TITLE 7 HEALTH
CHAPTER 27 EMERGENCY MEDICAL SERVICES
PART 7 TRAUMA CARE SYSTEM
7.27.7.1 ISSUING AGENCY: New Mexico Department of Health, Public Health Division, Injury Prevention and Emergency Medical Services (EMS) Bureau.
[7.27.7.1 NMAC - Rp 7 NMAC 27.7.1, 6/14/02]
7.27.7.2 SCOPE: These regulations apply to all agencies providing EMS services, local EMS Medical Directors, Regional Trauma Advisory Committees, the Trauma Advisory Committee, the Injury Prevention and EMS Bureau (IPEMS), the New Mexico Department of Health and hospitals participating in the New Mexico Trauma Care System.
[7.27.7.2 NMAC - Rp 7 NMAC 27.7.2, 6/14/02]
7.27.7.3 STATUTORY AUTHORITY: These regulations are promulgated by the Secretary of Health by the authority of Section 9-7-6.E. NMSA 1978, and the Emergency Medical Services (EMS) Act, Section 24-10B-4.H. NMSA 1978 (as amended by Laws of 1993, Chapter 161). Administration and enforcement of the Act is the responsibility of the Injury Prevention and Emergency Medical Services Bureau of the Public Health Division, Department of Health.
[7.27.7.3 NMAC - Rp 7 NMAC 27.7.3, 6/14/02]
7.27.7.4 DURATION: Permanent
[7.27.7.4 NMAC - Rp 7 NMAC 27.7.4, 6/14/02]
7.27.7.5 EFFECTIVE DATE: June 14, 2002, unless a later date is cited at the end of a section.
[7.27.7.5 NMAC - Rp 7 NMAC 27.7.5, 6/14/02]
7.27.7.6 OBJECTIVE: The purpose of these regulations is to implement the trauma system provisions of the EMS Act (as amended by the Laws of 1993, Chapter 161).
A. These regulations set forth standards governing the statewide trauma system in order to:
(1) prevent unnecessary death and disability due to injury,
(2) develop a statewide trauma system to assure timely, quality, cost-efficient and definitive care through coordination of pre-hospital, hospital and post-acute care,
(3) provide optimal care for the trauma patient,
(4) study and identify the epidemiology of injury; and,
(5) pursue trauma prevention activities to decrease the incidence of trauma.
B. These regulations establish procedures for:
(1) statewide trauma system oversight,
(2) requirements for all participating facilities,
(3) the designation process of hospitals/healthcare facilities to provide trauma care services; and,
(4) the development and operation of a statewide trauma registry.
C. These regulations are not intended to constitute detailed procedures for implementation of the state trauma system. Procedures and guidelines are available upon request from the IPEMS Bureau, Trauma Section, Public Health Division, Department of Health, PO Box 26110, Santa Fe, New Mexico, 87502-6110.
D. Trauma system design/components: the trauma system in New Mexico will be designed with the following framework:
(1) system roles and responsibilities define the organizational structure of the people and organizations instrumental to the trauma system. These include:
(a) New Mexico Department of Health
(b) IPEMS Bureau
(c) EMS Regional offices
(d) Trauma Advisory Committee
(e) pre-hospital services
(f) Regional Trauma Councils
(g) acute care facilities
(h) other state trauma systems
(i) evaluation and process improvement systems
(j) injury prevention professionals
(2) system structures are the tools, structure and processes of the trauma systems. These include:
(a) laws and regulations
(b) information systems
(c) evaluation and process improvement systems
E. System oversight:
(1) IPEMS Bureau
(2) Trauma Advisory Committee
(3) Regional Trauma Advisory Councils
(4) system process improvement program
(5) designated trauma centers (levels I-IV)
(6) state and hospital trauma registry
(7) coordinated linkages with pre-hospital care services, rehabilitation facilities and long term care providers
(8) support programs (e.g., public education, prevention, system finance)
F. The system will emphasize an inclusive approach with optimal participation by all providers in the continuum of trauma care.
[7.27.7.6 NMAC - Rp 7 NMAC 27.7.6, 6/14/02]
7.27.7.7 DEFINITIONS: Unless a different meaning is plainly required by the context, the following words and phrases used in these regulations shall have the meanings indicated.
A. “ACLS” means advanced cardiac life support, a course developed by the American Heart Association.
B. “activation of the trauma system” means procedures whereby a pre-hospital provider of hospital/healthcare facility identifies the major trauma patient by trauma triage criteria and pre-hospital and hospital resources are mobilized to care for the patient in accordance with the regional trauma plan and the trauma center’s policy and procedures for trauma team activation.
C. “approved” means approved by the IPEMS Bureau.
D. “ATLS” means advanced trauma life support, a course developed by the American College of Surgeons.
E. “board certified or board eligible” means completion of the examination and award of certification by the appropriate certifying body for the physician specialty. Eligible means meets the standards to sit for the appropriate certifying board and actively pursuing certification.
F. “BP” means blood pressure.
G. “Bureau” means the Injury Prevention and EMS Bureau of the Public Health Division of the Department of Health.
H. “certified ambulance service” means any provider of ambulance service subject to the jurisdiction of the Public Regulation Commission.
I. “continuum of care” means all services available to the population of persons either at risk of injury or who have incurred an injury, beginning with injury prevention and progressing to long term care services and including the return to the highest level of wellness and functioning.
J. “CME” means continuing medical education.
K. “Department” means the New Mexico Department of Health.
L. “designated trauma center” means a hospital identified by the Department as a Level I, II, III, or IV trauma care services provider.
M. “designation” means a formal determination by the Department that a hospital/healthcare facility is capable of providing special resources and care as a designated trauma center.
N. “Emergency Medical Services (EMS) Provider” means Emergency Medical Technicians (EMT) or trained EMS first responders who render care in response to a need for immediate medical care to prevent loss of life or aggravation of physical or psychological illness or injury.
O. “ENPC” means Emergency Nursing Pediatric Course, developed by the Emergency Nurses Association.
P. “E-Code” means external cause code, an etiology included in the International Classification of Diseases (ICD).
Q. “ED” means emergency department.
R. “facility patient care protocols” means the written procedures adopted by the medical staff of a participating facility that directs the care of the patient. These procedures shall be based upon the assessment of the patient’s medical needs and shall follow minimum statewide standards.
S. “hospital” means a facility with an emergency department and physician(s) available, licensed under state statute, or a comparable facility operated by the federal government or located and licensed in another state.
T. “hospital trauma registry” means a computerized trauma data base maintained by a hospital/healthcare facility.
U. “hospital trauma registry policy manual” means a written guideline used by New Mexico trauma data collection personnel to ensure uniform, complete and accurate trauma data.
V. “ICD” means the international classification of diseases, a coding system developed by the World Health organization.
W. “ICU” means intensive care unit.
X. “immediately available” means the immediate and rapid response upon notification and the physical presence of the health professional in the stated location at the time of need by the trauma patient which is continuously monitored by the process improvement plan.
Y. “inclusive trauma system” means a trauma system that encourages optimal participation by all providers in the continuum of trauma care as well as injury prevention, rehabilitation and long-term care service providers.
Z. “indicator” means a process improvement tool or process measure used to monitor the quality of important governance, management, clinical, and support processes and outcomes.
AA. “interfacility transfer criteria” means the criteria established to indicate the need for a level of care for the trauma patient that is not available at the transferring facility.
BB. “letter of intent” means a written document executed by a hospital/healthcare facility’s administration indicating their intention to participate in the New Mexico Trauma System.
CC. “level I trauma center” means a hospital which is designated by the Department as having met the hospital/healthcare facility resource standards for a level I trauma center as described in the most recent version of the Resources for Optimal Care of the Injured Patient, published by the Committee on Trauma of the American College of Surgeons. A level I trauma center is capable of providing immediately available comprehensive care on a twenty-four (24) hour basis for acutely injured patients of all ages. The hospital is committed with resources for the evaluation, stabilization, and definitive care of all injured patients as well as committed to trauma-related research, training, and community outreach. A level I trauma center shall satisfy the requirements for outreach, training and public education as specified in Appendix D, Table 1, Outreach, Training and Public Education Section.
DD. “level II trauma center” means a hospital which is designated by the Department as having met the hospital resource standards for a level II trauma center as described in the most recent version of the Resources for Optimal Care of the Injured Patient, published by the Committee on Trauma of the American College of Surgeons. A level II trauma center is capable of providing promptly available major trauma care on a twenty-four (24) hour basis for acutely injured patients of all ages. The hospital has the capability to provide subspecialty care in most areas and is committed with resources for the evaluation, stabilization, and definitive care of all injured patients. A level II trauma center shall satisfy the requirements for outreach, training and public education as specified in Appendix D, Table 1, Outreach, Training and Public Education Section.
EE. “level III trauma center” means a hospital which is designated by the Department as having met the hospital resource standards for a level III trauma center as described in Appendix D, Table 1 of these regulations. A level III trauma center is capable of providing promptly available trauma care on a twenty-four (24) hour basis, including on-call general surgery and select specialty coverage. The hospital is capable of providing evaluation, initial stabilization, limited ongoing care and for the transfer of acutely injured patients of all ages to level I or level II facilities which can provide further definitive surgical care.
FF. “level IV trauma center” means a hospital or other healthcare facility that is designated by the Department as having met the hospital/healthcare facility resource standards for a level IV trauma center as described in Appendix D, Table1 of these regulations. A level IV trauma center is capable of providing physician-directed basic services for the evaluation, initial stabilization, and early transfer of acutely injured patients of all ages to a higher level of care. Such facilities may have limited on-call general surgical and subspecialty services.
GG. “local EMS medical director” means a physician who is responsible for all aspects of patient care of a local EMS system or EMS provider service, including providing for or ensuring the medical control of EMTs; the development, implementation, and evaluation of protocols and oversight of process improvement activities as described in the Medical Direction for Emergency Medical Services, 7.27.3 NMAC, or such other regulations as may be adopted by the Public Health Division of the Department.
HH. “local trauma transport protocols” means protocols, developed and approved by the Regional Trauma Advisory Councils, to define destination procedures for major trauma patients.
II. “major trauma” means serious injury caused by external forces which may result in death or disability.
JJ. “mid-level practitioner” means an advance practice nurse or physician assistant.
KK. “New Mexico Trauma Foundation” means an organization established to conduct trauma related research, to develop and coordinate trauma injury prevention programs, to coordinate and facilitate the financial viability activities of the designated trauma centers and trauma team participating physicians and other trauma system related activities and purposes.
LL. “Office of the Medical Investigator (OMI)” means the office designated by the State of New Mexico to determine the causes of sudden or unexplained death.
MM. “PALS” means pediatric advance life support, a course developed by the American Heart Association.
NN. “participating facility” means any hospital that treats or admits trauma patients and that is an active participant in their Regional Trauma Advisory Council.
OO. “pediatric trauma patient” means a trauma patient known or estimated to be less than fourteen (14) years of age.
PP. “physician” means a doctor of medicine or osteopathy who is licensed or otherwise authorized to practice medicine or osteopathy in the State of New Mexico.
QQ. “PI” means process improvement, an organized method of monitoring, evaluating and improving care provided throughout the trauma system.
RR. “pre-hospital patient care protocols” means the written procedures adopted by the local EMS medical director or adopted by the Regional Trauma Council which directs the pre-hospital emergency care of a patient.
SS. “promptly available” means the physical presence of the health professionals in the stated location within a specified period of time, which is defined in the local or regional trauma plan and the hospital’s trauma center designation application.
TT. “qualifying trauma patient” means a patient who meets the statewide and approved regional pre-hospital trauma triage criteria and the Bureau approved criteria for statewide trauma registry inclusion.
UU. “recognized” means written acknowledgement by the Bureau.
VV. “region” means a geographic area served by local emergency medical service(s) and/or hospital(s)/healthcare facilities for the purpose of planning a local system which provides care for persons with injuries.
WW. “Regional Trauma Advisory Council (ReTrAC)” means a TAC and Bureau approved group from each recognized trauma region that develops and implements trauma plans that address the particular needs of the trauma service area.
