999 0 R/Prev 1693 0 R/SE 172 0 R/Title(\(A\) The facility shall be responsible for any expenses associated with 140 the survey. 141 )>>endobj1693 0 obj<</Dest[21 0 R/XYZ 36 717 null]/Next 1692 0 R/Parent 999 0 R/Prev 1694 0 R/SE 170 0 R/Title( 139 )>>endobj1694 0 obj<</Dest[19 0 R/XYZ 36 110 null]/Next 1693 0 R/Parent 999 0 R/Prev 1695 0 R/SE 169 0 R/Title(\(2\) The surveying organization shall notify the office of the date of the 137 scheduled survey and shall schedule the members of the survey team. 138 )>>endobj1695 0 obj<</Dest[19 0 R/XYZ 36 124 null]/Next 1694 0 R/Parent 999 0 R/Prev 1696 0 R/SE 168 0 R/Title( 136 )>>endobj1696 0 obj<</Dest[19 0 R/XYZ 36 152 null]/Next 1695 0 R/Parent 999 0 R/Prev 1697 0 R/SE 167 0 R/Title(\(C\) Level IV facilities shall request a trauma designation survey 134 through an organization approved by the office. 135 )>>endobj1697 0 obj<</Dest[19 0 R/XYZ 36 165 null]/Next 1696 0 R/Parent 999 0 R/Prev 1698 0 R/SE 166 0 R/Title( 133 )>>endobj1698 0 obj<</Dest[19 0 R/XYZ 36 207 null]/Next 1697 0 R/Parent 999 0 R/Prev 1699 0 R/SE 165 0 R/Title(\(B\) Level III facilities shall request a trauma verification survey 130 through the ACS trauma verification program, or request a trauma designation 131 survey through an organization approved by the office; or 132 )>>endobj1699 0 obj<</Dest[19 0 R/XYZ 36 221 null]/Next 1698 0 R/Parent 999 0 R/Prev 1700 0 R/SE 164 0 R/Title( 129 )>>endobj1700 0 obj<</Dest[19 0 R/XYZ 36 248 null]/Next 1699 0 R/Parent 999 0 R/Prev 1701 0 R/SE 163 0 R/Title(\(A\) Level I and II facilities shall request a trauma verification survey 127 through the American College of Surgeons \(ACS\) trauma verification program; 128 )>>endobj1701 0 obj<</Dest[19 0 R/XYZ 36 262 null]/Next 1700 0 R/Parent 999 0 R/Prev 1702 0 R/SE 162 0 R/Title( 126 )>>endobj1702 0 obj<</Dest[19 0 R/XYZ 36 290 null]/Next 1701 0 R/Parent 999 0 R/Prev 1703 0 R/SE 161 0 R/Title(\(1\) The facility shall be responsible for scheduling a verification or trauma 124 designation survey as follows: 125 )>>endobj1703 0 obj<</Dest[19 0 R/XYZ 36 303 null]/Next 1702 0 R/Parent 999 0 R/Prev 1704 0 R/SE 160 0 R/Title( 123 )>>endobj1704 0 obj<</Dest[19 0 R/XYZ 36 331 null]/Next 1703 0 R/Parent 999 0 R/Prev 1705 0 R/SE 159 0 R/Title( \(c\) Survey Process. A facility seeking designation shall undergo an onsite survey as 121 outlined in this section. 122 )>>endobj1705 0 obj<</Dest[19 0 R/XYZ 36 345 null]/Next 1704 0 R/Parent 999 0 R/Prev 1706 0 R/SE 158 0 R/Title( 120 )>>endobj1706 0 obj<</Dest[19 0 R/XYZ 36 386 null]/Next 1705 0 R/Parent 999 0 R/Prev 1707 0 R/SE 157 0 R/Title(\(5\) If a facility seeking redesignation fails to meet the requirements in 117 subsection \(b\)\(2\)\(A\) … \(F\) above, the application shall be denied and the original designation will 118 expire on its expiration date. 119 )>>endobj1707 0 obj<</Dest[19 0 R/XYZ 36 400 null]/Next 1706 0 R/Parent 999 0 R/Prev 1708 0 R/SE 156 0 R/Title( 116 )>>endobj1708 0 obj<</Dest[19 0 R/XYZ 36 441 null]/Next 1707 0 R/Parent 999 0 R/Prev 1709 0 R/SE 155 0 R/Title(\(4\) Renewal of designation. The applicant shall submit the documents 113 described in subsection \(b\)\(2\)\(A\) … \(F\) above, to the office at least 90 days prior to the 114 designation expiration date. 115 )>>endobj1709 0 obj<</Dest[19 0 R/XYZ 36 455 null]/Next 1708 0 R/Parent 999 0 R/Prev 1710 0 R/SE 154 0 R/Title( 112 )>>endobj1710 0 obj<</Dest[19 0 R/XYZ 36 497 null]/Next 1709 0 R/Parent 999 0 R/Prev 1711 0 R/SE 153 0 R/Title(\(3\) If a facility seeking initial designation fails to meet the requirements in 109 subsections \(b\)\(1\) … \(2\) above, the application shall be considered withdrawn by the 110 facility. 111 )>>endobj1711 0 obj<</Dest[19 0 R/XYZ 36 510 null]/Next 1710 0 R/Parent 999 0 R/Prev 1712 0 R/SE 152 0 R/Title( 108 )>>endobj1712 0 obj<</Dest[19 0 R/XYZ 36 524 null]/Next 1711 0 R/Parent 999 0 R/Prev 1713 0 R/SE 151 0 R/Title(\(F\) evidence of submission of data to the department trauma registry. 