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S.C. Emergency Medical Services

EMS Trauma Program

What are our current laws and regulations for the trauma system?

 

Trauma Regulation 61-116 (pdf)

The Golden Hour is a term used to describe the first hour immediately following a serious injury.  If a patient receives proper medical care in that first hour, his chances of survival triple and the long-term side effects of injury are significantly decreased.  This is one of the reasons distance between the scene of an accident and a trauma center as well as rapid response on the part to a trauma center following a severe injury, the chances for recovery diminish.

* Courtesy of:   A State of Emergency: Trauma in South Carolina.

What is a Trauma System

Much of the information contained below has been excerpted from the American College of Surgeons', 2006 edition of the "Resources for Optimal Care of the Injured Patient."

The magnitude of traumatic injury as a public health problem is enormous.  In terms of year of productive life lost, prolonged or permanent disability, and cost, it is now recognized as one of the most important threats to public health and safety in the United States. 

The trauma care system is a network of definitive care facilities that provides a spectrum of care for all injured patients.  An ideal trauma system includes all the components identified with optimal trauma care, such as prevention, access, acute hospital care, rehabilitation, and research activities.  In addition, trauma systems emphasize the need for various levels of trauma centers to cooperate in the care of injured patients to avoid wasting precious medical resources.  For, in the era of health care reform, we not only must strive for optimal care, but we must try to provide this optimal care in a cost-effective manner.

The care of injured patients requires a systematic approach to ensure optimal care.  A systematic approach is necessary within a facility; however, no one trauma center can do everything.  Thus, a system approach is necessary within an entire community regardless of its size. 

Since the early 1980's the EMS division of DHEC has been charged with identifying hospitals with the capabilities of serving as designating trauma and conducting the reviews necessary to verify that those hospitals can indeed be designated as a Level I, II or III trauma center. In the past EMS division has worked with the EMS regions throughout the state to develop trauma transport plans which will encourage EMS services to transport their serious trauma patients to the most appropriate hospital.

A Trauma Center is Not an Emergency Department

A study conducted in Winter of 2001 by the University of South Carolina’s Institute of Public Affairs reported that three-fourths of the South Carolina residents responding to the survey incorrectly believe that all hospitals are equally staffed and equipped to care for internal injuries, head injuries, heart attacks, strokes and spinal cord injuries. Two-thirds believe that emergency surgery is available 24 hours a day, 7 days a week at all hospitals.

Despite these beliefs, all emergency departments do not provide the same services 24/7.

The Difference Between a Trauma Center and the Emergency Department

Trauma center designation criteria set strict requirements for staffing, specialist availability, response times, training, quality improvement and community education. Additionally, trauma centers have organized trauma teams that respond promptly to trauma alerts, a surgeon who serves as trauma director and provides oversight to the hospital’s trauma program, trauma nurse coordinators and committees that provide quality improvement and direction for the hospital’s trauma program.

The emergency departments of hospitals that are not designated trauma centers may be staffed by an emergency physician day and night, but do not have organized trauma teams ready to respond to trauma call or access to the immediate, high level of surgical care available at a designated trauma center.

Trauma Advisory Council

The Trauma Advisory Council meets quarterly or at least twice a year, and has the responsibility of developing a state trauma plan, determining trauma resources and implementing a statewide trauma system based on state and regional trauma plans. This committee is to develop and monitor the trauma data system, develop state and regional QA/QI and review data for recommendations for changes.

Members of the Trauma Advisory Council include a balanced number of hospital personnel from each of the three levels of trauma centers.  Physicians representing a number of organizations with important roles in the state EMS system and the state trauma plan/system are also represented on the medical control committee.  These physicians represent medical direction for each of the four EMS regions, the S.C. Medical Association, the S.C. Chapter of the American College of Surgeons (ACS), the S.C. Chapter of American College of Emergency Physicians (ACEP), the two Schools of Medicine, and the state EMS Medical Director.  This group includes emergency medicine physicians, nurses, hospital administrators, paramedics, rehabilitation personnel, special interests groups and surgeons. The membership represents each of the trauma centers, with which much of the responsibility for trauma system development falls.  The Trauma Advisory Council includes members of the Medical Control Committee and other leaders that had both the interest and the capability to provide leadership in trauma system development.  The committee membership also includes representatives from several consumer interest groups.

Pediatric Trauma Center
Level I

  • Medical University of South Carolina (MUSC) Children's Hospital is the state's first pediatric trauma center.

Level I Trauma Centers
Highest level of capabilities available.