XX. “regional trauma plan” means a document created by a Regional Trauma Advisory Council and approved by the Bureau with the advice of the Trauma Advisory Committee that identifies goals, objectives, guidelines, and standards for the oversight, management and operation of a regional trauma program.
YY. “Secretary” means the Secretary of the New Mexico Department of Health.
ZZ. “trauma” means a major single or multi-system injury requiring immediate medical or surgical intervention or treatment to prevent death or permanent disability.
AAA. “Trauma Advisory Committee (TAC)” means the subcommittee on trauma of the Statewide EMS Advisory Committee established pursuant to the EMS Act.
BBB. “trauma center” means a hospital/healthcare facility designated by the Department to receive and provide services for trauma patients under these regulations.
CCC. “trauma clinical services” means the pre-hospital coordination, hospital resuscitation, hospital inpatient treatment, rehabilitation and follow-up medical care services for trauma patients which are the responsibility of the designated trauma center and the appropriate physician specialist, as defined by these regulations.
DDD. “trauma committee” means a multi-disciplinary, hospital-sponsored committee that meets regularly to provide input to the trauma program and to the hospital’s administrative and medical staff.
EEE. “trauma nurse coordinator” means a registered nurse with experience, special training and certification who is assigned by the trauma center to manage the requirements as provided for in these regulations and to provide trauma program coordination, leadership and direction according to a hospital-approved job classification.
FFF. “trauma program” means an administrative unit of a trauma center that includes the medical director, trauma nurse coordinator, and trauma program support staff, for the ongoing management and coordination of the hospital’s trauma program.
GGG. “TTP” means the approved prehospital trauma transport protocols, developed by the local/regional EMS medical director, that utilize the trauma triage guidelines to determine primary and alternative transport destinations for prehospital providers.
HHH. “trauma registry” means a database which documents and integrates medical and system information related to the provision of trauma care by hospitals/healthcare facilities.
III. “trauma surgeon” means a physician who is Board certified or Board eligible in general surgery, and who has trauma surgery privileges delineated by the hospital/healthcare facility’s medical staff.
JJJ. “trauma system” means an organized approach to providing personnel, trauma centers, and equipment for the coordinated and effective treatment of patients with an injury with the potential of requiring immediate medical or surgical intervention to prevent death or disability. The trauma care system includes prevention activities, pre-hospital care, hospital care, and rehabilitation. The components of a trauma system include:
(1) provision of manpower
(2) training of personnel
(3) communications
(4) transportation
(5) hospitals/healthcare facilities
(6) critical care units
(7) use of public safety agencies
(8) use of private agencies
(9) consumer participation
(10) accessibility to care
(11) transfer of patients
(12) standard medical record keeping and reporting
(13) public information/education and prevention
(14) independent review and evaluation, including formal total process improvement programs
(15) disaster linkages
(16) mutual aid agreements
KKK. “trauma system plan” means the State Trauma Plan that develops the infrastructure needed to support an inclusive statewide trauma system that recognizes the unique geo-political attributes of the regions and empowers the Regional Trauma Councils (ReTrACs) to meet the needs of their regions.
LLL. “trauma team” means personnel assigned for involvement with trauma resuscitation.
MMM. “trauma team physician” means a physician who has been identified by the designated trauma center and its trauma surgeon(s) as a member of the center's trauma team.
NNN. “trauma triage criteria” means the parameters established to identify the high-risk patients for major injury and/or critically injured trauma patients for treatment in accordance with the local trauma transport protocols. The criteria shall include such considerations as the anatomic components, physiologic conditions, and mechanism of injury.
OOO. “triage” means the sorting of trauma patients in terms of disposition, destination, or priority requiring and identifying injury severity and patient risk, so that the appropriate care level can be readily accessed according to patient care guidelines.
[7.27.7.7 NMAC - Rp 7 NMAC 27.7.7 & 7 NMAC 27.7.13, 6/14/02]
7.27.7.8 SYSTEM ADMINISTRATION:
A. General Responsibilities of the IPEMS Bureau:
(1) the Bureau shall administer the process, to designate and re-designate hospitals/healthcare facilities to provide trauma care services in accordance with these regulations.
(2) the Bureau shall establish and manage the Statewide Trauma Registry.
(3) the Bureau shall approve and periodically review statewide and regional pre-hospital trauma triage criteria guidelines, inter-facility transfer criteria for adult and pediatric patients, trauma center standards and the trauma register data set with the advice of the Trauma Advisory Committee (TAC).
(4) the Bureau may recognize the establishment of Regional Trauma Councils (ReTrACs) as appropriate.
(5) the Bureau shall develop and update the State Trauma System Plan periodically with advice from the TAC.
(6) the Bureau shall review, recommend changes to, and approve any proposed regional plans submitted by a ReTrAC, through TAC and shall take into account recommendation from the TAC. This approval shall be based upon consideration of the needs of trauma patients whose care may require resources from more than one (1) region and/or from adjacent states.
(7) the Bureau shall provide technical assistance and support to the TAC, ReTrACs and to hospitals/healthcare facilities and EMS providers as necessary to carry out the Trauma System Plan.
(8) the Bureau shall exercise, as necessary, the right to review, inspect, evaluate and audit all trauma patient records, trauma process improvement plans and committee minutes, physical facilities, and any other documents relevant to trauma care in any designated trauma center to verify compliance with trauma center standards. The Bureau shall maintain the confidentiality of such records in accordance with state and/or federal law.
(9) the Bureau shall facilitate the establishment of a statewide “inclusive” trauma system by encouraging participation of all agencies, facilities and services that treat or admit trauma patients in the statewide trauma data collection process, or in injury prevention programs, or in ReTrAC or in any other manner deemed by the Bureau to improve trauma care.
(10) the Bureau may periodically conduct special studies on the Statewide Trauma System to determine system coverage, quality and extent of care, and financial effect of the system components.
(11) the Bureau may develop other trauma regulations, with advice from TAC, and as necessary, to ensure the quality of the Statewide Trauma System.
(12) the Bureau shall facilitate, and where necessary, develop and maintain public information/education and prevention programs as an integral component of the trauma system.
B. Trauma Advisory Committee: Trauma Advisory Committee (TAC), a subcommittee of the Statewide EMS Advisory Committee established pursuant to the EMS Act, shall:
(1) adopt guidelines, with concurrence of the Statewide EMS Advisory Committee and Bureau, for its operations, including membership, attendance, maintenance of minutes and other guidelines necessary to assure the orderly conduct of business;
(2) periodically review and comment on the Department’s regulations, policies, and standards for trauma;
(3) review and comment annually on the Statewide EMS Advisory Committee’s budget for the trauma system;
(4) advise the Bureau regarding trauma system needs and progress throughout the state;
(5) review and comment on regional trauma plans;
(6) periodically review local/regional pre-hospital trauma triage guidelines and inter-facility transfer criteria; and,
(7) advise the Bureau on injury prevention and public information/educational programs.
C. Regional trauma advisory councils (ReTrACs):
(1) Regional Trauma Advisory Councils (ReTrACs) may be established by application made to the Bureau.
(2) the application shall be in a manner and format prescribed by the Bureau.
(3) such applications shall be reviewed and commented on the TAC prior to approval by the Bureau.
(4) ReTrAC, in order to be recognized, shall submit to the Bureau a membership list which includes a balance of representation from EMS providers, hospital(s)/healthcare facilities and other interested parties.
(5) an approved ReTrAC shall develop, update as appropriate, and implement a regional trauma plan that identifies particular regional needs and sets goals for special regional trauma needs. Additionally, a ReTrAC shall:
(a) seek and consider the recommendations of trauma system providers, governmental entities and consumers,
(b) consider the regional and state analyses provided by the Bureau based on trauma registry data and other appropriate sources; and,
(c) develop and implement regional trauma triage and treatment protocols bypass and diversion plans, process improvement methods and patient care protocols.
(d) the approved ReTrAC shall establish a medical review committee to conduct the regional process improvement program, as defined by the Bureau’s approved process improvement plan, including the review of patient outcome and regional system issues.
(e) the approved ReTrAC shall annually, identify and analyze system and patient care trends and outcomes, based on trauma registry data provided by the Bureau, to evaluate effectiveness of regional trauma system and its component subsystems.
(f) the approved ReTrAC shall advise the Bureau and TAC on other matters relating to the delivery of trauma care within the region; and,
(g) accomplish other purposes as approved by the Bureau.
(6) an approved ReTrAC shall adopt pre-hospital patient care protocols in consultation with the local EMS medical directors, EMS providers, trauma service providers, and emergency communication centers. These protocols shall identify the level of medical care personnel to be dispatched to an emergency scene, procedures for triage of patients, the level of trauma care facility to first receive the patient, and the name and location of other trauma centers to receive the patient should an inter-facility transfer be necessary. Procedures on inter-facility transfer of patients shall be consistent with the inter-facility transfer criteria and guidelines as provided for in Appendix B.
D. Trauma System Process Improvement Program:
(1) an overall Process Improvement (PI) program shall be developed for the State Trauma System. The PI program shall include patient care outcomes and compliance with these regulations. The PI program shall consist of:
(a) an approved state PI system plan,
(b) system trauma registry,
(c) Bureau and approved ReTrAC review of:
(i) trauma system trends/needs,
(ii) key indicators ad defined by the State Trauma PI Plan, and
(iii) patient care and other outcome issues and needs of the trauma system.
(d) trauma center review of:
(i) trends/needs,
(ii) key indicators as defined by the trauma center PI plan, and,
(iii) patient care and outcome studies as needed to verify compliance with standards of care and the needs of the trauma center.
(2) the Bureau shall:
(a) develop and maintain a Statewide Trauma System PI Plan with input from the TAC; and,
(b) provide guidelines for and review of regional trauma PI plans to evaluate regional trauma care delivery, patient care outcomes, and compliance with these standards.
(3) each ReTrAC shall:
(a) develop a written regional trauma PI plan, which includes policies for confidentiality of records and recordings of committee actions, including a requirement that each attendee of the trauma PI committee meeting is informed in writing of the confidentiality requirement. Information identifying individual patients shall not be publicly disclosed without the patient’s consent in accordance with applicable state and federal laws;
(b) include in its regional trauma PI plan, the process for informing the Bureau of the results of the PI review;
(c) appoint, at a minimum, one member for each designated trauma center, licensed medical staff, trauma coordinator/or nurse, licensed EMS provider, a local EMS pre-hospital provider medical director, and a member of the EMS regional office to participate on the regional PI subcommittee. Other healthcare providers and hospital/healthcare facilities providing trauma care in the region, including non-designated hospital/healthcare facilities and EMS providers and pre-hospital services, may be invited to participate in the PI process.
(d) implement the written regional trauma PI plan including periodic assessment of performance of the regional EMS and trauma care system, including area training plans, based on date supplied by the trauma registry and other sources, including:
(i) trauma care delivery,
(ii) patient care outcomes, including pediatric and adult patients,
(iii) all trauma deaths, and
(iv) compliance with these regulations.
(e) provide assessment of data governing all aspects of patient care; and
(f) establish the process for communication to and from the Bureau on identified trauma system issues and concerns.
(4) each designated trauma center shall:
(a) develop an internal trauma plan which, based on data supplied by the trauma registry and other sources, will provide for the ongoing assessment and improvement of performances of the trauma center, including;
(i) trauma care delivery,
(ii) all trauma deaths,
(iii) identification and analysis of injury trends, patient care outcomes, and other information,
(iv) periodic assessment of data governing aspects of patient care,
(v) policies regarding confidentiality of data elements related to identification of provider and trauma center care outcomes, in accordance with applicable state and/or federal law,
(vi) policies regarding confidentiality of records and committee minutes, including a requirement that each attendee of the trauma PI committee meeting is informed in writing of the confidentiality requirement. Information identifying individual patients shall not be publicly disclosed without the patient’s consent in accordance with applicable state and federal laws.
(vii) provision for feedback to the Bureau and the approved ReTrAC on identified trauma issues and concerns, and
(viii) compliance with these regulations.
