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.
DHS 118.03(38)
(38) “Resource hospital" means a hospital in Wisconsin or a bordering state that makes a written commitment to assist the level III coordinating facility of an RTAC to meet the needs required for the development, implementation, maintenance and evaluation of the regional trauma system.
DHS 118.03(39)
(39) “Rural" means outside a metropolitan statistical area specified under
42 CFR 412.62 (ii) (A) or in a city, village or town with a population of less than 14,000.
DHS 118.03(40)
(40) “Statewide trauma advisory council" or “STAC" means the entity established by the department to advise the department on a variety of issues pertaining to the establishment and operation of the statewide trauma care system.
DHS 118.03(41)
(41) “Trauma care system" means a comprehensive and organized approach to facilitating and coordinating a multidisciplinary system response to traumatically injured patients and includes the continuum of care from initial injury detection through definitive care, rehabilitation and injury control.
DHS 118.03(42)
(42) “Trauma care facility” or “TCF” means a hospital that the department has approved as having the services and capabilities of a level I, II, III or IV trauma care facility.
DHS 118.03(43)
(43) “Traumatic injury" means major or severe injuries to more than one system of a person's body or major injury to a single system of the body that has the potential of causing death or major disability.
DHS 118.03(44)
(44) “Trauma registry" means a system for collecting data from hospitals for which the department manages and analyzes the data and disseminates the results.
DHS 118.03(45)
(45) “Triage" means classifying patients according to the severity of their medical conditions at the scene of an injury or onset of illness and subsequently providing care first to those patients with the greatest medical needs and who are likely to benefit from that care.
DHS 118.03(45g)
(45g) “Type 1 Criteria” means required criteria identified in Appendix A that may significantly impact a trauma care facility's ability to provide optimal care for trauma patients.
DHS 118.03(45r)
(45r) “Type 2 Criteria” means required criteria identified in Appendix A that may impact a trauma care facility's ability to provide optimal care for trauma patients.
DHS 118.03(46)
(46) “Unclassified hospital" means a hospital that either has chosen not to be a part of Wisconsin's trauma care system, or a hospital that the department has not approved as a level I, II, III or IV trauma care facility.
DHS 118.03(47)
(47) “Urban" means an area within a metropolitan statistical area specified under
42 CFR 412.62 (ii) (A) or in a city, village or town with a population of 14,000 or more.
DHS 118.03(48)
(48) “Verification" means the process specified by the ACS whereby a hospital desiring recognition as a level I, II, III or IV trauma care facility is designated as that level by the ACS.
DHS 118.03 History
History: CR 04-055: cr.
Register December 2004 No. 588, eff. 1-1-05;
corrections in (1), (9), (11), (13), (14) and (17) made under s.
13.92 (4) (b) 6. and
7., Stats.,
Register January 2009 No. 637; correction in (11) made under s.
13.92 (4) (b) 7., Stats.,
Register July 2011 No. 667; correction in (13) made under s.
13.92 (4) (b) 7., Stats.,
Register March 2014 No. 699;
CR 19-086: cr. (2m), (3m), (6m), (10m), (17m), (24m), am. (32), cr. (34m), (40g), (40r), am. (42), cr. (45g), (45r)
Register May 2021 No. 785, eff. 10-1-21;
CR 23-046: cr. (10d), (10j), r. and recr. (11), r. (13), (14), am. (16) (g), (h), (25) (intro.), (a), (b), (28) to (30) Register April 2024 No. 820, eff. 5-1-24.
DHS 118.04(1)(1)
Designation. The department shall be the lead agency for the development, implementation and monitoring of the statewide trauma care system.
DHS 118.04(2)
(2)
Lead agency duties. The lead agency shall do all of the following:
DHS 118.04(2)(a)
(a) General duties. Develop and revise guidelines and administrative rules for the statewide trauma care system.
DHS 118.04(2)(b)1.1. Approve the designation of all trauma care geographic regions based on consideration of what represents the best care of the trauma patient.
DHS 118.04 Note
Note: Wisconsin is divided into 9 trauma care geographic regions. Each region has an RTAC. A trauma care region is defined by the location of the health care providers that have selected a particular RTAC for primary membership and in which the majority of each provider's trauma care and prevention occurs.
DHS 118.04(2)(b)2.
2. Review the geographic distribution and organization of regional trauma advisory councils and ensure executive councils that promote the optimal operation of the statewide trauma care system.
DHS 118.04(2)(b)4.
4. Approve coordinating facilities, fiscal agents, executive councils and resource hospitals under sub.
(6) (c).
DHS 118.04(2)(c)1.1. Establish and revise the assessment and classification criteria for characterizing a hospital as a trauma facility.
DHS 118.04(2)(c)2.
2. Review and approve hospital requests for trauma care facility classification in accordance with standards and guidance provided by the criteria in appendix A and according to the process under sub.
(6) (a).
DHS 118.04 Note
Note: Hospitals are verified by the ACS as level I or II trauma care facilities based on conformance with the standards and guidelines established by the ACS. The department determines its classification of hospitals as level III or IV trauma care facilities in accordance with the standards and guidelines provided in appendix A of this chapter.
DHS 118.04(2)(d)2.
2. Review and approve regional trauma needs assessments, triage and transport protocols and plans under sub.
(6) (c).
DHS 118.04(2)(f)2.