107 )>>endobj1713 0 obj<</Dest[19 0 R/XYZ 36 538 null]/Next 1712 0 R/Parent 999 0 R/Prev 1714 0 R/SE 150 0 R/Title( 106 )>>endobj1714 0 obj<</Dest[19 0 R/XYZ 36 566 null]/Next 1713 0 R/Parent 999 0 R/Prev 1715 0 R/SE 149 0 R/Title(\(E\) evidence of participation in the applicable Regional Advisory 104 Council \(RAC\); and 105 )>>endobj1715 0 obj<</Dest[19 0 R/XYZ 36 579 null]/Next 1714 0 R/Parent 999 0 R/Prev 1716 0 R/SE 148 0 R/Title( 103 )>>endobj1716 0 obj<</Dest[19 0 R/XYZ 36 662 null]/Next 1715 0 R/Parent 999 0 R/Prev 1717 0 R/SE 147 0 R/Title(\(D\) a plan of correction \(POC\), detailing how the facility will correct 97 any deficiencies cited in the survey report, to include: statement of the cited deficiency, the 98 corrective action to ensure compliance with the requirement, the title of the\ individual\(s\) 99 responsible for ensuring the correction action\(s\) is implemented, the date by which the corrective 100 action will be implemented, not to exceed 90 days from the date the facility received the official 101 survey report, and how the \corrective)>>endobj1717 0 obj<</Dest[19 0 R/XYZ 42 676 null]/Next 1716 0 R/Parent 999 0 R/Prev 1718 0 R/SE 146 0 R/Title( 96 )>>endobj1718 0 obj<</Dest[19 0 R/XYZ 42 717 null]/Next 1717 0 R/Parent 999 0 R/Prev 1719 0 R/SE 144 0 R/Title(\(C\) a completed trauma designation survey report, including patient 93 care reviews, if required by the department, submitted no later than 180 days from the date of the 94 survey; 95 )>>endobj1719 0 obj<</Dest[12 0 R/XYZ 42 96 null]/Next 1718 0 R/Parent 999 0 R/Prev 1720 0 R/SE 143 0 R/Title( 92 )>>endobj1720 0 obj<</Dest[12 0 R/XYZ 42 124 null]/Next 1719 0 R/Parent 999 0 R/Prev 1721 0 R/SE 142 0 R/Title(\(B\) any subsequent documents submitted by the date requested by the 90 office; 91 )>>endobj1721 0 obj<</Dest[12 0 R/XYZ 42 138 null]/Next 1720 0 R/Parent 999 0 R/Prev 1722 0 R/SE 141 0 R/Title( 89 )>>endobj1722 0 obj<</Dest[12 0 R/XYZ 42 152 null]/Next 1721 0 R/Parent 999 0 R/Prev 1723 0 R/SE 140 0 R/Title( 88 )>>endobj1723 0 obj<</Dest[12 0 R/XYZ 42 179 null]/Next 1722 0 R/Parent 999 0 R/Prev 1724 0 R/SE 139 0 R/Title(\(iii\) Level IV trauma facility applicants, the fee will be no more 86 than $10 per licensed bed with an upper limit of $1000 and a lower limit of $500. 87 )>>endobj1724 0 obj<</Dest[12 0 R/XYZ 42 193 null]/Next 1723 0 R/Parent 999 0 R/Prev 1725 0 R/SE 138 0 R/Title( 85 )>>endobj1725 0 obj<</Dest[12 0 R/XYZ 42 221 null]/Next 1724 0 R/Parent 999 0 R/Prev 1726 0 R/SE 137 0 R/Title(\(ii\) Level III trauma facility applicants, the fee will be no more 83 than $10 per licensed bed with an upper limit of $2,500 and a lower limit of $1,500; and 84 )>>endobj1726 0 obj<</Dest[12 0 R/XYZ 42 234 null]/Next 1725 0 R/Parent 999 0 R/Prev 1727 0 R/SE 136 0 R/Title( 82 )>>endobj1727 0 obj<</Dest[12 0 R/XYZ 42 262 null]/Next 1726 0 R/Parent 999 0 R/Prev 1728 0 R/SE 135 0 R/Title(\(i\) Level I and Level II trauma facility applicants, the fee will 80 be no more than $10 per licensed bed with an upper limit of $5,000 and a lower limit of $4,000; 81 )>>endobj1728 0 obj<</Dest[12 0 R/XYZ 42 276 null]/Next 1727 0 R/Parent 999 0 R/Prev 1729 0 R/SE 134 0 R/Title( 79 )>>endobj1729 0 obj<</Dest[12 0 R/XYZ 42 317 null]/Next 1728 0 R/Parent 999 0 R/Prev 1730 0 R/SE 133 0 R/Title(\(A\) an accurate and complete designation application form for the 76 appropriate level of requested designation, including full payment of the non-refundable, non-77 transferrable, designation fee as follows; 78 )>>endobj1730 0 obj<</Dest[12 0 R/XYZ 42 331 null]/Next 1729 0 R/Parent 999 0 R/Prev 1731 0 R/SE 132 0 R/Title( 75 )>>endobj1731 0 obj<</Dest[12 0 R/XYZ 42 359 null]/Next 1730 0 R/Parent 999 0 R/Prev 1732 0 R/SE 131 0 R/Title(\(2\) Application. A facility seeking designation, shall submit a completed 73 application to include: 74 )>>endobj1732 0 obj<</Dest[12 0 R/XYZ 42 372 null]/Next 1731 0 R/Parent 999 0 R/Prev 1733 0 R/SE 130 0 R/Title( 72 )>>endobj1733 0 obj<</Dest[12 0 R/XYZ 42 441 null]/Next 1732 0 R/Parent 999 0 R/Prev 1734 0 R/SE 129 0 R/Title(\(1\) Initial designation of a trauma facility. The CEO, TMD and TPM of the 67 facility shall attend a presurvey conference at the office designated by the department. 68 The purpose of the presurvey conference, conducted by department staff, is to revie\w and 69 discuss the designation requirements for the applicable level prior to the initial onsite 70 designation survey. The department may waive the presurvey conference requirement. 71 )>>endobj1734 0 obj<</Dest[12 0 R/XYZ 42 455 null]/Next 1733 0 R/Parent 999 0 R/Prev 1735 0 R/SE 128 0 R/Title( 66 )>>endobj1735 0 obj<</Dest[12 0 R/XYZ 42 469 null]/Next 1734 0 R/Parent 999 0 R/Prev 1736 0 R/SE 127 0 R/Title(\(b\) Designation Process. 