(b) implement the hospital-wide PI program in compliance with the trauma center plan to reflect and demonstrate continuous process improvement in the delivery of trauma care. The trauma center PI program shall include regular in-house, multi-disciplinary trauma conferences, which address:
(i) comprehensive review of patient care throughout the patient’s stay,
(ii) participation of members of the trauma team,
(iii) participation of the person responsible for coordination of trauma registry activities,
(iv) participation of the trauma center’s designated rehabilitation coordinator, as appropriate,
(v) feedback to staff and services areas that are involved with trauma care, and
(vi) provision of appropriate reports to the state and regional process improvement program.
(c) document the trauma center’s PI program proceedings, conclusions, actions taken, results of the actions taken and follow through, demonstrating that relevant findings are used to study and improve processes that affect trauma patient care;
(d) evaluate the results of the trauma PI program and include them with the trauma center’s process improvement program;
(e) participate in the System Trauma Registry by:
(i) identifying a person to be responsible for coordination of trauma registry activities,
(ii) downloading required trauma data as stipulated by the Bureau,
(iii) submit aggregate reports as stipulated by the Bureau, and
(iv) participate in the trauma registry workshops.
(f) participate in the appropriate ReTrAC PI program that may be required in these regulations.
[7.27.7.8 NMAC - Rp 7 NMAC 27.7.8, 6/14/02]
7.27.7.9 Trauma Center Designation
Process:
A. Levels of trauma centers: the Bureau shall identify trauma centers by levels of care capability as defined in these regulations. The levels are as follows:
(1) level I trauma center
(2) level II trauma center
(3) level III trauma center
(4) level IV trauma center
B. Phases of Designation:
(1) phase one (1), letter of intent: the first phase of the designation process is an invitation issued by the Bureau to all hospitals/healthcare facilities in the State that applications for designations are initiated by a letter of intent.
(2) phase two (2), application: the hospital shall submit an application, that has been developed by the Bureau, to the Bureau identifying the desired level of trauma center designation.
(3) phase three (3), review: the third phase is the review phase which begins with the on-site review of the hospital/healthcare facility and ends with the Bureau’s recommendation to the Secretary to designate the hospital/healthcare facility as a trauma center.
(4) phase four (4), final: the fourth phase is the final phase which begins with the Secretary reviewing the Bureau’s recommendations and ends with a final decision as to the level of trauma center designation by the Department. This phase also includes an appeal procedure for the denial of a designation application in accordance with these regulations.
C. Application Process:
(1) the Bureau shall develop and issue an application packet to hospitals or healthcare facilities, which have submitted a letter of intent in seeking initial designation as a trauma center.
(2) the application packet shall describe the information required from an applicant to be considered for trauma center designation. Such information shall include:
(a) application requirements,
(b) system standards for the level at which the hospital/healthcare facility is applying together with the current status on each standard and category of designation sought,
(c) evaluation criteria,
(d) statement and documentation of attendance and participation in the area ReTrAC and a commitment to serve the trauma care needs of their desired trauma services area and as a partner in the Statewide Trauma System,
(e) geographic area proposed to be covered, and appropriate utilization of data, and
(f) evidence of financial viability compliance.
(3) if there is a designated trauma center or centers at the same or higher level of designation in the proposed geographical area to be served by the applicant, the applicant shall include in its application the following:
(a) a statement of the proposed role of the applicant hospital assuring that the applicant’s trauma program and activities would not have a negative financial or operational impact on the existing designated trauma center(s) program or services, and
(b) a statement by the area ReTrAC that the proposed trauma program of the applicant is consistent with and addresses the needs of the regional trauma program as described in the approved regional trauma plan.
(4) the Bureau shall:
(a) conduct a review of each applicant’s submitted proposal for completeness. If any proposal is incomplete, the applicant shall be notified by the Bureau and afforded the opportunity to complete the application at least within twenty (20) working days of the Bureau’s notification; and,
(b) evaluate applications for potential multiple hospital designation following the same criteria as for a single-facility application. Applications for multiple hospital designation must demonstrate that the goals of these regulations are met as defined in their applications.
D. On-Site Review for Designation:
(1) the Bureau shall conduct an on-site review of an applicant hospital/healthcare facility for levels I, II, III, and IV trauma centers, prior to designation.
(2) the Bureau shall establish multi-disciplinary on-site review teams composed of individuals knowledgeable in trauma care and systems, appropriate to the level of designation requested.
(3) for the initial designation for a level I and II trauma center, the team shall include but not be limited to a:
(a) trauma surgeon,
(b) emergency physician, and
(c) trauma nurse coordinator.
(4) for the designation for a level III and IV trauma center, the team shall include a:
(a) trauma surgeon or emergency physician, and
(b) trauma nurse coordinator.
(5) the composition of subsequent survey teams shall be determined by the Bureau.
(6) such teams shall consist of professionals who do not live or work:
(a) in the same state as the applicant for the designation of levels I and II trauma centers, or,
(b) in the same county as the applicant for designation of level III or IV trauma centers.
(7) the Bureau will consider the allegation of conflict of interest of an on-site review team member if a hospital or healthcare facility can demonstrate a reasonable basis for concern as determined by the Department. Concerns accompanied by the proof upon which the hospital or healthcare facility relies on must be submitted in writing within ten (10) working days of the Bureau’s announcements of proposed on-site review team members.
(8) the applicant’s administration, faculty, medical staff, employees and representatives are prohibited from having any contact with any on-site review team member after the announcement of the team members and before the on-site review, except as authorized by the Bureau. A violation of this provision may be grounds for denying that applicant’s proposal, as determined by the Bureau.
(9) the on-site review team shall evaluate the appropriateness and capabilities of the applicant to provide trauma care services, and validate the hospital/healthcare facility’s ability to meet the responsibilities, equipment, and performance standards for the level of designation sought and to meet the overall needs of the trauma system in that region by:
(a) familiarizing themselves with the hospital or healthcare facility’s proposal;
(b) inspecting the hospital or healthcare facility’s physical plant and interviewing of key staff,
(c) examining hospital or healthcare facility trauma related documents, including patient care records;
(d) interviewing other appropriate individuals;
(e) reviewing past applicant or similar proposals for the regions; and, reviewing other materials as deemed appropriate by the Bureau.
(10) the on-site review team shall:
(a) make a verbal summary of preliminary findings to the applicant upon completion of the on-site review; and,
(b) make written recommendations to the Bureau of the on-site review.
(11) the Bureau and the members of the on-site review team shall maintain confidentiality of information, records, and reports developed pursuant to on-site reviews as permitted by state and federal laws. Information obtained by the on-site team, their oral and written reports, and deliberations shall be kept confidential by the Bureau.
(12) the applicant’s application will become the property of the Bureau and shall be considered public information at the end of the designation process, subject to state and federal laws.
(13) hospitals applying for level I or level II may, at their discretion, request a verification site survey by representatives of the American College of Surgeons. The Bureau will accept the findings of the verification site visit and incorporate a copy of the findings in its report to the Secretary recommending or not recommending designation at the level applied for.
E. Designation of Trauma Center:
(1) as soon as practical, but no later than forty five (45) days after receipt of the on-site report survey document, the Bureau shall make recommendations to the Secretary based on:
(a) evaluation of pre-review documentation submitted as part of the application,
(b) recommendations from the on-site review team,
(c) ability of each applicant to comply with goals of the State and regional trauma plans, and,
(d) compliance with agreements with the Bureau, including compliance with regional review criteria as applicable during the previous designation period.
(2) after completion of the on-site review, the Bureau:
(a) may recommend to the Secretary approval at the level of designation proposed by the hospital or healthcare facility; or,
(b) may recommend to the Secretary a lower designation, if, according to the site surveyor’s evaluation, the hospital or healthcare facility is unable to meet the standards of the designation for which the applicant applied; or,
(c) may require the hospital or healthcare facility to submit an application for the lower designation, to be followed by an on-site review.
(3) upon approval of the recommended level of designation by the Secretary, the Bureau shall require the hospital or healthcare facility, after receiving notification of the Secretary’s decision, to respond within ten (10) working days to accept or decline the proposed designation.
(4) hospitals or healthcare facilities designated as a trauma center shall comply with applicable standards as set forth by the Bureau.
F. Categories of Designation:
(1) provisional: the Bureau may initially designate a trauma center as “provisional” for a term not to exceed one (1) year except for good cause shown as granted by the Bureau;
(a) shall require all provisional trauma centers to have a written work plan of objectives to rectify deficiencies and to demonstrate progress on the work plan throughout the twelve (12) month time period; and,
(b) shall, at the end of the provisional period, grant full designation, extend the provisional period, or suspend the trauma center for cause.
(2) full designation: the Bureau may grant full designation to any hospital or healthcare facility in full compliance with these regulations, subject to the review process described, for a period not to exceed three (3) years.
G. Agreement Process: the Bureau and the designated trauma center shall enter into a written agreement. The agreement shall:
(1) authorize the hospital or healthcare facility to function and identify itself as a designated trauma center for either provisional or full designation;
(2) identify the requirements and responsibilities of both the trauma center and the Bureau, including attendance requirements at local, regional, state and national meetings;
(3) allow the Bureau to monitor compliance with regulations and standards during the designation period, including access to:
(a) patient discharge summaries
(b) patient care logs
(c) patient care records
(d) hospital trauma process improvement program records, including minutes, and,
(e) other relevant documents as determined by the Bureau, and
(4) require confidentiality of information relating to individual patient, provider, and hospital/healthcare facility’s care outcomes in accordance with state and federal laws.
H. Denial, Revocation or Suspension of Designation:
(1) the Bureau may deny the application for designation if it finds that the hospital/healthcare facility:
(a) is not the most qualified applicant within a geographic area;
(b) is unable to meet the requirements of these regulations for the level of designation sought;
(c) makes a false statement of a material fact in the hospital/healthcare facility’s application for designation;
(d) refuses to allow representatives of the Bureau to inspect any part of the hospital/healthcare facility, records, documentation, or files pertaining to the designation process;
(e) is unable to meet or comply with the requirements as stated in Paragraph (5) of Subsection C of 7.27.7.8 NMAC for participation in the activities of an area ReTrAC and the requirements of an approved regional trauma plan.
(f) engages in unauthorized contact with any on-site review team member.
(2) the Bureau may revoke or suspend a trauma center designation if the trauma center:
(a) fails, refuses to comply or violates the provisions of the State hospital licensure requirements of the State trauma regulations or provisions of applicable federal law; or the trauma center agreement;
(b) fails to provide data to the Trauma Registry;
(c) makes a false statement of a material fact in the application for designation, or in any record required by these regulations, or in a matter under investigation;
(d) prevents, interferes with, or attempts to impede in any way, the work of a representative of the Bureau in the lawful enforcement of these regulations or any other applicable state law;
(e) uses false, fraudulent, or misleading advertising, or makes any public claims regarding the hospital/healthcare facility’s ability to care for non-trauma patients based on its trauma center designation status;
(f) misrepresents or is fraudulent in any aspect of conducting business;
(g) is substantially out of compliance with the requirements of these regulations, and has been unable or refused to comply as required by the Bureau.
(3) the following procedures will be used for any investigation of a designated trauma center by the Bureau:
(a) any person or entity may communicate a complaint or knowledge of an incident of any alleged violation of these regulations to the Bureau. Complaints shall be submitted in signed written form to the Bureau. The Bureau may begin an investigation without a signed written complaint if there is sufficient cause.
(b) trauma centers being investigated shall receive written notification within ten (10) working days after a decision is made to begin a preliminary investigation.
(c) at the conclusion of the Bureau’s preliminary investigation, the Bureau shall report its findings to the trauma center in written form, including any requirements for corrective action.
(d) if the trauma center does not respond, the corrective action is insufficient, or if the complaint is of such serious nature as to warrant suspension or revocation of designation, as determined by the Bureau, the Bureau shall proceed to the procedure as outlined in Paragraph (4) of Subsection H of 7.27.7.9 NMAC below.
(4) preliminary and further investigations shall be conducted by the Bureau.
(a) preliminary investigations shall be initiated when the Bureau receives information, which might form the basis for action against a trauma center. This fact finding/information gathering investigation will determine for the Bureau whether justification exists to initiate an action or to conduct a further investigation.
