Code of Maryland Regulations
Title 30 - MARYLAND INSTITUTE FOR EMERGENCY MEDICAL SERVICES SYSTEMS (MIEMSS)
Subtitle 08 - DESIGNATION OF TRAUMA AND SPECIALTY REFERRAL CENTERS
Chapter 30.08.05 - Trauma Center Designation and Verification Standards
Section 30.08.05.03 - Trauma Center Designation and Verification Standards

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

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

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(a) The hospital agrees to meet the Trauma Center designation standards for the hospital's specific level of designation;

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(b) The hospital has a commitment to the infrastructure and the financial, human, and physical resources necessary to support the hospital's specific level of designation; and

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(c) The hospital has a commitment to the Quality Management (QM) process of the trauma patient; and

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

(a) Its mission statement;

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

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(c) The configuration of its physical plant;

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(d) Demonstrated participation and involvement in state and regional trauma system planning, development, and operations required for all designated Trauma Centers;

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(e) Assurance that all trauma patients receive medical care commensurate with the level of the hospital's designation; and

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(f) Demonstrated commitment to the infrastructure and financial, human, and physical resources necessary to support the hospital's level of trauma center designation through the hospital's bylaws, contracts, and budget specific to the trauma program;

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B. A hospital shall be licensed by the Department of Health as an acute care hospital.

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C. A hospital shall be accredited by The Joint Commission.

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D. A hospital shall maintain current equipment and technology to support optimal trauma care for the level of the hospital's Trauma Center designation.

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E. A hospital shall have:

(1) A heliport or helipad positioned so there is a limited distance from the helipad to the hospital, and positioned at the closest safe location, in order to minimize effects to the patient; or

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(2) Access to a helicopter-landing zone near the hospital.

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F. To administer the trauma program, a hospital shall have a trauma leadership team that includes:

(1) A Trauma Medical Director (TMD) -who:

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(a) Has administrative oversight for the trauma program;

(b) With the Trauma Program Manager (TPM), has the authority and is empowered by the hospital's governing body to lead the trauma program;

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

(d) Is responsible for all trauma patients through the QM process;

(e) Directs the Trauma QM Program and reports QM activity as directed by the institutional reporting structure;

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

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

(h) Participates in regional and state education, QM, and injury prevention activities;

(2) A full-time director of patient care services, who is a registered nurse, with direct authority for all nursing and ancillary trauma patient care services, operations, and the QM associated with these services;

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(3) An in-house resource coordinator who is available 24 hours a day and is responsible for the timely coordination of trauma patient care resources, services, patient flow and throughput;

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(4) A TPM who is dedicated full-time to the management of the trauma program and in collaboration with the TMD and nursing management, has oversight for, monitors, and coordinates the components of the trauma program, including:

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(a) Patient care;

(b) Provider education;

(c) Public education and prevention activities;

(d) Program management;

(e) The hospital's participation in the Maryland State Trauma Registry;

(f) QM for the trauma program; and

(g) Show evidence of 16 hours of external trauma-related CE a year and over a 2-year period, half of the CE hours shall be obtained outside the hospital and be recognized by a national accrediting body;

G. The Trauma Center shall have one or more committees that provide expert input to the hospital's management of trauma program issues that shall:

(1) Under the leadership of the TMD and TPM or designee, provide trauma multidisciplinary peer review and include representatives from general surgery, to address clinical care issues;

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(2) Conduct trauma multidisciplinary peer review that includes Orthopedic surgery, Emergency Medicine, Critical Care, Anesthesia, Neurosurgery, Radiology and Nursing, to address clinical care issues;

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(3) Monitor trauma patient care among hospital departments, medical and nursing staffs, and representative disciplines across the trauma care continuum; and

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(4) Collaborate with the Emergency Department (ED) Committee to address trauma care issues.

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H. The Trauma Resuscitation Team shall:

(1) Be in the Trauma Resuscitation Unit on arrival for all trauma patients;

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(2) Be in the trauma resuscitation area at the bedside within 15 minutes of being called for the highest level of activation;

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(3) Be activated by an emergency physician or nurse using clearly defined Trauma Center criteria for activation protocol;

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(4) Be directed by an in-house emergency physician who has experience and training in trauma resuscitation until the patient is formally transferred to the care of the trauma surgeon;

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(5) Be in the trauma resuscitation area at the bedside within 30 minutes of being called for the highest level of activation;

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(6) Be oriented to the trauma care system;

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(7) Be required to complete annual continuing education and demonstrate competence for trauma care that is appropriate and specific to each member's specialty roles;

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(8) Participate in:

(a) Trauma Quality Management (QM); and

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(b) Ongoing medical education or continuing education in trauma;

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(9) Be oriented to the internal trauma patient clinical management protocols or clinical practice guidelines, and algorithms derived from evidenced-based validated resources;

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(10) Be defined in writing, specifying the roles and responsibilities of each member; and

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(11) Be accountable to the trauma surgeon who becomes the team leader upon arrival in the resuscitation area.

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I. A hospital shall have written policies and procedures to direct the organized, safe, intra-hospital and inter-hospital transfer process of trauma patients.

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J. A hospital shall 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.

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K. A hospital shall 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 out-of-State hospital more than five times a year.

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L. A hospital shall have a multidisciplinary plan of care specific to the needs of each trauma patient and address all phases of care, including discharge disposition, and rehabilitation needs.

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