A Level I Trauma Center should be a regional resource center and generally serves large cities or population-dense areas.  This institution usually serves as the lead hospital for a system.  Generally, these trauma centers are attached to medical schools or will have residency programs because of the in-house requirements.

The Level I trauma center(s) in South Carolina:

Requirements for a Level I trauma center include:

  • In-house emergency medicine, general surgery, anesthesia capability at all times
  • Other specialists must be on-call and must respond within a short time to a trauma alert
    • Cardiac surgery
    • Hand surgery
    • Neurologic surgery
    • Obstetrics/gynecologic surgery
    • Pediatric surgery
    • Ophthalmic surgery
    • Reconstructive surgery
    • Orthopedic surgery
    • Plastic surgery
    • Surgical critical care medicine
    • Radiology
    • Thoracic surgery
  • Extensive equipment requirements
  • Specific clinical qualifications and trauma-specific continuing medical education requirements for physicians and other medical staff
  • Operating Room availability 24/7 and in-house OR staff
  • Specific quality improvement monitoring of trauma patient care and continual monitoring of trauma care protocols and policies
  • Participation in injury prevention activities within the community
  • Research requirements

Level II Trauma Centers
Extensive capabilities and meets the needs of most trauma patients

The major difference between Level I and II facilities is that the major surgical specialties are required to be on-call but with the clear commitment to be in the Emergency Department when the patient arrives.

Level II trauma centers provide comprehensive trauma care in two distinctive environments that have been recognized in the ongoing verification program.  The first environment is a population-dense area where a Level II trauma center may supplement the clinical activity and expertise of a Level I institution.  The second Level II environment occurs in less population-dense areas.  The Level II hospital serves as the lead trauma facility for a geographic area when a Level I institution is not geographically close.

The Level II trauma center(s) in South Carolina:

Requirements for a Level II trauma center include:

  • In-house emergency medicine and anesthesia capability at all times
  • Other specialists must be on-call and must respond within a short time to a trauma alert
    • General surgery
    • Neurologic surgery
    • Obstetrics/gynelogic surgery
    • Ophthalmic surgery
    • Reconstructive surgery
    • Orthopedic surgery
    • Plastic surgery
    • Radiology
    • Thoracic surgery
  • Extensive equipment requirements
  • Specific clinical qualifications and trauma-specific continuing medical education requirements for physicians and other medical staff
  • Operating Room availability 24/7 and OR staff on-call and available 24/7
  • Specific quality improvement monitoring of trauma patient care and continual monitoring of trauma care protocols and policies
  • Participation in injury prevention activities within the community

Level III Trauma Centers
Committed to caring for the trauma patient, and provides prompt assessment, resuscitation, emergency operations, stabilization and possible transfer to a facility that can provide definitive trauma care.

For many areas, a Level III trauma center represents an important part of the trauma system.  A Level III trauma center should have the capability to initially manage the majority of injured patients and have transfer agreements with a Level I or II trauma center for patients whose needs exceed their resources.

Although the specialist and equipment requirements are not as strict for Level III trauma centers, these hospitals must provide prompt general surgical and trauma team response to trauma alerts and care of the trauma patient is monitored by strict quality improvement.

The Level III trauma center(s) in South Carolina:

Level III trauma centers must meet the minimum requirements listed below, but specialist availability may be more extensive at some hospitals:

  • In-house emergency medicine and anesthesia capability at all times
  • Other specialists must be on-call and must respond within a short time to a trauma alert
    • General surgery
    • Radiology
    • Extensive equipment requirements
    • Board certification in the physician’s specialty is required and trauma-specific continuing medical education requirements is desired.
    • Operating Room availability 24/7 and OR staff on-call and available 24/7
    • Specific quality improvement monitoring of trauma patient care and continual monitoring of trauma care protocols and policies
    • Participation in injury prevention activities within the community

South Carolina’s criteria for trauma center designation are based on a modified version of the standards adopted by the American College of Surgeons in its guide “Resources for Optimal Care of the Injured Patient, 2006 edition.”

For further information about trauma centers and systems:

How did SC's trauma system originate?

Using the authority granted to DHEC in Act 1118 of 1974 for "categorization of hospitals and emergency room facilities", the EMS division, with the assistance of the state medical director and the four regional medical directors, developed criteria for designation of Level I trauma centers in 1984. Letters soliciting applications were mailed and Richland Memorial Hospital (now Palmetto Richland Hospital), Greenville Memorial Medical Center and the Medical University of South Carolina (MUSC) were subsequently designated as Level I hospitals.

