Wisconsin Legislature: DHS 118.08(2)(a)

(i) Analyze local and regional trauma registry data collected under s. DHS 118.09.

(j) Create a local and regional performance improvement process that is consistent with that specified in s. DHS 118.10.

(k) Develop and implement injury prevention and education strategies based on performance improvement findings.

(L)

1. Develop and submit to the department by June 1, 2006, a regional trauma plan based on a needs assessment and with the structure specified by the department.

2. Update the regional trauma plan specified under subd. 1. and submit the plan to the department every 2 years beginning June 1, 2008 following the submittal of the of the initial plan on June 1, 2006.

3. Beginning June 1, 2005, submit a yearly progress report to the department, in the format specified by the department, that contains a description of the progress being made towards achieving the actions specified under the most recent regional trauma plan.

(m) Resolve conflicts concerning trauma care and injury prevention within the region through a process having the following characteristics:

1. Conflicts needing resolution by the RTAC shall be addressed by the executive council.

2. If the executive council is unable to resolve a contested issue, the executive council chair shall submit the issue to the department for resolution.

(n) Notify the department within 30 days of any changes in leadership, bylaw revisions or other substantive revisions to the RTAC policies or operations.

(o) Develop regional triage and transport protocols.

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

DHS 118.07 EMS services.

(1) Responsibility to affiliate with one RTAC.

(a) All ambulance service providers and emergency medical responder services shall select one regional trauma advisory council for primary membership by July 30, 2005.

(b) Notwithstanding par. (a), an emergency medical services practitioner, emergency medical responder, or ambulance service provider may participate in any regional trauma advisory council.

(c) An ambulance service provider or emergency medical responder service shall notify the department if the service changes membership in an RTAC.

(2) Effect of non-participation. The department and the pertinent RTAC may not recognize as a trauma system participant an ambulance service provider that does not participate in the activities of its chosen RTAC pursuant to sub. (1) (a), or submit data to the department under s. DHS 118.09 (3).

Note: Pursuant to s. DHS 110.34 (11), an ambulance service provider must specify in its operational plan the name of the regional trauma advisory council that it has chosen for its primary membership.

History: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05; CR 23-046: am. (1) Register April 2024 No. 820, eff. 5-1-24.

DHS 118.08 Hospitals.

(1) Hospital responsibility to affiliate with an RTAC.

(a)

1. All hospitals shall select one regional trauma advisory council for primary membership by July 30, 2005.

2. Pursuant to s. DHS 118.04 (2) (c) 3., the hospital shall submit its selection under subd. 1. to the department for approval.

(b) Notwithstanding par. (a), a hospital may participate in the activities of any regional trauma advisory council.

(2) Classification of hospitals.

(a) Initial hospital selection of trauma care level.

1. ‘All hospitals.’

a. All hospitals shall declare their current trauma care capabilities to the department within 180 days of January 1, 2005, according to the criteria specified in this section.

b. A hospital desiring level I or II classification and verification shall be responsible for expenses associated with the verification process under s. DHS 118.04 (2) (c) 2. and (6) (a).

c. A hospital desiring level III or IV classification may be responsible for expenses associated with the classification process under s. DHS 118.04 (2) (c) 2. and (6) (a).

2. ‘Level I and II trauma care facilities.’

a. A hospital declaring itself as a Level I or II trauma care facility shall have been verified at that level by the ACS in accordance with the standards and guidelines established by the ACS.

b. A hospital desiring department approval as a level I or II trauma care facility, but which has not received ACS verification at that level, may only be approved as a level III or IV trauma care facility.

3. ‘Level III and IV trauma care facilities.’

a. A hospital desiring department approval as a level III or IV trauma care facility shall either submit documentation to the department that it has received ACS verification at level III or IV or complete the department’s assessment and classification criteria application form.

