Wisconsin Legislature: DHS 118.09(2)(c)

a. A level III or IV trauma care facility shall notify the department of the facility’s intent to change its level of trauma care. If the trauma care facility meets the department’s trauma care assessment and classification criteria under sub. (1), or has been verified by the ACS as being another level trauma care facility, the department shall recognize the facility at the level desired.

b. The department may revoke its approval of a level III or IV trauma care facility if the department determines the facility does not meet the criteria associated with the facility’s existing classification.

c. The department may perform a site visit of a level III or IV trauma facility to determine compliance with the evaluation criteria in accordance with s. DHS 118.04 (6) (a) 4.

d. If a level III or IV trauma care facility is unable to continue functioning at its current level of trauma care, the facility shall notify the department no more than 30 calendar days after the facility no longer continues to function as a level III or IV trauma care facility.

1. At least once every 3 years after initial classification, the department shall provide all level III and IV trauma care facilities an assessment and classification criteria form.

2. The trauma care facility shall declare to the department the facility’s level of trauma care capability on the assessment and classification form.

3. The trauma care facility shall submit the assessment and classification criteria form to the department at least 6 months before the expiration of the department’s approval of facility’s existing level of trauma care capability.

4. A level III or IV trauma care facility’s existing classification shall continue until the department makes a final decision on the renewal request, unless the department determines a compromise in patient care exists, at which time the department may immediately revoke the facility’s classification.

5. A level III or IV trauma facility that does not renew its classification within the time specified under this paragraph shall automatically lose its department approval as its existing level of trauma care facility and shall be considered an unclassified hospital.

(d) Restricted use of term “trauma care facility” or “trauma facility”.

1. A hospital may not advertise in any manner or otherwise represent itself as either a trauma care facility or trauma facility unless the hospital has been classified as a level I, II, III or IV trauma care facility by the department in accordance with this chapter.

2. A hospital’s advertisement or public representation of its classification as a trauma care facility shall include its level.

(3) Complaints.

(a) A trauma care facility may submit a complaint to the department regarding a department action.

(b) The department shall respond to the complaint pursuant to s. DHS 118.04 (3).

History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05; CR 19-086: am. (2) (a) 2. a., cr. (2) (a) 3. c. Register May 2021 No. 785, eff. 10-1-21.

Subchapter III — Trauma Care Improvement

DHS 118.09 Trauma registry.

(1) Purpose. The purpose of the trauma registry is to collect and analyze trauma system data to evaluate the delivery of adult and pediatric trauma care, develop injury prevention strategies for all ages, and provide resources for research and education.

(2) Department coordination of data collected by trauma care facilities, ambulance service providers and emergency medical responder services. The department shall do all of the following:

(a) Develop and publish a data submission manual that specifies all of the following:

1. Data elements and definitions.

2. Definitions of what constitutes a reportable trauma case.

3. Method of submitting data to the department.

4. Timetables for data submission.

5. Electronic record format.

6. Protections for individual record confidentiality.

(b) Notify trauma care facilities, ambulance service providers and emergency medical responder services of the required registry data sets and update the facilities and providers, as necessary, when the registry data set changes.

(c) Specify both the process and timelines for hospital and ambulance service provider submission of data to the department.

(3) Submission of data. All hospitals, ambulance service providers and emergency medical responder services shall submit to the department on a quarterly basis trauma data determined by the department to be required for the department’s operation of the state trauma registry. The department shall prescribe all of the following:

(a) Standard application and report forms to be used by all applicants and trauma care facilities.

(b) The form and content of records to be kept and the information to be reported to the department.

(4) Registry use.

(a) The department and RTACs shall use the trauma registry data to identify and evaluate patient care and to prepare standard quarterly and annual reports and other reports and analyses as requested by RTACs.

(b) The department shall use injury data collected under s. 256.25 (2), Stats., for confidential review relating to performance improvement in the trauma care system. The department may use the confidential injury data for no other purpose.

History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05; correction in (4) (b) made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637; CR 23-046: am. (2) (title), (b), (3) (intro.) Register April 2024 No. 820, eff. 5-1-24.

DHS 118.10 Performance improvement.

(1) Purpose. Each RTAC shall use the trauma registry data collected under s. DHS 118.09 to improve trauma care, reduce death and disability and correct local and regional injury problems.

Note: The RTAC should include in its performance improvement activities for all patient ages a surgeon involved in trauma care, an emergency department physician, an EMS representative, an EMS medical director, a person who coordinates the trauma program or the performance improvement process in a trauma facility, and other trauma care and prevention professionals the RTAC determines appropriate.

(2) Data confidentiality. Each RTAC shall observe the confidentiality provisions of the Health Insurance Portability and Accountability Act under 45 CFR 164.

(3) Process. The performance improvement process shall include all of the following for both pediatrics and adults:

(a) Data collection and analysis.

(b) Adult and pediatric-specific quality indicators for evaluating the trauma system and its components.

(d) A process for indicator review and audit.

(e) A mechanism for loop-closure.

(f) A mechanism for feedback to executive council.

(g) An evaluation of system performance.

(h) A procedure for ensuring that all parties having access to information associated with individuals and entities with respect to a trauma care system problem or issue keep the information confidential throughout the performance improvement process.

History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05.