Level IV Trauma Centers.

(i)

A physician director for the emergency department;

(ii)

Current Advanced Trauma Life Support certification for any provider who is not board-certified or eligible by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine.

(i)

The trauma team must be fully assembled within 30 minutes of patient arrival;

(ii)

The GACH shall provide universal screening for alcohol use for all injured patients, in accordance with American College of Surgeons guidelines;

(iii)

The GACH shall have protocols that define the clinical criteria and confirmatory testing required for the diagnosis of brain death.

(i)

Radiological service with twenty-four (24) hours per day, seven (7) days per week, 365 days a year availability of a radiological technician.

(ii)

Clinical laboratory and therapeutic service, including:

(i)

Recommending trauma team physician privileges;

(ii)

Working with nursing administration to support the nursing needs of trauma patients;

(iii)

Developing GACH trauma treatment protocols;

(iv)

Authority and accountability for the quality improvement (QI) peer review process;

(v)

Correcting deficiencies in trauma care, or excluding from trauma call, any trauma team member(s) who fail to meet the standards of the program; and

(vi)

Assisting in the coordination of the budgetary process for the trauma program.

(i)

Organizing the patient care services and administrative systems necessary for the multidisciplinary approach to the care of the injured patient;

(ii)

Coordinating day-to-day clinical process and performance improvement as it pertains to nursing and ancillary personnel; and

(iii)

Collaborating with the trauma program medical director in carrying out the educational, clinical, administrative and outreach activities of the trauma program.

(i)

Ability to identify opportunities for improvement and implement actions to reduce the risk of patient harm, regardless of the department, service, or provider;

(ii)

Review of all transfers to a higher level of care within the institution and re-triage of trauma patients;

(iii)

A process for reporting events and actions to a departmental/GACH PIPS program, enabling aggregation of data across the organization;

(iv)

A process to provide feedback to the trauma program;

(v)

A process to bring the providers across relevant disciplines and departments together to review and implement opportunities for improvement;

(vi)

A written plan that documents all process and outcome measures shall and that is reviewed and updated on at least an annual basis;

(vii)

Mechanisms in place to identify events for review by the trauma PIPS program. Once an event is identified, the trauma PIPS program shall verify and validate the event;

(viii)

A process to document that timely and appropriate intensive care unit (ICU) care and coverage are being provided, if available.

(i)

Trauma Program Medical Director Review. The trauma program medical director shall conduct an annual review, in accordance with the general acute care hospital's (GACH's) internal policies and procedures, to ensure that the trauma program demonstrates appropriate orientation, credentialing, and skills maintenance of advanced practitioners. The medical director's review shall include, at a minimum, the evaluation of documentation, credentialing records, and compliance with applicable standards, to ensure alignment with the approved trauma care system plan and the requirements of this subchapter. Documentation of the review and determination shall be included as attachments with the Initial Trauma Care System Plan Template (Rev. 11/2025), incorporated by reference, or the Annual Trauma System Status Report Template (Rev. 11/2025), incorporated by reference, as applicable.

(ii)

Trauma Peer Review Committee. A multidisciplinary trauma peer review committee that meets at least twice a year and includes medical staff who are actively involved in trauma resuscitation. The committee's review shall consist of assessing any systemic and care provider issues and proposing improvements to the care of injured patients. The review shall be conducted in accordance with the GACH policies and procedures for quality improvement.