Trauma Designation Application

If we apply for a specific designation, but can't meet all of the standards, will we be designated at a lower level?

Provided that your application process wasn't competitive, you would receive a provisional designation (two years) for the designation level for which you applied. The department will send to you a list of requirements you'll need to meet.

Once you address the requirements and your facility is in compliance with WAC, your contract will be amended and a full designation awarded.

What is a competitive application process?

A competitive application process, or simply “competition,” occurs when the number of facilities applying for a designation level within a single region outnumbers the total number of available slots as determined by the regional council.

Competitive designation processes require far more scrutiny than a standard designation process — as some facilities won't be designated.

What is a “provisional designation”?

A provisional designation is given to facilities that, through the application and/or site review process, don't meet WAC 246-976 standards. The provisional designation is shorter in duration than a standard designation award (one to two years instead of three) and requires the completion of department-determined requirements to regain full designation.

Provisional designation doesn't affect the facilities designation level or the amount of trauma grant funds received.

My facility is in the application process. What is the timeline required in the application for meeting provider education requirements?

All applicable personnel need to have met the education requirements sometime within the three-year designation cycle for which you're contracted, not for the designation cycle for which you're now applying.

Does a provider's currency in advanced trauma life support (ATLS) count towards accomplishing the pediatric education requirements (PERs)?

Yes. Currency in ATLS meets the WAC requirements for PERs.

Can a policy be referred to throughout the application without putting a copy of it in all the sections where it applies?


Will I need any supplementary documents to fill out my application?

Yes. You'll need three data reports, which the department will send to you shortly after you receive your application. These reports are the trauma profile, mechanism and transfer reports. The profile and mechanism report are necessary to complete Section 1: Trauma Service Profile. The transfer report is needed to answer response item 1 in Section 7: Patient Transfer and Diversion.

When looking at my trauma registry reports, I noticed that the total number of pediatric and adult patients add up to be more than the total number of patients meeting the Washington Trauma Registry criteria. Is this a problem?

No. The difference is small, so just use the number provided in the report specific to the total number of patients meeting the Washington Trauma Registry (WTR) criteria. The queries used in the current report for total pediatric and adult patients are based on age only. They don't include the inclusion criteria variable, so the total number of patients meeting the WTR criteria is slightly less than the totals of each age group when added individually. This is something that will be addressed in the next revision cycle of these reports.

Item 1 in "Section 7: Patient Transfer and Diversion" asks me to provide the trauma transfer-out report from the department and to include letters of commendation or concern for patients in the right column of the report. It's difficult to add a new column to this report, so may I just address this question in a Word document?

Yes. It's much easier and just as acceptable to include letters of commendation or concern in a Word document. Please be sure to reference as to which patient the letter is for. You may put this document at the end of the section and reference it with the title “Item 1 Response.”

In Section 6, the application asks me to submit QI committee attendance records. Do these have to be scanned original copies or may I create an attendance sheet?

We encourage you to create a summarized Word or Excel table showing who (position title; individual names not required) attended with an “x” or check. You don't have to send scanned copies of original sign-in sheets.

Not all of our staff has met the education requirements. Is there any allowance for new staff members?

Ninety percent of all trauma personnel must meet the education and training requirements at any given time. The intent of the 90-percent rule is to allow time for new hires to receive the appropriate trauma training. If your facility is temporarily out of compliance with this rule, you must submit a written plan of compliance with an expected completion date in your application for re-designation.

It's clear that my facility will not meet several requirements in the application. What should I do?

Respond to these issues openly in the application. The department encourages you to provide a response to these issues in the form of an action plan. This action plan should be a Word document that includes what item(s) for which you're not in compliance, a detailed process of how you plan on coming into compliance and a timeline for completion. Put this action plan at the end of the section and be sure to reference what item(s) it's in response to.

If not addressed in the application,we'll ask for an action plan in the final report anyways, so it's much better to show us that you have acknowledged the issue and are working to resolve it.

I'm unable to meet the application deadline. Does the department grant extensions on the due date?

Yes, but only case-by-case. It's important for the department to receive applications on time in order for us to make strict final report deadlines.

We submitted our application. When will we know if we are designated?

The designation announcement date is the same for all facilities in your designation group and is found on the Trauma Service and Trauma Rehab Service Designation Schedule (PDF) document. On that date, you'll receive official correspondence from us with the designation decision for your facility.

We received our designation decision letter, but haven't received our final report. When can we expect to receive our final report?

The Department of Health has 60 days from the designation decision announcement date to finish final reports for Level IV and V facilities. For Level I-III facilities, the department has 120 days from the date of the site review to get final reports out. Your report will arrive via email sometime within the applicable timeframe depending on your designation level.

If we activate a full trauma team but we know the patient is probably going to be transferred out, does the general surgeon have to see the patient anyway?

Yes, the purpose of trauma team activation is to use patient information from the field to identify trauma patients who would benefit from evaluation and treatment by a general surgeon upon their arrival in the emergency department, regardless of whether the patient would be admitted or transferred. Trauma services are required to develop and follow their patient criteria that trigger mandatory activation of the general surgeon.

For Levels I, II, III can a general surgeon be on-call at more than one facility at a time?

Washington Administrative Code (WAC) rules are clear about the required response times for general surgeons. If the on-call general surgeon is unavailable because he/she is managing trauma patient care or performing elective surgery at another facility, then the facility calling the trauma team activation would need to go on divert, and that facility would not be meeting trauma standards of care. Surgeon response times should be continuously monitored through the QI process.

For Levels I, II, III should a general surgeon be performing elective surgery while on trauma call?

Although this is not a direct violation of WAC it's strongly discouraged. If a surgeon performs elective surgery while on trauma call a written surgeon back-up protocol is necessary. The availability of the on-call surgeon or instances of surgeon unavailability must be monitored closely through the Trauma QI process. If the unavailability of the surgeon seriously hinders your obligations as a Level I, II, or III trauma center, measures must be taken to alleviate the problem.

How are the medical records selected for the designation site visit?

Medical records are selected based on a criteria which is given to trauma service (Levels I-III only) about three months prior to their scheduled site visit.


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