Free Pre Review Questionnaire and Application Checklist, DPH 7484 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 7484 (10/06)

STATE OF WISCONSIN

PRE REVIEW QUESTIONNAIRE AND APPLICATION CHECKLIST
Please answer ALL questions appropriate to your trauma care facility level. Do not use abbreviations. Use the "Tab" key to move from question to question. Return no later than one month prior to your site visit. Save this form after completion on your computer hard drive, title file as follows: "Hospital Name - Date", to email click on the following TDR and attach the saved file to the email. 1. Type of Trauma Visit State designation- first visit Renewal visit Date of last visit 2. Level of Review Level III Level IV 3. Primary Membership of Regional Trauma Advisory Council (RTAC) Northeast Southeast South central Southwest North/Northwest West Central Lake Superior North Central Fox Valley 4. What is your trauma care facility's attendance (in percentage) at the RTAC meetings in the 12 months prior to the site visit? 5. Trauma Care Facility Beds Year of Site Visit Number of beds licensed Number of beds staffed Average daily census Data collection date range: From: To:

TRAUMA SERVICE
6. Trauma Roles: Check all applicable positions and where applicable give name of staff. Attach job descriptions for the Trauma Coordinator and Trauma Service Medical Director Trauma Coordinator Name: Trauma Service Medical Director Name: Injury Prevention staff Name: Trauma Registrar (data entry staff) Name: Other Be prepared to discuss the Trauma Service: how roles interact on a daily basis, and how issues and problems are handled.

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7. Trauma Numbers: Major trauma patients based on Trauma Registry inclusion criteria. See appendix for definition. All data can be extracted from the Trauma Registry. Total number of trauma patients Number admitted to your facility Number transferred to higher level of trauma care Number of trauma deaths at your facility Number of patients ISS>15

Data collection date range: From: EMERGENCY DEPARTMENT

To:

8. What are your criteria for trauma team activation? Please attach copy. Do not write criteria on application. 9. Members of the Trauma Team Physician Nurses (number on team) ER ICU Other ED MD If not in house, how do you document response time? Respiratory Therapy Social Service/Chaplain Paramedic/EMT Anesthesia Physician Assistant (PA) Nurse Practitioner (NP) Other (list) Other (list) 10. Who has the authority to activate the trauma team (check all applicable) Physician Nurse Pre hospital provider (from the field) Other: (list) 11. How is the Trauma Team activated? (Check all applicable) Pager Telephone Overhead page Other 12. Trauma Surgeon is present within 30 minutes of patient arrival for major trauma patients % of the time. Not applicable if you do not have surgeons covering the TCF (Level IV)

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13. Call Schedules available on site for Emergency Medicine Total number of physicians that take call at your TCF Other level provider: General Surgery Not applicable- do not have surgeons covering TCF Total number of surgeons that take call at your TCF Anesthesia Other Other 14. Trauma Flow Sheet or ED record Available on site for review 15. Trauma protocols Available on site 16. Trauma Diversion Trauma diversion protocol available on site Date of Occurrence Length of diversion Reason

17. Trauma Equipment (Emergency Department) All required resources will be reviewed during the site visit. (DO NOT include equipment list with this document). 18. Laboratory All required resources will be reviewed during the site visit. (DO NOT include equipment list with this document). Have massive transfusion protocol available on site. 19. Intensive Care Unit Not applicable ­ TCF does not have an ICU. All required resources will be reviewed during the site visit. (DO NOT include equipment list with this document). 20. Operating Room Not applicable- TCF does not have an operating room. All required resources will be reviewed during the site visit. (DO NOT include equipment list with this document). 24 hour availability Notified with trauma team activation for major trauma patients Staff availability and responses documented for performance improvement process

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21. Radiology Not applicable- TCF does not have radiology. All required resources will be reviewed during the site visit. (DO NOT include equipment list with this document). 24 hour availability if definitive care of organ system Staff availability and responses documented for performance improvement process 22. Transfer agreements with higher level of trauma care. Available on site

PERFORMANCE IMPROVEMENT
23. Members of multidisciplinary trauma performance improvement committee (name and title).