(b) further investigations shall be undertaken when additional information is required to allow the Bureau to determine if it will initiate an action. Notice will be given to the trauma center, which is the subject of the investigation unless extenuating circumstances exist which would reasonably preclude notification.
(c) the Bureau will take every precaution to ensure that preliminary and further investigations are conducted in a confidential manner.
(d) an official record is maintained for every designated trauma center in New Mexico under these regulations. If the Bureau begins a preliminary or further investigation, a confidential record will be created containing all investigatory material. If the Bureau initiates an action, all records not exempt from disclosure under the Inspection of Public Records Act, Section 14-2-1, et seq, NMSA 1978, will be placed in the designated trauma center’s official record. Any request for records maintained by the Bureau will be processed in accordance with the Inspection of Public Records Act.
(5) the following process shall be used when designation is contemplated to be denied, revoked, or suspended:
(a) the Bureau shall notify a hospital/healthcare facility in writing of contemplated denial of designation, revocation, or suspension of designation by issuing a Notice of Contemplated Action (NCA). Such NCA shall include:
(i) the reasons for the action, and,
(ii) rights of the hospital/healthcare facility, which include a right to a hearing, and may, for contemplated suspension or revocation actions, at the discretion of the Bureau, include authorization to submit a plan of correction.
(b) the Bureau shall notify the recognized ReTrAC (if applicable) of the action taken.
(c) should a plan of correction be authorized by the Bureau pending contemplated revocation or suspension of designation of a trauma center, the following procedure shall be followed:
(i) the Bureau shall specify a deadline for submission of the plan of correction in the NCA. The plan shall include steps, which the trauma center intends to take in order to correct deficiencies and projected date of completion.
(ii) the Bureau shall approve or disapprove the plan within fifteen (15) calendar days of receipt. If the plan is disapproved by the Bureau, the hospital/healthcare facility shall have twenty (20) days to request a hearing in accordance with Paragraph (6) of Subsection H of 7.27.7.9 NMAC below.
(iii) upon notification that the plan of correction is approved by the Bureau, the trauma center shall begin implementation of the plan immediately and notify the Bureau upon completion of the plan.
(iv) upon satisfactory evidence of compliance, which may include an on-site review, the trauma center shall retain the designation status.
(6) the following process of appeal will be available to any hospital/healthcare facility which has received a Notice of Contemplated Action (NCA) to deny, suspend or revoke a trauma center designation.
(a) within twenty (20) calendar days of receipt of the contemplated action to deny, suspend or revoke a trauma center designation,
(b) a hospital/healthcare facility may formally appeal by requesting a hearing in writing, by certified return receipt letter to the Secretary of the Department, PO Box 26110, Santa Fe, New Mexico, 87502-6110.
(c) upon receipt of a timely appeal, and request for a hearing, the Secretary shall appoint a Hearing Officer and schedule a hearing, to be held in Santa Fe, New Mexico within forty five (45) working days. If no timely request for hearing is received, the Bureau will take the action contemplated in the NCA.
(d) the Department shall notify the hospital/healthcare facility of the date, time, and place of the hearing, the identity of the Hearing Officer, and the subject matter of the hearing, not less than thirty (30) days prior to the date of the hearing.
(e) the Hearing Officer shall preside over the hearing, administer oaths, take evidence and decide evidentiary objections and rule on any motions or other matters that arise prior to the hearing.
(f) the hearing is open to the public unless requested to be closed by the hospital or the Department.
(g) the Hearing Officer shall make a written report and recommendation(s) to the Secretary containing a statement of the issue raised at the hearing, proposed findings of fact, conclusions of law, and a recommended determination.
(h) The Hearing Officer, or designee, shall record the hearing by means of mechanical sound recording device provided by the Department.
(i) The Hearing Officer’s written report shall be submitted to the Secretary no later than thirty (30) working days after the close of the hearing.
(j) the Secretary shall render a final determination within ten (10) working days of the submission of the Hearing Officer’s report. A copy of the final decision shall be mailed to the appealing hospital/healthcare facility by certified mail, and a copy shall be provided to the Office of General Counsel of the Department of Health.
I. Change in Trauma Center Designation Status:
(1) a designated trauma center shall have the right, with ninety (90) days notice, to withdraw as a trauma center or to request a designation lower than their current designated level.
(2) a designated trauma center shall:
(a) notify the Bureau and the approved ReTrAC within five (5) calendar days if temporarily unable to comply, and the reasons, with designation standards;
(b) notify the Bureau and the ReTrAC if it chooses to no longer provide trauma services commensurate with its designation level; and,
(c) if the trauma center chooses to apply for a lower level of designation, the Bureau, at its discretion, may repeat all or part of the designation process as described in these regulations.
J. Renewal of Trauma Centers Designation:
(1) all trauma centers shall repeat the designation process as described in these regulations every three (3) years prior to the trauma center’s expiration of designation. The trauma center shall apply to the Bureau for re-designation for a period of three (3) years. A designated trauma center, in good standing, shall remain designated until the application process is completed.
(2) each level I, II, and III trauma center shall be resurveyed as described in the designation process in Section M of these regulations. Each level IV trauma center may be resurveyed, at the discretion of the Bureau.
(3) at the discretion, and for good cause, the Bureau may extend for up to one year the current designation status of any trauma center.
K. Trauma System Fees: the Bureau shall establish and publish a fee structure for trauma centers applicants for designation as a trauma center to help defray the costs associated with review of the application, the on-site review process and ongoing trauma system management.
L. Prohibition of the Use, Advertising or Marketing of Terms: to protect against public misconception of the capabilities of individual institutions and the usage of misleading terms, the following are prohibited:
(1) after January 1, 1996, no person, emergency medical service, hospital/healthcare facility shall, by any means, advertise, assert, represent, offer, provide or imply that such person, service, clinic or facility is a trauma center or use the terms; “trauma center”, “trauma facility”, trauma hospital”, “trauma care hospital” or similar terminology or state in any manner that the person, organization or facility has the capabilities for providing treatment to major trauma patients except as permitted within the scope of the trauma center designation as provided herein.
(2) no trauma center shall, in any manner, advertise or publicly assert that its trauma designation affects the hospital/healthcare facility’s care for non-trauma patients, nor that the designation should influence the referral of non-trauma system patients.
M. Trauma Center Fiscal Viability Requirement: in order to assure that each designated trauma center has adequate financial and facility resources and a qualified medical workforce to provide optimal care to the injured patient and to meet the requirements of these regulations, each designated trauma center shall:
(1) establish a trauma program fee and charge schedule for services rendered to qualifying trauma patients that accurately reflect the cost of services rendered to qualifying trauma patients and the financial risk associated with rendering trauma services as a designated trauma center;
(2) enter into reimbursement agreements or contracts with all third party payer organizations including, but not limited to, managed care organizations, Blue Cross and Blue Shield and preferred provider organizations. These reimbursement agreements are intended to:
(a) adequately reimburse the designated trauma center the cost for rendering emergency and in-hospital care to qualifying trauma patients, and
(b) adequately reimburse the hospital employed or contracted trauma team physicians the cost of rendering care to qualified trauma patients and the cost of trauma team alerting and trauma team activation.
(3) the designated trauma center, or an organization acting in its behalf such as the New Mexico Trauma Foundation, with the contractual authority to negotiate payment and reimbursement agreements and/or to perform other financial and collection services for the designated trauma center shall not discount or otherwise attempt to collect charges and fee less than the trauma program fee and charge schedule developed by the designated trauma center.
(4) a designated trauma center hospital may request from the Bureau a waiver of the financial viability requirements enumerated in this Section. The waiver request shall specify that the applicant’s trauma program generates sufficient revenue to cover the cost of the trauma program and the financial risk associated with trauma center designation.
N. Trauma Team Physician Fiscal Viability Requirement: in order to assure that each trauma team physician participating on the trauma teams at the designated trauma centers has the financial resources needed to provide optimal care to the injured patient and to meet the requirements of these regulations, each trauma team participating physician shall:
(1) establish a trauma fee and charge schedule for physician services rendered to qualifying trauma patients that accurately reflect the cost of physician services rendered to qualifying trauma patients and the financial risk associated with rendering trauma care services as a trauma team physician; and
(2) enter into reimbursement agreements or contracts with all third party payer organizations including, but not limited to, managed care organizations, Blue Cross and Blue Shield and preferred provider organizations. These reimbursement agreements shall adequately reimburse the physician for physician services rendered to qualifying trauma patients.
(3) the trauma team physician or, an organization acting in his or her behalf such as the New Mexico Trauma Foundation, with the authority to negotiate payment and reimbursement agreements and/or to perform other financial and collection services for the physician shall not discount or otherwise attempt to collect charges and fee less than the trauma fee and charge schedule developed by the physician.
(4) a physician participating on the trauma team at a designated trauma center hospital may request from the Bureau a waiver of the financial viability requirements enumerated in this Section. The waiver request shall specify that the physician generates sufficient revenue to cover the cost of the trauma program participation. “
O. Trauma Managed Care Patients: each designated trauma center shall:
(1) facilitate the transfer of a member of a health maintenance organization or system when the medical condition of the patient permits as defined by the patient’s attending trauma physician and trauma center’s trauma protocols.
(2) develop written policies, in cooperation with managed care healthcare systems and hospitals owned or contracted to provide care to the managed care providers, to:
(a) notifying the healthcare plan within forty-eight (48) hours of a trauma patient’s admission,
(b) coordinate discharge planning of plan patients, and,
(c) facilitate transfer of patients.
[7.27.7.9 NMAC - Rp 7 NMAC 27.7.9, 6/14/02]
7.27.7.10 TRAUMA SYSTEMS DATA COLLECTION:
A. Bureau Responsibilities: the bureau shall:
(1) establish a statewide trauma data registry to collect and analyze data on the incidence, severity, and causes of trauma, including traumatic brain and spinal cord injury for the purposes of:
(a) monitoring and providing information necessary to evaluate qualifying trauma patient care, outcome and cost,
(b) assessing compliance of pre-hospital providers, designated trauma centers, and other hospital/healthcare facilities with the standards of the state trauma system operation and designation,
(c) providing information necessary for resource planning and management,
(d) providing data for injury surveillance, analysis, and prevention programs, and
(e) providing a resource for research and education.
(2) establish criteria to identify patients to be included in the State trauma system data collection from:
(a) all EMS providers,
(b) hospital/healthcare facilities, both designated and non-designated,
(c) Office of Medical Investigator reports,
(d) other sources outside of the trauma system which may include, but not be limited to:
(i) death certificates,
(ii) Hospital Inpatient Discharge Data (HIDD), and
(iii) law enforcement agency records.
(3) establish, publish, and periodically review the required data elements to be submitted to provide information regarding injury, trauma care, and system operation, in the following categories:
(a) demographic,
(b) anatomic,
(c) physiologic,
(d) severity,
(e) epidemiologic,
(f) resource utilization,
(g) Process Improvement,
(h) outcome, and
(i) financial.
(4) require a case specific patient identifier common to all data sources used in the trauma registry;
(5) provide procedures and specifications for electronic and hard copy submission of data;
(6) develop a system for, and report mechanism on process improvement through:
(a) establishing protocols for quality control, consistent with the Bureau’s most current data quality guidelines,
(b) completing studies to assess the completeness and accuracy of case identification and data collection, and
(c) assuring the completeness and accuracy of data submitted for each provider submitting data to the trauma registry.
(7) evaluate requests from appropriate ReTrAC for collection of voluntarily submitted additional data elements from agencies and facilities in that region.
B. Provider Responsibilities:
(1) all certificated ambulance services shall:
(a) provide pre-hospital run reports for inclusion of trauma patient data on:
(i) trauma victims dead at scene,
(ii) all patients meeting local/regional trauma triage criteria who are transported to a hospital or healthcare facility and,
(iii) all patients transported in accordance with inter-facility transfer policies to a higher level of care or for special resources.
(b) submit data by electronic transfer or, if authorized in writing, to the EMS database as required, on approved forms.
(c) the transporting service shall be responsible for submitting to the receiving hospital/healthcare facility data, described in Appendix A, sub paragraph B (1), on all trauma patients.
