5 PROPOSED ADMINISTRATIVE RULES

 

SOAHR 2009-011

 

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH BUREAU OF HEALTH POLICY, PLANNING AND ACCESS EMS AND TRAUMA SERVICES SECTION

STATEWIDE TRAUMA SYSTEM

 

Filed with the Secretary of State on

 

These rules take effect immediately after filing with the Secretary of State unless adopted under sections 33, 44, or 45a(6) of 1969 PA 306. Rules adopted under these sections become effective 7 days after filing with the Secretary of State.

 

(By authority conferred on the department of community health by sections 9227 and 20910 of 1978 PA 368, MCL 333.9227 and 333.20910; 2004 PA 580, 2004 PA 581, 2004 PA 582, and

Executive Reorganization Order Nos. 1996-1 and 2003-1, being MCL 333.20917a, 333.20908, 33320910, 330.3101, and 445.2011.

 

Draft April 27, 2009

 

R 325.129 is being amended as follows:

 

PART 1. GENERAL PROVISIONS

 

R 325.129 Powers and duties of the department.

Rule 5. Subject to appropriations, (1) The department, with the advice of the emergency medical services coordinating committee and statewide trauma care advisory subcommittee, contingent upon sufficient funding being appropriated, shall do all of the following:

(a)    Implement an “all-inclusive” trauma system throughout the state. This type of system allows for the care of all injured patients in an integrated system of health care in the pre-hospital and healthcare facility environments by personnel that are well trained and equipped to care for injured patients of any severity. The system allows for a healthcare facility to participate in the system to the extent or level that it is willing to commit the resources necessary for the appropriate management of the trauma patients and prohibits the department from limiting the number of health care facilities that seek to qualify for any given level of trauma designation under this system. It also ensures that all trauma patients are served by a system of coordinated care, based on the degree of injury and care required.

(b)      Establish a statewide trauma quality improvement process using a statewide database, which is compatible with trauma, emergency departments, and pre-hospital data systems, monitor the statewide trauma system; ensure the coordination and performance of the regional trauma networks; and set minimum standards for system performance and trauma patient care.

(c)    Assign a dedicated state EMS/trauma medical director and supporting resources consistent with the criteria in the 2004 Michigan trauma systems plan, pursuant to MCL 333.20910.

 

 

(d)      Implement and maintain a statewide plan for a trauma system for this state Michigan, that addresses all of the following:

(i)    State leadership.

(ii)    Public information and prevention.

(iii)    Human resources.

(iv)    Communications.

(v)    Medical direction.

(vi)    Triage.

(vii)     Transport.

(viii)     Trauma care facilities.

(ix)    Inter-healthcare facility transfers.

(x)    Rehabilitation.

(xi)    Evaluation of trauma patient care and the trauma system.

(e)    Ensure integration of the trauma and Emergency Medical Systems (EMS), including all pre-hospital and organ procurement organization components.

(f)     Develop a statewide process to establish regional trauma networks comprised of local Medical Control Authorities (MCAs) in a manner that integrates into existing regional emergency preparedness, EMS, or medical control systems.

(g)    Develop a statewide process for the verification of trauma resources.

(h)    Develop a statewide process for the designation of trauma facilities.

(i)      Develop an appeals process for facilities contesting their designation.

(j)        Establish state trauma recommendations and approve regional trauma triage protocols which are established and adopted by the local medical control authority.

(k)    Establish regional trauma networks, consistent with the current emergency preparedness regions, in order to provide system oversight of the trauma care provided in each region of the state. Regional trauma networks shall be comprised of collaborating local medical control authorities (MCAs) in a region. The collaborating MCAs in a region shall apply to the department for approval and recognition as a regional trauma network. The department, with the advice and recommendation of the statewide trauma care advisory subcommittee and emergency medical services coordinating committee, shall review the appropriateness of the regional structure every 3 years. The establishment of the regional trauma networks shall not limit the transfer or transport of trauma patients between regional trauma networks.

(l)        Implement Tiered Triage Protocols. Major trauma patients requiring the resources of a Level I Regional Trauma Research Facility or Level II Regional Trauma Facility shall be identified by adult and pediatric field triage criteria established by the regional trauma networks. Protocols, which are established and adopted by local medical control, may be developed based on the standards incorporated by reference in these rules, Resources for Optimal Care Of The Injured Patient 2006 ; Committee On Trauma American College of Surgeons, available at a cost of $25.00 from the American College of Surgeons, 633 N. Saint Clair St. Chicago, Illinois 60611-3211, and those contained in R 325.135. A copy is also available at cost from the EMS & Trauma Systems Section, 201 Townsend Street, Lansing, MI 48913. Tables 1 & 2 apply to adult and pediatric triage criteria:

 

Table I

Model Adult Trauma Triage Criteria & Methodology

 

The  EMT  or  paramedic  shall  assess  the  condition  of  those  injured  persons  with  anatomical  and physiological characteristics of a person 15 years of age or older for the presence of at least 1 of the

 

following criteria to determine whether to transport as a trauma alert. These criteria are to be applied in the order listed, and once any 1 criterion is met that identifies the patient as a trauma alert, no further  assessment is required to determine the transport destination.

