Standards for Trauma Center Designation

PURPOSE: This rule establishes standards for level I, II, and III trauma center designation. EDITOR’S NOTE: I-R, II-R, or III-R after a standard indicates a requirement for level I, II, or III trauma center respectively. I-IH, II-IH, or III-IH after a standard indicates an in-house requirement for level I, II or III trauma center respectively. I-IA, II-IA, or III-IA indicates an immediately available requirement for level I, II or III trauma center respectively. I-PA, II-PA, or III-PA indicates a promptly available requirement for level I, II, or III trauma center respectively. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) General Standards for Trauma Center Designation. (A) The hospital board of directors, administration, medical staff, and nursing staff shall demonstrate a commitment to quality trauma care. Methods of demonstrating the commitment shall include but not be limited to a board resolution that the hospital governing body agrees to establish policy and procedures for the maintenance of services essential for a trauma center; assure that all trauma patients will receive medical care at the level of the hospital’s designation; commit the institution’s financial, human, and physical resources as needed for the trauma program; and establish a priority admission for the trauma patient to the full services of the institution. (I-R, II-R, III-R) (B) Trauma centers shall agree to accept all trauma victims appropriate for the level of care provided at the hospital, regardless of race, sex, creed, or ability to pay. (I-R, II-R, III-R) (C) The hospital shall demonstrate evidence of a trauma program that provides the trauma team with appropriate experience to maintain skill and proficiency in the care of trauma patients. Such evidence shall include meeting of continuing education unit requirements by all professional staff, documented regular attendance by all core trauma surgeons and liaison representation from neurosurgeons, orthopedic surgeons, emergency medicine physicians, and anesthesiologists at trauma program performance improvement and patient safety program meetings, documentation of continued experience as defined by the trauma medical director in management of sufficient numbers of severely injured patients to maintain skill levels, and outcome data on quality of patient care as defined by regional emergency medical service committees. Regular attendance shall be defined by each trauma service, but shall be not less than fifty percent (50%) of all meetings. The trauma medical director must ensure and document dissemination of information and findings from the peer review meetings to the non-core surgeons on the trauma call roster. (D) The trauma center shall have a helicopter landing area. (I-R, II-R, III-R) (E) The hospital shall appoint a board-certified surgeon to serve as the trauma medical director. (I-R, II-R, III-R) 1. There shall be a job description and organization chart depicting the relationship between the trauma medical director and other services. (I-R, II-R, III-R) 2. The trauma medical director shall be a member of the surgical trauma call roster. (I-R, II-R, III-R) 3. The trauma medical director shall be responsible for the oversight of the education and training of the medical and nursing staff in trauma care. (I-R, II-R, III-R) 4. The trauma medical director shall document thirty-six (36) hours of continuing medical education (CME) in trauma care every three (3) years. (I-R, II-R, III-R) 5. The trauma medical director shall participate in the trauma center’s research and publication projects. (I-R) (F) There shall be a trauma nurse coordinator/trauma program manager. (I-R, II-R, III-R) 1. There shall be a job description and organization chart depicting the relationship between the trauma nurse coordinator/trauma program manager and other services. (I-R, II-R, III-R) 2. The trauma nurse coordinator/trauma program manager shall document thirty-six (36) hours of continuing nursing education in trauma care every three (3) years. (I-R, II-R, III-R) (G) By the time of the initial review, all general surgeon members of the surgical trauma call roster shall have successfully completed or be registered for a provider Advanced Trauma Life Support (ATLS) course. Current certification must then be maintained by each general surgeon on the trauma call roster. (I-R, II-R, III-R) (H) The hospital shall demonstrate that there is a plan for adequate post-discharge follow-up on trauma patients, including rehabilitation. (I-R, II-R, III-R) (I) A trauma registry shall be completed on each patient who sustains a traumatic