Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 185 - NEBRASKA STATEWIDE TRAUMA SYSTEM
Chapter 1 - STATEWIDE TRAUMA SYSTEM
Section 185-1-004 - STANDARDS FOR DESIGNATION OF TRAUMA CENTERS - LEVELS OF TRAUMA CENTERS

CATEGORIES

ADVANCED

GENERAL

BASIC

Institutional organization must include the following:

Institutional support as evidenced by a signed board resolution; a signed medical staff resolution; hospital administrator and trauma medical director working together; and an organizational chart that places the trauma program in equal authority with other departments.

X

X

X

The trauma program must demonstrate its ability to influence care across all phases of trauma treatment within the hospital.

X

X

X

Trauma medical director who is a current board certified general surgeon (or general surgeon eligible for certification by the American Board of Surgery) or a general surgeon who is an American College of Surgeons Fellow with a special interest in trauma care and who participates in trauma call.

X

X

Trauma medical director who is a physician on staff at the hospital.

X

Trauma coordinator or manager.

X

X

X

Trauma team that consists of physicians, advanced practice providers, nurses, and allied health professionals to respond to a trauma emergency in the hospital emergency department. At a minimum:

a. The team is under the leadership of the trauma surgeon, general surgeon or in basic trauma centers, a physician or an advanced practice provider covering the emergency department;

b. When the trauma surgeon is not inhouse, the physician or advanced practice provider covering the emergency department will act as team leader until the trauma surgeon arrives in the resuscitation area; and

c. A trauma team that includes a registered nurse.

X

X

X

Trauma peer review committee where the trauma medical director must attend 50% of the meetings. Meeting minutes that reflect detailed discussion, action steps, and conclusions must be maintained.

At the advanced level, the committee meeting must be conducted independently from hospital or department based peer review and be incorporated into the hospital wide activities.

X

X

X

At the general or basic level, the committee meeting may be part of another hospital quality meeting but the meeting minutes must reflect a separate section devoted to trauma care.

Multidisciplinary trauma review committee may have members from all disciplines that are involved in the care of the trauma patient, meets at least twice a year, and meets all requirements in 185 NAC 1-008 and all subsections.

X

X

X

Hospital departments, divisions, or sections must include the following:

General surgery.

X

X

Neurological surgery.

X

Orthopedic surgery.

X

Emergency medicine.

X

Anesthesia.

X

X

Services available in-house and immediately available 24 hours a day include:

Emergency services physician.

X

X

Services available within 15 minutes of patient's arrival include:

General surgery.

X

Has a written physician back-up call schedule for general surgery. In trauma centers with accredited residency training programs, the chief resident may serve as back up.

X

Has a surgeon dedicated to a single hospital. This means the surgeon is not on call at another hospital at the same time.

X

Anesthesia.

X

Services on-call 24 hours a day include:

General surgery.

X

X

Primary care physician or advanced practice provider covering the emergency department.

In basic trauma centers where an advanced practice provider takes first call for the emergency department, there must be written criteria stating when the on-call back up attending physicians must be contacted for unstable patients.

X

Anesthesia.

X

Orthopedic surgery.

X

Has an orthopedic surgeon dedicated to single hospital (meaning not on call at another hospital at the same time) or back up call. In trauma centers with accredited residency training programs, the chief resident may serve as back up.

X

Neurologic surgery.

X

Has a neurosurgeon dedicated to single hospital (meaning not on call at another hospital at the same time) or back up call in trauma centers with accredited residency training programs the chief resident may serve as back up.

X

Obstetrics gynecologic surgery.

X

Oral maxillofacial surgery.

X

Ophthalmic surgery.

X

Plastic surgery.

X

Critical care medicine.

X

Radiology.

X

X

X

Interventional radiology.

In advanced trauma centers, an interventional radiologist must either be available within 30 minutes, 24 hours a day or a written contingency plan with 100% performance improvement program review of all patients must be in place.

X

Thoracic surgery.