65 )>>endobj1736 0 obj<</Dest[12 0 R/XYZ 42 483 null]/Next 1735 0 R/Parent 999 0 R/Prev 1737 0 R/SE 126 0 R/Title( 64 )>>endobj1737 0 obj<</Dest[12 0 R/XYZ 42 524 null]/Next 1736 0 R/Parent 999 0 R/Prev 1738 0 R/SE 125 0 R/Title(\(6\) In Active Pursuit of Designation \(IAP\) -- subsection applies only to an 61 undesignated facility in accordance with Texas Administrative Code \(TAC\) Designated 62 Trauma Facility and Emergency Medical Services Account Section 157.131\(a\)\(10\). \63 )>>endobj1738 0 obj<</Dest[12 0 R/XYZ 42 538 null]/Next 1737 0 R/Parent 999 0 R/Prev 1739 0 R/SE 124 0 R/Title( 60 )>>endobj1739 0 obj<</Dest[12 0 R/XYZ 42 566 null]/Next 1738 0 R/Parent 999 0 R/Prev 1740 0 R/SE 123 0 R/Title(\(D\) Basic \(Level IV\) trauma facility designation. The facility shall 58 meet the Level IV Program Requirements in subsection \(n\) of this section. 59 )>>endobj1740 0 obj<</Dest[12 0 R/XYZ 42 579 null]/Next 1739 0 R/Parent 999 0 R/Prev 1741 0 R/SE 122 0 R/Title( 57 )>>endobj1741 0 obj<</Dest[12 0 R/XYZ 42 621 null]/Next 1740 0 R/Parent 999 0 R/Prev 1742 0 R/SE 121 0 R/Title(\(C\) Advanced \(Level III\) trauma facility designation. The facility shall 54 meet the "Level III Program RequirementsŽ in subsection \(m\) of this section, or the facility shall 55 meet the current ACS essential criteria for a verified Level III traum\a center. 56 )>>endobj1742 0 obj<</Dest[12 0 R/XYZ 42 635 null]/Next 1741 0 R/Parent 999 0 R/Prev 1743 0 R/SE 120 0 R/Title( 53 )>>endobj1743 0 obj<</Dest[12 0 R/XYZ 42 662 null]/Next 1742 0 R/Parent 999 0 R/Prev 1744 0 R/SE 119 0 R/Title(\(B\) Major \(Level II\) trauma facility designation. The facility shall 51 meet the current ACS essential criteria for a verified Level II trauma center. 52 )>>endobj1744 0 obj<</Dest[12 0 R/XYZ 42 676 null]/Next 1743 0 R/Parent 999 0 R/Prev 1745 0 R/SE 118 0 R/Title( 50 )>>endobj1745 0 obj<</Dest[12 0 R/XYZ 42 717 null]/Next 1744 0 R/Parent 999 0 R/Prev 1746 0 R/SE 116 0 R/Title(\(A\) Comprehensive \(Level I\) trauma facility designation. The facility 47 shall meet the current American College of Surgeons \(ACS\) essential criteria for a verified Level 48 I trauma center. 49 )>>endobj1746 0 obj<</Dest[3 0 R/XYZ 42 96 null]/Next 1745 0 R/Parent 999 0 R/Prev 1747 0 R/SE 115 0 R/Title( 46 )>>endobj1747 0 obj<</Dest[3 0 R/XYZ 42 124 null]/Next 1746 0 R/Parent 999 0 R/Prev 1748 0 R/SE 114 0 R/Title(\(5\) The four levels of trauma designation and the requirements for each are as 44 follows: 45 )>>endobj1748 0 obj<</Dest[3 0 R/XYZ 42 138 null]/Next 1747 0 R/Parent 999 0 R/Prev 1749 0 R/SE 113 0 R/Title( 43 )>>endobj1749 0 obj<</Dest[3 0 R/XYZ 42 193 null]/Next 1748 0 R/Parent 999 0 R/Prev 1750 0 R/SE 112 0 R/Title(\(4\) a trauma facility designation is issued for the physical location and to the 39 legal owner of the operations of the facility. If a designated facility has a change of ownership or 40 a change of the physical location of the facility, the designatio\n shall not be transferred or 41 assigned. 42 )>>endobj1750 0 obj<</Dest[3 0 R/XYZ 42 207 null]/Next 1749 0 R/Parent 999 0 R/Prev 1751 0 R/SE 111 0 R/Title( 38 )>>endobj1751 0 obj<</Dest[3 0 R/XYZ 42 221 null]/Next 1750 0 R/Parent 999 0 R/Prev 1752 0 R/SE 110 0 R/Title( 37 )>>endobj1752 0 obj<</Dest[3 0 R/XYZ 42 248 null]/Next 1751 0 R/Parent 999 0 R/Prev 1753 0 R/SE 109 0 R/Title(\(iii\) Departments or services within a facility shall not be 35 separately designated. 36 )>>endobj1753 0 obj<</Dest[3 0 R/XYZ 42 262 null]/Next 1752 0 R/Parent 999 0 R/Prev 1754 0 R/SE 108 0 R/Title( 34 )>>endobj1754 0 obj<</Dest[3 0 R/XYZ 42 303 null]/Next 1753 0 R/Parent 999 0 R/Prev 1755 0 R/SE 107 0 R/Title(\(ii\) Designation does not include provider based departments 31 of the designated facility, which are not contiguous with the designated 32 facility; and 33 )>>endobj1755 0 obj<</Dest[3 0 R/XYZ 42 317 null]/Next 1754 0 R/Parent 999 0 R/Prev 1756 0 R/SE 106 0 R/Title( 30 )>>endobj1756 0 obj<</Dest[3 0 R/XYZ 42 359 null]/Next 1755 0 R/Parent 999 0 R/Prev 1757 0 R/SE 105 0 R/Title(\(i\) Each facility operating on a single general hospital license 27 with multiple locations \(multi-location license\) shall be considered 28 separately for designation. 29 )>>endobj1757 0 obj<</Dest[3 0 R/XYZ 42 372 null]/Next 1756 0 R/Parent 999 0 R/Prev 1758 0 R/SE 104 0 R/Title( 26 )>>endobj1758 0 obj<</Dest[3 0 R/XYZ 42 386 null]/Next 1757 0 R/Parent 999 0 R/Prev 1759 0 R/SE 103 0 R/Title(\(C\) a general hospital owned and operated by the federal government. 