Subchapter II — Statewide Organization for Trauma Care
DHS 118.05 Statewide trauma advisory council.
DHS 118.06 Regional trauma advisory councils.
Subchapter III — Trauma Care Improvement
DHS 118.09 Trauma registry.
DHS 118.10 Performance improvement.
Ch. DHS 118 Note
Note: Chapter HFS 118 was renumbered chapter DHS 118 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7, Stats.,
Register January 2009 No. 637.
DHS 118.01
DHS 118.01 Authority and purpose. This chapter is promulgated under the authority of s.
256.25 (2), Stats., to develop and implement a statewide trauma care system. The purpose of the statewide trauma care system is to reduce death and disability resulting from traumatic injury by decreasing the incidence of trauma, providing optimal care of trauma victims and their families, and collecting and analyzing trauma-related data.
DHS 118.01 History
History: CR 04-055: cr.
Register December 2004 No. 588, eff. 1-1-05;
correction made under s.
13.92 (4) (b) 7., Stats.,
Register January 2009 No. 637.
DHS 118.02
DHS 118.02 Applicability. This chapter applies to all of the following:
DHS 118.02(3)
(3) A hospital approved under subch.
II of ch. 50, Stats., and ch.
DHS 124, excluding hospitals whose principal purpose is to treat persons with a mental illness.
DHS 118.02(6)
(6) Any health care provider involved in the detection, prevention or care of an injured person and is a member of a Wisconsin RTAC.
DHS 118.02(7)
(7) A Wisconsin law enforcement agency that is a member of a Wisconsin RTAC.
DHS 118.02 History
History: CR 04-055: cr.
Register December 2004 No. 588, eff. 1-1-05;
corrections in (3), (4) and (5) made under s.
13.92 (4) (b) 7., Stats.,
Register January 2009 No. 637; correction in (4) made under s.
13.92 (4) (b) 7., Stats.,
Register July 2011 No. 667;
CR 23-046: am. (2) (a), r. (2) (b), (c), am. (2) (e) Register April 2024 No. 820, eff. 5-1-24. DHS 118.03
DHS 118.03 Definitions. In this chapter:
DHS 118.03(1)
(1) “Ambulance service provider" has the meaning specified in s.
256.01 (3), Stats., namely, a person engaged in the business of transporting sick, disabled or injured individuals by ambulance to or from facilities or institutions providing health services.
DHS 118.03(3)
(3) “Assessment and classification criteria" means the required trauma care services and capabilities for a hospital to be classified as a Level III or IV trauma care facility.
DHS 118.03(4)
(4) “Audit" means a close examination of a situation or event in a multidisciplinary peer review.
DHS 118.03(5)
(5) “Bypass" means to forego delivery of a patient to the nearest hospital for a hospital whose resources are more appropriate for the patient's injury pursuant to direction given to a pre-hospital emergency medical service by on-line medical direction or predetermined triage criteria.
DHS 118.03(6)
(6) “Classification" means the process whereby a hospital identifies its service level as a trauma care facility and the department reviews and approves the hospital as a provider of a level of trauma care services to meet the needs of the severely injured patient.
DHS 118.03(7)
(7) “Coordinating facility" means an ACS verified level I or II hospital that has a collaborative relationship with the regional trauma advisory council and the department as specified under s.
DHS 118.06 (3) (c).
DHS 118.03(8)
(8) “Definitive care" means comprehensive care for the full spectrum of injuries beyond the initial assessment and resuscitation phase.
DHS 118.03(9)
(9) “Department" means the department of health services.
DHS 118.03(10)
(10) “Dispatch" means identifying and coordinating the emergency resources needed to respond to a specific traumatic injury or illness.
DHS 118.03(10j)
(10j) “Emergency medical responder service” means a group of persons licensed by the department under s.
256.15 (8), Stats., who are employed or organized to provide emergency care to sick, disabled, or injured individuals as a response for aid requested through a public service access point in conjunction with the dispatch of an ambulance, but who do not provide ambulance transportation of a patient.
DHS 118.03(12)
(12) “Executive council" means the RTAC leadership body, which is composed of professionals from each region who reflect trauma care expertise, leadership and diversity within each trauma care region.
DHS 118.03(15)
(15) “Fiscal agent" means the person or organization responsible for transactions of RTAC funds.
DHS 118.03(16)
(16) “Health care provider" means a medical professional who or organization that is involved in either the detection, prevention, or care of an injured person and includes all of the following:
DHS 118.03(17)
(17) “Hospital" means entities approved under subch.
II of ch. 50, Stats., and ch.
DHS 124, including critical access hospitals, that routinely provide trauma care, excluding hospitals whose principal purpose is to treat persons with a mental illness.