X

General or Trauma Surgeon must meet the following:

Board certified or eligible for board certification by an appropriate specialty board recognized by the American Board of Medical Specialists or meets all of the following alternative criteria:

a. Completed an approved residency program;

b. Is approved for privileges by the hospital's credentialing committee;

c. Meet all criteria established by the hospital's trauma director;

d. Experienced in trauma care that is tracked by a p performance improvement program; and

X

X

Has a physician representative from general or trauma surgery who attends at least 50% of the trauma peer review committee meeting held at least twice a year.

X

X

Has a physician representative from general or trauma surgery who attends at least 50% of the trauma peer review committee meetings held at least twice a year if one is on staff and actively involved in the care of trauma patients.

X

Emergency medicine physician; primary care physician or advanced practice provider covering the emergency department must meet the following:

Has a physician who is board certified or eligible for board certification by an appropriate specialty board recognized by the American Board of Medical Specialists or meets all of the following alternative criteria:

a. Completed an approved residency program;

b. Approved for privileges by the hospital's credentialing committee;

c. Meet all criteria established by the hospital's trauma director;

d. Is experienced in trauma care that is tracked by a performance improvement program; and

X

Has a physician representative who attends at least 50% of the trauma peer review committee meetings held a minimum of twice a year.

X

X

X

Neurosurgery must meet the following:

General level trauma centers are not required to have a neurosurgeon on staff. If one is on staff and participates in the care of trauma patients, they must meet the standards indicated by an X under "general" in the following.

Has a neurological surgeon who is board certified or eligible for board certification by an appropriate specialty board recognized by the American Board of Medical Specialists or meets all of the following alternative criteria:

a. Completed an approved residency program;

b. Is approved for privileges by the hospital's credentialing committee;

c. Meet all criteria established by the hospital's trauma director;

d. Experienced in trauma care that is tracked by a performance improvement program; and

X

X

A neurosurgical surgeon attends at least 50% of the trauma peer review committee meetings held a minimum of twice a year.

X

A neurosurgical surgeon, if one is on staff and actively involved in trauma care, attends at least 50% of the trauma peer review committee meetings held a minimum of twice a year.

X

X

Orthopedic surgery must meet the following:

Orthopedic surgeon who is board certified or eligible for board certification by an appropriate specialty board recognized by the American Board of Medical Specialists or meets all of the following alternative criteria:

a. Completed an approved residency program;

b. Is licensed to practice medicine and approved for privileges by the hospital's credentialing committee;

c. Meet all criteria established by the hospital's trauma director;

d. Experienced in trauma care that is tracked by a performance improvement program; and

X

An orthopedic surgeon attends at least 50% of the trauma peer review committee meetings held a minimum of twice a year.

X

An orthopedic surgeon, if one is on staff and actively involved in trauma care, attends at least 50% of the trauma peer review committee meetings held a minimum of twice a year.

X

X

Radiology must include the following:

A radiologist attends at least 50% of the trauma peer review committee meetings held a minimum of twice a year.

X

X

A radiologist, if one is on staff and actively involved in trauma care, attends at least 50% of the trauma peer review committee meetings held a minimum of twice a year.

X

Facilities, resources, and capabilities include:

Presence of a surgeon at resuscitation. In a hospital with a general surgery accredited residency program, if a team of surgeons initiates evaluation and treatment of the trauma patient, that team of surgeons may include a surgical resident from the hospital's residency program, if the resident has reached a seniority level of post graduate year (PGY) 4 or higher. If the surgical resident is a member of the evaluation and treatment team, the attending surgeon may take call from outside the hospital if the hospital establishes local criteria defining what requires the attending surgeon's immediate presence.

X

Emergency department must meet the following:

Trauma team activation criteria that includes physiologic, anatomic, and mechanism of injury with written protocol defining activation process.

X

X

X

Heliport or landing zone located close enough to permit the facility to receive or transfer patients by air.

X

X

X

Have a designated physician director for the emergency department.

X

X

X

Emergency department includes equipment for patient resuscitation of all ages:

Airway control and ventilation equipment including airway control and ventilation equipment; bag valve mask and reservoir; oropharyngeal airway devices; laryngoscope and blades; endotracheal tubes; supraglottic airway device; or alternate airway device and portable video laryngoscope.

