DHS 118.04 HistoryHistory: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05; corrections in (6) (d) 1. a. and c. made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637; CR 19-086: am. (2) (c) 2. Register May 2021 No. 785, eff. 10-1-21. DHS 118.05DHS 118.05 Statewide trauma advisory council. The statewide trauma advisory council shall be responsible for all of the following: DHS 118.05(1)(1) Advising the department on issues related to the development, implementation and evaluation of the statewide trauma care system. DHS 118.05(2)(2) Reviewing and approving the department’s proposed format and content of RTAC trauma plans. DHS 118.05 HistoryHistory: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05. DHS 118.06DHS 118.06 Regional trauma advisory councils. DHS 118.06(1)(1) Purpose. The purpose of a regional trauma advisory council is to develop, implement, monitor and improve the regional trauma system. DHS 118.06(2)(2) Participation in RTAC activities. A regional trauma advisory council may include facilities or organizations located in a neighboring state that provide trauma care to Wisconsin residents. DHS 118.06(3)(3) Regional trauma advisory council responsibilities. A regional trauma advisory council shall do all of the following: DHS 118.06 NoteNote: To obtain an application, 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 118.06(3)(b)1.1. Establish an executive council that has all of the following characteristics: DHS 118.06(3)(b)1.a.a. Reflects professional representation from out-of-hospital trauma care providers, trauma care facilities, education and injury prevention. DHS 118.06 NoteNote: Out-of-hospital trauma care providers include emergency medical services practitioners, emergency medical responders, or air medical personnel.
DHS 118.06(3)(b)1.b.b. May have representation of an out-of-state hospital or ambulance service provider if the hospital or ambulance service provider regularly provides care for persons injured in Wisconsin. DHS 118.06(3)(b)1.d.d. Does not have more than 50 percent of its representation from any single organization. In this subdivision paragraph, “organization” means corporate affiliation, entity or ownership. DHS 118.06 NoteNote: The Department believes that limiting primary service to the executive council of one RTAC will promote a representative’s focus on and allegiance to that RTAC. Any person, however, may participate in the activities of more than one RTAC.
DHS 118.06(3)(c)1.1. Select a coordinating facility. The coordinating facility shall be or do all of the following: DHS 118.06(3)(c)1.a.a. Work in collaboration with the department and the regional trauma advisory council to meet the needs required for the development, implementation, maintenance and evaluation of the regional trauma system. DHS 118.06(3)(c)1.c.c. If a regional trauma advisory council area contains no ACS-verified level I or II trauma facility, the coordinating facility may be an entity that provides written commitment to the department that the entity will become an ACS-verified level I or II trauma facility within 3 years of that assurance. DHS 118.06(3)(c)1.d.d. If a regional trauma advisory council area contains no ACS-verified level I or II trauma facility, and no entity can provide the department the assurance under subd. 1. c., the coordinating facility may be an entity that assures the department in writing that the entity will obtain the department’s recognition as a level III trauma facility within the time frame specified in the RTAC application. DHS 118.06(3)(c)1.e.e. Have an ACS-verified level I or II hospital, or an equivalent hospital from an adjoining state, serving as its resource hospital if a level III hospital is serving as the coordinating facility. DHS 118.06(3)(c)1.f.f. If 2 facilities agree to serve as co-coordinating facilities, one of the facilities shall be an ACS-verified level I or II trauma facility. DHS 118.06(3)(c)3.3. Notify the department and the RTAC executive council at least 30 days before relinquishing the title of coordinating facility if the coordinating facility is unable to fulfill the duties required by the regional trauma advisory council. DHS 118.06(3)(d)2.2. Ensure that the fiscal agent holds and distributes funds only for the purpose of RTAC activities by not commingling RTAC funds with other funds or using RTAC funds for personal purposes. DHS 118.06(3)(d)3.3. Ensure that the fiscal agent notifies the department and the executive council at least 30 days before relinquishing the title of fiscal agent if the fiscal agent is unable to fulfill the duties required by the regional trauma advisory council. DHS 118.06(3)(f)(f) Transmit all pertinent materials to all regional trauma advisory council members in a timely manner. DHS 118.06(3)(g)(g) Develop a format for meetings, agendas and minutes, and provide the department with all RTAC meeting times, agendas and minutes. DHS 118.06(3)(j)(j) Create a local and regional performance improvement process that is consistent with that specified in s. DHS 118.10. DHS 118.06(3)(k)(k) Develop and implement injury prevention and education strategies based on performance improvement findings. DHS 118.06(3)(L)1.1. Develop and submit to the department by June 1, 2006, a regional trauma plan based on a needs assessment and with the structure specified by the department. DHS 118.06(3)(L)2.2. Update the regional trauma plan specified under subd. 1. and submit the plan to the department every 2 years beginning June 1, 2008 following the submittal of the of the initial plan on June 1, 2006. DHS 118.06(3)(L)3.3. Beginning June 1, 2005, submit a yearly progress report to the department, in the format