25 )>>endobj1759 0 obj<</Dest[3 0 R/XYZ 42 400 null]/Next 1758 0 R/Parent 999 0 R/Prev 1760 0 R/SE 102 0 R/Title( 24 )>>endobj1760 0 obj<</Dest[3 0 R/XYZ 42 414 null]/Next 1759 0 R/Parent 999 0 R/Prev 1761 0 R/SE 101 0 R/Title(\(B\) a general hospital owned and operated by the state of Texas, or 23 )>>endobj1761 0 obj<</Dest[3 0 R/XYZ 42 428 null]/Next 1760 0 R/Parent 999 0 R/Prev 1762 0 R/SE 100 0 R/Title( 22 )>>endobj1762 0 obj<</Dest[3 0 R/XYZ 42 455 null]/Next 1761 0 R/Parent 999 0 R/Prev 1763 0 R/SE 99 0 R/Title(\(A\) A General Hospital, licensed or otherwise meeting the description 20 \(in accordance with Texas Administrative Code \(TAC\) Hospital Licensing Section 133.21\) 21 )>>endobj1763 0 obj<</Dest[3 0 R/XYZ 42 469 null]/Next 1762 0 R/Parent 999 0 R/Prev 1764 0 R/SE 98 0 R/Title( 19 )>>endobj1764 0 obj<</Dest[3 0 R/XYZ 42 483 null]/Next 1763 0 R/Parent 999 0 R/Prev 1765 0 R/SE 97 0 R/Title(\(3\) Facilities eligible for trauma designation include: 18 )>>endobj1765 0 obj<</Dest[3 0 R/XYZ 42 497 null]/Next 1764 0 R/Parent 999 0 R/Prev 1766 0 R/SE 96 0 R/Title( 17 )>>endobj1766 0 obj<</Dest[3 0 R/XYZ 42 552 null]/Next 1765 0 R/Parent 999 0 R/Prev 1767 0 R/SE 95 0 R/Title(\(2\) The Office of Emergency Medical Services \(EMS\)/Trauma Systems 13 Coordination \(office\) shall recommend to the Commissioner of the Department of State Health 14 Services \(commissioner\) the trauma designation of a facility at the level the offic\e deems 15 appropriate. 16 )>>endobj1767 0 obj<</Dest[3 0 R/XYZ 42 566 null]/Next 1766 0 R/Parent 999 0 R/Prev 1768 0 R/SE 94 0 R/Title( 12 )>>endobj1768 0 obj<</Dest[3 0 R/XYZ 42 621 null]/Next 1767 0 R/Parent 999 0 R/Prev 1769 0 R/SE 93 0 R/Title(\(1\) The Department of State Health Services \(department\) shall determine the 8 designation level for each location, based on, but not limited to, the location's own resources and 9 levels of care capabilities; Trauma Service Area \(TSA\) capabilities;\ and compliance with the 10 essential criteria and standard requirements outlined in this section. 11 )>>endobj1769 0 obj<</Dest[3 0 R/XYZ 48 635 null]/Next 1768 0 R/Parent 999 0 R/Prev 1770 0 R/SE 92 0 R/Title( 7 )>>endobj1770 0 obj<</Dest[3 0 R/XYZ 48 690 null]/Next 1769 0 R/Parent 999 0 R/Prev 1771 0 R/SE 91 0 R/Title(\(a\) General Provisions. The goal of the trauma system is to reduce the morbidity and 3 mortality of the trauma patient. The objective of the trauma system is to get the right patient, to 4 the right place, at the right time, to receive the right care. T\he purpose of this section is to set 5 forth the requirements for a health care facility to become a designated trauma facility. 6 )>>endobj1771 0 obj<</Dest[3 0 R/XYZ 48 704 null]/Next 1770 0 R/Parent 999 0 R/Prev 1000 0 R/SE 90 0 R/Title( 2 )>>endobj1772 0 obj<</Dest[21 0 R/XYZ 36 456 null]/Parent 1681 0 R/SE 191 0 R/Title(\(iv\) the current Executive Sponsor of the trauma program 158 )>>endobj1773 0 obj<</Count 1/Dest[21 0 R/XYZ 36 469 null]/First 1774 0 R/Last 1774 0 R/Next 1681 0 R/Parent 1679 0 R/Prev 1775 0 R/SE 188 0 R/Title(\(iii\) the current Trauma Medical Director 157 )>>endobj1774 0 obj<</Dest[21 0 R/XYZ 36 469 null]/Parent 1773 0 R/SE 189 0 R/Title(\(iii\) the current Trauma Medical Director 157 )>>endobj1775 0 obj<</Count 1/Dest[21 0 R/XYZ 36 483 null]/First 1776 0 R/Last 1776 0 R/Next 1773 0 R/Parent 1679 0 R/Prev 1680 0 R/SE 186 0 R/Title(\(ii\) the Chief Nursing Officer 156 )>>endobj1776 0 obj<</Dest[21 0 R/XYZ 36 483 null]/Parent 1775 0 R/SE 187 0 R/Title(\(ii\) the Chief Nursing Officer 156 )>>endobj1777 0 obj<</Dest[21 0 R/XYZ 36 497 null]/Parent 1680 0 R/SE 185 0 R/Title(\(i\) the Chief Executive Officer 155 )>>endobj1778 0 obj<</Dest[21 0 R/XYZ 36 235 null]/Parent 1671 0 R/SE 201 0 R/Title(\(7\) A recommendation for designation will be made to the commissioner if the 174 facility meets the requirements for designation found in this section. 175 )>>endobj1779 0 obj<</Dest[27 0 R/XYZ 36 580 null]/Parent 1658 0 R/SE 216 0 R/Title(\(9\) The facility shall have the right to withdraw its application at any time prior to 195 being recommended for trauma facility designation by the office. 