X

X

X

Suction equipment and devices.

X

X

X

Drugs necessary for Rapid Sequence Intubation.

X

X

X

Pulse oximetry.

X

X

X

Electrocardiograph-oscilloscope-defibrillator.

X

X

X

Qualitative end-tidal carbon dioxide.

X

X

Quantitative or qualitative end-tidal carbon dioxide.

X

Large bore, long intravenous catheter for needle decompression (minimum 14 gauge, 3.25 inch).

X

X

X

Standard IV fluids and administration sets.

X

X

X

Large bore intravenous catheters.

X

X

X

Intraosseous needle or kit.

X

X

X

Cricothyroidotomy kit or equipment for surgical airway.

X

X

X

Thoracostomy tray.

X

X

X

Hemorrhage control tourniquets.

X

X

X

Traction splints (in basic trauma centers, traction splints may be shared with local emergency medical service with a written plan for obtaining equipment).

X

X

X

Pelvic binder (in basic trauma centers, pelvic binders may be shared with local emergency medical service with a written plan for obtaining equipment).

X

X

X

Pediatric resuscitation tape.

X

X

X

Thermal control for patient.

X

X

X

Equipment for communication with Emergency medical services.

X

X

X

Device capable of detecting severe hypothermia.

X

X

X

Thermal control for fluids and blood.

X

X

Rapid infuser system in general trauma centers, the rapid infuser may be shared with the operating room.

X

X

Ultrasound.

X

X

Central venous pressure monitoring equipment.

X

X

Reversal agents for anti-coagulant and anti-platelet medications.

X

Central line insertion.

X

Thoracotomy equipment.

X

Arterial catheters.

X

Internal paddles.

X

Cervical traction devices.

X

Operating room must include:

Basic trauma centers are not required to have an operating room. If available and used in the care of trauma patients, they must meet the standards indicated by an X under "basic".

Personnel available within 15 minutes, 24 hours a day seven days a week.

X

Personnel available within 30 minutes, 24 hours a day seven days a week.

X

X

Age specific equipment.

X

X

Thermal control for patient.

X

X

X

Thermal control for fluids and blood.

X

X

X

X-Ray capability including c-arm image intensifier.

X

Endoscopes and bronchoscope

X

X

Craniotomy instruments.

X

Equipment for long bone and pelvic fixation.

X

Rapid infuser system (in general trauma centers, the rapid infuser may be shared with the emergency department).

X

X

X

Post anesthetic recovery room (Critical Care Unit is acceptable) must include:

Basic trauma centers are not required to have post anesthetic recovery rooms. If available and used in the care of trauma patients, they must meet the standards indicated by an X under "basic".

Registered nurses available 24 hours a day, seven days a week.

X

X

Monitoring equipment.

X

X

X

Pulse oximetry.

X

X

X

Thermal control.

X

X

X

Critical Care Unit for injured patients must include the following equipment for monitoring and resuscitation:

Basic Trauma Centers are not required to have a Critical Care Unit. If available and used in the care of trauma patients, they must meet the standards indicated by an X under "basic.

Airway control and ventilation equipment including bag valve mask with reservoir; oropharyngeal airway devices; laryngoscope and blades; endotracheal tubes; airway suction equipment; supraglottic airway device; or alternate airway device and portable video laryngoscope.

X

X

X

Ventilator.

X

X

Suction equipment and devices.

X

X

X

Pulse oximetry.

X

X

X

Electrocardiograph-oscilloscope-defibrillator.

X

X

X

Qualitative end-tidal carbon dioxide.

X

X

X

Designated surgical director or surgical co-director.

X

X

Intracranial pressure monitoring

equipment.

X

Pediatric patients treated in an adult center (Patients estimated to be less than 16 years of age that are admitted to an observation or inpatient bed that is designated for adult patients.)

Advanced, basic, and general level facilities are not required to have a formal Pediatric Critical Care Unit; however, if pediatrics patients are treated on-site they must meet the standards indicated by an X in the applicable category.