(2) designated trauma centers shall use the following patient criteria to identify trauma patients for submission of data as defined in Appendix D, Table 1 as follows:
(a) discharge diagnosis ICD-0-CM codes of 800.0-904.99, including 940.0 - 949.00 (burns) when associated with major trauma,
(b) meets local, regional or state trauma triage criteria,
(c) emergency admissions (less than twenty-four (24) hours after arrival) for traumatic injuries,
(d) transferred to another hospital for trauma evaluation and/or definitive care by a trauma service,
(e) trauma patients who are pronounced dead on arrival at a hospital/healthcare facility,
(f) all trauma patients who are pronounced dead after admission to a hospital/healthcare facility, and
(g) submit required trauma system trauma registry data as indicated in Appendix C, via electronic transfer or, if authorized, in writing by the Bureau on approved paper forms.
(3) the Office of Medical Investigator (OMI) shall submit data to the Systems Trauma Registry, and appropriate hospital facility trauma registry, on all patients with injury listed as an underlying cause or contributing factor to death on the death certificate.
C. Trauma Registry Reports:
(1) the Bureau shall report:
(a) annually on all patient data entered into the System Trauma Registry;
(b) on trends, patient care outcomes, and other data, for each trauma region and for the state, for the purpose of regional evaluation as required in the State and Regional PI Plan; and,
(c) periodically on financial trends and needs.
(2) the Bureau shall provide:
(a) periodic reports to all providers submitting data to the System Trauma Registry;
(b) provider-specific raw data to the provider that originally submitted the data, upon request;
(c) aggregate regional data semiannually to the appropriate ReTrAC, excluding any confidential or identifying data; and,
(d) aggregate state trauma system data for hospitals, public or private, agencies and other interested parties for prevention activities, epidemiologic/demographic studies, and education and research projects.
D. Access and Release of Systems Trauma Registry Information:
(1) data elements related to the identification of individual patient’s, provider’s, and hospital/healthcare facility’s outcomes shall be confidential.
(2) persons with access to information collected under these regulations shall use the information for only those purposes stipulated.
(3) the Bureau may approve requests for data and other information from the Trauma Registry for special studies and analyses, consistent with requirements for confidentiality of patient and quality management records. The Bureau may require requestors to pay any or all of the reasonable costs associated with special preparation of such requests, which may be approved. In accordance with those provisions, confidential information shall not be disclosed, except:
(a) on request, to an approved regional process improvement program which is bound by the same confidentiality guidelines as the Bureau;
(b) on request, to a scientific research professional associated with a scientific research organization, providing:
(i) the research professional’s written research proposal has been reviewed and approved by the Bureau with respect to the scientific merit and confidentiality safeguards;
(ii) the Bureau has given administrative approval for the proposal; and,
(c) data does not provide specific hospital/healthcare facility or patient identification.
[7.27.7.10 NMAC - Rp 7 NMAC 27.7.10, 6/14/02]
7.27.7.11 PRE-HOSPITAL TRANSPORT
GUIDELINES:
A. Each pre-hospital EMS provider shall: ensure, upon arrival at the location of an injury, a trained first responder or EMT assessment of the condition of each trauma patient using the local/regional trauma triage criteria to determine the transport destination according to local trauma transport protocols (TTPs).
B. The local TTPs will take into consideration the following exceptions:
(1) EMS Air Ambulance; when transporting by ground is not appropriate due to distance, terrain, traffic or other reasons, activation of an EMS air ambulance should be considered as provided for in the local TTPs. Consideration for EMS air ambulance activation shall include:
(a) multiple trauma patients,
(b) disaster situations,
(c) poorly accessible terrain,
(d) excessive or impeding traffic,
(e) transport time greater than thirty (30) minutes, or,
(f) potential to overload the closest hospital or EMS service.
(2) pediatric trauma: pediatric trauma patients shall be transported to the nearest designated trauma center that meets essential pediatric guidelines pursuant to these regulations, as provided for in the local TTPs.
(3) special needs: if a designated trauma center is farther from the location of the incident, has special resources that the nearest designated trauma care hospital does not have (such as burn capability), which is needed for the immediate condition of the trauma patient, the pre-hospital EMS provider may transport to the designated trauma center having the needed resource based on a specific approved local TTP. Special needs may include:
(a) burns,
(b) re-implantation,
(c) pregnancy,
(d) spinal cords/head injuries,
(e) hazardous material exposure, or,
(f) age less than two (2) years or greater than sixty (60) years and,
(g) other medical conditions requiring specialized services that may be included in the local TTP specific and appropriate to the patient’s needs.
(4) other circumstances: if a designated trauma center is greater than thirty (30) minutes away by ground transport, a trauma patient may be transported to a hospital other than a trauma center only if the hospital is closer to the incident and the patient’s immediate condition is such that the patient’s life would be endangered if care was delayed by proceeding directly to the nearest trauma center. Transport of patients shall be based on approved local TTPs.
C. Pre-hospital EMS providers shall: have an approved TTP that requests alternative transport destinations as provided for in this paragraph. The local TTP shall specify specific exceptions and define the Process improvement (PI) plan to monitor protocols.
D. Where a pre-hospital EMS provider intends to transport a trauma patient to a facility, as provided for in the approved local TTPs: the pre-hospital EMS service and the medical director in collaboration with the Bureau shall ensure that the hospital meets all of the following:
(1) is staffed twenty-four (24) hours per day with a physician or at least a mid-level practitioner who is qualified in emergency airway management, ventilatory support, and control of life threatening circulatory problems which shall include, but not be limited to:
(a) placement of endotracheal tubes,
(b) establishment of intravenous access, and
(c) insertion of chest tubes.
(2) has equipment and staff to conduct chest and cervical/spinal radiological exams.
(3) has laboratory facilities, equipment and staff available to analyze and report patients blood and chemistry results;
(4) has equipment and staff promptly on call to initiate definitive care required by a trauma patient within thirty (30) minutes of the patient’s arrival at the hospital, or can initiate procedures within thirty (30) minutes of the patient’s arrival to transfer the trauma patient; and
(5) has written transfer agreements with a designated trauma center which identifies specific procedures to ensure the timely transfer of the trauma patient to the designated trauma care hospital.
E. A hospital/healthcare facility licensed in another state: which meets the above criteria may be identified in the local TTPs as a hospital/healthcare facility to which the EMS provider may transport a trauma patient.
F. These transport guidelines are considered in conjunction with all applicable laws and regulations. The Bureau may request copies of the local TTPs
[7.27.7.11 NMAC - Rp 7 NMAC 27.7.11, 6/14/02]
7.27.7.12 APPENDIX A TRAUMA PATIENT TRIAGE
CRITERIA GUIDELINES
A. Trauma Patient Triage Criteria Guidelines. The following guidelines were developed by the TAC standards committee and presented to the TAC for review in January 2001. It was subsequently brought before the JOE (Joint Organization on EMS Education) and the EMS Medical Direction Committee for discussion.
(1) purpose: To present for consideration by the TAC a standardized framework of Statewide Prehospital Trauma Triage Guidelines for use by all levels of EMS providers using clear text communications. This criteria does not affect the ability of a local area to further define specific triage criteria. Rather it establishes a common language for EMS to communicate regarding patient condition. It is not meant to replace local area triage, treatment and transport guidelines.
(2) history: In the early 1990’s EMS training programs adopted the definitions of critical patients as defined by University Hospital, function as the only Level I Trauma Center in the state. Level I, II and III criteria for trauma patients were subsequently taught to all New Mexico EMS providers. As local triage criteria changed and was further defined, the changes were not reflected in EMS training statewide.
(3) goal of this guideline:
(a) create a statewide minimum trauma triage criteria guideline for all EMS personnel.
(b) assist regional trauma centers with educating EMS personnel to better understand trauma patient triage criteria.
(c) use as a tool by non-designated facilities to better understand trauma patient triage criteria.
(d) adopt (and further clarify as appropriate) within area existing trauma plan(s) in conjunction with ReTrAC’s.
(4) approval will require review and approval by the ReTrAC’s, Statewide Trauma Advisory Committee, EMS Medical Direction Committee and the Joint Organization on EMS Education (JOE).
(5) impact:redefining of learning objectives, scenarios, test questions and educational related information for all levels of EMS providers. Current EMS providers will be taught the revised criteria during the 2001-2002 EMS refresher cycles. New EMS providers will begin to be taught the revised criteria effective July 2001.
(6) target implementation date: July 1, 2002.
(7) patient status: based on information obtained by physical examination and history, patients are classified according to stability as follows:
(a) stable - patient is stable, with no apparent risk of developing a life threatening or disabling condition. Non-emergent transport is appropriate.
(b) serious - patient is at moderate risk of developing a life threatening or disabling condition. Most circumstances will merit non-emergent transport.
(c) Critical - Patient has a severe & acute life threatening or disabling condition. Immediate intervention is required. Emergency transport at EMS providers’ discretion. Examples include penetrating and/or blunt trauma injuries to chest and/or abdominopelvic cavity with unstable vitals, or if patient presents with vitals indicating they are likely to deteriorate
(8) transport destination decisions
(a) stable status patients will be transported to the nearest appropriate facility of the patient’s choice only when that destination does not compromise the patient and the destination location does not result in the transport vehicle moving outside of the established EMS response area. If the patient is a minor, incapable of making an informed decision, incarcerated, or subject to the guardianship of another, Medical Control will be contacted when the decision of the responsible party, is not, in the EMS provider’s opinion, in the best interest of the patient.
(b) serious status patients will be transported to the closest appropriate facility within the transporting vehicle’s service area. The destination decision process will fall on the EMS providers and in some cases Medical Control.
(c) critical status patients will be transported to the most readily accessible facility that is staffed and equipped to provide initial stabilization care upon arrival. The destination decision process will fall on the EMS providers and in some cases Medical Control.
B. Institutional Trauma Team Activation Criteria
(1) pre-hospital guidelines for requesting trauma team activation.
(a) systolic BP < 90 mm Hg with clear evidence of hemodynamic instability
(b) decreased level of consciousness secondary to trauma (GCS < 10)
(c) all non-superficial penetrating injuries to head, neck or torso
(d) evidence of airway compromise not manageable in the field
(e) significant respiratory compromise of traumatic origin
(f) suspected pelvic fracture with hemodynamic instability
(g) burns > 10% of body surface, or burns involving face and/or airway
Special considerations should be given for all patients <5 or >65 years of age, pregnancy greater than 20 weeks, or other related co-morbid factors (Coumadin, Beta Blockers, etc.)
(2) EMS notification of significant MOI: Mechanism of Injury (MOI) should be a consideration for adoption in each area trauma activation criteria. It is recognized that the inclusion of MOI has different advantages and disadvantages for urban and rural communities. As a minimum, EMS should report all incidents involving high evidence of significant MOI:
(a) falls greater than two times the patient height
(b) incidents involving rapid deceleration
(c) passenger space vehicle intrusion greater than twenty inches.
(d) death of another occupant from same vehicle.
(e) vehicle ejection
(f) high speed rollover
[7.27.7.12 NMAC - Rp 7 NMAC 27.7.14, 6/14/02]
7.27.7.13 APPENDIX B TRAUMA PATIENT
INTERFACILITY TRANSFER CRITERIA
A. Transfer Criteria: All patients from the following categories are at high risk for death or disability and should be considered for transfer to a Level I or Level II Trauma Center.
(1) Central Nervous System
(a) head injury: penetrating injury or depressed skull fracture
(i) open injury with or without CSF(Cerebral Spinal Fluid) leak
(ii) Glasgow Coma Score (GCS) < 12 or GCS deterioration of 1 point or more
(iii) lateralizing signs
(b) spinal cord injury
(2) chest
(a) widened mediastinum
(b) major chest wall injury
(c) cardiac injury
(d) patients who may require protracted ventilation
(3) pelvis
(a) unstable pelvic ring disruption
(b) pelvic ring disruption with shock and evidence of continuing hemorrhage
(c) open pelvic injury
(4) multiple system injury
(a) severe face injury with head injury
(b) chest injury with head injury
(c) abdominal or pelvic injury with head injury
(d) burns with associated injuries
(e) multiple fractures
(5) co- morbid factors
(a) age < 2 years or > 60 years
(b) pregnancy
(c) known cardio-respiratory or metabolic diseases
(6) secondary deterioration (late sequelae)
(a) protracted ventilation required
(b) sepsis
(c) single or multiple organ system failure
(d) major tissue necrosis
B. Transfer Guidelines: prior to transport, the following minimal patient care standards are to be met:
(1) establish and assure an adequate airway and ventilation.