24. Indicators for trauma performance improvement (types of charts are reviewed, i.e.: deaths, complications, interaction with EMS) Available on site. Do not need to list on this document. 25. Explain your facilities trauma performance improvement process, including loop closure:

26. Trauma Education for Physicians Nurses Other trauma team members Available on site 27. Collaboration with existing regional, state, or national Injury Prevention programs. Yes No Explain programs:

28. Injury Prevention Activities: List activities. (Desired criteria for Level III and IV TCF)

29. Strengths of your Trauma Program:

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30. Areas for Improvement of your Trauma Program:

OPTIONAL:
31. Disaster Planning Activities:

32. Comments:

Return no later than one month prior to your site visit. Save this form after completion to the hard drive on your computer, title file as follows: "Hospital Name - Date", email the saved file to [email protected] .
Appendix: General Information and Instructions Note: Trauma Care Facility (TCF) and hospital have the same definition in the document and may be used interchangeably. 1. Type of visit: initial on-site state designation site visit to the TCF, check the first box. If this is a return site visit, check the second box and give the date of the last site visit. 2. Level of review- check which level of trauma care facility that the hospital is currently operating and functioning. This should match the level on the application. 3. RTAC participation- note which primary RTAC your trauma care facility is a member. 4. Attendance by a designated representative(s) from your trauma care facility is required for RTAC meetings. Please note that attendance can be fulfilled by not just one person but shared responsibility from several people. 5. Trauma Care facility beds- provide the trauma care facility beds information as shown in the table for the year that your institution has their trauma designation site visit. Must be a number. Make sure to add the date the data was collected so the state knows the dates included in your data collection. 6. Trauma roles: define the members of your Trauma Service Team. At a minimum, the members must include a Trauma Coordinator and a Trauma Service Medical Director. The Trauma Coordinator most commonly is a nurse, but may be another TCF staff personnel with trauma/emergency care experience. The Trauma Service Director is a physician on staff who has a role in leadership for the trauma program and acts as a liaison for trauma care. Injury prevention staff can be a nurse or other TCF personnel involved in injury prevention activities. This is not a required role. Other staff could include a Trauma Registrar or data collection personnel, research personnel or administrative assistants. Be able to explain how the Trauma Service works- review how the above roles interact on a daily basis, and how problems/issues are handled. Job descriptions for the Trauma Coordinator and Trauma Medical Director must be sent with the completed Pre-review Questionnaire.

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7. Trauma Numbers ­ provide trauma numbers for major trauma patients only. Major trauma patients are defined by trauma registry inclusion criteria. The trauma registry inclusion criteria include: ICD-9 discharge diagnosis 800.00 ­ 959.9 Excluding 905-909 (late effects of injury) Excluding 910-924 (blisters, contusions, abrasions, insect bites) Excluding 930-939 (foreign bodies) Excluding drowning, unless consequence of MVC Excluding strangulation/asphyxiation Excluding poisoning or drug overdose Excluding falls from same level resulting in isolated closed distal extremity fracture or isolated hip fracture AND: Admitted to the trauma care facility or transferred to another facility for trauma care OR DOA transported to trauma care facility and admitted to the ED Injury-related death in the ED or after trauma care facility admission Facility-specified trauma response has been activated The data will be provided for the same year as the trauma care facility bed information is given. Make sure to include the date range for data collection so the state knows the dates included in your data collection. 8. Definition of trauma activation criteria - attach a copy of what your TCF uses to activate the trauma team. This can be based on the triage and transport criteria or the American College of Surgeons minimum criteria for the definition of a major resuscitation: CONFIRMED Blood pressure < 90 at any time in adults and age specific hypotension for children; Respiratory compromise/obstruction and/or intubation; Transfer patients from other hospitals receiving blood to maintain vital signs; Emergency physician's discretion; Gunshot wounds to the abdomen, neck, or chest; GCS < 8 with mechanism attributed to trauma. 9. Members of the Trauma team- include all members who are part of your Emergency Department Trauma Team or resuscitation team. The institution and its resources define the members of the team. Roles for the team members should be defined. Each TCF may have a trauma team unique to their institution. At a minimum, the team should include a nurse and a physician. The physician is optimally in house, but if not in house 24 hours, must be readily available when the patient arrives at the TCF. 10. Who has the authority to activate the trauma team? It could be by the Emergency Department staff, physician, EMS personnel or other. Be able to explain your TCF process. 11. How do you activate the team? With telephone calls, overhead pages, cell phones or pagers. Be able to explain your Trauma Care facility's process. The surgeon must be readily available, in house within 30 minutes from the time of the patient arrival, for a Level III trauma care facility. The surgeon must be present for the major trauma patient resuscitations based on: CONFIRMED Blood pressure < 90 at any time in adults and age specific hypotension for children; Respiratory compromise/obstruction and/or intubation; Transfer patients from other hospitals receiving blood to maintain vital signs; Emergency physician's discretion; Gunshot wounds to the abdomen, neck, or chest; GCS < 8 with mechanism attributed to trauma. 12. How do you document the surgeon response time and track the response time? Times can be documented on the trauma flow sheet, in a logbook, on a computer, etc... All response times must be documented. At a minimum, surgeons must meet attendance within 30 minutes of patient arrival 80% of the time.

