File No. 35196
This rule was published in the September 15, 2011, issue (Vol. 2011, No. 18) of the Utah State Bulletin.
Health, Family Health and Preparedness, Emergency Medical Services
Statewide Trauma System Standards
Notice of Proposed Rule
DAR File No.: 35196
Filed: 08/30/2011 01:38:43 PM
Purpose of the rule or reason for the change:
The purpose of this amendment is to simplify and reduce the duplication of survey personnel participating in hospital on-site trauma center designation surveys. In addition, reporting requirements for trauma center is reduced, while still protecting the public.
Summary of the rule or change:
The rule change eliminates duplication in the present rule which requires a state site designation team for American College of Surgeons (ACS) Verified Trauma Centers and reduces the burden of reporting required for trauma centers already verified by the (ACS).
State statutory or constitutional authorization for this rule:
- Section 26-8a-252
Anticipated cost or savings to:
the state budget:
$6,000 savings per year by eliminating the expense of two surveyors for ACS verified trauma centers.
Local governments do not operate hospitals affected by this rule and no cost is expected.
Small businesses do not operate hospitals affected by this rule and no cost is expected.
persons other than small businesses, businesses, or local governmental entities:
$1,000 savings per year by eliminating the need to file duplicate/separate applications for trauma center designation in Level I and Level II trauma centers.
Compliance costs for affected persons:
$1,000 savings per year by eliminating the need to file duplicate/ separate applications for trauma center designation in Level I and Level II trauma centers.
Comments by the department head on the fiscal impact the rule may have on businesses:
This rule change will reduce the fees paid by hospitals voluntarily seeking a trauma center designation as well as the reporting requirement while still protecting the public.
David Patton, PhD Executive Director
The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:Health
Family Health and Preparedness, Emergency Medical Services
3760 S HIGHLAND DR
SALT LAKE CITY, UT 84106
Direct questions regarding this rule to:
- Guy Dansie at the above address, by phone at 801-273-6671, by FAX at 801-273-4165, or by Internet E-mail at firstname.lastname@example.org
Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:
This rule may become effective on:
David Patton, Executive Director
R426. Health, Family Health and Preparedness, Emergency Medical Services.
R426-5. Statewide Trauma System Standards.
R426-5-6. Trauma Center Designation Process.
Hospitals wishing designation recognition shall complete a
Department application as outlined in R426-5-7. (2) The Department shall, upon receipt of the completed
application and appropriate fees, verify compliance to the
designation level sought in accordance with protocols established
by the department. (3) Trauma centers shall be designated for a period of
three years unless the designation is rescinded by the Department
for non-compliance to standards set forth in R426-5-7. (4) The Department shall disseminate a list of designated
trauma centers to all Utah hospitals, and state EMS agencies, and
as appropriate, to hospitals in nearby states which refer
patients to Utah hospitals.
R426-5-7. Trauma Center Verification Process. (1)] [ All] designated Trauma Centers desiring to remain designated,
shall apply for [ verification] by submitting the following information to the
Department at least [ six months] prior to the [ anniversary date of initial designation]:
(a) A completed and signed application and appropriate fees for trauma center verification;
(b) A letter from the hospital administrator of continued commitment to comply with current trauma center designation standards as applicable to the applicant's designation level;
(c) The data specified under R426-5-8 ;
The minutes of pertinent hospital committee meetings for
the previous year as specified by the Trauma Review Subcommittee,
for example, trauma conferences, surgical morbidity and mortality
meetings, emergency department or trauma death audits].
A brief narrative report of trauma outreach education
activities for the previous year][ ;]
(f) A brief narrative report of trauma research activities
for the previous year including protocols and
] (2) [
All trauma centers desiring to apply for verification shall
submit the required application and appropriate fees to the
Department no later than January 1].[ (3) Upon receipt of a verification application from the
Department, accompanied by the information specified under
R426-5-7(1)(a) through (f), the Trauma Review Committee shall
conduct a review and report the results to the
(4) Every three years, the Level I and II Trauma Centers
must submit written documentation detailing the results of an
American College of Surgeons site visit. (5) Every three years from the date of initial
designation or from a date specified by the Department, the
Trauma Review Subcommittee shall conduct a formal site visit for
each designated Level III, IV, or V trauma center and report the
results to the Department.
6]) The Department and [ the Trauma Review Committee] may conduct activities with any
designated trauma center to verify compliance with designation
requirements[ which may include:]
(a) Site visits to observe, unannounced, an actual trauma
resuscitation, including the care and treatment of a trauma
patient. (b) Interview or survey prehospital care providers who
frequent the trauma center, to ascertain that the pledged level
of trauma care commitment is being maintained by the trauma
8]. Data Requirements for an Inclusive Trauma System.