(2) establish and maintain adequate access routes for fluid administration.
(3) initiate adequate fluid and/ or blood replacement.
(4) assure that the patient's vital signs are sufficient to sustain organ perfusion.
(5) initiate control of hemorrhage.
(6) stabilize and splint suspect spinal and extremity fractures.
(7) provide pain management.
(8) establish physician acceptance of patient at receiving facility.
(9) assure personnel are appropriately trained for level of care for transfer.
(10) provide pre- transfer report between nursing staff.
[7.27.7.13 NMAC - Rp 7 NMAC 27.7.15, 6/14/02]
7.27.7.14 APPENDIX C: TRAUMA DATA COLLECTION/ DOCUMENTATION CRITERIA
A. Prehospital
(1) scene calls, first responders, licensed ground or certified air ambulance services data shall include:
(a) pre-hospital incident run number
(b) name or name code, when available
(c) date of birth when available
(d) age
(e) sex
(f) social security number when available
(g) agency identification number
(h) first agency on scene (yes/ no)
(i) transporting agency identification
(j) level of transporting agency (BLS/ ALS)
(k) incident county code
(l) date of incident
(m) time
(i) call received
(ii) dispatched
(iii) arrived at scene
(iv) departed scene
(n) initial systolic blood pressure (if obtainable, palpable or best pulse)
(o) respiratory rate
(p) Glasgow coma score- (eye, verbal, and motor when applicable)
(q) narrative description of the mechanism of injury
(r) meets trauma triage criteria (yes/ no)
(s) extrication required
(t) safety restraint or device used
(u) field interventions done
(v) additional information if patient died at scene
(i) patient home zip code
(ii) patient race when available
(2) for interfacility transfers, the transporting service shall include:
(a) agency identification number
(b) pre-hospital run sheet number
(c) inter-facility transfer (yes/ no)
(d) mode of transportation
(e) level of transportation (BLS/ ALS)
(f) patient name or name code
(g) date of birth, when available
(h) social security number, when available
(i) age
(j) sex
(k) agency incident number
(l) name of first hospital
(m) name of receiving hospital
(n) time
(i) depart first hospital
(ii) arrive at receiving facility
B. Designated Trauma Centers
(1) for designated trauma centers, the data shall include:
(a) *indicates a data element currently included in the HTR (Hospital Trauma Registry)
(b) **indicates a data element to be downloaded to the STR (State Trauma Registry)
(c) **identification of facility
(d) **unique patient identification number assigned to the patient by the facility
(e) level of transporting agency (BLS/ALS)
(f) *pre-hospital run sheet number
(g) **date of ED arrival
(h) *time of ED arrival
(i) **date of incident
(j) **initial hospital
(k) **facility patient was transferred from
(2) for designated trauma centers, patient information shall include:
(a) *name or name code
(b) **date of birth
(c) **sex
(d) **race
(e) **patient's trauma identification number (same as b above in section 1)
(f) **social security number
(g) home zip code
(3) **mechanism of injury (narrative)
(4) **E Code, including E Code 849
(5) **occupational injury (yes/ no)
(6) **safety restraint/ device used
(7) time of patient radio report
(8) **trauma team activated (yes/ no)
(9) activation response times
(a) time of activation
(b) time of call to surgeon
(c) *time of arrival of surgeon in ED
(d) *time of arrival of subspecialist
(10) initial vital signs in ED
(a) **systolic blood pressure
(b) **respiratory rate
(c) first temperature
(d) ** Glasgow coma score (eye, verbal, and motor)
(11) **ED respiratory status (spontaneous/ intubated)
(12) **ED procedures performed
(13) *time of ED discharge
(14) **ED discharge disposition
(15) *admitting service
(16) CT scan of head done (yes/ no)
(a) date of head CT scan
(b) time of head CT scan
(17) for initial surgery
(a) **date and time patient arrived or
(b) date/ time operation started
(c) **ICD-9- CM procedure code
(d) *total cc's PRBC infused
(18) **length of primary stay in ICU
(19) *co- morbidity complications
(20) disability at acute care discharge
(a) **feeding
(b) **locomotion
(c) **expression
(d) **rehabilitation potential
(21) **date of facility discharge
(22) **discharge disposition
(23) **extended care facility identification number
(24) autopsy done (yes/ no)
(25) **date of death
(26) **organ/tissue donor (yes/ no)
(27) **final ICD-9 discharge code
(28) *unplanned readmission
(29) **payer source
(30) **total billed charges
C. Office of Medical Investigator- data may include:
(1) name or name code
(2) **date of birth
(3) **social security number
(4) **sex
(5) **race
(6) **date of incident
(7) **date of death
(8) **place of death
(9) home zip code
(10) **medical examiner identification number
(11) **medical examiner facility identification number
(12) **autopsy done
(13) **mechanism of injury
(14) **organ donor
(15) **cause of death
(16) most recent ICD diagnosis code or equivalent description
[7.27.7.14 NMAC - Rp 7 NMAC 27.7.16, 6/14/02]
7.27.7.15 Appendix D Table 1
|
STATE OF NEW MEXICO Trauma Care System
Regulations/ Standards for Designation |
||
|
Organization/
Management
(E)
Essential (D) Desirable (N/A) Not Applicable |
||
|
|
Level III
|
Level IV
|
|
(1) A Trauma Center must demonstrate substantial medical, administrative and financial commitment for the level of designation requested. Commitment must be demonstrated and include documentation from hospital’s: |
||
|
a. Board of Directors; |
E |
E |
|
b. Medical Staff; and |
E |
E |
|
c. Administrative team. |
E |
E |
|
(2) For the purpose of administrating trauma care, a designated Trauma Center shall have a trauma program. The trauma program includes a management team, which oversees the trauma program. The trauma program shall: |
||
|
a. Be organized and directed by a trauma program medical director who is proficient in, and committed to the care of the injured. The trauma program medical director shall be: |
||
|
(i) Board certified or eligible in general surgery, or other surgical specialties or emergency medicine as justified by the applicant and approved by the State. |
E |
E |
|
(ii) With training in trauma services and care. |
D |
D |
|
(iii) Responsible for overall clinical direction, management and administration of the hospital’s trauma program. |
E |
D |
|
(iv) Currently certified in ATLS (Advanced Trauma Life Support) |
E |
E |
|
(v) Demonstrate a commitment to trauma research; and |
D |
D |
|
(vi) Must agree to actively participate in a defined trauma related continuing education program on an annual basis. |
E |
D |
|
b. Define a program for providing care to the trauma patient to include coordination with the departments of surgery and emergency medicine and other hospital departments. |
E |
E |
|
c. Provide ongoing coordination of the trauma program by a Trauma Nurse Coordinator who: |
||
|
(i) In collaboration with the trauma program medical director, monitors and coordinates trauma programs and system elements, including: |
||
|
(A) Clinical Activities; |
E |
E |
|
(B) Trauma education and prevention activities; |
E |
E |
|
(C) Research; |
D |
D |
|
(D) Management activities per hospital needs; |
E |
E |
|
(E) Trauma Registry; and |
E |
E |
|
(F) Quality Improvement |
E |
E |
|
(ii) Is a full-time position |
E |
D |
|
(iii) Is licensed in State of New Mexico as a Registered Nurse |
E |
E |
|
(iv) Has appropriate resources/staff to meet the requirements of these regulations and commitments of the hospital. |
E |
E |
|
(v) Has demonstrated expertise in trauma care as identified by a minimum of 5 years recent nursing experience in one of the following areas: |
||
|
(A) Trauma systems/care |
D |
D |
|
(B) Emergency department |
D |
D |
|
(C) Critical Care |
D |
D |
|
(D) Trauma Program |
D |
D |
|
(vi) Minimum current/continuing education: |
||
|
(A) 5 hours/year trauma |
E |
E |
|
(B) 2 hours/year pediatric |
E |
E |
|
(C) TNCC (Trauma Nurse Core Curriculum) or equivalent |
E |
E |
|
(vii) Participates in the development, implementation or continuation of trauma care systems at their appropriate ReTrAC (Regional Trauma Advisory Council) |
E |
E |
|
d. Provide a multidisciplinary trauma committee, which provides input to the trauma program and to hospital administration as needed. The Trauma Committee shall demonstrate coordination between the Departments of Surgery and Emergency Medicine and be responsible for, but not limited to, the trauma program’s Process Improvement process. Membership shall include: |
||
|
(i) An emergency physician; |
E |
E |
|
(ii) Trauma medical director; |
E |
D |
|
(iii) A neurosurgeon; |
D |
D |
|
(iv) An orthopedic surgeon; |
D |
D |
|
(v) A pediatrician; |
D |
D |
|
(vi) An anesthesiologist/CRNA; |
D |
D |
|
(vii) The trauma rehabilitation coordinator, trauma social worker and discharge planner; and input from physiatrist; (if available) |
D |
D |
|
(viii) Trauma Nurse Coordinator; |
E |
E |
|
(ix) Other appropriate nursing disciplines; |
E |
E |
|
(x) Radiology; and |
D |
D |
|
(xi) Administration. |
E |
D |
|
e. Include a trauma resuscitation team which shall be; |
||
|
(i) Directed by an emergency medical physician who is proficient in the care of the injured, and who assumes responsibility for the overall care and coordination of the trauma patient until the care is formally turned over to the trauma/general surgeon (as appropriate per Level of designation) |
E |
N/A |
|
(ii) The team shall be organized and directed by an in-house ED physician |
E |
D |
|
(iii) All members of the team shall be promptly available upon notification. (Trauma PI process must verify prompt availability, outcome driven) |
E |
D |
|
(iv) The trauma resuscitation team shall be activated in accordance with the hospital’s trauma program and consistent with the regional trauma plan. |
E |
E |
|
(v) Members of the trauma team shall: |
||
|
(A) Be oriented to the trauma care system; |
E |
D |
|
(B) Participate in the trauma PI (Performance/Process Improvement) program; |
E |
D |
|
(C) Participate in ongoing CME/CE in trauma; |
E |
D |
|
(D) Be oriented to the internal trauma patient clinical management system at the hospital; |
E |
E |
|
(E) Be oriented to the trauma program policies and procedures to include all operations of the trauma program including internal written triage, treatment and transfer protocols and procedures to identify which patients are triaged in and out of trauma program’s clinical service. |
E |
E |
|
(3) A Trauma Center shall have an Emergency Department with established standards and procedures to ensure immediate and appropriate care for the adult and pediatric trauma patients and a designated trauma resuscitation and treatment space with the capacity to meet the needs of the expected volume. |
E |
E |
|
(4) A Trauma Center shall have a surgery department, including: |
||
|
a. General surgery on call and promptly available as requested. |
E |
D |
|
b. Trauma/general surgeons must be Board certified or eligible in general surgery. |
E |
D |
|
c. Trauma/general surgeons must have received ATLS (Advanced Trauma Life Support) once in their career (note: if surgeon is available) |
E |
E |
|
d. A minimum of 6 hours per year or 18 hours over a three year period of continuing education related to trauma. (note: if surgeon is available) |
E |
E |
|
e. Neurosurgery, Board certified and promptly available on-call. |
D |
N/A |
|
f. The following surgical services on-call and available promptly: |
||
|
(i) Gynecological surgery; |
D |
D |
|
(ii) Hand surgery; |
D |
D |
|
(iii) Microsurgery; |
D |
D |
|
(iv) Obstetric surgery; |
D |
D |
|
(v) Orthopedic surgery; |
D |
D |
|
(vi) Otorhinolaryngologic/maxillofacial surgery and capable of managing upper airway trauma; |
D |
D |
|