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13. Have the current and preceding 3 months worth of call schedules for the required physician coverage pertinent to your level of trauma care. For the Level IV facility, the Emergency Physician is required. Other call schedules are dependent on the resources of the TCF. For the Level III facility, it is dependent on the resources available, but must have at a minimum, Surgeon and Anesthesia call schedules. 14. Trauma Flow sheet- has on site, a blank trauma flow sheet or emergency department record to review. Be prepared to talk about how it is utilized. 15. Trauma protocols- each trauma care facility is required to have trauma protocols. Have them available for review. As a minimum requirement, the trauma protocols shall define how trauma care is managed at the TCF: identifies trauma team members, and their responsibilities. TCF may have additional protocols based on their TCF resources. 16. Trauma diversion: have your trauma diversion protocol available. List any times and reasons in the last year that the Emergency Department and TCF have been on diversion for trauma. Diversion is the term used when your TCF is not able to care for the trauma victim. It may be for various reasons: the system is overwhelmed (disaster scenario), ICU full, surgeon unavailable, OR unavailable, etc... Under normal circumstances, your TCF can care for the traumatically injured but something has occurred to change your status. May last for a few hours to a couple of days. 17. Trauma equipment- all required resources will be reviewed during the site visit. (DO NOT include equipment list with this document). 18. Laboratory- all required resources will be reviewed during the site visit. (DO NOT include equipment list with this document). 19. Intensive Care Unit- All required resources will be reviewed during the site visit. (DO NOT include equipment list with this document). Check "Not applicable" if the TCF does not have an ICU. 20. Operating Room- all required resources will be reviewed during the site visit. (DO NOT include equipment list with this document). Check "Not applicable" if the TCF does not have an Operating Room. 24-hour availability is a requirement with staff promptly available. Staff availability and response times (if not in house) are required to be documented and reviewed through your performance improvement process. This includes loop closure for any delays. 21. Radiology- all required resources will be reviewed during the site visit. (DO NOT include equipment list with this document). Check "Not applicable" if the TCF does not have Radiology. These components are required 24 hours a day if your institution provides definitive care of an organ system. 22. Transfer agreements- have transfer agreements available for higher level of trauma care. 23. List the personnel (name and title) who are involved with trauma performance improvement. Performance improvement can be known as quality assurance, total quality management. There are many terms. Performance improvement of trauma care is a continuous cycle of monitoring, assessment, and management. The emphasis is a multidisciplinary effort to measure, evaluate, and improve the process and outcome. Data collection is important to identify opportunities for improvement. Analysis of the data should define corrective strategies that must be documented. (Resources for the Optimal Care of the Injured Patient: 1999, p. 69). It can include peer review, department or staff review, and tracking of quality indicators or review of systems issues. 24. Indicators for peer review- will be able to discuss and show what your facility personnel review for trauma performance improvement. This should at a minimum include review of trauma deaths, delays in treatment and any trauma related complications, such as airway issues. Each hospital will have different indicators for review based on the needs and resources available within that hospital.

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25. Peer review process- explain how performance improvement is done at your facility- how indicators are used to pull charts, chart review and identified trauma related problems fit into the PI process. Loop closure process, explain how your hospital performance improvement plan follows and tracks issues or problems identified. The follow through is called loop closure. 26. Trauma Education- list any requirement of trauma education or any education provided for each of these professions. 27. Collaboration with existing national, regional, or state injury prevention programs is expected for all levels. List some injury prevention links that you have within your organization. 28. Injury Prevention activities- while this is not required please list any injury prevention activities that you do. Examples might be drinking and driving presentations to schools, seatbelt campaigns, and bike helmet clinics. These programs can be small or large scale and they can be combined with public health initiatives or other community initiatives. 29. Strengths- give your TCF credit for strengths of your hospital trauma program. 30. Areas for improvement - explain your opportunities for improvement in the future. 31. Disaster planning- this is an optional area. List disaster activities that you have been involved with. This can include HRSA initiatives, tabletop exercises, local exercises, or any improvement your institution has done to prepare for a disaster or mass casualty event. 32. Comments- any comments that you have or other things you would like to list can be put in this area.

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