Chapter DHS 118

DHS 118.03(25)(b) (b) Establishing standard operating protocols for emergency medical services practitioners performing under the plan.

DHS 118.03(25)(c) (c) Coordinating and supervising evaluation activities carried out under the plan.

DHS 118.03(25)(d) (d) Designating on-line medical control physicians, if the physicians are to be used in implementing the emergency medical services program.

DHS 118.03(26) (26) “Needs assessment” means a written report prepared by an RTAC identifying and documenting trauma care and injury prevention resources and deficiencies within a defined area of the trauma system and which serves as the basis for developing a regional trauma plan.

DHS 118.03(27) (27) “Nurse anesthetist” means a professional nurse licensed under ch. 441, Stats., who has obtained, through additional education and successful completion of a national examination, a certification as an anesthesia nursing specialist.

DHS 118.03(28) (28) “Off-line medical direction” means medical direction that does not involve voice communication provided to emergency medical services practitioners and emergency medical responders providing direct patient care.

DHS 118.03(29) (29) “On-line medical direction” means medical direction of the activities of an emergency medical services practitioner that involves voice communication provided to the emergency medical services practitioners by the medical director or by a physician designated by the medical director.

DHS 118.03(30) (30) “On-line medical control physician” means a physician who is designated by the medical director to provide voice communicated medical direction to emergency medical services practitioner and emergency medical responder personnel and to assume responsibility for the care provided by emergency medical technician and first responder personnel in response to that direction.

DHS 118.03(31) (31) “Out-of-hospital” means care provided to sick or injured persons before or during transportation to a medical facility, including any necessary stabilization of the sick or injured person.

DHS 118.03(32) (32) “Pediatric trauma center” means a freestanding or separate administrative unit in a hospital that is dedicated to addressing the trauma needs of a pediatric patient population and meets the resource requirements outlined by the ACS for verification as a pediatric trauma center.

DHS 118.03(33) (33) “Performance improvement” means a method of evaluating and improving processes of trauma patient care that emphasizes a multidisciplinary approach to problem solving.

DHS 118.03(34) (34) “Physician” means a person licensed under ch. 448, Stats., to practice medicine and surgery.

DHS 118.03(34m) (34m) “PIPS” means performance improvement and patient safety.

DHS 118.03(35) (35) “Protocol” means a written statement approved by the department and signed and dated by the medical director that lists and describes the steps any out-of-hospital care provider is to follow in assessing and treating a patient.

DHS 118.03(36) (36) “Regional trauma advisory council” or “RTAC” means an organized group of healthcare entities and other concerned individuals who have an interest in organizing and improving trauma care within a specified geographic region approved by the department.

DHS 118.03(37) (37) “Regional trauma plan” means a written report prepared by an RTAC that meets all of the following criteria:

DHS 118.03(37)(a) (a) Identifies the region’s current trauma care development strengths and weaknesses.

DHS 118.03(37)(b) (b) Describes specific goals for future growth and activities in the region.

DHS 118.03(37)(c) (c) Is based on the RTAC’s needs assessment.

DHS 118.03(38) (38) “Resource hospital” means a hospital in Wisconsin or a bordering state that makes a written commitment to assist the level III coordinating facility of an RTAC to meet the needs required for the development, implementation, maintenance and evaluation of the regional trauma system.

DHS 118.03(39) (39) “Rural” means outside a metropolitan statistical area specified under 42 CFR 412.62 (ii) (A) or in a city, village or town with a population of less than 14,000.

DHS 118.03(40) (40) “Statewide trauma advisory council” or “STAC” means the entity established by the department to advise the department on a variety of issues pertaining to the establishment and operation of the statewide trauma care system.

DHS 118.03(40g) (40g) “TMD” means trauma medical director.

DHS 118.03(40r) (40r) “TPM” means trauma program manager.

DHS 118.03(41) (41) “Trauma care system” means a comprehensive and organized approach to facilitating and coordinating a multidisciplinary system response to traumatically injured patients and includes the continuum of care from initial injury detection through definitive care, rehabilitation and injury control.

DHS 118.03(42) (42) “Trauma care facility” or “TCF” means a hospital that the department has approved as having the services and capabilities of a level I, II, III or IV trauma care facility.

DHS 118.03(43) (43) “Traumatic injury” means major or severe injuries to more than one system of a person’s body or major injury to a single system of the body that has the potential of causing death or major disability.

DHS 118.03(44) (44) “Trauma registry” means a system for collecting data from hospitals for which the department manages and analyzes the data and disseminates the results.

DHS 118.03(45) (45) “Triage” means classifying patients according to the severity of their medical conditions at the scene of an injury or onset of illness and subsequently providing care first to those patients with the greatest medical needs and who are likely to benefit from that care.