Trauma surgeons must be credentialed in pediatric care and have pediatric advance life support certification. Criteria must include Pediatric Advanced Life Support certification.

X

X

Equipment in all patient care areas for monitoring and resuscitation of pediatric patients must include:

Pediatric airway control and ventilation equipment: including bag valve mask with reservoir; oropharyngeal airway devices; laryngoscope and blades; endotracheal tubes; airway suction equipment; supraglottic airway device; or alternate airway device and portable video laryngoscope.

X

X

X

Electrocardiograph-oscilloscope-defibrillator.

X

X

X

Pulse oximetry.

X

X

X

Thermal control.

X

X

X

The hospital must have a pediatric critical care unit or a written plan for the transfer of pediatric trauma patients.

X

X

X

A trauma center that has a dedicated Pediatric Critical Care Unit on-site must have equipment for monitoring and resuscitation for pediatric patients of all ages that include:

Airway control and ventilation equipment including bag valve mask with reservoir; oropharyngeal airway devices; laryngoscope and blades; endotracheal tubes; airway suction equipment; supraglottic airway device; or alternate airway device and portable video laryngoscope.

X

X

Ventilator.

X

X

Suction equipment and devices.

X

X

Drugs necessary for Rapid Sequence Intubation.

X

X

Pulse oximetry.

X

X

Electrocardiograph-oscilloscope-defibrillator.

X

X

Qualitative end-tidal carbon dioxide.

X

X

Thermal control.

X

X

Intracranial pressure monitoring

equipment.

X

Respiratory therapy service must be:

Available in-house 24 hours a day, seven days a week.

X

On-Call 24 hours a day, seven days a week.

X

Radiological services-available 24 hours every day and includes:

In-house radiology technician.

X

Angiography.

X

Ultrasound.

X

X

Computerized tomography.

X

X

In-house computerized tomography

X

technician.

Magnetic Resonance Imaging.

X

On-call radiology.

X

X

Clinical laboratory service available 24 hours every day and includes:

Standard analyses of blood, urine, and other body fluids including point of care testing and micro sampling.

X

X

X

Blood typing and cross matching.

X

X

Coagulation studies.

X

X

Packed red blood cells, frozen fresh plasma, platelets, and cryoprecipitate rapidly available for massive transfusion.

X

Packed red blood cells, frozen fresh plasma, and rapidly available for massive transfusion.

X

Two or more units of O Negative blood available or rapidly released in an alternate system.

X

Massive transfusion policy.

X

X

Laboratory technologist available inhouse 24 hours a day seven days a week.

X

X

Laboratory technologist available within 30 minutes of patient's arrival.

X

Blood gases and Potential of Hydrogen (PH) determinations.

X

X

Microbiology.

X

X

Acute hemodialysis includes:

The hospital must have acute hemodialysis in-house. A written plan must be in place to transfer the patient if hemodialysis is not immediately available.

X

The hospital must have a written plan for the transfer of trauma patients to receive acute hemodialysis if not in-house.

X

X

Burn care includes:

The hospital must have a written plan for the transfer of burn patients to receive burn care if not in-house.

X

X

X

Acute spinal cord and head injury management includes:

The hospital must provide management of acute spinal cord and head injury care in-house. A written plan must be in place to transfer the patient if these services are not immediately available.

X

The hospital must have a written plan for the transfer of patients with acute spinal cord and head injury to receive care for acute spinal cord and head injury if not inhouse.

X

X

If head injury patients are managed inhouse, the equipment and a surgeon credentialed by the hospital to perform a craniotomy or craniectomy and intracranial pressure monitoring must be available.

X

If spinal cord injured patients are managed in-house, a surgeon credentialed by the hospital to perform operative spinal stabilization and the necessary equipment to treat and monitor spinal cord injuries must be available.

X

Rehabilitation service includes:

Hospitals must provide for in-patient acute rehabilitation or have a written plan for the transfer of trauma patients to rehabilitation services if not provided in house.

X

X

X

Hospitals must provide for in-patient physical therapy.

X

X

Hospitals must provide for in-patient occupational therapy.

X

X

Hospitals must provide for in-patient speech therapy.