injury and meets the following criteria: Includes at least one (1) code within the range of the following injury diagnostic codes as defined in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9)-(CM) 800-959.9, which is incorporated by reference in this rule as published by the Centers for Disease Control and Prevention in 2006 and is available at National Center for Health Statistics, 1600 Clifton Road, Atlanta, GA 30333. This rule does not incorporate any subsequent amendments or additions. Excludes all diagnostic codes within the following code ranges: 905–909.9 (late effects of injury), 910–924.9 (superficial injuries, including blisters, contusions, abrasions, and insect bites), 930–939.9 (foreign bodies), and must include one (1) of the following criteria: hospital admission, patient transfer out of facility, or death resulting from the traumatic injury (independent of hospital admission or hospital transfer status). Trauma centers shall enter trauma care data elements for each patient who meets these criteria. The trauma care data elements shall be those identified and defined by the National Trauma Data Standard, which is incorporated by reference in this rule as published by the American College of Surgeons in 2022 and is available at the American College of Surgeons, 633 N. St. Clair St., Chicago, IL 60611. This rule does not incorporate any subsequent amendments or additions. (I-R, II-R, III-R. 1. Trauma centers shall enter trauma care data elements for each patient who meets the criteria above into the following: A. Trauma centers shall submit data into the department’s Missouri trauma registry. The data required in subsection (1) (I) above shall be submitted electronically into the Missouri trauma registry via the department’s website at www.health. mo.gov; or (I-R, II-R, III-R) B. Trauma centers shall submit data into a national data registry or data bank capable of being used by the trauma center to perform its ongoing performance improvement and patient safety program requirements for its trauma patients. The trauma center shall submit data for each data element included in the national data registry or data bank’s data system. (I-R, II-R, III-R) 2. Electronic data shall be submitted quarterly, ninety (90) days after the quarter ends. The trauma registry must be current and complete. (I-R, II-R, III-R) 3. Information provided by hospitals on the trauma registry shall be subject to the same confidentiality requirements and procedures contained in section 192.067, RSMo. (I-R, II-R, III-R) (J) A patient log of those patients entered into the trauma registry with admission date, patient name, and injuries must be available for use during the site review process. (I-R, II-R, III-R. (K) The hospital shall have a trauma team activation protocol that establishes the criteria used to rank trauma patients according to the severity and type of injury and identifies the persons authorized to notify trauma team members when a severely injured patient is en route or has arrived at the trauma center. (I-R, II-R, III-R. 1. The trauma team activation protocol shall provide for immediate notification and response requirements for trauma team members when a severely injured patient is en route to the trauma center. (I-R, II-R, III-R) (L) The hospital shall have a plan to notify an organ or tissue procurement organization and cooperate in the procurement of anatomical gifts in accordance with the provisions in section 194.233, RSMo. (I-R, II-R, III-R) (M) There shall be no level III trauma centers designated within fifteen (15) miles of any Missouri level I or II trauma center. Hospitals which have continually been level III trauma centers since January 1, 1989, and which are within fifteen (15) miles of a Missouri level I or II trauma center may continue as level III trauma centers, provided they continue to meet standards for level III trauma centers. (2) Hospital Organization Standards for Trauma Center Designation. (A) There shall be a delineation of privileges for the trauma service staff made by the medical staff credentialing committee. (I-R, II-R, III-R) (B) All members of the surgical trauma call roster shall comply with the availability and response requirements in subsection (2)(D) of this rule. If not on the hospital premises, trauma team members who are immediately available shall carry electronic communication devices at all times to permit contact by the hospital and shall respond immediately to a contact by the hospital. (I-R, II-R, III-R) (C) Surgeons who are board-certified or board-admissible or complete an alternate pathway as documented and defined by the trauma medical director using the criteria established by the American College of Surgeons (ACS) in the current Resource for Optimal Care Document in the following specialties and who are credentialed by the hospital for trauma care shall be on the trauma center staff and/or be available to the patient as indicated. The Resource for Optimal Care Document is incorporated by reference in this rule as published by the American College of Surgeons in 2006 and is available at the American College of Surgeons, 633 N. St. Clair St., Chicago, IL 60611. This rule does not incorporate any subsequent amendments or additions. 