 

Criteria:

1. GCS≤ 13

2.Meets color-coded triage system (see below)

3.Meets local criteria (specify)                                                                                                                       4.  Patient does not meet any of the trauma criteria listed above but, in the judgment of the EMT or  paramedic, should be transported as a trauma alert (document)                                

 

 

Component                    ▼Blue▼                                                          ▼Red▼

Airway	Respiratory rate of 30 or greater		Active airway assistance1  or RR<10 or flail chest
Circulation	HR  of  120  beats  per  minute  or  greater		Lack of radial pulse with systolic BP, 90 mmHg
Best Motor Response2	BMR = 5		BMR=4 or less or presence of new paralysis, or suspicion of spinal cord injury or loss of sensation
Cutaneous	Soft  tissue  loss3   or  penetrating injury to extremities distal to knee  or elbow		Amputation proximal to the wrist or  ankle or any penetrating injury4 to head, neck, or torso or extremity at or proximal to elbow or knee.
Fracture	Single   FX   site   due   to   trauma excluding ground-level fall		Fracture or two or more long bones5  or pelvic fracture
Age	55 years or older
Mechanism of Injury	Prolonged extrication (>20 min.)  evidence of high speed crash or significant vehicle damage or bent steering wheel or rollover, or motorcycle crash		Ejection from vehicle, death in same passenger compartment,  pedestrian struck, falls >20 feet
Burns	<10% 2nd or 3rd degree		>10% 2nd  or 3rd  degree or burns to face, hands, feet, genitalia/perineum and major joints, electrical burn or lighting injury, chemical burns, inhalation injury, or burn  injury in patient with pre-existing chronic medical condition

B = any 2 transport as a trauma alert              R = any 1 transport as a trauma alert

 

5: Purposeful movement to pain                                       of the wound the can be determined 4: Withdraws to pain                                        5. Longbone defined as humerous or femur

3: Flexes to pain (decorticate posturing)                   

 

            2: Extension response to pain (decelerate posturing)

            1: No response                                                          

 

Table II

Model Pediatric Trauma Triage Criteria & Methodology

 

The EMT or paramedic shall assess the condition of those injured persons with anatomical and physiological characteristics of a person 14 years of age or younger for the presence of at least 1 of the  following criteria to determine whether to transport as a trauma alert. These criteria are to be applied in the order listed, and once any 1 criterion is met that identifies the patient as a trauma alert, no further  assessment is required to determine the transport destination.

 

Criteria:

1.Meets color-coded triage system (see below)

2.Meets local criteria (specify)                                                                                                                       3.  Patient does not meet any of the trauma criteria listed above but, in the judgment of the EMT or  paramedic, should be transported as a trauma alert (document)                                

 

 

Component                    ▼Blue▼                                                          ▼Red▼

Size	Weight ≤ 11 Kg or length ≤ 33  inches on a pediatric length and weight emergency tape
Airway			Active airway assistance1 or crush injury to the chest
Consciousnes s	Amnesia or loss of consciousness		Altered   mental   status2     or   coma   or presence  or  paralysis  or  suspicion  of spinal cord injury or loss of sensation
Circulation	Carotid or femoral pulses palpable, but the radial or pedal pulse not palpable or SBP < 90 mm of Hg2		Lack of radial pulse with systolic BP < 90  mmHg2
Fracture (FX)	Single closed long bone4 fracture5		Open  long  bone4   fracture6   or  multiple fracture sites or multiple dislocations6
Cutaneous			Major  soft  tissue  disruption7  or  major flap avulsion or 2nd or 3rd degree burns to ≥  10%  TBSA  or  amputation8   or  any penetrating injury to head, neck or torso9

B = any 2 transport as a trauma alert                         R = any 1 transport as a trauma alert

 

1. Airway assistance beyond administration of oxygen  2.  OR < 70 + 2 x age in years

3.Altered mental states include drowsiness, lethargy, inability to follow commands, unresponsiveness  to voice, totally unresponsive

4.Long bones include the humerus, (radius, ulna) femur, (tibia or fibula)  5. Long bone fractures do not include isolated wrist or ankle fractures

6. Long bone fractures do not include isolated wrist or ankle fractures or dislocations 7. Includes major degloving injury

 

 

8.Amputation proximal to ankle or wrist

9.Excluding superficial wounds where the depth of the wound can be determined

 

(m)     Verify the trauma care resources of all healthcare facilities in this state Michigan over a 3-year period.

(n)      Establish a mechanism for periodic re-designation of all healthcare facilities.

(o)        Develop a comprehensive statewide data collection system that shall be phased in over a 5-year period.

(p)          Formulate recommendations for the development of performance improvement plans by the regional trauma networks, consistent with those in R 325.135.

(q)     Develop a process for trauma system performance improvement, which will include responsibility for monitoring compliance with standards, maintaining confidentiality, and providing periodic review of trauma facility standards. The following standards are incorporated by reference in these rules, as specified in R 325.129(2)(l) and R 325.135.

(r)     Develop a process for the evaluation of trauma system effectiveness based on standards that are incorporated by reference in these rules, as specified in R 325.129(2)(l) and R 325.135.

(s)      Coordinate and integrate appropriate injury prevention initiatives and programs.

(t)      Support and fund the components of the state trauma system and the regional trauma networks and provide adequate staffing and resources to carry out its                       responsibilities and functions.

(u)     Conduct an accurate assessment of the training and education needs and resources of trauma care personnel throughout the state.

(2)   In developing a statewide trauma system, the department shall consider all of the following factors:

(a)    Efficient implementation and operation.

(b)    Decrease in morbidity and mortality.

(c)    Cost effective implementation.

(d)    Incorporation of national standards.

(e)    Availability of funds for implementation to implement.

(3)    The 2004 Michigan Trauma Systems Plan may be periodically updated by the statewide trauma advisory subcommittee and the emergency medical services coordinating committee.