6 Colo. Code Regs. § 1015-4-304

Current through Register Vol. 47, No. 24, December 25, 2024

Section 6 CCR 1015-4-304 - Trauma Quality Improvement Programs for Designated Trauma Centers Level III-V

1. All designated Level III-V trauma centers shall have an organized trauma quality improvement program that demonstrates a plan, process, and accountability for continuous quality improvement in the delivery of trauma care.

A. Each facility shall define its Scope of Care (SOC) based on the resources that are available to the facility.

B. Each facility shall have a formal transfer policy when specialty resources are not available.

C. Administration must support the trauma program and the Trauma Medical Director (TMD) in providing staff education commensurate with the level of care and based on patient population served.

2. The trauma quality improvement plan shall address the entire spectrum of services necessary to ensure optimal care to the trauma patient, from prehospital to rehabilitative care. The plan shall ensure the continuity of care for all admitted patients.

A. In Level III facilities, this plan may be parallel to, and interactive with, the hospital-wide quality improvement program as defined in Section 25-3-109, C.R.S. but may not be replaced by the facility process.

B. In Level IV-V facilities, this plan may be part of the hospital-wide quality improvement program but must have facility-defined, trauma-related indicators and components. Trauma-related issues must be documented separately, and the TMD has authority over any trauma issues.

C. This plan shall include identification of:

(1) The trauma center's organizational structure responsible for the administration of the plan, to include a description of who has the authority to change policies, procedures, or protocols related to trauma care.

(2) The responsibility of the TMD, in coordination with the trauma nurse coordinator (TNC), for:

a. The implementation of and responsibility for the oversight of the plan.

b. The facility-defined standards of medical care for the trauma patient.

c. The data sources to support an effective monitoring system, to include but not be limited to, retrospective and concurrent medical record review, including:

i. Primary level of review at least weekly.

ii. Secondary level of review, TMD in collaboration with TNC, at least twice a month.

iii. Tertiary level of review at least every other month at level IIIs and at least quarterly at Level IV and Vs.

d. Identification of system issues to be addressed in multidisciplinary committee.

e. Identification of peer issues to be addressed in trauma peer review.

f. Review of all inpatients, transfers in or out, and trauma deaths.

g. Provide appropriate physician, mid-level, ancillary, and nursing staff education commensurate with the scope of care as described in 304.1.A.

h. Provide a mechanism for external review of specialty specific trauma cases that are not just limited to deaths.

3. The trauma quality program shall include a multidisciplinary committee responsible for trauma program performance.

A. At a minimum, attendance at multidisciplinary committee shall include representation from specialties and service lines involved in the care of trauma patients.

B. At a minimum, attendance requirements shall be 50 percent attendance by emergency medicine, orthopedics, general surgery, neurosurgery, anesthesia, and medicine in facilities where those specialties are involved in the care of trauma patients.

C. Facility-defined specialty care filters shall be based on the written scope of care and nationally recognized best practice guidelines.

D. The committee must meet on a regular basis, but not less than every two months for Level III facilities and quarterly for Level IV-V facilities, to assure timely review and corrective action.

E. The committee must review all services essential to the care and management of the trauma patient.

F. Performance management functions include, but are not limited to:

(1) A process for issue identification, case summarization, discussion, action plan, resolution, or outcome for loop closure.

(2) Initiation of corrective action as needed.

(3) A process for prehospital trauma care review.

(4) A process for the identification and review of facility-defined audit filters, patient sentinel events, complications, and trends.

(5) Facility-specific nursing audits for nursing documentation.

(6) Establishing and enforcing policies and procedures.

(7) Reviewing system issues, e.g., communications, notification times, and response times.

(8) Promoting educational offerings.

(9) Reviewing and analyzing trauma registry data for program evaluation and utilization.

(10) Provision for case presentations of interest for educational purposes to improve overall care of the trauma patient including all aspects and contributing factors of trauma care, from prehospital to discharge or death.

4. The trauma quality program shall include a method and process for conducting multidisciplinary trauma peer review comparable to the peer review defined in Section 12-30-201 et seq., C.R.S.

A. The facility shall define standards of care for the trauma patient.

B. The performance improvement process shall monitor compliance with, or adherence to, facility-defined standards.

C. Documentation of findings and recommendations must be maintained with an identified reporting process for loop closure.

D. Review any event that deviates from an anticipated outcome.

E. Compliance with all facility trauma care policies, protocols, and practice guidelines.

F. Conducting a review of all trauma deaths with:

(1) A report summary of the trauma peer review findings to the trauma multidisciplinary committee.

(2) All trauma centers shall have a policy that includes the process and criteria for utilization of a resource outside the facility for specialty specific peer review. Qualifications of outside peer reviewer must be identified by the facility as defined in Section 12-30-201 et seq., C.R.S.

(3) The deaths shall be identified as unanticipated mortality with opportunity for improvement (preventable), anticipated mortality with opportunity for improvement (potentially preventable), or mortality without opportunity for improvement (non-preventable), or equivalent taxonomy.

5. The trauma quality program shall demonstrate accountability by:

A. The development and implementation of on-going reporting and trending of facility-specific audit filters.

B. Documenting and maintaining minutes available for trauma multidisciplinary committee, trauma peer review committee, or any other committees used in this process. Written documentation of the process to include date, issue identification, case summarization, assessment, any corrective action, recommendations, policy revision, education, and resolution.

C. Maintaining a system (such as a log) for tracking patient disposition and deaths.

D. Evidence of provider response times when the trauma team is activated.

E. Evidence of provider response times when consultations are required.

F. Evidence that nursing care issues are reviewed as part of the trauma program.305. Scope of Care for Designated Trauma Centers Level III-V

6 CCR 1015-4-304

39 CR 02, January 25, 2016, effective 2/14/2016

40 CR 08, April 25, 2017, effective 5/15/2017

41 CR 22, November 25, 2018, effective 12/15/2018

42 CR 10, May 25, 2019, effective 6/14/2019

43 CR 09, May 10, 2020, effective 6/14/2020

44 CR 10, May 25, 2021, effective 7/1/2021