1. General surgery—I-R, II-I/A, III-P/A. A. The general surgery staffing requirement may be fulfilled by a senior surgery resident credentialed in general surgery, including trauma care, and Advanced Trauma Life Support (ATLS) certification and capable of assessing emergency situations in general surgery. B. The trauma surgeon shall be immediately available and in attendance with the patient when a trauma surgery resident is fulfilling availability requirements. C. In a level I or II center, call rosters providing back-up coverage will be maintained for general trauma surgeons. In a level III center, call rosters providing for back-up coverage for general trauma surgeons will be maintained or a written transfer agreement to a level I or II trauma center provided. D. Surgeons who are board-certified or board-admissible and who are credentialed by the hospital for trauma care shall be on the trauma center staff. 2. Neurologic surgery—I-IH, II-IA. A. The neurologic surgery staffing requirement may be fulfilled by a surgeon who has been approved by the chief of neurosurgery for care of patients with neural trauma. B. The surgeon shall be capable of initiating measures toward stabilizing the patient and performing diagnostic procedures. 3. Cardiac/Thoracic surgery—I-R/PA, II-R/PA. 4. Obstetric-gynecologic surgery—I-R/PA, II-R/PA. 5. Ophthalmic surgery—I-R/PA, II-R/PA. 6. Orthopedic surgery—I-R/PA, II-R/PA. 7. Maxillofacial trauma surgery—I-R/PA, II-R/PA. 8. Otorhinolaryngolic surgery—I-R/PA, II-R/PA. 9. Pediatric surgery/trauma surgeon credentialed and privileged in pediatric trauma care—I-R/IA, II-R/PA; this requirement will be waived in centers that provide evaluation and care to adults only. 10. Plastic surgery—I-R/PA, II-R/PA. 11. Urologic surgery—I-R/PA, II-R/PA. 12. Emergency medicine—I-R/IH, II-R/IH, III-R/IH. 13. Cardiology—I-R/PA, II-R/PA. 14. Chest pulmonary medicine—I-R/PA, II-R/PA. 15. Gastroenterology—I-R/PA, II-R/PA. 16. Hematology—I-R/PA, II-R/PA. 17. Infectious diseases—I-R/PA, II-R/PA. 18. Internal medicine—I-R/PA, II-R/PA, III-R/PA. 19. Nephrology—I-R/PA, II-R/PA. 20. Pathology—I-R/PA, II-R/PA. 21. Pediatrics—I-R/PA, II-R/PA. 22. Psychiatry—I-R/PA, II-R/PA. 23. Radiology—I-R/PA, II-R/PA. 24. Anesthesiology—I-R/IH, II-R/IA, III-R/PA. A. In a level I or II trauma center, anesthesiology staffing requirements may be fulfilled by anesthesiology residents or certified registered nurse anesthetists (CRNA) capable of SENIOR SERVICES assessing emergent situations in trauma patients and of providing any indicated treatment including induction of anesthesia or may be fulfilled by anesthesiologist assistants with anesthesiologist supervision in accordance with sections 334.400 to 334.430, RSMo. B. In a level III trauma center, anesthesiology requirements may be fulfilled by a CRNA with physician supervision, or an anesthesiologist assistant with anesthesiology supervision. (3) Standards for Special Facilities/Resources/Capabilities for Trauma Center Designation. (A) The hospital shall meet emergency department standards for trauma center designation. 1. The emergency department staffing shall ensure immediate and appropriate care of the trauma patient. (I-R, IIR, III-R) A. The physician director of the emergency department shall be board-certified or board-admissible in emergency medicine. (I-R, II-R) B. There shall be a physician trained in the care of the critically injured as evidenced by credentialing in ATLS in the emergency department twenty-four (24) hours a day. ATLS is incorporated by reference in this rule as published by the American College of Surgeons in 2003 and is available at American College of Surgeons, 633 N. St. Clair St., Chicago, IL 60611. This rule does not incorporate any subsequent amendments or additions. (I-R, II-R, III-R) C. All emergency department physicians shall be certified in ATLS at least once. Physicians who are certified by boards other than emergency medicine who treat trauma patients in the emergency department are required to