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Become a member and receive career-enhancing benefits

Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

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Trauma Programs

2022 Standards Q&A

General

What are the credentialing requirements for advanced practice providers (APPs)?

The institution will determine the credentialing requirements for APPs.

The 2022 publication does not include standards for Level IV trauma centers. Will the Committee on Trauma (COT) provide current guidance in a separate publication for Level IV trauma centers, or should we continue to use the 2014 Standards?

The COT is giving this careful consideration and will determine how best to address the concerns. In the meantime, the 2014 Resources for Optimal Care of the Injured Patient (aka, the Orange Book) contains Level IV criteria that are still relevant, current, and can continue to be used.

If a trauma center was reviewed under the 2014 Standards and requires a focused visit, will the focused visit be based on the 2014 Standards or the new 2022 Standards?

For focused visits, the trauma center will be reviewed using the same standards by which it was previously reviewed. In this instance, the focused visit will be reviewed using the 2014 Standards.

Can I assume if a criterion existed in the 2014 Standards but not in the 2022 Standards, then it is obsolete?

The 2022 Standards defines all standards required for trauma center verification by the ACS VRC program. The 2022 version should be able to be used alone, independent from previous versions of the standards. It’s important to understand that the 2022 version organizes the standards based on the nine categories. Some criteria have moved out of their placement in the Orange Book to a new standard in the Gray Book and some criteria were absorbed into standards with broader requirements.

Program Scope and Governance

Are trauma centers required to have a registered nurse (RN) serve as Trauma Program Manager (TPM)?

In all trauma centers, a registered nurse is not required to serve as a TPM.

Can the trauma program manager (TPM) or the performance improvement (PI) personnel serve as the designated injury prevention professional?

In Level I trauma centers, the injury prevention professional must be someone other than the TPM or PI personnel. In Level II and III trauma centers, the TPM or the PI personnel may serve as the designated injury prevention professional as long as they meet the requirements stated in Standard 2.10 or Standard 4.34.

Does "injury prevention activities" refer to one-time events or ongoing programs?

Injury prevention activities refer to one-time events.

Facilities and Equipment Resources

Can Level I and Level II trauma centers use the dedicated operating room for non-orthopaedic surgical procedures?

In Level I and II trauma centers, the dedicated operating room must be prioritized for fracture care in nonemergent orthopaedic traumas. Operational details related to staffing, frequency of availability, and use by other services should be collaboratively determined and approved by the TMD and the orthopaedic trauma leader. The frequency of availability should be sufficient to provide timely fracture care for patients.

Personnel and Services

Is a neurosurgery published backup call schedule required?

To meet the standard, a neurosurgery published backup call schedule is not required.

Can anesthesia providers take call from home if they can respond timely within 15 minutes of request?

In Level I and II centers, anesthesia services are required to be available within 15 minutes of request. Providers can take call onsite or offsite. Time of request to time of response must be tracked.

For Level II and III trauma centers, has the option for a surgical co-director for ICU been taken off the table? Do we need to hire a board certified/eligible in surgical critical care MD?

In all trauma centers, the ICU surgical director, whether it is the director or co-director, must be board-certified or board-eligible in general surgery. In Level I adult trauma centers, the ICU surgical director must be board-certified or board-eligible in surgical critical care.

What qualifications are required for Intensive Care Unit (ICU) physicians?

The qualifications for ICU physicians are determined by the hospital.

Our trauma center does not have one of the required specialists. Can we use a transfer agreement with another facility to meet this standard?

As noted in the standard’s additional information section, “’continuous’ is defined as 24/7/365 and implies there are no gaps in coverage.” The required surgical expertise must exist in Level I and II trauma centers. Therefore, transfer agreements are not acceptable to meet this standard.

Does this standard include patients entries who does not meet the NTDS inclusion criteria?

As stated in the definitions and requirements section, the standard defines the count of entries as all patients who meet NTDS inclusion criteria, and those patients who meet inclusion criteria for hospital, local, regional, and state purposes. Therefore, patients who meet your hospital’s inclusion criteria, but do not meet NTDS criteria, do count towards the FTE requirements for the standard. 

Can a trauma program manager (TPM) who is a Certified Abbreviated Injury Scale Specialist (CAISS) meet this requirement?

In Level II and III trauma centers, the standard can be met by having the TPM who is CAISS certified serve as the 0.5 FTE registrar.

Are the 24 hours of trauma-related continuing education required for both clinical and non-clinical registry staff?

All trauma registrars, clinical and non-clinical, are required to meet Standard 4.33.

Standard 4.34 Performance Improvement Staffing Requirements states: “When the annual volume exceeds 1,000 registry patient entries, the trauma center must have at least 1 FTE PI personnel.” Does this mean 1 FTE PI for volume more than 1,000 patient entries or 1 FTE for every 1,000? For example, if the center has 4,000 patients annually, would they need 4 FTEs?

When the annual volume exceeds 1,000 registry patient entries, the trauma center must have at least 1 FTE PI personnel. However, in the Additional Information section, it states that greater trauma center volumes might necessitate additional personnel. The trauma center determines PI personnel needs based on its patient volume.

Is Disaster Management and Emergency Preparedness (DMEP) the only course that meets the standard?

The only disaster course that meets this standard is the DMEP course.

Where can I find information on upcoming onsite or online DMEP courses?

An online version of the course, eDMEP, will be launched in the spring of 2023. Please check the course webpage for current offerings and updates.

Patient Care: Expectations and Protocols

Are all patients who are admitted regardless of the length of stay required to be screened?

All admitted patients greater than 12 years old, regardless of length of stay, must be screened.  Trauma centers must achieve a screening rate of at least 80 percent to meet the standard. 

Performance Improvement and Patient Safety

Are standards that did not carry over to the 2022 Resources manual still applicable? For example, requirements related to undertriage.

The 2022 version should be able to be used alone, independent from previous versions of the standards. It’s important to understand that the 2022 version organizes the standards differently.  For PIPS, many of the requirements from the 2014 Standards are listed in the Resources section as audit filters, event review, and report reviews.  For example, ‘Accuracy of trauma team activation protocols’ should flag both undertriage and overtriage situations for review.

What are the attendance requirements for the Geriatric Trauma Liaison?

There are no attendance requirements for geriatric liaisons.

Research

Is it required for research articles to be included in a specific journal index (e.g., PubMed/Index Medicos)?

Articles must be published or accepted for publication in peer-reviewed and indexed journals. The standard does not list specific index services/databases to meet this requirement.