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FAQs – Minnesota Department of Health

Frequently Asked Questions



  1. I have the final version of the Statewide Trauma Plan from December 2004. What has happened since its publication?
  2. Much has happened since the Statewide Trauma Plan was first published in 2004. Here is a synopsis:
    • Legislation authorizing and funding a statewide trauma system went into effect August 2005.
    • The State Trauma Advisory Council (STAC) was appointed and began meeting. At their June 2006 meeting they finalized criteria for trauma hospitals and approved an application/designation process.
    • The state trauma registry was created and is now available for use by hospitals at no cost. Trauma hospitals can submit their data through this Web-based application. Also, hospitals will use the trauma registry to submit TBI/SCI data to MDH.
    • In June 2006 the MDH trauma program published the applications for designation as a trauma hospital and opened the doors for business!
    • Several hospitals have already been designated!
  1. Why can’t I find the Statewide Trauma Plan on the Web site?
    Since the statewide trauma system has been refined since the plan’s publication, it was removed from the Web site to avoid confusion. Refer to more current documents, available on the Web site, for information about the trauma system and the criteria for participation.
  1. Is participation mandatory?
    No. Participation in the trauma system is voluntary, but wide-scale participation will further the system goal of ensuring that a statewide, cooperative effort is in place to care for seriously injured patients.
  1. Do you expect that critical access hospitals will apply for level IV designation?
    Yes. Most critical access hospitals will likely choose to pursue a level IV designation. However, it is up to each hospital to determine, based on the criteria and their resources, which level they would like to pursue.
  1. Is it true that hospitals that do not participate in the trauma system cannot receive trauma patients unless there is no designated trauma hospital within 30 minutes of the scene?
    Yes. The "30 minute rule" in the trauma system statute requires EMS to transport major trauma patients to a designated trauma hospital if one exists within 30 minutes transport time.
  1. Does the 30 minutes rule refer to transport by ground or by air?
    The 30 minutes applies to ground ambulances. If patients are transported by helicopter from the scene, they would be transported directly to definitive care (i.e., a level I or II).
  1. I seem to remember hearing about a deadline in 2010. What is that?
    July 1, 2010 is the deadline when licensed ambulance services must have triage and transport guidelines in place reflecting compliance with the statewide trauma system criteria. Essentially, it is the date that ambulance services must comply with the “30 minute rule.”

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  1. Do you have any templates for the policies and/or job descriptions required by the statewide trauma system?
    Yes, the Trauma Hospital Resource Manual contains templates and reference tools in Microsoft Word format. You may download, copy to your computer and edit them to suit your needs.
  1. Regarding the level III application, what specifically are you looking for when asking for a description of how the hospital provides for 24/7 OR availability?
    We are looking for a description of how surgical resources are managed to accommodate emergent trauma care (e.g., how rooms are vacated to accommodate trauma patients, how elective cases are scheduled/staggered).
  1. What are the criteria for each level of trauma hospital designation?
    The criteria are available on the Web site under Hospital Resources/Applications. The guidance document for each application contains the criteria as do the documents on the Hospital Resources page.
  1. Is it true that there is no requirement for orthopedic surgeons to be on call?
    Yes. It is not expected that orthopedic surgeons be on call for emergent response. It is expected that there is orthopedic surgery coverage necessary to appropriately manage basic orthopedic cases in a reasonable and timely fashion in level III facilities.
  1. Is it adequate to have a transfer agreement that speaks to the transfer of the "trauma patient" but does not define specific conditions (e.g. burn, traumatic brain injury, spinal cord injury)?
    Yes. A comprehensive transfer agreement that addresses the transfer of trauma patients but does not specifically define anatomical and physiological conditions is adequate as long as the receiving facility is capable of definitively caring for all trauma patients.
  1. Do we need a separate transfer agreement with a rehab hospital?
  1. Level III trauma hospitals are expected to manage basic orthopedic surgical cases. What is meant by “basic orthopedic surgical cases?”
    There is no prescriptive criterion defining what orthopedic surgical cases the hospital must treat in-house or transfer. Rather, it is left up to each individual facility to make this determination and describe it in their application. The system is concerned that the surgeon performing the procedures is properly credentialed to do so.
  1. The surgeon must be present during surgical procedures. Does that mean that the surgeon must be present for the insertion of a chest tube or surgical airway?
    No. Chest tube insertion and surgical airways are all examples of procedures that ED providers are expected to perform without the presence of a surgeon. The intent of the criteria is to ensure that surgical procedures such as laparotomies are not being performed by residents or mid-level practitioners in the absence of a surgeon.
  1. The Trauma Hospital Resource Manual contains sample trauma team activation protocols that specify the need for two RNs to respond to trauma activations. Is this a requirement?
    No. There is no prescribed number of nurses who must respond to an activation. You can determine how many nurses you will need to call to the ED to assist with a trauma resuscitation. (Nurses called in from other areas to assist with a trauma resuscitations must have the required education.) The protocols in the Resource Manual are only suggestions and reflect ideal conditions with unlimited resources. Adapt them to reflect the reality of your hospital's resources and practices.
  1. When our ED is covered by physician assistants or nurse practitioners, do the physicians on-call need to be readily available by telephone or must they also be available to respond?
    If the ED is being covered by a mid-level practitioner there must be a physician who meets the training standards of the System on-call and available to the mid-level practitioner for phone consultation. There is no requirement that the physician be able to respond to the emergency department.
  1. We have a transfer agreement with a level II trauma center that is not a verified burn center. Since the criterion requires two burn transfer agreements, must we obtain two additional burn agreements or will the existing agreement suffice for one of them?
    Since Minnesota's level II trauma centers typically are not able to care for severely burned patients definitively, the transfer agreement would not suffice as one of the two burn agreements. You should obtain two additional transfer agreements with trauma centers that are capable of caring for burn patients definitively.
  1. Does the trauma system allow trauma transfers from a designated trauma hospital to an undesignated hospital?
    No. Designated trauma centers must transfer their trauma patients only to other designated trauma centers.

