16 Del. Admin. Code § 4305-6.0

Current through Register Vol. 28, No. 7, January 1, 2025

Section 4305-6.0 - State of Delaware Trauma Center Standards

6.1 At a minimum, Delaware Trauma Center Standards must meet the requirements and trauma standards set forth in the ACS Committee on Trauma's Verification, Review and Consultation (VRC) Committee Resources for Optimal Care of the Injured Patient, 2006 Standards and all subsequent updates for verification and designation.

6.1.1 The Division may modify existing American College of Surgeons' Committee on Trauma Standards to increase the level of the requirement.

6.1.2 American College of Surgeons Trauma Standards may not be modified so as to decrease the level of the requirement.

6.1.3 The process for modifying an existing American College of Surgeons Standard is as follows:

6.1.3.1 The Trauma System Committee shall discuss and vote to recommend to the Division Director that a modification should be made.

6.1.3.2 If approved by the Division Director, the existing Delaware Trauma System regulations shall be revised pursuant to 29 Del.C. Ch. 101.

6.1.4 Copies of the current ACS Resources for Optimal Care of the Injured Patient may be obtained by contacting the ASC Publication Orders Department at 633 N. Saint Clair Street in Chicago, IL, 60611 or by telephone at (312) 202-5000. Copies can also be found at https://www.facs.org/quality-programs/trauma/quality/verification-review-and-consultation-program/.

6.2 Facility requirements.

6.2.1 Facility administration and medical staff must demonstrate commitment to the trauma program, including:

6.2.1.1 Development and adoption of written resolution of support from both the facility Board of Trustees and the medical staff;

6.2.1.2 Establishment of written policies and procedures to provide and maintain the services for trauma patients as outlined in Delaware's Trauma Center Standards;

6.2.1.3 Demonstrated evidence of budgetary support of the facility's trauma program such as facility-funded positions for Trauma Medical Director (TMD), Trauma Program Manager (TPM), trauma registry personnel or Trauma Quality Improvement Program personnel;

6.2.1.4 Active participation and attendance of trauma leadership staff in the Delaware Trauma System Committee and Trauma Quality Evaluation Committee;

6.2.1.5 Adherence to State Trauma Registry guidelines for providing facility trauma registry data to the State Trauma Registry for utilization in trauma system management and quality improvement activities;

6.2.1.6 Establishment and maintenance of written transfer procedures and agreements with appropriate trauma centers, specialty centers, and facilities, providing for movement of both critical and convalescing patients within the trauma system. Compliance with these procedures is to be monitored by the quality improvement process in each facility. It is the responsibility of each receiving facility to provide timely feedback to transferring facilities on the status and outcome of all patients received.

6.2.1.7 Designated trauma system facilities shall continue to function in accordance with the Trauma Facility - Division of Public Health Memoranda of Agreement signed upon designation.

6.2.2 Facilities must incorporate the following trauma services procedures:

6.2.2.1 Written protocols and standards of care for the major trauma patient, including definitions of response and turnaround times as well as team participant roles; and

6.2.2.2 Written trauma activation procedures.

6.2.3 Facilities must retain a Trauma Program Manager (TPM). The TPM shall have the following qualifications and responsibilities:

6.2.3.1 The TPM shall work with the Trauma Medical Director (TMD) and shall be responsible for the organization of services and systems necessary for a multidisciplinary approach throughout the continuum of trauma care. The TPM role has the following components: clinical, educational, registry/quality improvement/research, administrative, and liaison.

6.2.3.2 In Level I, II, and III trauma centers, the TPM must have 1 full-time equivalent (FTE) commitment to the trauma program.

6.2.3.3 The TPM is not required to be a full-time (1 FTE) position for Level IV centers.

6.2.3.4 The TPM must be certified in Trauma Nursing Core Course (TNCC).

6.2.3.5 The TPM must attend a minimum of 36 hours of trauma-related continuing education during the verification cycle, and records must be available documenting these trauma-specific continuing education hours.

6.2.3.7 The TPM must actively participate in and attend meetings of the Delaware Trauma System Committee and Trauma Quality Evaluation Committee.

6.2.4 Facilities must retain a Trauma Medical Director (TMD). The TMD shall have the following qualifications and responsibilities:

6.2.4.1 The TMD shall be a board-certified or board-eligible surgeon or emergency department physician.

6.2.4.2 Through the quality improvement process, the TMD shall have responsibility for all trauma patients and administrative authority for the facility's Trauma Program.

6.2.4.3 The TMD must attend a minimum of 8 trauma-related hours of continuing education annually and records must be available documenting these trauma-specific continuing education hours.

6.2.4.4 Additional qualifications for the TMD shall include regular involvement in the care of injured patients and participation in trauma-related educational activities.

6.2.4.5 The TMD shall maintain current Advanced Trauma Life Support certification.

6.2.4.6 The TMD must actively participate in and attend meetings of the Delaware Trauma System Committee and Trauma Quality Evaluation Committee.

6.2.5 Each facility must have a Performance Improvement and Patient Safety (PIPS) Program that conducts the following:

6.2.5.1 In accordance with Section 9.0, provide facility trauma registry data to the State Trauma Registry for utilization in trauma system management and quality improvement activities;

6.2.5.2 Special audits for all trauma deaths;

6.2.5.3 Morbidity and mortality reviews;

6.2.5.4 Nursing performance improvement reviews;

6.2.5.5 Reviews of prehospital trauma care;

6.2.5.6 Documentation of times of and reasons for trauma-related bypass;

6.2.5.7 Reviews of trauma patients admitted to medical services (non-surgical service admissions); and

6.2.5.8 Establishment of a Trauma Program Performance Improvement Committee, which shall:

6.2.5.8.1 Meet regularly for the purpose of peer-review and trauma center performance;

6.2.5.8.2 Be chaired by the Trauma Medical Director;

6.2.5.8.3 Have representation from the major services and applicable specialists that were involved in the treatment of the reviewed trauma patient with membership including the Trauma Program Manager, emergency medicine physician, and if applicable the surgeon and anesthesiologist; and

6.2.5.8.4 Conduct the following tasks: critically review, evaluate, and discuss the quality and appropriateness of care in cases of adverse outcome (complications and deaths, particularly unexpected deaths), monitor complication trends, identify well-managed cases which can be utilized as teaching cases, and designate focused audits.

6.4 Transfer agreements.

6.4.1 Written transfer procedures and agreements with appropriate trauma centers, specialty centers, and facilities, providing for timely movement of both critical and convalescing patients within the Trauma System, must be established and maintained. Compliance with these procedures is to be monitored by each facility's PIPS program.

6.4.2 Transfer agreements are required for the following:

6.4.2.1 Regional trauma resources/capabilities, or specialty centers;

6.4.2.2 Recognized burn centers; and

6.4.2.3 Tertiary pediatric referral center with critical care capabilities.

6.5 Rehabilitative services.

6.5.1 Consultation with appropriate rehabilitative services shall be made early in the patient's hospitalization. Patients with rehabilitative needs shall have access to early rehabilitative evaluation and bedside therapy during the acute phase of their care. Optimal time for rehabilitation consult is within 72 hours of admission.

6.5.2 There must be identifiable evidence of early and adequate discharge planning for patients, including assessment of function to assure that all trauma patients have access to the inpatient or outpatient services that may be required post-acute care discharge.

6.5.3 Facilities that do not have in-house trauma rehabilitation services must have a transfer agreement with a rehabilitation facility.

16 Del. Admin. Code § 4305-6.0

27 DE Reg. 529( 1/1/2024) (Final)