X

X

Hospitals must provide for in-patient social services or have a written plan for the provision of trauma patients to social service if not provided in-house.

X

X

X

Trauma education

32 hours of trauma continuing medical education every four years or eight hours each full year employed if employed less than four years:

General or trauma surgeons.

X

Emergency medicine physicians who are certified by the American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine are exempt from continuing medical education with documentation of current board certification.

X

Emergency medicine physicians that are not board certified, primary care physician, or advanced practice provider covering the emergency department.

X

Neurosurgeon.

X

Orthopedic surgeon.

X

16 hours of trauma continuing medical education every four years or four hours each full year employed if employed less than four years:

General or trauma surgeons.

X

X

Emergency medicine physicians who are certified by the American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine are exempt from continuing medical education with documentation of current board certification.

X

X

Emergency medicine physicians that are not board certified, primary care physician, or advanced practice provider covering the emergency department.

X

X

Neurosurgeon.

X

Orthopedic surgeon, if on staff and involved in the care of trauma patients.

X

X

Advanced Trauma Life Support certification:

General and trauma surgeons within one year of hire.

X

X

X

Locum Tenens general and trauma surgeons upon date of hire.

X

X

X

Physicians who specialized in emergency medicine, primary or family care, and advanced practice providers providing care to trauma patients in the emergency department within one year of hire.

X

X

X

Locum Tenens physicians providing care to trauma patients in the emergency department upon date of hire.

X

X

X

The Emergency Nurses Association Trauma Nurse Core Course Certification or a Department approved equivalent:

Trauma Nurse Core Course certification will not count towards any other nursing continuing trauma education requirements.

All registered nurses covering the emergency department within one year of hire.

X

X

X

Upon use for all registered nurses not directly employed by the hospital

X

X

X

8 hours of trauma continuing nursing education every four years or two hours of such education for each full year employed if employed less than four years. Four of the eight hours must be in pediatric trauma or one hour of such education for each full year employed if employed less than four years:

All registered nurses covering the emergency department.

X

X

X

16 hours of trauma continuing nursing education every four years or four hours of such education for each full year employed if employed less than four years:

All critical care unit registered nurses.

X

X

All registered nurses treating pediatric trauma patients in an adult critical care unit must have four hours of pediatric trauma.

X

All registered nurses in a dedicated pediatric critical care unit on-site must have four hours of pediatric trauma.

X

X

Disaster planning and drills must:

Hold a minimum of two disaster drills per year to include emergency medical services. One of these may be a tabletop drill.

X

X

X

Performance improvement program must include the following

Trauma performance improvement activities must include use of trauma registry reports (written by the facility or obtained from the State Registrar). The facility must track: performance improvement indicators; response times in order to identify opportunities for improvement; event identification and levels of review resulting in development of corrective action plans; methods of monitoring and reevaluation; and detailed documentation of discussions in process improvement meetings. Distribution of such information within the trauma system is required. Facilities must use the trauma registry to run statistical reports.

Performance improvement program with written plan.

X

X

X

Pediatric-specific performance improvement indicators.

X

X

X

Submits trauma registry data as required by the Department.

X

X

X

There is a peer review process in place to review and categorize deaths.

X

X

X

Multidisciplinary trauma review committee that meets at least twice a year and meets all requirements in 185 NAC 1008 and subsections.

X

X

X

The trauma registry data is used for: improving patient care and addressing provider and system related issues.

X

X

X

Medical, nursing, or allied health (such as X-ray, lab, or radiology) participates in the multidisciplinary trauma review committee.

X

X

X

Review and provide feedback to emergency medical services on patient documentation reports. This may include, but is not limited to: chart review, education and training on patient care, or hands on skills training on trauma patient care.

X

X

X

Hospital provided or sponsored programs to include:

The hospital must provide physicians, advanced practice providers, and registered nurse's continuing education within the hospital's trauma system at least once a year.

X

X

Provide feedback on patient care and outcomes to the referring hospital.

X

X

Prevention activities include:

Coordinate and participate in injury prevention programs.

X

X

X