In 1987, the Medical Control Committee adopted modified ACS guidelines as criteria for the designation of Level I trauma centers. In 1988, the original three Level I trauma centers were designated again, but under the ACS criteria.

The EMS division began receiving federal grant funding in the early 1990's to designated trauma centers and begin the development of a trauma system. In 1990 the new ACS guidelines were adopted as criteria for Levels I, II and III trauma centers. It was determined that out of state site review teams would be required for site visits for Levels I and II trauma centers and that in-state teams (volunteers) would review Level III designation.

By the end of 1991, with funding provided by a DOT grant, one Level I, one Level II and 14 Level III trauma centers had been designated under the new process. These new designations were added to the original three Level I trauma centers and brought the total designations to 19.

In 1992, EMS division received grant funding from the Department of Trauma and EMS to develop a state trauma plan based on the federal model trauma plan. At that time a 37-member Trauma System Committee, a subcommittee of the Medical Control Committee, was formed to meet the federal requirements for a multidisciplinary trauma committee. The Committee was responsible for formulating policy recommendations for inclusion in the state plan. These policies addressed issues ranging from public education, regional planning, evaluation, and designation criteria. Finally, in 1995, a state trauma plan was developed and approved in a public meeting. Shortly after the approval of the state plan, four regional trauma plans were developed through a process of regional meetings and public hearings, spearheaded by the four EMS regional offices.

Today, the Trauma Advisory Council is responsible for determining the initial recommendation for designation and redesignations of hospitals as trauma centers. The Committee also looks at registry and quality improvement issues, and general system development issues, such as transport destinations and future legislative needs.

How are hospitals designated and redesignated?

The trauma center application cycle begins each year in January. At that time, letters are sent to the administrators of any hospital which is not designated as a trauma center, but possibly has the capabilities to become one. Included in that letter is a trauma center application, a copy of the American College of Surgeon criteria and a copy of the policy outlining the process for designation. Administrators are asked to notify the EMS division by February 1 of their intent to apply for designation. The letter also notifies the administrators that if they choose to apply for designation, that they should make an appointment to have the trauma registry software installed and the letter recommends setting up a technical assistance visit with EMS trauma staff.

If a hospital chooses to pursue designation, the application must be submitted by June 30 of that year. Before a site review team visit is scheduled, the hospital must have accumulated information on 100 patients meeting trauma registry criteria. Once that minimum number is met, the hospital notifies DHEC's EMS division and EMS staff begins to arrange a date for the review and enlist a site review team. For the designation (and redesignation) of Level III trauma centers, the site review team is made up of volunteers from within the state. Each team is led by a trauma surgeon, emergency physician and nurse. The team is not provided any stipends, but expenses are paid by the EMS division. For Level I and II trauma centers, the team is made of a trauma surgeon, emergency physician and trauma nurse coordinator from an out of state trauma center. The physicians and nurses are paid a stipend and the hospital pays all expenses.

For the initial designation of any level hospital, the team conducts a tour of the hospital, checking for accuracy of the information submitted in the application and a chart review. There is a standardized form to verify whether the hospital meets the criteria and a standardized chart review form.

A recent change of policy has determined that redesignations will be conducted every 5 years in the same manner as initial designations.

Trauma Registry

The South Carolina Trauma Registry is an information system of the most seriously injured patients in South Carolina.  The trauma registry ensures that the various elements of the trauma system are, in fact, operating in an organized coordinated manner that improves overall outcomes from traumatic injury.

Participation in the state trauma registry is a requirement for designation.

The criteria for patients who should be included in the trauma registry are:

Inclusion Criteria

  • At least one of the following injury diagnostic codes defined in the International  Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM): 800 - 959.9

And MUST INCLUDE one of the following in addition to ICD-9-CM: 800 - 959.9

  • Hospital admission as defined by your trauma registry inclusion criteria; OR
  • Patient transfer via EMS transport (including air ambulance) from one hospital to another; OR
  • Death resulting from the traumatic injury (independent of hospital admission or hospital transfer status)

Exclusion Criteria

Exclude the following injuries:

  • 905 - 909.9 (late effects of injury)
  • 910 - 924.9 (superficial injuries, including blisters, contusions, abrasions and insect bites)
  • 930 - 939.9 (foreign bodies)
  • Age > 65 years with the same level fall (E code 885.9 & 888.9) and isolated hip fracture (ICD-9 808.0 – 808.9 and 820.0 – 820.9)

Trauma Registry Data Submission Schedule


Admission Period

Due Date

January – March

Due July 1

April – June

Due October 1

July – September

Due January 1

October – December

Due April 1

 


For additional information, call (803) 545-4204