(1) All hospitals shall collect, and quarterly submit to the Department, Trauma Registry information necessary to maintain an inclusive trauma system. The Department shall provide funds to hospitals, excluding designated trauma centers, for the data collection process. The inclusion criteria for a trauma patient are as follows:
(a) ICD9 Diagnostic Codes between 800 and 959.9 (trauma); and
(b) At least one of the following patient conditions:
admitted to the hospital for 24 hours or longer; transferred in or out of your hospital via EMS transport (including air ambulance); death resulting from the traumatic injury (independent of hospital admission or hospital transfer status; all air ambulance transports (including death in transport and patients flown in but not admitted to the hospital).
(c) Exclusion criteria are ICD9 Diagnostic Codes:
930-939.9 (foreign bodies)
905-909.9 (late effects of injury)
910-924.9 (superficial injuries, including blisters, contusions, abrasions, and insect bites)
The information shall be in a standardized electronic format specified by the Department which includes:
Database Record Number
Institution ID number
Medical Record Number
Social Security Number
Patient Home Zip Code
Date of Birth
Age Number and Units
Patient's Home Country
Patient's Home State
Patient's Home County
Patient's Home City
Alternate Home Residence
Date of Injury
Time of Injury
Blunt, Penetrating, or Burn Injury
Cause of Injury Description
Cause of Injury Code
Work Related Injury (y/n)
Patient's Occupational Industry
Incident Location Zip Code
Child Specific Restraint
Name of EMS Service
Transport Origin Scene or Referring Facility
Trip Form Obtained (y/n)
EMS Dispatch Date
EMS Dispatch Time
EMS Unit Arrival on Scene Date
EMS Unit Arrival on Scene Time
EMS Unit Scene Departure Date
EMS Unit Scene Departure Time
Other Transport Mode
Initial Field Systolic Blood Pressure
Initial Field Pulse Rate
Initial Field Respiratory Rate
Initial Field Oxygen Saturation
Initial Field GCS-Eye
Initial Field GCS-Verbal
Initial Field GCS-Motor
Initial Field GCS-Total
(iv) Referring Hospital:
Transfer from Another Hospital (y/n)
Name or Code
Admitted or ER
Glascow Coma Score Total
Revised Trauma Score Total
(v) Emergency Department Information:
Mode of Transport
Initial ED/Hospital Pulse Rate
Initial ED/Hospital Temperature
Initial ED/Hospital Respiratory Rate
Initial ED/Hospital Respiratory Assistance
Initial ED/Hospital Oxygen Saturation
Initial ED/Hospital Systolic Blood Pressure
Initial ED/Hospital GCS-Eye
Initial ED/Hospital GCS-Verbal
Initial ED/Hospital GCS-Motor
Initial ED/Hospital GCS-Total
Initial ED/Hospital GCS Assessment Qualifiers
Revised Trauma Score Total
Alcohol Use Indicator
Drug Use Indicator
ED Discharge Disposition
ED Discharge Date
ED Discharge Time
(vi) Emergency Department Treatment:
Procedures Done (pick list)
Paralytics used prior to GCS (y/n)
(vii) Admission Information:
Admit from ER or Direct Admit
Admitted from what Source
Time of Hospital Admission
Date of Hospital Admission
Hospital Procedure Start Date
Hospital Procedure Start Time
(viii) Hospital Diagnosis:
ICD9 Diagnosis Codes
AIS Score for Diagnosis (calculated)
Injury Severity Score
(ix) Quality Assurance Indicators:
Total Days Length of Stay
Total ICU Length of Stay
Total Ventilator Days
Disposition from Hospital
9]. Trauma Triage and Transfer Guidelines.
The Department adopts by reference the 2009 Resources and Guidelines for the Triage and Transfer of Trauma Patients published by the Utah Department of Health as model guidelines for triage, transfer, and transport of trauma patients. The guidelines do not mandate the transfer of any patient contrary to the judgment of the attending physician. They are a resource for pre-hospital and hospital providers to assist in the triage, transfer and transport of trauma patients to designated trauma centers or acute care hospitals which are appropriate to adequately receive trauma patients.
10]. Noncompliance to Standards.
(1) The Department may warn, reduce, deny, suspend, revoke, or place on probation a facility designation, if the Department finds evidence that the facility has not been or will not be operated in compliance to standards adopted under R426-5.
(2) A hospital, clinic, health care provider, or health care delivery system may not profess or advertise to be designated as a trauma center if the Department has not designated it as such pursuant to this rule.
11]. Statutory Penalties.
A person who violates this rule is subject to the provisions of Title 26, Chapter 23.
KEY: emergency medical services, trauma, reporting
Date of Enactment or Last Substantive Amendment: [
March 15, 2010]
Notice of Continuation: July 18, 2007
Authorizing, and Implemented or Interpreted Law: 26-8a-252
The Portable Document Format (PDF) version of the Bulletin is the official version. The PDF version of this issue is available at https://rules.utah.gov/publicat/bull-pdf/2011/b20110915.pdf. The HTML edition of the Bulletin is a convenience copy. Any discrepancy between the PDF version and HTML version is resolved in favor of the PDF version.
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For questions regarding the content or application of this rule, please contact Guy Dansie at the above address, by phone at 801-273-6671, by FAX at 801-273-4165, or by Internet E-mail at email@example.com.