have current ATLS status. (I-R, II-R, III-R) D. There shall be written protocols defining the relationship of the emergency department physicians to other physician members of the trauma team. (I-R, II-R, III-R) E. All registered nurses assigned to the emergency department shall be credentialed in trauma nursing by the hospital within one (1) year of assignment. (I-R, II-R, III-R) (I) Registered nurses credentialed in trauma care shall maintain current provider status in the Trauma Care After Resuscitation (TCAR), Trauma Nurse Core Curriculum (TNCC), or Advanced Trauma Care for Nurses (ATCN) and either Pediatric Care After Resuscitation (PCAR), Pediatric Advanced Life Support (PALS), Advanced Pediatric Life Support (APLS), or Emergency Nursing Pediatric Course (ENPC) within one (1) year of employment in the emergency department. The requirement for Pediatric Care After Resuscitation, Pediatric Advanced Life Support, Advanced Pediatric Life Support, or Emergency Nursing Pediatric Course may be waived in centers where policy exists diverting injured children to a pediatric trauma center and where a pediatric trauma center is adjacent and a performance improvement filter reviewing any children seen is maintained. The Trauma Nurse Core Curriculum is incorporated by reference in this rule as published in 2007 by the Emergency Nurses Association and is available at the Emergency Nurses Association, 915 Lee Street, Des Plaines, IL 60016-9659. This rule does not incorporate any subsequent amendments or additions. Advanced Trauma Care for Nurses is incorporated by reference in this rule as published in 2003 by the Society of Trauma Nurses and is available at the Society of Trauma Nurses, 1926 Waukegan Road, Suite 100, Glenview, IL 60025. This rule does not incorporate any subsequent amendments or additions. Pediatric Advanced Life Support is incorporated by reference in this rule as published in 2005 by the American Heart Association and is available at the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231. This rule does not incorporate any subsequent amendments or additions. The Emergency Nursing Pediatric Course is incorporated by reference in this rule as published by the Emergency Nurses Association in 2004 and is available at the Emergency Nurses Association, 915 Lee Street, Des Plaines, IL 60016-9659. This rule does not incorporate any subsequent amendments or additions. Trauma Care After Resuscitation and Pediatric Care After Resuscitation are incorporated by reference in this rule as published in 2022 by TCAR Education Programs and are available at TCAR Education Programs, 33456 Havlik Drive, Scappoose, Oregon 97056. This rule does not incorporate any subsequent amendments or additions. (I-R, II-R, III-R) 2. Equipment for resuscitation and life support with age appropriate sizes for the critically or seriously injured shall include the following: A. Airway control and ventilation equipment including laryngoscopes, endotracheal tubes, bag-mask resuscitator, sources of oxygen, and mechanical ventilator—I-R, II-R, III-R; B. Suction devices—I-R, II-R, III-R; C. Electrocardiograph, cardiac monitor, and defibrillator—I-R, II-R, III-R; D. Central line insertion equipment—I-R, II-R, III-R; E. All standard intravenous fluids and administration devices including intravenous catheters—I-R, II-R, III-R; F. Sterile surgical sets for procedures standard for the emergency department—I-R, II-R, III-R; G. Gastric lavage equipment—I-R, II-R, III-R; H. Drugs and supplies necessary for emergency care— I-R, II-R, III-R; I. Two-way radio linked with emergency medical service (EMS) vehicles—I-R, II-R, III-R; J. End-tidal carbon dioxide monitor—I-R, II-R, III-R and mechanical ventilators—I-R, II-R; K. Temperature control devices for patient, parenteral fluids, and blood—I-R, II-R, III-R; and L. Rapid infusion system for parenteral infusion—I-R, II-R, III-R. 3. There shall be documentation that all equipment is checked according to the hospital preventive maintenance schedule. (I-R, II-R, III-R) 4. There shall be a designated trauma resuscitation area in the emergency department. (I-R, II-R) 5. There shall be X-ray capability with twenty-four (24)- hour coverage by technicians. (I-IH, II-IH, III-IA) 6. Nursing documentation for the trauma patient shall be on a trauma flow sheet approved by the trauma medical director and trauma nurse coordinator/trauma program manager. (I-R, II-R, III-R) (B) The hospital shall meet intensive care unit (ICU) standards for trauma center designation. 