New Mexico Administrative Code
Title 7 - HEALTH
Chapter 27 - EMERGENCY MEDICAL SERVICES
Part 7 - TRAUMA CARE SYSTEM
Section 7.27.7.8 - SYSTEM ADMINISTRATION
Universal Citation: 7 NM Admin Code 7.27.7.8
Current through Register Vol. 35, No. 18, September 24, 2024
A. General Responsibilities of the IPEMS Bureau:
(1) the Bureau shall administer the process,
to designate and re-designate hospitals/healthcare facilities to provide trauma
care services in accordance with these regulations.
(2) the Bureau shall establish and manage the
Statewide Trauma Registry.
(3) the
Bureau shall approve and periodically review statewide and regional
pre-hospital trauma triage criteria guidelines, inter-facility transfer
criteria for adult and pediatric patients, trauma center standards and the
trauma register data set with the advice of the Trauma Advisory Committee
(TAC).
(4) the Bureau may recognize
the establishment of Regional Trauma Councils (ReTrACs) as
appropriate.
(5) the Bureau shall
develop and update the State Trauma System Plan periodically with advice from
the TAC.
(6) the Bureau shall
review, recommend changes to, and approve any proposed regional plans submitted
by a ReTrAC, through TAC and shall take into account recommendation from the
TAC. This approval shall be based upon consideration of the needs of trauma
patients whose care may require resources from more than one (1) region and/or
from adjacent states.
(7) the
Bureau shall provide technical assistance and support to the TAC, ReTrACs and
to hospitals/healthcare facilities and EMS providers as necessary to carry out
the Trauma System Plan.
(8) the
Bureau shall exercise, as necessary, the right to review, inspect, evaluate and
audit all trauma patient records, trauma process improvement plans and
committee minutes, physical facilities, and any other documents relevant to
trauma care in any designated trauma center to verify compliance with trauma
center standards. The Bureau shall maintain the confidentiality of such records
in accordance with state and/or federal law.
(9) the Bureau shall facilitate the
establishment of a statewide "inclusive" trauma system by encouraging
participation of all agencies, facilities and services that treat or admit
trauma patients in the statewide trauma data collection process, or in injury
prevention programs, or in ReTrAC or in any other manner deemed by the Bureau
to improve trauma care.
(10) the
Bureau may periodically conduct special studies on the Statewide Trauma System
to determine system coverage, quality and extent of care, and financial effect
of the system components.
(11) the
Bureau may develop other trauma regulations, with advice from TAC, and as
necessary, to ensure the quality of the Statewide Trauma System.
(12) the Bureau shall facilitate, and where
necessary, develop and maintain public information/education and prevention
programs as an integral component of the trauma system.
B. Trauma Advisory Committee: Trauma Advisory Committee (TAC), a subcommittee of the Statewide EMS Advisory Committee established pursuant to the EMS Act, shall:
(1) adopt guidelines, with concurrence of the
Statewide EMS Advisory Committee and Bureau, for its operations, including
membership, attendance, maintenance of minutes and other guidelines necessary
to assure the orderly conduct of business;
(2) periodically review and comment on the
Department's regulations, policies, and standards for trauma;
(3) review and comment annually on the
Statewide EMS Advisory Committee's budget for the trauma system;
(4) advise the Bureau regarding trauma system
needs and progress throughout the state;
(5) review and comment on regional trauma
plans;
(6) periodically review
local/regional pre-hospital trauma triage guidelines and inter-facility
transfer criteria; and,
(7) advise
the Bureau on injury prevention and public information/educational
programs.
C. Regional trauma advisory councils (ReTrACs):
(1) Regional Trauma Advisory Councils
(ReTrACs) may be established by application made to the Bureau.
(2) the application shall be in a manner and
format prescribed by the Bureau.
(3) such applications shall be reviewed and
commented on the TAC prior to approval by the Bureau.
(4) ReTrAC, in order to be recognized, shall
submit to the Bureau a membership list which includes a balance of
representation from EMS providers, hospital(s)/healthcare facilities and other
interested parties.
(5) an approved
ReTrAC shall develop, update as appropriate, and implement a regional trauma
plan that identifies particular regional needs and sets goals for special
regional trauma needs. Additionally, a ReTrAC shall:
(a) seek and consider the recommendations of
trauma system providers, governmental entities and consumers,
(b) consider the regional and state analyses
provided by the Bureau based on trauma registry data and other appropriate
sources; and,
(c) develop and
implement regional trauma triage and treatment protocols bypass and diversion
plans, process improvement methods and patient care protocols.
(d) the approved ReTrAC shall establish a
medical review committee to conduct the regional process improvement program,
as defined by the Bureau's approved process improvement plan, including the
review of patient outcome and regional system issues.
(e) the approved ReTrAC shall annually,
identify and analyze system and patient care trends and outcomes, based on
trauma registry data provided by the Bureau, to evaluate effectiveness of
regional trauma system and its component subsystems.
(f) the approved ReTrAC shall advise the
Bureau and TAC on other matters relating to the delivery of trauma care within
the region; and,
(g) accomplish
other purposes as approved by the Bureau.