DHS 118.03(18)
(18) “Indicator review" means the RTAC's assessment of trauma system performance based on desired trauma system measurements and used by the RTAC in the performance improvement process.
DHS 118.03(19)
(19) “Lead agency" means an organization or agency that serves as the focal point for program development on the local, regional and state level. In this chapter, the department serves as the lead agency.
DHS 118.03(20)
(20) “Level I" means a class of trauma care facility that is characterized by the hospital's capability of providing leadership and total care for every aspect of traumatic injury from prevention through rehabilitation, including research.
DHS 118.03(21)
(21) “Level II" means a class of trauma care facility that is characterized by the hospital's ability to provide initial definitive trauma care regardless of the severity of injury, but may not be able to provide the same comprehensive care as a level I trauma center.
DHS 118.03(22)
(22) “Level III" means a class of trauma care facility that is characterized by the hospital's ability to:
DHS 118.03(22)(b)
(b) Provide emergency surgery and arrange, when necessary, transfer to a level I or II trauma facility for definitive surgical and intensive trauma care.
DHS 118.03(23)
(23) “Level IV" means a class of trauma care facility that is characterized by the hospital's ability to stabilize and provide advanced trauma life support prior to patient transfer.
DHS 118.03(24)
(24) “Loop-closure" means the process whereby an RTAC has identified a quality improvement problem, completed an evaluation, developed an action plan and notified appropriate health care providers of the results.
DHS 118.03(25)
(25) “Medical director" means the physician who is designated in an operational plan to be responsible for all of the following off-line medical direction activities:
DHS 118.03(25)(a)
(a) Controlling, directing and supervising all phases of the emergency medical services program operated under the plan and the emergency medical services practitioners performing under the plan.
DHS 118.03(25)(b)
(b) Establishing standard operating protocols for emergency medical services practitioners performing under the plan.
DHS 118.03(25)(c)
(c) Coordinating and supervising evaluation activities carried out under the plan.
DHS 118.03(25)(d)
(d) Designating on-line medical control physicians, if the physicians are to be used in implementing the emergency medical services program.
DHS 118.03(26)
(26) “Needs assessment" means a written report prepared by an RTAC identifying and documenting trauma care and injury prevention resources and deficiencies within a defined area of the trauma system and which serves as the basis for developing a regional trauma plan.
DHS 118.03(27)
(27) “Nurse anesthetist" means a professional nurse licensed under ch.
441, Stats., who has obtained, through additional education and successful completion of a national examination, a certification as an anesthesia nursing specialist.
DHS 118.03(28)
(28) “Off-line medical direction" means medical direction that does not involve voice communication provided to emergency medical services practitioners and emergency medical responders providing direct patient care.
DHS 118.03(29)
(29) “On-line medical direction" means medical direction of the activities of an emergency medical services practitioner that involves voice communication provided to the emergency medical services practitioners by the medical director or by a physician designated by the medical director.
DHS 118.03(30)
(30) “On-line medical control physician" means a physician who is designated by the medical director to provide voice communicated medical direction to emergency medical services practitioner and emergency medical responder personnel and to assume responsibility for the care provided by emergency medical technician and first responder personnel in response to that direction.
DHS 118.03(31)
(31) “Out-of-hospital" means care provided to sick or injured persons before or during transportation to a medical facility, including any necessary stabilization of the sick or injured person.
DHS 118.03(32)
(32) “
Pediatric trauma center” means a freestanding or separate administrative unit in a hospital that is dedicated to addressing the trauma needs of a pediatric patient population and meets the resource requirements outlined by the ACS
for verification as a pediatric trauma center.
DHS 118.03(33)
(33) “Performance improvement" means a method of evaluating and improving processes of trauma patient care that emphasizes a multidisciplinary approach to problem solving.
DHS 118.03(34)
(34) “Physician" means a person licensed under ch.
448, Stats., to practice medicine and surgery.
DHS 118.03(34m)
(34m) “PIPS” means performance improvement and patient safety.
DHS 118.03(35)
(35) “Protocol" means a written statement approved by the department and signed and dated by the medical director that lists and describes the steps any out-of-hospital care provider is to follow in assessing and treating a patient.
DHS 118.03(36)
(36) “Regional trauma advisory council" or “RTAC" means an organized group of healthcare entities and other concerned individuals who have an interest in organizing and improving trauma care within a specified geographic region approved by the department.
DHS 118.03(37)
(37) “Regional trauma plan" means a written report prepared by an RTAC that meets all of the following criteria:
DHS 118.03(37)(a)
(a) Identifies the region's current trauma care development strengths and weaknesses.
DHS 118.03(37)(b)
(b) Describes specific goals for future growth and activities in the region.