1. There shall be a designated surgeon medical director for the ICU. (I-R, II-R, III-R) 2. A physician who is not the emergency department physician shall be on duty in the ICU or available in-house twenty-four (24) hours a day in a level I trauma center and shall be on call and available within twenty (20) minutes in a level II trauma center. 3. The minimum registered nurse/trauma patient ratio used shall be one to two (1:2). (I-R, II-R, III-R) 4. Registered nurses shall be credentialed in trauma care within one (1) year of assignment. (I-R, II-R, III-R) 5. Nursing care documentation shall be on a patient flow sheet. (I-R, II-R, III-R) 6. Nurses assigned to the ICU shall maintain current provider status in Advanced Cardiac Life Support (ACLS) or Advanced Life Support (ALS). ACLS is incorporated by reference in this rule as published in 2021 by the American Heart Association and is available for purchase at the American Heart Association, 7272 Greenville Ave., Dallas, TX 75231 or online at www.cpr.heart.org. This rule does not incorporate any subsequent amendments or additions. ALS is incorporated by reference in this rule as published in 2022 by the American Red Cross and is available for purchase at the American Red Cross, National Headquarters, 430 17th St. NW, Washington DC 20006 or online at www.redcross.org. This rule does not incorporate any subsequent amendments or additions. At the time of the initial review, nurses assigned to ICU shall have successfully completed or be registered for a provider ACLS or ALS course. The requirement for ACLS or ALS may be waived in pediatric centers where policy exists diverting injured adults to an adult trauma center and where an adult trauma center is adjacent to the affected pediatric facilities, and a performance improvement filter reviewing any adult trauma patients seen is maintained. (I-R, II-R, III-R) 7. There shall be separate pediatric and adult ICUs or a combined ICU with nurses trained in pediatric intensive care. In ICUs providing care to children, registered nurses shall maintain credentialing in PALS, APLS, or ENPC. (I-R, II-R) 8. There shall be beds for trauma patients or comparable level of care provided until space is available in ICU. (I-R, II-R, III-R) 9. Equipment for resuscitation and to provide life support for the critically or seriously injured shall be available for the intensive care unit. In ICUs providing care for the pediatric patient, equipment with age appropriate sizes shall also be available. This equipment shall include but not be limited to – A. Airway control and ventilation equipment including laryngoscopes, endotracheal tubes, bag-mask resuscitator, and a mechanical ventilator—I-R, II-R, III-R; B. Oxygen source with concentration controls—I-R, II-R, III-R; C. Cardiac emergency cart, including medications—I-R, II-R, III-R; D. Temporary transvenous pacemakers—I-R, II-R, III-R; E. Electrocardiograph, cardiac monitor, and defibrillator—I-R, II-R, III-R; F. Cardiac output monitoring—I-R, II-R; G. Electronic pressure monitoring and pulse oximetry— I-R, II-R; H. End-tidal carbon dioxide monitor and mechanical ventilators—I-R, II-R, III-R; I. Patient weighing devices—I-R, II-R, III-R; J. Temperature control devices—I-R, II-R, III-R; K. Drugs, intravenous fluids, and supplies—I-R, II-R, IIIR; and L. Intracranial pressure monitoring devices—I-R, II-R. 10. There shall be documentation that all equipment is checked according to the hospital preventive maintenance schedule. (I-R, II-R, III-R) (C) The hospital shall meet post-anesthesia recovery room (PAR) standards for trauma center designation. 1. Registered nurses and other essential personnel who are not on duty shall be on call and available within sixty (60) minutes. (I-R, II-R, III-R) 2. Equipment for resuscitation and to provide life support for the critically or seriously injured shall include but not be limited to: A. Airway control and ventilation equipment including laryngoscopes, endotracheal tubes of all sizes, bag-mask resuscitator, sources of oxygen, and mechanical ventilator— I-R, II-R, III-R; B. Suction devices—I-R, II-R, and III-R; C. Electrocardiograph, cardiac monitor, and defibrillator—I-R, II-R, III-R; D. Apparatus to establish central venous pressure monitoring—I-R, II-R; E. All standard intravenous fluids and administration devices, including intravenous catheters—I-R, II-R, III-R; F. Sterile surgical set for emergency procedures—I-R, II-R, and III-R; G. Drugs and supplies necessary for emergency care— I-R, II-R, III-R; H. Temperature control devices for the patient, for parenteral fluids, and for blood—I-R, II-R, III-R; I. Temporary pacemaker—I-R, II-R, III-R; J. Electronic pressure monitoring—I-R, II-R; and K. Pulmonary function measuring