DHS 118.03(45g) (45g) “Type 1 Criteria” means required criteria identified in Appendix A that may significantly impact a trauma care facility’s ability to provide optimal care for trauma patients.

DHS 118.03(45r) (45r) “Type 2 Criteria” means required criteria identified in Appendix A that may impact a trauma care facility’s ability to provide optimal care for trauma patients.

DHS 118.03(46) (46) “Unclassified hospital” means a hospital that either has chosen not to be a part of Wisconsin’s trauma care system, or a hospital that the department has not approved as a level I, II, III or IV trauma care facility.

DHS 118.03(47) (47) “Urban” means an area within a metropolitan statistical area specified under 42 CFR 412.62 (ii) (A) or in a city, village or town with a population of 14,000 or more.

DHS 118.03(48) (48) “Verification” means the process specified by the ACS whereby a hospital desiring recognition as a level I, II, III or IV trauma care facility is designated as that level by the ACS.

DHS 118.03 History History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05; corrections in (1), (9), (11), (13), (14) and (17) made under s. 13.92 (4) (b) 6. and 7., Stats., Register January 2009 No. 637; correction in (11) made under s. 13.92 (4) (b) 7., Stats., Register July 2011 No. 667; correction in (13) made under s. 13.92 (4) (b) 7., Stats., Register March 2014 No. 699; CR 19-086: cr. (2m), (3m), (6m), (10m), (17m), (24m), am. (32), cr. (34m), (40g), (40r), am. (42), cr. (45g), (45r) Register May 2021 No. 785, eff. 10-1-21; CR 23-046: cr. (10d), (10j), r. and recr. (11), r. (13), (14), am. (16) (g), (h), (25) (intro.), (a), (b), (28) to (30) Register April 2024 No. 820, eff. 5-1-24.

subch. II of ch. DHS 118 Subchapter II — Statewide Organization for Trauma Care

DHS 118.04 DHS 118.04 Lead agency.

DHS 118.04(1) (1) Designation. The department shall be the lead agency for the development, implementation and monitoring of the statewide trauma care system.

DHS 118.04(2) (2) Lead agency duties. The lead agency shall do all of the following:

DHS 118.04(2)(a) (a) General duties. Develop and revise guidelines and administrative rules for the statewide trauma care system.

DHS 118.04(2)(b) (b) Organize and structure RTACs.

DHS 118.04(2)(b)1. 1. Approve the designation of all trauma care geographic regions based on consideration of what represents the best care of the trauma patient.

DHS 118.04 Note Note: Wisconsin is divided into 9 trauma care geographic regions. Each region has an RTAC. A trauma care region is defined by the location of the health care providers that have selected a particular RTAC for primary membership and in which the majority of each provider’s trauma care and prevention occurs.

DHS 118.04(2)(b)2. 2. Review the geographic distribution and organization of regional trauma advisory councils and ensure executive councils that promote the optimal operation of the statewide trauma care system.

DHS 118.04(2)(b)3. 3. Approve regional trauma advisory councils under sub. (6) (c).

DHS 118.04(2)(b)4. 4. Approve coordinating facilities, fiscal agents, executive councils and resource hospitals under sub. (6) (c).

DHS 118.04(2)(c) (c) Classify trauma care facilities.

DHS 118.04(2)(c)1. 1. Establish and revise the assessment and classification criteria for characterizing a hospital as a trauma facility.

DHS 118.04(2)(c)2. 2. Review and approve hospital requests for trauma care facility classification in accordance with standards and guidance provided by the criteria in appendix A and according to the process under sub. (6) (a).

DHS 118.04 Note Note: Hospitals are verified by the ACS as level I or II trauma care facilities based on conformance with the standards and guidelines established by the ACS. The department determines its classification of hospitals as level III or IV trauma care facilities in accordance with the standards and guidelines provided in appendix A of this chapter.

DHS 118.04(2)(c)3. 3. Review and approve a hospital’s selection of an RTAC with which the hospital will participate under s. DHS 118.08 (1).

DHS 118.04(2)(d) (d) Guide RTAC plan development.

DHS 118.04(2)(d)1. 1. With the advice of the STAC, establish the guidelines for RTAC needs assessments and trauma plans developed pursuant to s. DHS 118.06 (3) (L) and triage and transport protocols developed pursuant to s. DHS 118.06 (3) (o).

DHS 118.04(2)(d)2. 2. Review and approve regional trauma needs assessments, triage and transport protocols and plans under sub. (6) (c).

DHS 118.04(2)(e) (e) Develop and operate state trauma registry.

DHS 118.04(2)(e)1. 1. Develop, implement and maintain the state trauma registry under s. DHS 118.09.