196 )>>endobj1780 0 obj<</Dest[31 0 R/XYZ 36 359 null]/Parent 1603 0 R/SE 274 0 R/Title(\(iv\) the availability of all necessary equipment and services to 303 provide the appropriate level of care and support of the 304 patient population served; 305 )>>endobj1781 0 obj<</Dest[31 0 R/XYZ 36 304 null]/Parent 1600 0 R/SE 278 0 R/Title(\(v\) a written policy and procedure for massive transfusion 307 developed collaboratively between the trauma service and 308 the blood bank and appropriate resources for 309 implementation; 310 )>>endobj1782 0 obj<</Dest[33 0 R/XYZ 36 235 null]/Parent 1572 0 R/SE 308 0 R/Title(\(A\) The Trauma QAPI plan shall be reviewed and approved by the 358 facility•s governing body. The governing body shall ensure that the 359 requirements of this section are implemented and enforced. 360 )>>endobj1783 0 obj<</Dest[33 0 R/XYZ 36 152 null]/Parent 1567 0 R/SE 314 0 R/Title(\(i\) A description of the facility's trauma program and the 364 services provided. All facility services \(including those 365 services furnished under contract or arrangement\) shall 366 focus on decreasing deviations from the trauma standards 367 )>>endobj1784 0 obj<</Dest[35 0 R/XYZ 36 717 null]/Parent 1565 0 R/SE 317 0 R/Title(of care to ensure achievement of optimal trauma outcomes, 368 patient safety standards and cost effective care. 369 )>>endobj1785 0 obj<</Dest[35 0 R/XYZ 36 677 null]/Parent 1562 0 R/SE 322 0 R/Title(\(ii\) Demonstrate how the staff evaluate the provision of trauma 371 care and patient services, identify opportunities for 372 improvement, develop and implement improvement plans, 373 and evaluate the implementation of those plans until 374 resolution i\s achieved. Evidence shall support that 375 aggregate patient data, including identification and tracking 376 of trauma patient complications or variances from 377 standards of care, is continuously reviewed for trends by 378 the trauma multidisciplinary \QAPI)>>endobj1786 0 obj<</Dest[35 0 R/XYZ 36 538 null]/Parent 1559 0 R/SE 326 0 R/Title(\(iii\) Composition of the Trauma Multidisciplinary QAPI 381 committee to include the trauma medical director \(TMD\), 382 the trauma program manager \(TPM\), an executive officer 383 of the facility, a trauma nurse active in the management of 384 trauma \patients, a trauma nurse active in the management 385 of pediatric trauma patients as applicable, and physicians 386 and surgeons that provide coverage or care to trauma 387 patients, and other healthcare professionals participating in 388 the care of maj\or or se)>>endobj1787 0 obj<</Dest[35 0 R/XYZ 36 400 null]/Parent 1556 0 R/SE 330 0 R/Title(\(iv\) Committee meeting documentation of the attendance, 391 activities, actions, and follow-up with ongoing monthly 392 review of key elements of trauma care. 393 )>>endobj1788 0 obj<</Dest[35 0 R/XYZ 36 304 null]/Parent 1550 0 R/SE 337 0 R/Title(\(A\) A defined individual to coordinate the facility•s community outreach 398 and education programs for the public and professionals is evident; 399 )>>endobj1789 0 obj<</Dest[35 0 R/XYZ 36 262 null]/Parent 1547 0 R/SE 341 0 R/Title(\(B\) Provide education to and consultations with physicians of the 401 community and outlying areas; and 402 )>>endobj1790 0 obj<</Dest[35 0 R/XYZ 36 97 null]/Parent 1544 0 R/SE 357 0 R/Title(\(vi\) prehospital personnel; and 413 )>>endobj1791 0 obj<</Count 1/Dest[35 0 R/XYZ 36 111 null]/First 1792 0 R/Last 1792 0 R/Next 1544 0 R/Parent 1542 0 R/Prev 1793 0 R/SE 354 0 R/Title(\(v\) specialty and community physicians; 412 )>>endobj1792 0 obj<</Dest[35 0 R/XYZ 36 111 null]/Parent 1791 0 R/SE 355 0 R/Title(\(v\) specialty and community physicians; 412 )>>endobj1793 0 obj<</Count 1/Dest[35 0 R/XYZ 36 124 null]/First 1794 0 R/Last 1794 0 R/Next 1791 0 R/Parent 1542 0 R/Prev 1795 0 R/SE 352 0 R/Title(\(iv\) allied health personnel 411 )>>endobj1794 0 obj<</Dest[35 0 R/XYZ 36 124 null]/Parent 1793 0 R/SE 353 0 R/Title(\(iv\) allied health personnel 411 )>>endobj1795 0 obj<</Count 1/Dest[35 0 R/XYZ 36 152 null]/First 1796 0 R/Last 1796 0 R/Next 1793 0 R/Parent 1542 0 R/Prev 1797 0 R/SE 350 0 R/Title(\(iii\) Advanced Practice clinicians including Physician 409 Assistants and Advanced Nurse Practitioners; 410 )>>endobj1796 0 obj<</Dest[35 0 R/XYZ 36 152 null]/Parent 1795 0 R/SE 351 0 R/Title(\(iii\) Advanced Practice clinicians including Physician 409 Assistants and Advanced Nurse Practitioners; 410 )>>endobj1797 0 obj<</Count 1/Dest[35 0 R/XYZ 36 166 null]/First 1798 0 R/Last 1798 0 R/Next 1795 0 R/Parent 1542 0 R/Prev 1799 0 R/SE 348 0 R/Title(\(ii\) nurses; 408 )>>endobj1798 0 obj<</Dest[35 0 R/XYZ 36 166 null]/Parent 1797 0 R/SE 349 