Preparing for a Trauma Site Review in Colorado
Information for new Trauma Nurse Coordinators on what to anticipate when preparing for a trauma designation site review
What is a Trauma Site Review?
At the core, it is a regulatory visit to see if your facility meets the minimum trauma standards; however, it is also a time to acknowledge program strengths, provide consultation and make suggestions for trauma program improvement.
While a site review is an event, it should also be the culmination of what you do every day to develop and run an effective patient care program.
It assesses:
- Commitment to the trauma program
- Readiness to care for the trauma patient
- Resources and capabilities
- Policies, protocols and practices
- Quality of care
- Performance improvement
You don’t want to wait until a few months before the site visit to assess the progress made since your last review. To avoid stress, program assessment and improvements should occur throughout the designation period.
Ensure educational requirements are being maintained by relevant staff members (Board certification, ATLS, CME, TNCC, etc.). Consider adding education/certification as an agenda item for each trauma team meeting.
Timeline to prepare for a site review:
1. 18 months prior:
- Review requirements for your level trauma center (see Scoring Tool available on state website: www.cotrauma.info Score your facility to identify strengths weaknesses and deficits. Now is the time to correct.
- Ensure educational requirements are being maintained
- Call the state trauma staff to ask questions
- Review all policies annually and make sure they reflect actual practice
- Define or refine your scope of care
- Assess your performance improvement program
o Are audit filters still relevant?
o Are you learning things from cases caught by your filters?
o Are you reviewing system issues, medical issues, provider issues and patient outcomes?
o Is loop closure occurring, and is it documented?
2. 12-14 months prior:
1. Begin the application process- If you are not applying with a paper application, go
to the CEMSIS portal.
- If you don't have a CEMSIS user ID, use the link to request a new user ID.
- If you have a CEMSIS user ID already, make sure your permissions give you access to trauma designation forms for your facility.
- Click "Trauma Designation Forms" link to view your application
- Begin editing your section and click save and continue before you exit the section.
2. Begin gathering as many attachments as you can
- Trauma policies, organization chart, catchment area maps,
- Trauma protocols, guidelines
- Job descriptions
- Trauma patients from this point forward will be subject to the medical record review during the survey. Some records to become familiar with include:
o All trauma deaths
o All LOS > 2 weeks
o All transfers
o Spinal cord trauma
o Major head trauma
o Returns within 72 hrs.
o Combination chest & abdominal trauma
3. 4-6 months prior:
- Identify who will participate on the day of the review, include:
o Administration
o Nursing
o Radiology
o Laboratory
o EMS
o Medical directors for ED, surgery, ICU, rehab
o Quality
o ED Manager
- Obtain Board of Directors resolution, CEO commitment letter, Medical Executive Committee commitment letter.
- Work with CDPHE staff to select date
- Get date on calendars!
4. 4-8 weeks prior to the review:
- Complete the application
- Submit the required copies
- Book a conference room for the review
Before submitting application, double check your numbers and have key trauma team personnel review application for accuracy and completeness. Have a non-clinical individual read for comprehension.
5. 1 – 2 week prior:
- Prepare a short program overview
- Remind all invitees about review
- Notify relevant personnel regarding facility tour
- Make food arrangements for the review team
- Secure necessary equipment & supplies: pens, notepad
- We are at altitude, so have water and tissues available
- Organize documents to be reviewed during the site visit
o Consider using binders, folders, posters, samples of materials
6. Day before the survey:
Relax. Your advance planning and preparation has paid off!
Preparing for the visit and participation on the day of the visit should involve everyone on the trauma team, not just the trauma nurse coordinator so be sure to engage all team members.
The Trauma Coordinator & Trauma Medical Director are encouraged to participate in the entire site visit.
Prepare a short program overview (just a few minutes) this does NOT have to be a formal program with a PowerPoint presentation. Just give the team highlights of what your trauma program has done over the past three years. Note major personnel changes or discuss a good example of a quality improvement project. Notify relevant personnel regarding facility tour – it is good to let the nurses, physicians, techs and other staff know that there will be a bunch of strangers asking questions about trauma on survey day.
If you have items you have used for injury prevention or a health fair or some other presentations (for example a tabletop display) feel free to bring those to the review so you can show the reviewers what you have been doing. Do not do a tabletop display just for the reviewers.
Site Review Schedule (for Levels III-V)
The site review team will have reviewed your application for designation prior to arriving at the facility.
1. Opening Conference: The site review will begin with an opening conference. The opening conference allows an opportunity for the reviewers to provide an overview of the designation process, ask clarifying questions regarding the designation application and interview key personnel including the trauma medical director and trauma coordinator, EMS representatives, hospital administration, chief nursing officer, interested physicians and midlevel providers, and key personnel from the Emergency Department, Radiology, Laboratory/Blood Bank and Quality/Performance Improvement.
- Usually scheduled to begin at 7 AM.
- This is a good time to offer the reviewers breakfast
- After introductions, facilities are encouraged to begin with a short informal presentation.
- Areas to highlight include:
o Program success since the last review
o Changes since the last review
o Program growth
o Current challenges
- The reviewers will jump in with questions for staff members
2. Facility Tour: (follow the path of the patient)
Ideally, this tour will be guided by the trauma medical director and trauma coordinator. Reviewers like to speak with staff working in each area regarding the care provided to trauma patients. Be sure to notify the staff ahead of time of the survey and their role during the tour.