2. Develop guidelines for a regional performance improvement program under s.
DHS 118.10 that includes all of the following:
DHS 118.04(2)(f)2.c.
c. The requirements for membership of the regional performance improvement committee.
DHS 118.04(2)(f)2.d.
d. The authority and responsibilities of the performance improvement committee.
DHS 118.04(2)(g)1.1. Resolve conflicts concerning trauma care and prevention issues between the RTAC and trauma care providers and any other entity within the RTAC's geographic region according to the process specified under sub.
(3).
DHS 118.04(2)(g)2.
2. Maintain awareness of national trends in trauma care and periodically report on those trends to RTACs and trauma care system participants.
DHS 118.04(2)(g)3.
3. Encourage public and private support of the statewide trauma care system.
DHS 118.04(2)(g)4.
4. Assist the RTACs with developing injury prevention, training and education programs.
DHS 118.04(2)(g)5.
5. Seek the advice of the statewide trauma advisory council in developing and implementing the statewide trauma care system.
DHS 118.04(3)(a)1.1. Upon receipt of a complaint about the trauma system, the department shall either investigate the complaint or request one or more RTACs to initially investigate and respond to the complaint. The department shall monitor how the RTAC or RTACs are addressing and responding to the complaint. When the RTAC has completed its investigation and has prepared its response, the RTAC shall communicate its response to the department.
DHS 118.04(3)(a)2.
2. Regardless of whether the department has requested one or more RTACs to investigate and respond to the complaint, the department may initiate an investigation of and response to a complaint within 2 business days following the department's receipt of the complaint.
DHS 118.04 Note
Note: The time within which the Department resolves a complaint depends on the nature of the complaint and the resources required to investigate and resolve the complaint.
DHS 118.04(3)(b)1.1. The department shall maintain a record of every complaint and how each complaint was addressed and resolved.
DHS 118.04(3)(b)2.
2. Within the constraints imposed by laws protecting patient confidentiality, the department shall make available its complaint record under subd.
1. to any person requesting to review it.
DHS 118.04 Note
Note: To request review of the Department's complaint record, contact the Statewide Trauma Care Coordinator by calling 608-266-0601 or by writing to Statewide Trauma Care System Coordinator, Bureau of Local Public Health Practice and Emergency Medical Services, Room 118, 1 West Wilson St., Madison, WI 53701, or by sending a fax to 608-261-6392.
DHS 118.04(4)(a)(a) An authorized employee or agent of the department, upon presentation of identification, shall be permitted to examine equipment or vehicles or enter the offices of an RTAC, a hospital seeking or having department recognition as a trauma care facility or an ambulance service provider during business hours with 24 hour advance notice or at any other reasonable prearranged time. The authorized employee or agent of the department shall be permitted to inspect and review all equipment and vehicles and inspect, review and reproduce records of the trauma care facility, ambulance service provider or RTAC pertinent to the nature of the complaint, including, but not limited to, administrative records, personnel records, training records and vehicle records. The right to inspect, review and reproduce records applies regardless of whether the records are maintained in written, electronic or other form.
DHS 118.04(4)(b)
(b) If, based on the department's investigation, the department determines that corrective action by the trauma care facility is necessary, the trauma care facility shall make the corrective actions. The department may subsequently conduct a final investigation following corrective action and notify the trauma facility of the results.
DHS 118.04(5)
(5)
Waivers. The department may waive any nonstatutory requirement under this chapter, upon written request, if the department finds that strict enforcement of the requirement will create an unreasonable hardship for the provider in meeting the emergency medical service needs of an area and that waiver of the requirement will not adversely affect the health, safety or welfare of patients or the general public. The department's denial of a request for a waiver shall constitute the final decision of the department and is not subject to a hearing under sub.
(7).
DHS 118.04 Note
Note: To request a waiver from a nonstatutory requirement under this chapter, contact the statewide trauma care coordinator by calling 608-266-0601 or by writing to Statewide Trauma Care System Coordinator, Bureau of Local Public Health Practice and Emergency Medical Services, Room 118, 1 West Wilson St., Madison, WI 53701, or by sending a fax to 608-261-6392.
DHS 118.04(6)(a)
(a)
Department review of and decision on hospital trauma care facility applications. DHS 118.04(6)(a)1.1. A hospital requesting department approval to act or advertise as a trauma care facility shall submit an application to the department on a form provided by the department.
DHS 118.04 Note
Note: For a copy of the Department's assessment and classification criteria application form for approval as a trauma care facility, write to the Wisconsin Trauma Care System Coordinator, Division of Public Health, P.O. Box 2659, Madison WI 53701–2659 or download the form from the DHS website at:
http://www.dhs.wisconsin.gov/forms/F4/F47479.doc.
DHS 118.04(6)(a)3.
3. The department may require a hospital to document the basis for the hospital's professed level of trauma care facility.
DHS 118.04(6)(a)4.
4. The department may perform a site visit of a level III or IV trauma facility to determine compliance with the trauma facility assessment and classification criteria in accordance with all of the following conditions:
DHS 118.04 Note
Note: The Department recommends that a trauma surgeon, emergency room physician and a trauma coordinator, all from a Level I or II verified trauma care facility, minimally comprise the site visit team.
DHS 118.04(6)(a)4.b.
b. The department's site visit shall be to determine whether the facility meets the assessment and classification criteria in appendix A.
DHS 118.04(6)(a)4.c.
c. The site visit team shall submit their findings to the department within 30 calendar days of completing the site visit.