0 R/Title(\(ii\) nurses; 408 )>>endobj1799 0 obj<</Count 1/Dest[35 0 R/XYZ 36 180 null]/First 1800 0 R/Last 1800 0 R/Next 1797 0 R/Parent 1542 0 R/Prev 1543 0 R/SE 346 0 R/Title(\(i\) staff physicians; 407 )>>endobj1800 0 obj<</Dest[35 0 R/XYZ 36 180 null]/Parent 1799 0 R/SE 347 0 R/Title(\(i\) staff physicians; 407 )>>endobj1801 0 obj<</Dest[35 0 R/XYZ 36 221 null]/Parent 1543 0 R/SE 345 0 R/Title(\(C\) Training programs in trauma continuing education provided by facility 404 for staff and community members involved in trauma care based on 405 needs identified from the QAPI program for: 406 )>>endobj1802 0 obj<</Dest[44 0 R/XYZ 36 718 null]/Parent 1541 0 R/SE 360 0 R/Title(\(vii\) other appropriate personnel involved in trauma care 414 )>>endobj1803 0 obj<</Dest[44 0 R/XYZ 36 663 null]/Parent 1536 0 R/SE 367 0 R/Title(\(A\) A public education program to address the major injury problems 418 identified within the facility•s service area; and 419 )>>endobj1804 0 obj<</Dest[44 0 R/XYZ 36 621 null]/Parent 1533 0 R/SE 371 0 R/Title(\(B\) Coordination and/or participation in community and/or RAC injury 421 prevention activities. 422 )>>endobj1805 0 obj<</Dest[46 0 R/XYZ 36 290 null]/Parent 1492 0 R/SE 416 0 R/Title(\(i\) shall be a registered nurse; 491 )>>endobj1806 0 obj<</Dest[46 0 R/XYZ 36 304 null]/Parent 1491 0 R/SE 414 0 R/Title(\(A\) The TPM: 490 )>>endobj1807 0 obj<</Dest[46 0 R/XYZ 36 262 null]/Parent 1488 0 R/SE 420 0 R/Title(\(ii\) is current in the Trauma Nurse Core Course \(TNCC\) or 493 Advanced Trauma Course for Nurses \(ATCN\) or a DSHS-494 approved equivalent; 495 )>>endobj1808 0 obj<</Dest[46 0 R/XYZ 36 207 null]/Parent 1485 0 R/SE 424 0 R/Title(\(iii\) is current in a nationally recognized pediatric advanced life 497 support course \(\(e.g. Pediatric Advanced Life Support 498 \(PALS\) or the Emergency Nurse Pediatric Course 499 \(ENPC\)\); 500 )>>endobj1809 0 obj<</Dest[46 0 R/XYZ 36 138 null]/Parent 1482 0 R/SE 428 0 R/Title(\(iv\) has completed a course designed for his/her role which 502 provides essential information on the structure, process, 503 organization and administrative responsibilities of a trauma 504 )>>endobj1810 0 obj<</Dest[48 0 R/XYZ 36 717 null]/Parent 1480 0 R/SE 431 0 R/Title(program \(e.g. Trauma Coordinators Core Course \(TCCC\) 505 or an office approved equivalent course\); 506 )>>endobj1811 0 obj<</Dest[48 0 R/XYZ 36 677 null]/Parent 1477 0 R/SE 436 0 R/Title(\(v\) has completed a course designed for his/her role which 508 provides essential information of a trauma PI program to 509 include trauma outcomes and performance improvement 510 \(e.g. Trauma Outcomes Performance Improvement Course 511 \(TOPIC\) or an\ office approved equivalent course\); 512 )>>endobj1812 0 obj<</Dest[48 0 R/XYZ 36 594 null]/Parent 1474 0 R/SE 440 0 R/Title(\(vi\) is responsible for the integration of trauma nursing 514 standards of care; 515 )>>endobj1813 0 obj<</Dest[48 0 R/XYZ 36 552 null]/Parent 1471 0 R/SE 444 0 R/Title(\(vii\) has the responsibility and authority to: 517 )>>endobj1814 0 obj<</Dest[48 0 R/XYZ 36 525 null]/Parent 1468 0 R/SE 448 0 R/Title(\(I\) monitor the clinical outcomes, direction 519 and oversight of the trauma program. 520 )>>endobj1815 0 obj<</Dest[48 0 R/XYZ 36 483 null]/Parent 1465 0 R/SE 452 0 R/Title(\(II\) monitor trauma patient care from ED 522 arrival through operative intervention\(s\), 523 ICU care, stabilization, rehabilitation care, 524 and discharge, including the trauma 525 performance improvement \(PI\) program; 526 )>>endobj1816 0 obj<</Dest[48 0 R/XYZ 36 400 null]/Parent 1462 0 R/SE 456 0 R/Title(\(viii\) participates in a leadership role in the facility including the 528 facility-wide QAPI Committee, community, and regional 529 emergency management \(disaster\) response committee; and 530 )>>endobj1817 0 obj<</Dest[48 0 R/XYZ 36 221 null]/Parent 1453 0 R/SE 466 0 R/Title(\(1\) The Trauma Medical Director shall be a physician who is: 541 )>>endobj1818 0 obj<</Dest[48 0 R/XYZ 36 138 null]/Parent 1448 0 R/SE 472 0 R/Title(\(B\) a general surgeon who has continuously served as the Trauma Medical 547 Director at the designated facility for the last consecutive five years 548 and is currently credentialed in Advanced Trauma Life Support 549 \(ATLS\). 550 )>>endobj1819 0 obj<</Dest[50 0 R/XYZ 36 704 null]/Parent 1445 0 R/SE 477 0 R/Title(\(2\) General Surgery. 