Md. Code Regs. 30.08.08.02

Current through Register Vol. 51, No. 24, December 2, 2024

Section 30.08.08.02 - Organization

A. The hospital's board of directors, administrators, and medical and nursing staffs shall demonstrate commitment to the optimal care of injured pediatric patients by:

(1) Formulating a board of director's resolution stating that:

(a) The hospital agrees to meet the Maryland Pediatric Trauma Center designation standards; and

(b) The hospital has a commitment to the infrastructure and the financial, human, and physical resources necessary to support the hospital's designation as a pediatric trauma center;

(2) Establishing an identifiable organization whose dedication to the care of injured children is shown in:

(a) Its mission statement;

(b) The configuration of its medical, administrative, and support staffs; and

(c) The configuration of its physical plant;

(3) Participating in the Statewide trauma system, including submission of patient care data to the State Trauma Registry for system and quality management (QM);

(4) Assuring that all pediatric trauma patients shall receive medical care commensurate with the hospital's designation as a pediatric trauma center; and

(5) A board of director's resolution, bylaws, contracts, and budgets, all specific to the pediatric trauma center, indicating the hospital's commitment to the financial, human, and physical resource infrastructure that is necessary to support the hospital's designation as a pediatric trauma center.

B. The hospital shall:

(1) Be licensed as an acute care hospital by the Maryland Department of Health or, if located outside Maryland, in the state in which it is located;

(2) Be accredited by The Joint Commission;

(3) Maintain current equipment and technology to support optimal pediatric trauma care;

(4) Admit annually 200 or more injured children who are younger than 15 years old;

(5) Have the ability to treat effectively all types of pediatric injuries, including:

(a) Brain injury;

(b) Spinal cord injury;

(c) Solid organ injury;

(d) Chest injury;

(e) Complex musculoskeletal injury;

(f) Burns;

(g) Eye injury;

(h) Hand and upper extremity injury; and

(i) Lower extremity injury; and

(6) Have a heliport or helipad positioned at the closest safe location so there is a limited distance from the helipad to the hospital.

C. The pediatric trauma center shall have a pediatric trauma leadership team responsible for monitoring and coordinating all components of the pediatric trauma program, including:

(1) A pediatric trauma medical director (TMD) who:

(a) Is a board-certified pediatric surgeon;

(b) Demonstrates expertise and commitment to the care of injured children;

(c) With the trauma program manager (TPM), is empowered by the hospital 's governing body to lead the pediatric trauma center;

(d) Has the authority and scope for administering all aspects of trauma care and is responsible for the overall clinical coordination of the pediatric trauma center;

(e) Has the responsibility for the oversight of the QM process related to all pediatric trauma patients;

(f) Participates in and publishes pediatric trauma research;

(g) Has a job description developed by the hospital to reflect the role and responsibilities as defined by COMAR;

(h) Appears on the hospital's organizational chart where the relationship between the TMD and other hospital services are depicted and delineated;

(i) Participates in local, regional, state and national activities related to pediatric injury care and prevention; and

(j) Participates in pediatric trauma education activities such as undergraduate medical education, postgraduate training programs, and continuing education (CE); and

(2) A pediatric trauma program manager (TPM) who:

(a) Is a 1.0 full-time equivalent (FTE) committed to the management of the pediatric trauma center;

(b) Meets the requirements of Regulation .20 of this chapter; and

(c) If the 1.0 FTE TPM has oversight of additional centers or services, the TPM is assisted by a 1.0 FTE QM nurse coordinator for each additional center or service.

D. There shall be one or more committees that provide expert input to the hospital's management of the pediatric trauma program. The committees shall:

(1) Under the leadership of the TMD and TPM or designee, ensure physician trauma peer review includes active participation by representatives from general surgery to address clinical care issues;

(2) Under the leadership of the TMD, conduct trauma multidisciplinary review that includes orthopedic surgery, emergency medicine, critical care, anesthesia, neurosurgery, radiology, rehabilitation, and nursing to address and ensure multidisciplinary review of clinical care and systematic issues; and

(3) Monitor, track, and trend pediatric trauma care within hospital departments, medical and nursing staffs, and representative disciplines across the trauma care continuum.

E. The pediatric trauma center shall have a pediatric trauma resuscitation team:

(1) Whose members are:

(a) Present in house and immediately available upon notification;

(b) Oriented to the internal pediatric trauma clinical management protocols and policies; and

(c) Have demonstrated skills for pediatric trauma care that are appropriate and specific to their specialty roles;

(2) That is available in the trauma resuscitation areas upon arrival of all trauma patients when there is advanced notification;

(3) That follows clearly defined policies and protocols for activation criteria and roles and responsibilities;

(4) That includes a team leader, who shall be either:

(a) An attending pediatric surgeon; or

(b) A postgraduate, year-3 or above general surgeon; and

(5) That includes an in-house emergency medicine physician who has experience and training in pediatric trauma resuscitation, and shall act as the pediatric trauma resuscitation team leader until relieved by the pediatric trauma surgeon in the resuscitation area.

F. There is a pediatric trauma multidisciplinary team that, in addition to physicians and nurses, consists of professionals with a focus on the unique needs of children and families, including:

(1) Social work;

(2) Child psychiatry;

(3) Child life therapy;

(4) Rehabilitation services, that is, physical, occupational, and speech therapies; and

(5) Respiratory therapy.

G. The hospital shall have a completed interdisciplinary plan of care specific to the needs of each pediatric trauma patient that addresses all phases of care, including acute care of injuries, disposition, discharge, and rehabilitation needs.

H. The hospital shall have written policies and procedures to direct the organized and safe interhospital transfer process of pediatric trauma patients. The hospital shall:

(1) Complete transfers to in-State hospitals, or to out-of-State hospitals listed in the Maryland Emergency Medical Services Interhospital Transfer Resource Manual, in accordance with the guidelines contained in the Maryland Emergency Medical Services Interhospital Transfer Resource Manual, without the need for separate transfer agreements; and

(2) Have a written transfer agreement in place for transfer of a patient to an out-of-State hospital not listed in the Maryland Emergency Medical Services Interhospital Transfer Resource Manual, if the hospital transfers to such an out-of-State hospital more than five times a year.

Md. Code Regs. 30.08.08.02

Regulation .02 adopted effective 50:14 Md. R. 594, eff. 7/24/2023