devices—I-R, II-R, III-R. (D) The hospital shall have acute hemodialysis capability or a written transfer agreement. (I-R, II-R, III-R) (E) The hospital shall have a physician-directed burn unit or a written transfer agreement. (I-R, II-R, III-R) (F) The hospital shall have injury rehabilitation and spinal cord injury rehabilitation capability or a written transfer agreement. (I-R, II-R, III-R) (G) The hospital shall possess pediatric trauma management capability or maintain written transfer agreements. (I-R, II-R, III-R) (H) Radiological capabilities for trauma center designation including a mechanism for timely interpretation to aid in patient management shall include: 1. Angiography with interventional capability available twenty-four (24) hours a day with a one- (1-) hour maximum response time from time of notification—I-R, II-R; 2. Sonography available twenty-four (24) hours a day with a thirty- (30-) minute maximum response time—I-R; 3. Resuscitation equipment available to the radiology department—I-R, II-R, III-R; 4. Adequate physician and nursing personnel present with monitoring equipment to fully support the trauma patient and provide documentation of care during the time the patient is physically present in the radiology department and during transportation to and from the radiology department. Nurses providing care for the trauma patients that are not accompanied by a trauma nurse while in the radiology department during initial evaluation and resuscitation shall maintain the same credentialing required of emergency department nursing personnel—I-R, II-R, III-R; 5. In-house computerized tomography—I-R, II-R; and 6. Computerized tomography technician—I-IH, II-IA. (I) There shall be documentation of adequate support services in assisting the patient’s family from the time of entry into the facility to the time of discharge. (I-R, II-R, III-R) (J) Medical surgical floors of a designated trauma center shall have the following personnel and equipment: 1. Registered nurses and other essential personnel on duty twenty-four (24) hours a day—I-R, II-R, III-R; 2. Equipment for resuscitation and to provide support for the injured patient including but not limited to: A. Airway control and ventilation equipment including laryngoscopes, endotracheal tubes of all sizes, bag-mask resuscitator, and sources of oxygen—I-R, II-R, III-R; B. Suction devices—I-R, II-R, III-R; SENIOR SERVICES C. Electrocardiograph, cardiac monitor, and defibrillator—I-R, II-R, III-R; D. All standard intravenous fluids and administration devices and intravenous catheters—I-R, II-R, III-R; and E. Drugs and supplies necessary for emergency care— I-R, II-R, III-R; and 3. Documentation that all equipment is checked according to the hospital preventive maintenance schedule—I-R, II-R, IIIR. (K) The operating room personnel, equipment, and procedures of a trauma center shall include but not be limited to: 1. An operating room adequately staffed in-house twentyfour (24) hours a day—I-R, II-R; 2. Equipment including, but not limited to: A. Operating microscope—I-R. . B. Thermal control equipment for patient, parenteral fluids, and blood—I-R, II-R, III-R; C. X-ray capability—I-R, II-R, III-R; D. Endoscopic capabilities, all varieties—I-R, II-R, III-R; E. Instruments necessary to perform an open craniotomy—I-R, II-R; and F. Monitoring equipment—I-R, II-R, III-R; and 3. Documentation that all equipment is checked according to the hospital preventive maintenance schedule—I-R, II-R, IIIR; (L) The following clinical laboratory services shall be available twenty-four (24) hours a day: 1. Standard analyses of blood, urine, and other body fluids—I-R, II-R, III-R; 2. Blood typing and cross-matching—I-R, II-R, III-R; 3. Coagulation studies—I-R, II-R, III-R; 4. Comprehensive blood bank or access to a community central blood bank and adequate hospital blood storage facilities—I-R, II-R, III-R; 5. Blood gases and pH determinations—I-R, II-R, III-R; 6. Serum and urine osmolality—I-R, II-R; 7. Microbiology—I-R, II-R, III-R; 8. Drug and alcohol screening—I-R, II-R, III-R; and 9. A written protocol that the trauma patient receives priority—I-R, II-R, III-R. (4) Standards for Programs in Performance Improvement and Improvement Patient Safety Program, Outreach, Public Education, and Training for Trauma Center Designation. (A) There shall be an ongoing performance improvement and patient safety program designed to objectively and systematically monitor, review, and evaluate the quality and appropriateness of patient care, pursue opportunities to improve patient care, and resolve identified problems. (I-R, II-R, III-R) (B) The following additional performance