552 )>>endobj1820 0 obj<</Dest[52 0 R/XYZ 36 566 null]/Parent 1412 0 R/SE 512 0 R/Title(\(A\) Orthopedic and Neurosurgery surgeons shall: 608 )>>endobj1821 0 obj<</Dest[52 0 R/XYZ 36 538 null]/Parent 1409 0 R/SE 516 0 R/Title(\(i\) be board certified or board eligible in the applicable 610 surgical specialty; or 611 )>>endobj1822 0 obj<</Dest[52 0 R/XYZ 36 442 null]/Parent 1404 0 R/SE 522 0 R/Title(\(iii\) be appropriately credentialed through the trauma service; 617 )>>endobj1823 0 obj<</Dest[52 0 R/XYZ 36 414 null]/Parent 1401 0 R/SE 526 0 R/Title(\(iv\) average at least 9 hours of traumarelated continuing 619 medical education annually; 620 )>>endobj1824 0 obj<</Dest[52 0 R/XYZ 36 373 null]/Parent 1398 0 R/SE 530 0 R/Title(\(v\) maintain compliance with trauma protocols; 622 )>>endobj1825 0 obj<</Dest[52 0 R/XYZ 36 345 null]/Parent 1395 0 R/SE 534 0 R/Title(\(vi\) participate in the trauma QAPI/Multidisciplinary PI 624 program and a designated liaison shall attend at least 50% 625 of the trauma multidisciplinary and peer review trauma 626 committee meetings; and 627 )>>endobj1826 0 obj<</Dest[52 0 R/XYZ 36 276 null]/Parent 1392 0 R/SE 538 0 R/Title(\(vii\) at a minimum, orthopedic surgeons and neurosurgeons, 629 participate in the published, on-call schedule and backup 630 on-call schedule or plan readily available to all staff to 631 obtain specialty surgical care. 632 )>>endobj1827 0 obj<</Dest[54 0 R/XYZ 36 456 null]/Parent 1371 0 R/SE 561 0 R/Title(\(6\) Anesthesia Services. If the facility furnishes anesthesia services, it shall do so 662 in compliance with 25 TAC 133.41 Hospital Functions and Services. The 663 anesthesiologist providing trauma coverage shall: 664 )>>endobj1828 0 obj<</Dest[54 0 R/XYZ 36 152 null]/Parent 1354 0 R/SE 579 0 R/Title(\(7\) Radiology Services. 684 )>>endobj1829 0 obj<</Dest[54 0 R/XYZ 36 124 null]/Parent 1351 0 R/SE 583 0 R/Title(\(A\) A radiologist shall be oncall and promptly available within 30 686 minutes of request from inside or outside the hospital. This system 687 shall be continuously monitored by the trauma PI program. 688 )>>endobj1830 0 obj<</Dest[56 0 R/XYZ 36 704 null]/Parent 1348 0 R/SE 588 0 R/Title(\(B\) The rate of change in interpretation of radiologic studies must be 690 routinely monitored and reviewed with the radiology department. 691 Identified cases should be reviewed to determine the reason for 692 misinterpretation, adverse outcomes, and \opportunities for 693 improvement. 694 )>>endobj1831 0 obj<</Dest[56 0 R/XYZ 36 621 null]/Parent 1345 0 R/SE 592 0 R/Title(\(8\) Advanced Practice clinicians \(advanced practice registered nurses or 696 physician assistants\) utilized in the care of major and/or severe trauma 697 patients, shall not be a substitute for the required physician response, in 698 patient care pla\nning nor in QAPI activities. Any Advanced Practice clinician 699 who provides care to trauma patients shall be current in ATLS and be 700 appropriately credentialed by the Texas Board of Nursing \(TBON\) or the 701 Texas Medical Board \(TMB\) respectivel\y. 702 )>>endobj1832 0 obj<</Dest[56 0 R/XYZ 36 511 null]/Parent 1342 0 R/SE 596 0 R/Title(\(9\) Nursing Staff. As part of the facility•s trauma program approved by the 704 governing body, the program will have an identified Trauma Program 705 Manager with equivalent authority and responsibility as granted to other 706 department or nurse manag\ers. There shall be a demonstrated commitment by 707 the facility for furthering the education and understanding of trauma standards 708 of care for all nursing staff caring for the trauma patient. 709 )>>endobj1833 0 obj<</Dest[56 0 R/XYZ 36 414 null]/Parent 1339 0 R/SE 600 0 R/Title(\(10\) Nursing Services for all critical care and patient care areas shall provide 711 evidence of the following: 712 )>>endobj1834 0 obj<</Dest[58 0 R/XYZ 36 400 null]/Parent 1319 0 R/SE 623 0 R/Title(\(11\) Texas EMS/Trauma Registry Requirements. Any designated trauma 757 facility must participate in the Texas EMS/Trauma Registry. Participation 758 shall include: 759 )>>endobj1835 0 obj<</Dest[60 0 R/XYZ 36 469 null]/Parent 1296 0 R/SE 648 0 R/Title(\(A\) The facility shall provide equipment and supplies in compliance with 798 25 TAC 133.41 Hospital Functions and Services \(e\)\(3\)-\(4\). 