Note: For a copy of the Department’s assessment and classification criteria application form for approval as a trauma care facility, please write to the Wisconsin Trauma Care System Coordinator, Division of Public Health, P.O. Box 2659, Madison WI 53701–2659 or download the form from the DHS website at: http://www.dhs.wisconsin.gov/forms/F4/F47479.doc.

b. The department shall review the information in the hospital’s application and base its approval or disapproval of the application on the conformance of the facility with the criteria in appendix A.

c. If any Type 1 Criteria or more than three Type 2 Criteria are not demonstrated at the time of the initial classification site visit or at the initial site visit for any subsequent renewal of classification, the hospital’s application may not be approved. If all Type 1 Criteria are demonstrated but one to three Type 2 Criteria are not demonstrated at the time of a site visit, then a one-year provisional certificate of classification may be issued and another review shall be required before the hospital’s application may be approved. This second review must occur within one year from the date of notification and may include an onsite re-visit or a review of documents submitted by the hospital to the department. If the trauma care facility successfully corrects the deficiencies, the period of classification will be extended to three years from the date of the initial site visit.

4. ‘Pediatric trauma center.’ A hospital may not refer to itself as a pediatric trauma center unless it has received ACS verification as a pediatric trauma center.

5. ‘Unclassified hospital.’ A hospital that chooses not to participate in the Wisconsin trauma care system or that has not been approved by the department as a level I, II, III or IV trauma care facility shall be considered an unclassified hospital.

Note: To obtain a form for selection of trauma care level and application for Department approval of the chosen level, contact the Statewide Trauma Care Coordinator by phone at 608-266-0601 or by writing to the Statewide Trauma Care System Coordinator, Department of Health Services, Bureau of Local Public Health Practice and Emergency Medical Services, Room 118, 1 West Wilson, Madison, WI 53701 or by sending a fax to 608-261-6392.

(b) Trauma care facility change in capability.

1. ‘Level I or II trauma care facility.’ If a hospital loses its ACS verification as a level I or II trauma care facility, the following shall occur:

a. The hospital shall notify the department of that change within 30 calendar days.

b. The department may no longer recognize the hospital as having the level of trauma care that the ACS previously verified the hospital as having.

c. The hospital may complete and submit to the department a new application form under par. (a) or choose to be an unclassified hospital.

2. ‘Level III or IV trauma care facility.’

a. A level III or IV trauma care facility shall notify the department of the facility’s intent to change its level of trauma care. If the trauma care facility meets the department’s trauma care assessment and classification criteria under sub. (1), or has been verified by the ACS as being another level trauma care facility, the department shall recognize the facility at the level desired.

b. The department may revoke its approval of a level III or IV trauma care facility if the department determines the facility does not meet the criteria associated with the facility’s existing classification.

c. The department may perform a site visit of a level III or IV trauma facility to determine compliance with the evaluation criteria in accordance with s. DHS 118.04 (6) (a) 4.

d. If a level III or IV trauma care facility is unable to continue functioning at its current level of trauma care, the facility shall notify the department no more than 30 calendar days after the facility no longer continues to function as a level III or IV trauma care facility.

1. At least once every 3 years after initial classification, the department shall provide all level III and IV trauma care facilities an assessment and classification criteria form.

2. The trauma care facility shall declare to the department the facility’s level of trauma care capability on the assessment and classification form.

3. The trauma care facility shall submit the assessment and classification criteria form to the department at least 6 months before the expiration of the department’s approval of facility’s existing level of trauma care capability.

4. A level III or IV trauma care facility’s existing classification shall continue until the department makes a final decision on the renewal request, unless the department determines a compromise in patient care exists, at which time the department may immediately revoke the facility’s classification.

5. A level III or IV trauma facility that does not renew its classification within the time specified under this paragraph shall automatically lose its department approval as its existing level of trauma care facility and shall be considered an unclassified hospital.

(d) Restricted use of term “trauma care facility” or “trauma facility”.

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.

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

(3) Complaints.

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

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

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.

Subchapter III — Trauma Care Improvement

DHS 118.09 Trauma registry.

(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.

(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:

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

1. Data elements and definitions.

2. Definitions of what constitutes a reportable trauma case.

3. Method of submitting data to the department.

4. Timetables for data submission.

5. Electronic record format.

6. Protections for individual record confidentiality.

(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.

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

(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:

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

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

(4) Registry use.

(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.

(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.

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 Performance improvement.