DHS 118.04(2)(e)2. 2. Develop and prepare standard reports on Wisconsin’s trauma system using the state trauma registry as described in s. DHS 118.09 (4).

DHS 118.04(2)(f) (f) Guide improvement of regional trauma care performance.

DHS 118.04(2)(f)1. 1. Provide all of the following reports to RTACs:

DHS 118.04(2)(f)1.a. a. Quarterly standard reports of trauma registry results for the region.

DHS 118.04(2)(f)1.b. b. Other reports as requested by RTACs.

DHS 118.04(2)(f)2. 2. Develop guidelines for a regional performance improvement program under s. DHS 118.10 that includes all of the following:

DHS 118.04(2)(f)2.a. a. The purpose and principles of the program.

DHS 118.04(2)(f)2.b. b. How to establish and maintain the program.

DHS 118.04(2)(f)2.c. c. The requirements for membership of the regional performance improvement committee.

DHS 118.04(2)(f)2.d. d. The authority and responsibilities of the performance improvement committee.

DHS 118.04(2)(g) (g) Maintain statewide trauma care system.

DHS 118.04(2)(g)1. 1. Resolve conflicts concerning trauma care and prevention issues between the RTAC and trauma care providers and any other entity within the RTAC’s geographic region according to the process specified under sub. (3).

DHS 118.04(2)(g)2. 2. Maintain awareness of national trends in trauma care and periodically report on those trends to RTACs and trauma care system participants.

DHS 118.04(2)(g)3. 3. Encourage public and private support of the statewide trauma care system.

DHS 118.04(2)(g)4. 4. Assist the RTACs with developing injury prevention, training and education programs.

DHS 118.04(2)(g)5. 5. Seek the advice of the statewide trauma advisory council in developing and implementing the statewide trauma care system.

DHS 118.04(2)(h) (h) Enforce chapter requirements.

DHS 118.04(2)(h)1. 1. Regulate and monitor trauma care facilities.

DHS 118.04(2)(h)2. 2. Investigate complaints and alleged violations of this chapter.

DHS 118.04(2)(h)3. 3. Enforce the requirements of this chapter.

DHS 118.04(3) (3) Complaint and dispute resolution.

DHS 118.04(3)(a) (a)

DHS 118.04(3)(a)1. 1. Upon receipt of a complaint about the trauma system, the department shall either investigate the complaint or request one or more RTACs to initially investigate and respond to the complaint. The department shall monitor how the RTAC or RTACs are addressing and responding to the complaint. When the RTAC has completed its investigation and has prepared its response, the RTAC shall communicate its response to the department.

DHS 118.04(3)(a)2. 2. Regardless of whether the department has requested one or more RTACs to investigate and respond to the complaint, the department may initiate an investigation of and response to a complaint within 2 business days following the department’s receipt of the complaint.

DHS 118.04 Note Note: The time within which the Department resolves a complaint depends on the nature of the complaint and the resources required to investigate and resolve the complaint.

DHS 118.04(3)(b) (b)

DHS 118.04(3)(b)1. 1. The department shall maintain a record of every complaint and how each complaint was addressed and resolved.

DHS 118.04(3)(b)2. 2. Within the constraints imposed by laws protecting patient confidentiality, the department shall make available its complaint record under subd. 1. to any person requesting to review it.

DHS 118.04 Note Note: To request review of the Department’s complaint record, 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 118.04(4) (4) Investigations.

DHS 118.04(4)(a) (a) An authorized employee or agent of the department, upon presentation of identification, shall be permitted to examine equipment or vehicles or enter the offices of an RTAC, a hospital seeking or having department recognition as a trauma care facility or an ambulance service provider during business hours with 24 hour advance notice or at any other reasonable prearranged time. The authorized employee or agent of the department shall be permitted to inspect and review all equipment and vehicles and inspect, review and reproduce records of the trauma care facility, ambulance service provider or RTAC pertinent to the nature of the complaint, including, but not limited to, administrative records, personnel records, training records and vehicle records. The right to inspect, review and reproduce records applies regardless of whether the records are maintained in written, electronic or other form.

DHS 118.04(4)(b) (b) If, based on the department’s investigation, the department determines that corrective action by the trauma care facility is necessary, the trauma care facility shall make the corrective actions. The department may subsequently conduct a final investigation following corrective action and notify the trauma facility of the results.

DHS 118.04(5) (5) Waivers. The department may waive any nonstatutory requirement under this chapter, upon written request, if the department finds that strict enforcement of the requirement will create an unreasonable hardship for the provider in meeting the emergency medical service needs of an area and that waiver of the requirement will not adversely affect the health, safety or welfare of patients or the general public. The department’s denial of a request for a waiver shall constitute the final decision of the department and is not subject to a hearing under sub. (7).