A. Emergency Department
- EMS and public entrances
- Helipad if nearby
- Equipment, staffing, availability of resources
- Staff readily available who know how to use the equipment and where things are located
- Communication with EMS
- Trauma team activation
- Decontamination resources
The equipment and supplies listed in the scoring tool will be inspected while the reviewers are in the Emergency Department. Be sure to know what items are on the list and ensure that each item is available. Assign a staff member to assist the team in locating the items.
B. Radiology
- Equipment, staffing, availability
- Oxygen, suction, crash cart and patient monitoring
- Method for film interpretation
- Process for over-reading and follow up through PI process
C. Laboratory
- Response to trauma team activation
- Turnaround for STAT tests
- Point of care testing
- Blood availability to the ED
- Massive transfusion protocol (if applicable)
- Involvement in PI process
D. OR/PACU (if applicable)
- Equipment and staffing
- Anesthesia coverage
- Availability after hours
- Trauma-related education
- Availability of an OR for a trauma patient requiring immediate surgery
- Involvement in PI process
E. ICU (if applicable)
- Equipment
- Nurse to patient ratio
- Bed availability for the critical trauma patient
- Management of trauma patients in the ICU
- Trauma related education for the staff
- Involvement in PI process
F. Rehab (if applicable)
- Range of services available
- Policy regarding the referral of trauma patients
- Availability of services during acute phase of treatment
- Transfer agreements if services are not available on-site
3. Documentation to be reviewed
Medical records may be on paper charts or electronic. If electronic, please have one computer and one staff member available (to help navigate the electronic chart) for each reviewer. Not necessary to have one for state observer. Have your charts available in a way that the review team can understand.
a. Medical record review
- Refer to application for specifics about number/types of patient records to have available
- Organize records by categories –
-Deaths -Admits with LOS > 2 weeks
-Transfers -Returns within 72 hrs.
- Admits - ISS > 15
- Pediatrics - Cases of interest or good PI
- Trauma charts will be reviewed for –
- Completeness of data acquisition and documentation
- Timeliness of care
- Adherence to trauma policies
- Evidence-based clinical management
b. Policy review
- Completeness of data acquisition and documentation
- Timeliness of care
- Adherence to trauma policies
- Evidence-based clinical management
c. Staff qualifications and education
- Trauma education offerings for staff
- Public education regarding trauma and injury prevention
- Documentation of CME and ATLS for physicians, TNCC and CEUs for nurses
d. Trauma performance improvement
- Systematic evaluation of care for trauma patients
- Standardized approach to recurring care issues to:
- Minimize unnecessary variation
- Provide better outcome assessment
- Makes changes in care easier to implement and more uniform
e. Trauma performance improvement
- A written trauma performance improvement plan
- A clear process to identify issues for review with:
o Staff reporting of quality issues
o Level of review
1. Primary: TNC,
2. Secondary: TMD
3. Trauma Committee, Peer Review, etc.
4. Quaternary, external review
o Based on standards of care
Types of audit filters including:
o Process – resuscitation, patient handoff, length of time in ED, TTA response times, etc.
o Clinical – Operative timeliness, failed non-operative management, c-spine clearance, etc.
o Performance – Diagnosis delays, radiology misreads, timeliness of interventions, discharge planning, etc.
o Trauma deaths receive automatic review
o Activations receive automatic primary level review
Committee meetings (both trauma committee and peer review committee)
o Written documentation of meeting minutes, agendas, attendance
o Documentation of committee meeting discussions
o Case reviews, conclusions and subsequent actions
o Implementation of actions
o Evaluation method for loop closure
o PI trending summaries (if available)
Trauma Committee
- Multidisciplinary medical providers involved in care of trauma patients
f. Injury Prevention
- Assess needs based on local data/information
- Build community partnerships
- Use regional & state resources where possible
- Determine methodology to use
- Complete the intervention
- Determine impact
4. Review team closed session
- Reviewers confer on findings from the tour, interviews and review of documentation
- Reviewers document areas of strength and weakness
- Suggestions for policy/protocol changes are developed
- The facility’s scoring tool is completed
- Any areas that are not fully met will have an explanation of what is necessary to come into full compliance
- The team makes a recommendation to the department on the designation of the facility
Facility staff may be called into this session to clarify questions if needed
5. Exit interview
- Review team makes a verbal report on whether the facility has met all expectations
- Report on strengths and weaknesses
- Suggest areas for growth
- Answer lingering questions
- Discuss the designation process/next steps
Facilities are welcome to tape the exit conference. Findings and scoring tool determinations will be discussed in detail during the exit conference, however a written document will not be provided.
The site review team report is forwarded to the monthly Designation Review Committee (for Level III-V facilities) or the quarterly State Trauma Care Committee meeting (for levels I and II.) This group will make a recommendation to the department regarding the trauma designation of the applicant facility.
6. Within 3 months of a completed review:
- Review deficiencies/weaknesses/suggestions from the review
- Develop work plan for addressing necessary or desired changes
- Develop timeline for completion
Trauma site review conclusion
Take a breath Repeat the process
Questions???
The trauma program staff is here to help with any questions or concerns regarding this process. You are free to contact staff members AT ANY TIME. Please do not hesitate to contact us.
Grace Sandeno Trauma Section Manager – 303-692-2983 grace.sandeno@state.co.us
Martin Duffy Trauma System Specialist – 303-692-6495 martin.duffy@state.co.us
Eileen Brown STEMI and Stroke Coordinator 303-692-6406 eileen.brown@state.co.us