799 )>>endobj1836 0 obj<</Dest[60 0 R/XYZ 36 400 null]/Parent 1291 0 R/SE 654 0 R/Title(\(i\) Mechanical ventilator; 803 )>>endobj1837 0 obj<</Dest[60 0 R/XYZ 36 373 null]/Parent 1288 0 R/SE 658 0 R/Title(\(ii\) Supraglottic airway management device \(LMA\); 805 )>>endobj1838 0 obj<</Dest[60 0 R/XYZ 36 345 null]/Parent 1285 0 R/SE 662 0 R/Title(\(iii\) Quantitative end tidal CO2 monitor; 807 )>>endobj1839 0 obj<</Dest[60 0 R/XYZ 36 318 null]/Parent 1282 0 R/SE 666 0 R/Title(\(iv\) Central venous pressure monitoring equipment; 809 )>>endobj1840 0 obj<</Dest[60 0 R/XYZ 36 290 null]/Parent 1279 0 R/SE 670 0 R/Title(\(v\) Internal age-specific paddles; 811 )>>endobj1841 0 obj<</Dest[60 0 R/XYZ 36 262 null]/Parent 1276 0 R/SE 674 0 R/Title(\(vi\) Standard intravenous fluids and administration devices, 813 including large-bore intravenous catheters and a rapid 814 infuser system; 815 )>>endobj1842 0 obj<</Dest[60 0 R/XYZ 36 207 null]/Parent 1273 0 R/SE 678 0 R/Title(\(vii\) Sterile surgical sets for procedures standard for emergency 817 care including but not limited to: thoracostomy, 818 thoracotomy, diagnostic peritoneal lavage, venous 819 cutdown, central line insertion, airway 820 control/cricothyrotomy; 821 )>>endobj1843 0 obj<</Dest[60 0 R/XYZ 36 124 null]/Parent 1270 0 R/SE 682 0 R/Title(\(viii\) Current length-based pediatric body weight & tracheal tube 823 size evaluation system, resuscitation medications and 824 equipment that are dose-appropriate for all ages; 825 )>>endobj1844 0 obj<</Dest[62 0 R/XYZ 36 704 null]/Parent 1267 0 R/SE 687 0 R/Title(\(ix\) Long bone stabilization capability; 827 )>>endobj1845 0 obj<</Dest[62 0 R/XYZ 36 677 null]/Parent 1264 0 R/SE 691 0 R/Title(\(x\) Pelvic stabilization capability; and 829 )>>endobj1846 0 obj<</Dest[62 0 R/XYZ 36 649 null]/Parent 1261 0 R/SE 695 0 R/Title(\(xi\) Thermal control equipment for patients and a rapid 831 warming device for blood and fluids; 832 )>>endobj1847 0 obj<</Dest[62 0 R/XYZ 36 483 null]/Parent 1254 0 R/SE 703 0 R/Title(\(B\) Services. 843 )>>endobj1848 0 obj<</Dest[62 0 R/XYZ 36 138 null]/Parent 1242 0 R/SE 716 0 R/Title(\(C\) Arrangements for 24-hour surgical coverage of all trauma patients 868 shall be provided for emergencies and routine care. This system shall 869 be continuously monitored by the trauma PI program; 870 )>>endobj1849 0 obj<</Dest[64 0 R/XYZ 36 207 null]/Parent 1215 0 R/SE 745 0 R/Title(\(C\) Spinal cord/head injury rehabilitation management capability. 909 )>>endobj1850 0 obj<</Dest[66 0 R/XYZ 36 608 null]/Parent 1204 0 R/SE 758 0 R/Title(\(ii\) The facility shall have the following services available for a 926 critically injured patient: 927 )>>endobj1851 0 obj<</Dest[66 0 R/XYZ 36 566 null]/Parent 1201 0 R/SE 762 0 R/Title(\(I\) Physical therapy; 929 )>>endobj1852 0 obj<</Dest[66 0 R/XYZ 36 538 null]/Parent 1198 0 R/SE 766 0 R/Title(\(II\) Occupational therapy; 931 )>>endobj1853 0 obj<</Dest[66 0 R/XYZ 36 511 null]/Parent 1195 0 R/SE 770 0 R/Title(\(III\) Speech therapy; and 933 )>>endobj1854 0 obj<</Dest[66 0 R/XYZ 36 483 null]/Parent 1192 0 R/SE 774 0 R/Title(\(IV\) Social services. 935 )>>endobj1855 0 obj<</Dest[66 0 R/XYZ 36 262 null]/Parent 1181 0 R/SE 786 0 R/Title(\(D\) has continuously served as the Trauma Medical Director at the 951 designated facility for the last consecutive five years and is currently 952 credentialed in Advanced Trauma Life Support \(ATLS\). 953 )>>endobj1856 0 obj<</Dest[68 0 R/XYZ 36 414 null]/Parent 1158 0 R/SE 811 0 R/Title(\(A\) A radiologist shall be on-call and promptly available within 30 986 minutes of request from inside or outside the hospital. This system 987 shall be continuously monitored by the trauma PI program. 988 )>>endobj1857 0 obj<</Dest[68 0 R/XYZ 36 359 null]/Parent 1155 0 R/SE 815 0 R/Title(\(B\) The rate of change in interpretation of radiologic studies must be 990 routinely monitored and reviewed with the radiology department. 991 Identified cases should be reviewed to determine the reason for 992 misinterpretation, adverse outcomes, and \opportunities for 993 improvement. 994 )>>endobj1858 0 obj<</Dest[72 0 R/XYZ 30 442 null]/Parent 1116 0 R/SE 857 0 R/Title(\(V\) four hours of continuing education annually specific 1075 to trauma data quality. 1076 )>>endobj1859 0 obj<</Dest[74 0 R/XYZ 30 166 null]/Parent 1071 0 R/SE 904 0 R/Title(\(12\) Specialized Capabilities/Services/Units. 1141 )>>endobj1860 0 obj<</Dest[74 0 R/XYZ 30 138 null]/Parent 1068 0 R/SE 908 0 R/Title(\(A\) Organized Burn Care. 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