Chapter DHS 118

DHS 118.08(2)(d)1. 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.

DHS 118.08(2)(d)2. 2. A hospital’s advertisement or public representation of its classification as a trauma care facility shall include its level.

DHS 118.08(3) (3) Complaints.

DHS 118.08(3)(a) (a) A trauma care facility may submit a complaint to the department regarding a department action.

DHS 118.08(3)(b) (b) The department shall respond to the complaint pursuant to s. DHS 118.04 (3).

DHS 118.08 History 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.

subch. III of ch. DHS 118 Subchapter III — Trauma Care Improvement

DHS 118.09 DHS 118.09 Trauma registry.

DHS 118.09(1) (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.

DHS 118.09(2) (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:

DHS 118.09(2)(a) (a) Develop and publish a data submission manual that specifies all of the following:

DHS 118.09(2)(a)1. 1. Data elements and definitions.

DHS 118.09(2)(a)2. 2. Definitions of what constitutes a reportable trauma case.

DHS 118.09(2)(a)3. 3. Method of submitting data to the department.

DHS 118.09(2)(a)4. 4. Timetables for data submission.

DHS 118.09(2)(a)5. 5. Electronic record format.

DHS 118.09(2)(a)6. 6. Protections for individual record confidentiality.

DHS 118.09(2)(b) (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.

DHS 118.09(2)(c) (c) Specify both the process and timelines for hospital and ambulance service provider submission of data to the department.

DHS 118.09(3) (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:

DHS 118.09(3)(a) (a) Standard application and report forms to be used by all applicants and trauma care facilities.

DHS 118.09(3)(b) (b) The form and content of records to be kept and the information to be reported to the department.

DHS 118.09(4) (4) Registry use.

DHS 118.09(4)(a) (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.

DHS 118.09(4)(b) (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.

DHS 118.09 History 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 DHS 118.10 Performance improvement.

DHS 118.10(1) (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.

DHS 118.10 Note 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.

DHS 118.10(2) (2) Data confidentiality. Each RTAC shall observe the confidentiality provisions of the Health Insurance Portability and Accountability Act under 45 CFR 164.

DHS 118.10(3) (3) Process. The performance improvement process shall include all of the following for both pediatrics and adults:

DHS 118.10(3)(a) (a) Data collection and analysis.

DHS 118.10(3)(b) (b) Adult and pediatric-specific quality indicators for evaluating the trauma system and its components.

DHS 118.10(3)(c) (c) A system for case referral.

DHS 118.10(3)(d) (d) A process for indicator review and audit.

DHS 118.10(3)(e) (e) A mechanism for loop-closure.

DHS 118.10(3)(f) (f) A mechanism for feedback to executive council.

DHS 118.10(3)(g) (g) An evaluation of system performance.

DHS 118.10(3)(h) (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.

DHS 118.10 History History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05.