improvement and patient safety measures shall be required: 1. Regular reviews of all trauma-related deaths—I-R, II-R, III-R; 2. A regular morbidity and mortality review, at least quarterly—I-R, II-R, III-R; 3. A regular multidisciplinary trauma conference that includes representation of all members of the trauma team, with minutes of the conferences to include attendance and findings—I-R, II-R, III-R; 4. Regular reviews of the reports generated by the Department of Health and Senior Services from the Missouri trauma registry and the head and spinal cord injury registry— I-R, II-R, and III-R; 5. Regular reviews of pre-hospital trauma care including inter-facility transfers and all adult patients seen in pediatric centers—I-R, II-R, III-R; 6. Participation in reviews of regional systems of trauma care as established by the Department of Health and Senior Services— I-R, II-R, III-R; and 7. Trauma patients remaining greater than six (6) hours prior to transfer will be reviewed as a part of the performance improvement and patient safety program—I-R, II-R, III-R. (C) An outreach program shall be established to assure twenty-four (24)-hour availability of telephone consultation with physicians in the outlying region. (I-R) (D) A public education program shall be established to promote injury prevention and trauma care and to resolve problems confronting the public, medical profession, and hospitals regarding optimal care for the injured. These must address major trauma issues as identified in that program’s performance improvement and patient safety process. (I-R, II-R) (E) The hospital shall be actively involved in local and regional emergency medical services systems by providing training and clinical resources. (I-R, II-R, III-R) (F) There shall be a hospital-approved procedure for credentialing nurses in trauma care. (I-R, II-R, III-R) 1. All nurses providing care to severely injured patients and assigned to the emergency department or ICU shall complete a trauma nursing course in order to become credentialed in trauma care. (I-R, II-R, III-R) 2. The content and format of any trauma nursing courses developed and offered by a hospital shall be developed in cooperation with the trauma medical director. A copy of the course curriculum used shall be filed with the department’s time critical diagnosis unit. (I-R, II-R, III-R) 3. Trauma nursing courses offered by institutions of higher education in Missouri such as the Advanced Trauma Care for Nurses, Emergency Nursing Pediatric Course, Trauma Care After Resuscitation, Pediatric Care After Resuscitation, or the Trauma Nurse Core Curriculum may be used to fulfill this requirement. To receive credit for this course, a nurse shall obtain advance approval for the course from the trauma medical director and trauma nurse coordinator/trauma program manager and shall present evidence of satisfactory completion of the course. (I-R, II-R, III-R). (G) Hospital diversion information must be maintained to include date, length of time, and reason for diversion. This must be monitored as a part of the Performance Improvement and Patient Safety program, and available when the hospital is site reviewed. (H) Each trauma center shall have a disaster plan. A copy of this disaster plan must be maintained within the trauma center policies and procedures and should document the trauma services role in planning and response. (5) Standards for the Programs in Trauma Research for Trauma Center Designation. (A) The hospital and its staff shall support a research program in trauma as evidenced by any of the following: 1. Publications in peer reviewed journals—I-R; 2. Reports of findings presented at regional or national meetings—I-R; 3. Receipt of grants for study of trauma care—I-R; and 4. Production of evidence-based reviews—I-R. (B) The hospital shall agree to cooperate and participate with the EMS Bureau in conducting epidemiological studies and individual case studies for the purpose of developing injury control and prevention programs. (I-R, II-R, III-R) AUTHORITY: section 190.185, RSMo 2016, and section 190.241, RSMo Supp. 2022.* Emergency rule filed Aug. 28, 1998, effective Sept. 7, 1998, expired March 5, 1999. Original rule filed Sept. 1, 1998, effective Feb. 28, 1999. Amended: Filed Jan. 16, 2007, effective Aug. 30, 2007. Amended: Filed May 19, 2008, effective Jan. 30, 2009. Emergency amendment filed Nov. 21, 2022, effective Dec. 7, 2022, expires June 4, 2023. Amended: Filed Nov. 21, 2022, effective June 30, 2023. *Original authority: 190.185, RSMo 1973, amended 1989, 1993, 1995, 1998, 2002, and 90.241, RSMo 1987, amended 1998, 2008, 2016, 2017, 2022.