specified by the department, that contains a description of the progress being made towards achieving the actions specified under the most recent regional trauma plan. DHS 118.06(3)(m)(m) Resolve conflicts concerning trauma care and injury prevention within the region through a process having the following characteristics: DHS 118.06(3)(m)1.1. Conflicts needing resolution by the RTAC shall be addressed by the executive council. DHS 118.06(3)(m)2.2. If the executive council is unable to resolve a contested issue, the executive council chair shall submit the issue to the department for resolution. DHS 118.06(3)(n)(n) Notify the department within 30 days of any changes in leadership, bylaw revisions or other substantive revisions to the RTAC policies or operations. DHS 118.06 HistoryHistory: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05. DHS 118.07(1)(a)(a) All ambulance service providers and emergency medical responder services shall select one regional trauma advisory council for primary membership by July 30, 2005. DHS 118.07(1)(b)(b) Notwithstanding par. (a), an emergency medical services practitioner, emergency medical responder, or ambulance service provider may participate in any regional trauma advisory council. DHS 118.07(1)(c)(c) An ambulance service provider or emergency medical responder service shall notify the department if the service changes membership in an RTAC. DHS 118.07(2)(2) Effect of non-participation. The department and the pertinent RTAC may not recognize as a trauma system participant an ambulance service provider that does not participate in the activities of its chosen RTAC pursuant to sub. (1) (a), or submit data to the department under s. DHS 118.09 (3). DHS 118.07 NoteNote: Pursuant to s. DHS 110.34 (11), an ambulance service provider must specify in its operational plan the name of the regional trauma advisory council that it has chosen for its primary membership. DHS 118.08(1)(1) Hospital responsibility to affiliate with an RTAC. DHS 118.08(1)(a)1.1. All hospitals shall select one regional trauma advisory council for primary membership by July 30, 2005. DHS 118.08(1)(b)(b) Notwithstanding par. (a), a hospital may participate in the activities of any regional trauma advisory council. DHS 118.08(1)(c)(c) A hospital shall notify the department if the hospital changes membership in an RTAC. DHS 118.08(2)(a)1.a.a. All hospitals shall declare their current trauma care capabilities to the department within 180 days of January 1, 2005, according to the criteria specified in this section. DHS 118.08(2)(a)2.a.a. A hospital declaring itself as a Level I or II trauma care facility shall have been verified at that level by the ACS in accordance with the standards and guidelines established by the ACS. DHS 118.08(2)(a)2.b.b. A hospital desiring department approval as a level I or II trauma care facility, but which has not received ACS verification at that level, may only be approved as a level III or IV trauma care facility. DHS 118.08(2)(a)3.a.a. A hospital desiring department approval as a level III or IV trauma care facility shall either submit documentation to the department that it has received ACS verification at level III or IV or complete the department’s assessment and classification criteria application form. DHS 118.08 NoteNote: For a copy of the Department’s assessment and classification criteria application form for approval as a trauma care facility, please 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 118.08(2)(a)3.b.b. The department shall review the information in the hospital’s application and base its approval or disapproval of the application on the conformance of the facility with the criteria in appendix A. DHS 118.08(2)(a)3.c.c. If any Type 1 Criteria or more than three Type 2 Criteria are not demonstrated at the time of the initial classification site visit or at the initial site visit for any subsequent renewal of classification, the hospital’s application may not be approved. If all Type 1 Criteria are demonstrated but one to three Type 2 Criteria are not demonstrated at the time of a site visit, then a one-year provisional certificate of classification may be issued and another review shall be required before the hospital’s application may be approved. This second review must occur within one year from the date of notification and may include an onsite re-visit or a review of documents submitted by the hospital to the department. If the trauma care facility successfully corrects the deficiencies, the period of classification will be extended to three years from the date of the initial site visit. DHS 118.08(2)(a)4.4. ‘Pediatric trauma center.’ A hospital may not refer to itself as a pediatric trauma center unless it has received ACS verification as a pediatric trauma center. DHS 118.08(2)(a)5.5. ‘Unclassified hospital.’ A hospital that chooses not to participate in the Wisconsin trauma care system or that has not been approved by the department as a level I, II, III or IV trauma care facility shall be considered an unclassified hospital. DHS 118.08 NoteNote: To obtain a form for selection of trauma care level and application for Department approval of the chosen level, contact the Statewide Trauma Care Coordinator by phone at 608-266-0601 or by writing to the Statewide Trauma Care System Coordinator, Department of Health Services, Bureau of Local Public Health Practice and Emergency Medical Services, Room 118, 1 West Wilson, Madison, WI 53701 or by sending a fax to 608-261-6392.
DHS 118.08(2)(b)1.1. ‘Level I or II trauma care facility.’ If a hospital loses its ACS verification as a level I or II trauma care facility, the following shall occur:
