DHS 118.07(2)(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). DHS 118.07 NoteNote: 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. DHS 118.08(1)(1) Hospital responsibility to affiliate with an RTAC. DHS 118.08(1)(a)1.1. All hospitals shall select one regional trauma advisory council for primary membership by July 30, 2005. DHS 118.08(1)(b)(b) Notwithstanding par. (a), a hospital may participate in the activities of any regional trauma advisory council. DHS 118.08(1)(c)(c) A hospital shall notify the department if the hospital changes membership in an RTAC. DHS 118.08(2)(a)1.a.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. DHS 118.08(2)(a)2.a.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. DHS 118.08(2)(a)2.b.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. DHS 118.08(2)(a)3.a.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. DHS 118.08 NoteNote: 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. DHS 118.08(2)(a)3.b.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. DHS 118.08(2)(a)3.c.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. DHS 118.08(2)(a)4.4. ‘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. DHS 118.08(2)(a)5.5. ‘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. DHS 118.08 NoteNote: 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.
DHS 118.08(2)(b)1.1. ‘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: DHS 118.08(2)(b)1.a.a. The hospital shall notify the department of that change within 30 calendar days. DHS 118.08(2)(b)1.b.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. DHS 118.08(2)(b)1.c.c. The hospital may complete and submit to the department a new application form under par. (a) or choose to be an unclassified hospital. DHS 118.08(2)(b)2.a.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. DHS 118.08(2)(b)2.b.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. DHS 118.08(2)(b)2.d.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. DHS 118.08(2)(c)1.1. 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. DHS 118.08(2)(c)2.2. The trauma care facility shall declare to the department the facility’s level of trauma care capability on the assessment and classification form. DHS 118.08(2)(c)3.3. 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. DHS 118.08(2)(c)4.4. 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. DHS 118.08(2)(c)5.5. 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. DHS 118.08(2)(d)(d) Restricted use of term “trauma care facility” or “trauma facility”. DHS 118.08(2)(d)1.1. 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. DHS 118.08(2)(d)2.2. A hospital’s advertisement or public representation of its classification as a trauma care facility shall include its level. DHS 118.08(3)(a)(a) A trauma care facility may submit a complaint to the department regarding a department action. DHS 118.08 HistoryHistory: 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. DHS 118.09(1)(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. DHS 118.09(2)(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: DHS 118.09(2)(a)(a) Develop and publish a data submission manual that specifies all of the following: DHS 118.09(2)(b)(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. DHS 118.09(2)(c)(c) Specify both the process and timelines for hospital and ambulance service provider submission of data to the department. DHS 118.09(3)(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: DHS 118.09(3)(a)(a) Standard application and report forms to be used by all applicants and trauma care facilities. DHS 118.09(3)(b)(b) The form and content of records to be kept and the information to be reported to the department. DHS 118.09(4)(a)(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. DHS 118.09(4)(b)(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. DHS 118.09 HistoryHistory: 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(1)(1) Purpose. Each RTAC shall use the trauma registry data collected under s. DHS 118.09 to improve trauma care, reduce death and disability and correct local and regional injury problems. DHS 118.10 NoteNote: The RTAC should include in its performance improvement activities for all patient ages a surgeon involved in trauma care, an emergency department physician, an EMS representative, an EMS medical director, a person who coordinates the trauma program or the performance improvement process in a trauma facility, and other trauma care and prevention professionals the RTAC determines appropriate.
DHS 118.10(2)(2) Data confidentiality. Each RTAC shall observe the confidentiality provisions of the Health Insurance Portability and Accountability Act under 45 CFR 164. DHS 118.10(3)(3) Process. The performance improvement process shall include all of the following for both pediatrics and adults: DHS 118.10(3)(b)(b) Adult and pediatric-specific quality indicators for evaluating the trauma system and its components. DHS 118.10(3)(h)(h) A procedure for ensuring that all parties having access to information associated with individuals and entities with respect to a trauma care system problem or issue keep the information confidential throughout the performance improvement process. DHS 118.10 HistoryHistory: CR 04-055: cr. Register December 2004 No. 588, eff. 1-1-05.
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