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  1. Do all nurses have to be current in their trauma education?
    No. All nurses involved in the care of the trauma patient (e.g., ER and ICU) are expected to have completed the educational requirement but do not have to remain current in their certification.
  1. Do all physicians who work in the emergency department need ABEM or AOBEM credentialing?
    No. There is no requirement for ABEM or AOBEM credentialing for physicians working in either level III or IV emergency departments. There is, however, a requirement for physicians without an ABEM-approved or AOBEM certification to be current in their ATLS or CALS.
  1. I am board–certified in Emergency Medicine through the Board of Certification in Emergency Medicine (BCEM), not the American Board of Emergency Medicine (ABEM). Must I remain current in ATLS or CALS?
  1. I am board–certified in Emergency Medicine but my ATLS is expired. Is this a barrier to designation?
    No. If you are board–certified with an ABEM or AOBEM-approved certification or in general surgery, you need only to have taken ATLS or CALS once. Similarly, physicians who are eligible for a board certification approved by ABEM or AOBEM or in general surgery need only to have taken ATLS or CALS once. However, the trauma medical director/advisor must remain current in ATLS or CALS regardless of which board certification they hold.
  1. The ICU nurses have a considerable amount of education on topics that overlap many of the trauma system’s in-house training objectives. Do I have to create a whole new course using all the state objectives, or can I utilize some of their previous education to account for the state’s required training?
    It is not expected that ICU nurses repeat education that they already have in order to meet the educational objectives for nurses who care for trauma patients. You can evaluate to what extent their previous training fulfills the System criteria then bridge the remaining training requirements with focused educational offerings, customized classes or packet learning.
  1. Does the trauma program medical director in a level III trauma hospital have to be board–certified in emergency medicine or general surgery?
    No. The criteria requires that trauma program medical director in a level III trauma hospital be board–certified but does not prescribe a specialty. A board certification in any specialty is acceptable.
  1. What percentage of nurses must have the required trauma education?
    The criterion states that all nurses who care for trauma patients have the required training. That translates into all nurses who work in or float to the ER (and ICU for level IIIs). So, if all nurses float everywhere, they all need the training. If only certain RNs work in the ER (and/or ICU), it would suffice to train just them. There is no prescribed percentage of staff who must be trained before designation since there is always some waxing and waning due to staff turnover. The site reviewers and the State Trauma Advisory Council will look for evidence that your hospital expects its nursing staff in the ER (and ICU) to have the training and that there is a policy/practice in place to acquire that training in a reasonable time frame after hire.
  1. Comprehensive Advanced Life Support (CALS) consists of two distinct parts: The Provider Course and the Benchmark Lab. What does it mean to “complete” CALS?
    Physicians and mid-level practitioners must complete both the Provider Course and either the Benchmark Lab or the Trauma Module components in order to satisfy the trauma system educational requirement. Nurses can satisfy the educational requirement by completing only the Provider Course.
  1. Some of our medical providers have not taken ATLS or CALS within the last four years but are scheduled to take a course soon. Do we have to wait until they have completed the class before we can submit our application?
    No. If they have been scheduled for a class you can submit your application, it can be reviewed and the site visit can be scheduled. The training must be completed before the application goes to the State Trauma Advisory Council for final recommendation.
  1. Our hospital uses mid–level practitioners who are responsible for the staffing of the emergency department and who are backed up by family practice physicians from the clinic. Must the physicians from the clinic remain current in either CALS or ATLS as well?
    Yes. Physicians who back up mid–level practitioners must also have the required training.
  1. Our emergency room is usually staffed by locum tenens but occasionally a clinic physician will cover for a sick call or similar scheduling crisis. Must the clinic physician also have the required training?
    Yes. Physicians and mid-level practitioners who only occasionally provide lead coverage in the emergency department must also meet the educational requirement of the System.

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  1. Is there an application fee?
    No. There is no fee for either the application or the site visit.
  1. What is the timeline for application submission?
    Applications may be submitted at any time; there is no deadline for participation in the state trauma system.
  1. The application requires that both the board of directors and the staff make a commitment to provide trauma care at the level the hospital has elected. How is this support demonstrated in the application?
    Support for the hospital’s participation in the statewide trauma system can be demonstrated by passing a resolution at both the board of directors meeting and the medical staff board meeting to that effect. The application should then include a copy of the discussions as they appear in the minutes of those meetings and the motions that carry subsequent to those discussions. An example of the wording from the board of directors meeting minutes is, "A motion was made and seconded to commit to provide the resources necessary to achieve and sustain a level [III or IV] trauma hospital designation. The motion carried." An example of the wording from the medical staff meeting minutes is, "A motion was made and seconded to support the hospital's trauma program and to provide trauma care commensurate with the standards published by the Minnesota Statewide Trauma System for level [III or IV] trauma hospitals. The motion carried." This demonstrates to the State Trauma Advisory Council that the hospital board and medical staff recognize the individual and collective commitments required of a trauma hospital. Sample resolutions can also be found int the Resource Manual.
  1. Until now, we did not have a trauma program and so we have no performance improvement data, no registry entries and have had no performance improvement committee meetings. How long do we have to wait before we can apply for designation?
    Everyone is just starting out. It is not necessary to delay your application until you have collected a substantial amount of data. However, you should have a program in place, responsible people identified, a performance improvement and data collection system in place and begin using the registry. Before your site visit, your performance improvement committees should have met at least once. The first time out, the site reviewers will be looking more at your system structure than outcomes.
  1. Our hospital contracts with a company that provides new locum tenens to our ER every few days. Do we need to provide documentation of ATLS/CALS training for all of these physicians?
    Essentially, yes. The System must be able to verify that physicians have the educational qualifications required. The company should provide you with a photocopy of their ATLS or CALS certification along with their credentialing materials.
  1. We would like to participate in the Statewide Trauma System as a level III trauma hospital but at this time we do not meet the criteria. Can we apply for level IV now and submit a level III application in the future?
    Yes. You may initially become a level IV trauma hospital, then at any time submit an application for level III designation.
  1. We use a tele-radiology provider for our radiology coverage during the night. How should we monitor and evaluate their performance improvement activities?
    Your performance improvement activity regarding radiology should ensure that the films and scans that the tele-radiology providers are reading get a second read by another radiologist at some later time and that any discrepancies between those interpretations are addressed by your performance improvement process. If the tele-radiology provider is the one supplying the second read too, they should periodically provide you with a report of the results of their performance improvement activities.

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  1. The information you are collecting in the trauma registry is private patient data. How is it affected by HIPAA regulations?
    The data you submit to MDH is exempted from HIPAA regulations since it is being collected under the auspices of public health surveillance within the state.
  1. Will we need to obtain patient consent before including a patient in the trauma registry?
    No. Patient consent is not required to submit data to MDH that is required by statute.

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Updated Wednesday, 05-Oct-2022 00:17:33 CDT