(vii) Plastic surgery; |
D |
D |
|
(viii) Thoracic surgery; and |
D |
D |
|
(ix) Urologic surgery; |
D |
D |
|
(x) General surgery for trauma service backup. |
D |
D |
|
(xi) Pediatric surgeon available for consultation. |
D |
D |
|
(5) A Trauma Center shall have other specialties including: |
||
|
a. Anesthesiology, with an anesthesiologist or CRNA who is on-call and promptly available and current in ACLS (Advanced Cardiac Life Support). |
E |
D |
|
b. The following services on-call and available promptly: |
||
|
(i) Cardiology; |
D |
D |
|
(ii) Gastroenterology; |
D |
D |
|
(iii) Hematology; |
D |
D |
|
(iv) Internal medicine; |
E |
D |
|
(v) Nephrology; |
D |
D |
|
(vi) Pathology; |
D |
D |
|
(vii) Pediatrics; |
E |
D |
|
(viii) Pulmonology/Intensivist |
D |
D |
|
(ix) Psychiatry; and |
D |
N/A |
|
(x) Radiology. |
E |
D |
|
c. Other physician specialists on-call and available to the trauma as defined by their protocols. |
E |
D |
|
Note: Internal Trauma PI process must verify “promptly” available services; outcome driven |
||
|
(6) A Trauma Center shall have approved policies to divert/redistribute and transfer patients to other designated facilities, based on it’s ability each patient at a particular time and collaborative work with their respective ReTrAC. |
E |
E |
|
(7) A Trauma Center shall |
||
|
a. Have a PI program, which includes quality improvement principals and an outcome orientation as provided for in this chapter. |
E |
E |
|
b. Participate in regional trauma PI programs via their respective ReTrAC |
E |
E |
Resources
and Capabilities/Interhospital Transfer Guidelines
|
||
|
(1) A Trauma Center shall have an Emergency Department with: |
||
|
a. A physician director who is: |
||
|
(i) Board certified or eligible in emergency medicine; and/or |
D |
D |
|
(ii) If not Board certified in emergency medicine; |
||
|
(A) Current with ATLS and PALS (Pediatric Advanced Life Support) |
E |
E |
|
(B) Must have 5 years or 7,000 hours experience in emergency medicine |
E |
D |
|
b. Emergency physicians; |
||
|
(i) With 50% Board certified or eligible in emergency medicine, with the remainder practicing emergency medicine as their primary practice with special competency in the care of trauma patients and Board certified in pediatrics, family practice, internal medicine, or general surgery. |
D |
D |
|
(ii) In-house and immediately available upon the patient’s arrival to the ED. |
E |
D |
|
(iii) If not emergency medicine Board certified: |
||
|
(A) Current with ATLS; |
E |
E |
|
(B) Current with PALS; or |
E |
E |
|
(iv) If not Board certified in any of the above specialties, they must be/have; |
||
|
(A) Current with ATLS; |
E |
E |
|
(B) Current with PALS; and |
E |
E |
|
(C) Five (5) years or seven thousand (7,000) hours experience in emergency medicine. |
E |
D |
|
(v) A minimum of 6 hours per year or 18 hours over a three year period of continuing education related to trauma. |
E |
E |
|
(vi) Must have had ATLS once in their career |
E |
E |
|
c. Trauma resuscitation/ED nurses: |
||
|
(i) In the ED 24 hours per day |
E |
D |
|
(A) At least two trauma resuscitation nurses |
D |
D |
|
(B) At least one trauma-trained nurse |
E |
D |
|
(ii) Currently RN licensed; |
E |
E |
|
(iii) TNCC provider verification or an approved equivalent; |
E |
E |
|
(iv) Orientation to their nurse role (trauma resuscitation nurse) |
E |
D |
|
(v) Participates in a formal trauma PI program by representation; |
E |
D |
|
(vi) Minimum of 6 hours per year continuing education related to trauma which may include credit for the TNCC; |
E |
E |
|
(vii) Collaborates with health care professional and families in donor identification and care, the organ and tissue procurement process and recipient care. |
E |
E |
|
d. An ED nurse manager |
||
|
(i) Is currently RN licensed; |
E |
E |
|
(ii) TNCC provider verification or an approved equivalent; |
D, Note |
D, Note |
|
(iii) Participates in a formal trauma PI program; |
E |
D |
|
(iv) Minimum of 6 hours per year continuing education related to trauma which may include TNCC |
E |
D |
|
Note: The ED nurse manager who routinely staffs to provide patient care, shall meet the requirements of the trauma resuscitation/ED nurse (as described above) |
||
|
e. Equipment for resuscitation and life support of adult trauma patients, including: |
||
|
(i) Airway control and ventilation equipment including: |
||
|
(A) Airways; |
E |
E |
|
(B) Laryngoscopes, including curved and straight; |
E |
E |
|
(C) Endotracheal tubes of all sizes; |
E |
E |
|
(D) Bag-valve mask resuscitator, with full range of mask sizes |
E |
E |
|
(E) Sources of oxygen; |
E |
E |
|
(F) Mechanical ventilation; |
E |
E |
|
(ii) Suction devices, including: |
||
|
(A) Back-up suction source; |
E |
E |
|
(B) Suction catheters; and |
E |
E |
|
(C) Tonsil suction tip. |
E |
E |
|
(iii) Electrocardiograph; |
E |
E |
|
(iv) Cardiac monitor; |
E |
E |
|
(v) Defibrillator, including internal and external paddles; |
E |
D N/A for internal paddles |
|
(vi) All standard apparatus to establish central venous pressure monitoring; |
E |
E |
|
(vii) All standard intravenous fluids and administering devices |
E |
E |
|
(viii) Sterile surgical sets for procedures standard for ED trauma care such as thoracotomy, vascular access, chest decompression; |
E |
D |
|
(ix) Gastric lavage equipment; |
E |
E |
|
(x) Drugs and supplies necessary for emergency care; |
E |
E |
|
(xi) Capability for the rapid infusion of fluids; |
E |
E |
|
(xii) Capability for rapid fluid recovery and transfusion; |
E |
E |
|
(xiii) Thermal control equipment for; |
||
|
(A) Patient; |
E |
E |
|
(B) Blood; |
E |
E |
|
(xiv) Two-way radio linked with prehospital vehicles; |
E |
E |
|
(xv) Cervical injury immobilization devices; |
E |
E |
|
(xvi) Long-bone stabilization devices. |
E |
E |
|
f. Trauma social services or crisis intervention services based on an approved hospital protocol. |
D |
D |
|
(2) A Trauma center shall have an Operating Room (OR) that: |
||
|
a. Assures prompt availability of an OR suite 24 hours per day; and |
E |
D |
|
b. Staffs with at least one RN in-house for the anticipated volume of patients and the remainder of the OR team and support staff on-call and promptly available. |
D |
D |
|
c. Has OR nurses who: |
||
|
(i) Are currently licensed as RNs; |
E |
E |
|
(ii) Can demonstrate trauma preparedness for the care of the trauma patient in the OR through hospital approved competencies and/or formal training course; |
E |
D |
|
(iii) Complete a structured orientation program related to the perioperative care of the trauma patient; |
E |
D |
|
(iv) Minimum of 6 hours per year continuing education related to the perioperative care of the trauma patient; |
E |
D |
|
(v) Participates in the multidisciplinary trauma committee by representation including patient care conferences; |
E |
E |
|
(vi) Participates in trauma PI activities by representation. |
E |
E |
|
d. Has a documented method for prompt mobilization of consecutive surgical teams for trauma patients; |
E |
D |
|
e. Collaborates with health professionals and families in donor identification and care, the organ and tissue procurement process and recipient care. |
E |
E |
|
f. Includes equipment or capabilities including; |
||
|
(i) Cardiopulmonary bypass; |
D |
D |
|
(ii) Operating microscope; |
D |
N/A |
|
(iii) Thermal control equipment for patients; |
E |
E |
|
(iv) Thermal control for blood; |
E |
E |
|
(v) Rapid infusion capability; |
E |
E |
|
(vi) Rapid fluid recovery capability; |
E |
D |
|
(vii) Radiology capability; |
E |
E |
|
(viii) Bronchoscope in operating room; |
E |
D |
|
(ix) Endoscopes available |
E |
D |
|
(x) Monitoring equipment; and |
E |
E |
|
(xi) Instruments for external and internal fixation of fractures; |
D |
D |
|
(xii) Instruments and equipment appropriate for pediatric trauma care; |
D |
D |
|
g. Designated operative treatment space with the capacity to meet the needs of the expected patient volume. |
E |
D |
|
(3) A Trauma Center shall have a post-anesthesia care unit or an acceptable surgical intensive care unit designated for surgical patient recovery with: |
||
|
a. Essential personnel, including at least one nurse with critical care and post-anesthesia care training, readily available 24 hours a day; |
E |
D |
|
b. Can demonstrate trauma preparedness for the care of the post-anesthesia trauma patient through approved competencies and/or formal training courses; |
E |
D |
|
c. Completes a structured orientation program related to the post-anesthesia perioperative care of the trauma patient; |
E |
D |
|
d. Appropriate monitoring and resuscitative equipment. |
E |
D |
|
(4) A Trauma Center shall have an intensive care unit (ICU) with: |
||
|
a. A medical director who is Board certified or eligible in critical care, internal medicine, pulmonary medicine, cardiology, or surgery; |
E |
D |
|
b. A physician on duty in the ICU 24 hours a day, or who is immediately available; Note: May be met by an ED physician meeting the requirements of these regulations |
E |
D |
|
c. A physician-directed code team; |
E |
D |
|
d. Intensive care registered nurses who: |
||
|
(i) Are currently RN licensed; |
E |
D |
|
(ii) TNCC verified or an equivalent course; |
E |
D |
|
(iii) Completes a structured orientation and competency program which includes content related to the care of a trauma patient; |
E |
D |
|
(iv) Minimum of 6 hours per year continuing education related to trauma; |
E |
D |
|
(v) Participates in a multidisciplinary trauma committee including patient-care conferences by representation; |
E |
D |
|
(vi) Participates in trauma PI activities; |
E |
D |
|
(vii) Collaborates with health care professionals and families in donor identification and care, the organ and tissue procurement and recipient care. |
E |
E |
|
e. Equipment appropriate for adult including: |
||
|
(i) Airway control and ventilation devices; |
E |
E |
|
(ii) Oxygen source with concentration controls; |
E |
E |
|
(iii) Cardiac emergency cart; |
E |
E |
|
(iv) Temporary pacemaker; |
E |
D |
|
(v) Electrocardiograph-cardiac monitor-defibrillator; |
E |
E |
|
(vi) Cardiac output monitoring; |
D |
D |
|
(vii) Electronic pressure monitoring |
D |
D |
|
(viii) Mechanical ventilator devices; |
E |
D |
|
(ix) Patient weighing devices; |
E |
E |
|
(x) Pulmonary function measuring devices; |
D |
D |
|
(xi) Temperature control devices; |
E |
D |
|
(xii) Drugs, intravenous fluids, and supplies; and |
E |
E |
|
(xiii) Intracranial pressure monitoring devices. |
D |
D |
|
f. Designated trauma critical care and treatment space with the capacity to meet the needs of the expected patient volume. |
E |
D |
|
(5) A Trauma Center shall have a clinical laboratory immediately available based upon the expected volume of patients, including: |
||
|
a. Standard analysis of blood, urine, and other body fluids; |
E, Note |
E, Note |
|
b. Coagulation studies; |
E, Note |
E, Note |
|
c. Blood gases and pH determination; |
E, Note |
E, Note |
|
d. Serum and urine osmolality; |
E, Note |
D |
|
e. Microbiology; |
E, Note |
D |
|
f. Alcohol determination; |
E, Note |
D |
|
g. Drug screening; and |
D |
D |
|
h. Microtechnique. |
E, Note |
D |
|
Note: Shall be promptly available |
||
|
(6) A Trauma Center shall have transfusion services including: |
||
|
a. Blood and blood components available from in-house or through community services, to meet patient needs in a timely fashion; |
E |
D |
|
b. Ability to have non-crossmatched blood available on patient arrival to the ED; |
E |
D |
|
c. Procedures and ability to perform massive transfusions and autotransfusion; and |
E |
D |
|
d. Blood storage capability; |
E |
D |
|
(7) A Trauma Center shall have radiological services including: |
||
|
a. The following services in-house and immediately available: |
