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. 6, March 26, 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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