(6) an approved ReTrAC shall adopt
pre-hospital patient care protocols in consultation with the local EMS medical
directors, EMS providers, trauma service providers, and emergency communication
centers. These protocols shall identify the level of medical care personnel to
be dispatched to an emergency scene, procedures for triage of patients, the
level of trauma care facility to first receive the patient, and the name and
location of other trauma centers to receive the patient should an
inter-facility transfer be necessary. Procedures on inter-facility transfer of
patients shall be consistent with the inter-facility transfer criteria and
guidelines as provided for in Appendix B.
D. Trauma System Process Improvement Program:
(1) an overall Process
Improvement (PI) program shall be developed for the State Trauma System. The PI
program shall include patient care outcomes and compliance with these
regulations. The PI program shall consist of:
(a) an approved state PI system
plan,
(b) system trauma
registry,
(c) Bureau and approved
ReTrAC review of:
(i) trauma system
trends/needs,
(ii) key indicators
ad defined by the State Trauma PI Plan, and
(iii) patient care and other outcome issues
and needs of the trauma system.
(d) trauma center review of:
(i) trends/needs,
(ii) key indicators as defined by the trauma
center PI plan, and,
(iii) patient
care and outcome studies as needed to verify compliance with standards of care
and the needs of the trauma center.
(2) the Bureau shall:
(a) develop and maintain a Statewide Trauma
System PI Plan with input from the TAC; and,
(b) provide guidelines for and review of
regional trauma PI plans to evaluate regional trauma care delivery, patient
care outcomes, and compliance with these standards.
(3) each ReTrAC shall:
(a) develop a written regional trauma PI
plan, which includes policies for confidentiality of records and recordings of
committee actions, including a requirement that each attendee of the trauma PI
committee meeting is informed in writing of the confidentiality requirement.
Information identifying individual patients shall not be publicly disclosed
without the patient's consent in accordance with applicable state and federal
laws;
(b) include in its regional
trauma PI plan, the process for informing the Bureau of the results of the PI
review;
(c) appoint, at a minimum,
one member for each designated trauma center, licensed medical staff, trauma
coordinator/or nurse, licensed EMS provider, a local EMS pre-hospital provider
medical director, and a member of the EMS regional office to participate on the
regional PI subcommittee. Other healthcare providers and hospital/healthcare
facilities providing trauma care in the region, including non-designated
hospital/healthcare facilities and EMS providers and pre-hospital services, may
be invited to participate in the PI process.
(d) implement the written regional trauma PI
plan including periodic assessment of performance of the regional EMS and
trauma care system, including area training plans, based on date supplied by
the trauma registry and other sources, including:
(i) trauma care delivery,
(ii) patient care outcomes, including
pediatric and adult patients,
(iii)
all trauma deaths, and
(iv)
compliance with these regulations.
(e) provide assessment of data governing all
aspects of patient care; and
(f)
establish the process for communication to and from the Bureau on identified
trauma system issues and concerns.
(4) each designated trauma center shall:
(a) develop an internal trauma plan which,
based on data supplied by the trauma registry and other sources, will provide
for the ongoing assessment and improvement of performances of the trauma
center, including;
(i) trauma care
delivery,
(ii) all trauma
deaths,
(iii) identification and
analysis of injury trends, patient care outcomes, and other
information,
(iv) periodic
assessment of data governing aspects of patient care,
(v) policies regarding confidentiality of
data elements related to identification of provider and trauma center care
outcomes, in accordance with applicable state and/or federal law,
(vi) policies regarding confidentiality of
records and committee minutes, including a requirement that each attendee of
the trauma PI committee meeting is informed in writing of the confidentiality
requirement. Information identifying individual patients shall not be publicly
disclosed without the patient's consent in accordance with applicable state and
federal laws.
(vii) provision for
feedback to the Bureau and the approved ReTrAC on identified trauma issues and
concerns, and
(viii) compliance
with these regulations.
(b) implement the hospital-wide PI program in
compliance with the trauma center plan to reflect and demonstrate continuous
process improvement in the delivery of trauma care. The trauma center PI
program shall include regular in-house, multi-disciplinary trauma conferences,
which address:
(i) comprehensive review of
patient care throughout the patient's stay,
(ii) participation of members of the trauma
team,
(iii) participation of the
person responsible for coordination of trauma registry activities,
(iv) participation of the trauma center's
designated rehabilitation coordinator, as appropriate,
(v) feedback to staff and services areas that
are involved with trauma care, and
(vi) provision of appropriate reports to the
state and regional process improvement program.
(c) document the trauma center's PI program
proceedings, conclusions, actions taken, results of the actions taken and
follow through, demonstrating that relevant findings are used to study and
improve processes that affect trauma patient care;
(d) evaluate the results of the trauma PI
program and include them with the trauma center's process improvement
program;
(e) participate in the
System Trauma Registry by:
(i) identifying a
person to be responsible for coordination of trauma registry
activities,
(ii) downloading
required trauma data as stipulated by the Bureau,
(iii) submit aggregate reports as stipulated
by the Bureau, and
(iv) participate
in the trauma registry workshops.
(f) participate in the appropriate ReTrAC PI
program that may be required in these regulations.
Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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