||
|
(i) Computerized tomography |
E, Note |
D |
|
Note: Shall be promptly available |
||
|
(ii) Radiology capability; |
E, Note |
E, Note |
|
Note: If not in-house 24 hours per day, must have an approved early notification process |
||
|
(iii) In-house CT technician 24 hours a day |
E, Note |
D |
|
Note: Shall be promptly available |
||
|
(iv) In-house radiology technician 24 hours a day |
E, Note |
D |
|
Note: Shall be promptly available |
||
|
Note: Trauma PI process must verify promptly available services, outcome driven |
||
|
b. The following services on-call and promptly available: |
||
|
(i) Angiography |
D |
D |
|
(ii) Sonography |
D |
D |
|
(8) A Trauma Center shall have acute dialysis capability, or a written agreement with an appropriate facility for such. |
E |
E |
|
(9) A Trauma Center shall have: |
||
|
a. A physician-directed burn unit which is staffed by nursing personnel trained in burn care and is equipped to care for extensively burned patients; and/or |
D |
D |
|
b. Written transfer agreement with a burn center or hospital with a burn unit. |
E |
E |
|
(10) A Trauma Center shall be able to manage Traumatic Brain Injury and/or spinal cord injury; or have written transfer agreements with a facility with such capabilities. Adherence to current management guidelines shall be considered. |
E |
E |
|
(11) A Trauma Center shall have a designated trauma rehabilitation coordinator. |
D |
D |
|
(12) A Trauma Center shall have: |
||
|
a. A physician-directed rehabilitation medicine service which is staffed by personnel trained in rehabilitation care and is equipped to care for the trauma patient and/or; |
D |
D |
|
b. Written agreements to transfer patients to a designated rehabilitation service when medically feasible. |
E |
E |
|
(13) A Trauma Center shall have a heliport or helipad meeting applicable standards and any applicable Department-approved procedures and located close enough to permit the facility to receive and transfer patients by air. |
E, Note |
E, Note |
|
Note: May be fulfilled through a designated landing site with supporting written protocols. |
||
|
(14) In addition to all transfer agreements in this section, designated Trauma Centers shall have additional written transfer agreements for the identification and transfer of patients with special care needs who meet inter-hospital transfer criteria, to include the following patients categories: |
||
|
a. Pediatrics |
E |
E |
|
b. Obstetrics |
E |
E |
|
c. Other considerations based upon the specific hospital needs |
E |
E |
|
(15) Transfer agreements shall include the responsibility of the transferring hospital and the receiving hospital, and shall assign medical control during inter-hospital transfer. |
E |
E |
|
(16) Transferring facilities shall use Department-approved pre-hospital services for inter-facility transfer of trauma patients. |
E |
E |
Outreach,
Training, and Public Education
|
||
|
(1) A Trauma Center shall have: |
||
|
a. An outreach consultation and referral program with physicians of the community, prehospital care agencies and outlying areas regarding trauma care developed through participation with their respective ReTrAC. |
E |
E |
|
b. An outreach program with other designated trauma centers and hospitals developed through participation with their respective ReTrAC to include: |
E |
E |
|
(i) Agreement to participate in regional trauma monitoring and PI meetings as defined by the State IPEMS Bureau; |
E |
E |
|
(ii) Monitoring of the transfers in and out of the designated trauma center; |
E |
E |
|
(iii) Establishing transfer agreements and referral feedback mechanisms. |
E |
E |
|
c. Training, including; |
||
|
(i) Offers or participates in a formal program of continuing trauma care education for: |
||
|
(A) Staff and community physicians; |
E |
E |
|
(B) Staff and community nurses; |
E |
E |
|
(C) System and trauma clinical training for all allied health care professionals throughout the continuum; |
E |
D |
|
(D) Prehospital personnel; |
E |
D |
|
(ii) Hospital to cooperate and make available initial and maintenance training of invasive skills for prehospital personnel. |
E |
D |
|
d. A public awareness/education program, developed through collaboration with their respective ReTrAC addressing: |
||
|
(i) Injury prevention and wellness issues relevant to the region; |
E |
E |
|
(ii) Problems confronting the medical and nursing professions including hospitals regarding; hospital diversion, ED saturation as well as hospital capacity and access to care within their respective regions. |
E |
E |
|
e. Planning and implementation policies and procedures for Mass Casualty Incidents (MCI) developed through collaboration with their respective ReTrAC. |
E |
E |
|
Educational and Certification Requirements of Designated Trauma Care Personnel |
||
|
Unless otherwise stated in these regulations, all trauma personnel educational and or certification standards shall be met within six months of employment or contract. |
E |
E |
STATE OF NEW MEXICO
Trauma Care Regulations/Standards for
Designation Pediatric
Guidelines for Trauma Center Designation
(E) Essential (D) Desirable (N/A) 3.Not Applicable |
||
|
|
Level III
|
Level IV
|
|
(1) HOSPITAL SHALL: |
||
|
1.1 Meet the requirements of a basic 24-hour emergency facility and be licensed under the New Mexico Administrative Code. |
E |
E |
|
(2) PROFESSIONAL STAFF: Physician |
||
|
2.1 All full-time Emergency Department physicians’ education should consist of at least 16 hours of pediatric emergency CME credit every 2 years or have an acceptable hospital plan documenting pediatric proficiency. |
E |
D |
|
(3) PROFESSIONAL STAFF: Nursing |
||
|
3.1 Emergency Department: At least one Registered Nurse (RN) per shift shall have successfully completed the ENPC or PALS provider course and be designated for providing and/or monitoring pediatric nursing care. |
E |
D |
|
3.2 Intensive Care Unit (Hospital without PICU): at least one RN per shift shall be currently verified as a PALS provider or equivalent pediatric critical care course and be designated for providing and/or monitoring pediatric nursing care. |
E |
D |
|
3.3 Post-Anesthesia Care Unit (PACU) or designated post-recovery area: at least one RN per shift shall be currently verified as a PALS provider or have completed competency verification in the post-operative care of the pediatric patient. |
E |
D |
|
3.4 All nurses assigned to each department for providing and/or monitoring pediatric care shall complete two hours of pediatric education per year. |
E |
D |
|
3.5 Pediatric Liaison Nurse: one shall be designated. This nurse works in collaboration with the Trauma Nurse Coordinator to ensure and document all pediatric data for the Hospital Trauma Registry and to assist in coordination and documenting pediatric nursing education. |
E Note 4 |
D |
|
3.5.1 Minimum Qualifications include: Works in the ED, ICU, PICU, Pediatric or QI Minimum of one-year experience in the care of the pediatric patient. Completion of at least two hours of education in pediatric topics (in addition to ENPC) per year. |
D |
D |
|
(4) EQUIPMENT STATNDARDS, EMERGENCY DEPARTMENT |
||
|
The Emergency Department shall have: |
||
|
4.1 Resuscitation area with dedicated pediatric equipment. |
E Note 1 |
E Note 1 |
|
4.2 Airway control and ventilation equipment |
E |
E |
|
4.2.1 Laryngoscope blades with handles, curved, straight for infant and child |
E |
E |
|
4.2.2 Pediatric airways: endotracheal tubes postoperative, cuffed with stylets (all appropriate sizes) and lubricant; pediatric McGill forceps; pediatric airways |
E |
E |
|
4.2.3 Suction device with pediatric suction catheters (all appropriate sizes) |
E |
E |
|
4.2.4 Pediatric cricothyroidotomy tray with set up for needle cricothyroidotomy (all appropriate sizes) |
E |
SC
|
|
4.2.5 Pediatric bag-valve-mask (BVM) resuscitation device with premature infant, infant, child and adult clear mask to use with the BVM device with over-riding pop-off valve. |
E |
D |
|
4.2.6 Oxygen with oxygen-delivery device overriding for premature infant, infant, child and adult clear mask to use. |
E |
D |
|
4.2.7 Pediatric chest tubes (all appropriate sizes) |
E |
SC
|
|
4.2.8 Pulse oximeter with pediatric and adult sensors |
E |
D |
|
4.2.9 Equipment for needle thoracostomy for tension pneumothorax |
E |
D |
|
4.3 Circulatory Support Equipment |
|
|
|
4.3.1 Pediatric IV supplies (all appropriate sizes) with IV rate-control devices |
E |
E |
|
4.3.2 Appropriate fluids for pediatric resuscitation (ACLS/PALS Guidelines) |
E |
E |
|
4.3.3 Introsseous needles or spinal needles for introsseous infusion (all appropriate sizes) |
E |
E |
|
4.3.4 Monitor defibrillator and pediatric paddles with 0-400 watt/second capabilities |
E |
E |
|
4.3.5 Pediatric blood-pressure cuffs; premature infant, infants, child, adult and thigh sizes |
E |
D |
|
4.3.6 Doppler monitor |
E |
D |
|
4.3.7 Temperature control device for IV fluids |
E Note 2 |
E Note 3 |
|
4.3.8 Multilumen catheter (all appropriate sizes) |
D |
D |
|
4.4 Special Trays |
|
|
|
4.4.1 Thoractomy |
SC
|
SC
|
|
4.4.2 Thoracostomy |
D |
SC
|
|
4.4.3 Tracheostomy |
D |
SC
|
|
4.4.4 Diagnostic Peritoneal Lavage |
D |
D |
|
4.4.5 Lumbar Puncture |
E |
D |
|
4.4.6 Venesection |
D |
D |
|
4.4.7 Obstetrical Emergency Delivery |
E |
E |
|
4.5 Miscellaneous Equipment |
||
|
4.5.1 Spinal Immobilization device: backboards, head-rolls, or head immobilization devices, cervical collars to include sizes for children six years or younger |
E |
E |
|
4.5.2 Pediatric patient warming devices |
E Note 3 |
E Note 3 |
|
4.5.3 Thermometers |
E |
E |
|
4.5.4 Pediatric Foley catheters (all appropriate sizes) |
E |
E |
|
4.5.5 Pediatric splinting devices, femur traction device, general traction equipment |
E |
E |
|
4.5.6 Casting capabilities |
E |
E |
|
4.5.7 Sterile dressings for burn care |
E |
E |
|
4.5.8 Nasogastric tubes/infant feeding tubes (all appropriate sizes) |
E |
E |
|
4.5.9 Pediatric scales for weight measurement |
E |
E |
|
4.6 Medications; all appropriate medications in pediatric dosages as required for resuscitation (ATLS/PALS recommendations) |
E |
E |
|
4.7 Pediatric reference materials for drug dosage listed in kg (i.e. Broslow Tape) |
E |
E |
|
4.8 Quality Management; The hospital shall: |
||
|
4.8.1 Review all pediatric deaths and transfer complications |
E |
E |
|
4.8.2 Maintain a pediatric log or registry of all pediatric deaths and transfers |
E |
E |
|
Notes 1. Pediatric crash carts should be utilized to maintain the proper pediatric equipment and supplies. The pediatric crash cart should be labeled or color coded for clear recognition, 2. Fluid may be warded in standard warmer if IV fluid warming devices are unavailable so long as the appropriate temperature is maintained. 3. Warming methods may be used if devices are unavailable (warmed blankets, warmed bags of IV fluids. 4. The Trauma Nurse Coordinator may meet this standard without the need for additional personnel. SC Special Consideration: This term is
applicable to items that are not essential or desired components for
designation. However, facilities
wishing to meet specific criteria must provide the appropriate documentation for certifications and ongoing training. |
||
[7.27.7.15 NMAC - Rp 7 NMAC 27.7.12, 6/14/02]
History of 7.27.7
NMAC:
Pre-NMAC History: The Material in this part was derived from that previously filed with the State Records Center and Archives:
DOH Regulation 95-01 (CHSD), Regulation Governing the New Mexico Trauma Care System, 4-12-95.
History of Repealed Material: 7 NMAC 27.7, Trauma Care System, filed 11-26-96.
Other History: 7 NMAC 27.7, Trauma Care System, filed 11-26-96 replaced by 7.27.7 NMAC Trauma Care System, effective 6/14/02.