DAL 14-10: Two-Year Verification Visits for Trauma Center Designation

October 27, 2014

DAL #14-10

Dear Administrator:

The last consultative visit with the American College of Surgeons has been completed. As of this writing, all of the currently designated trauma centers have undergone a consultative visit, and four centers have gone on to have their verification visits. Three of those centers have been successfully verified and designated, with the fourth pending.

Following the consultative visit, each facility will be required to contact the College to schedule their verification visit two years from the date of the final consultative report. Failure to do so will result in a facility’s de-designation. There will be no extensions given. Facilities may re-enter the trauma system once they are prepared to schedule their verification visit.

As you are aware, successful verification hinges on the strength of a center’s performance improvement process, and a region’s performance improvement process hinges on the participation of centers within that region. Section 708.5 of the Public Health Law, which contains the current regulations governing trauma, requires that “Each hospital within a region will have a written agreement to cooperate with a regional trauma center in a quality assurance program for the regional trauma system”. The new regulations that will replace Section 708.5 (Part 405.33) elaborate on this requirement, and require the Regional Trauma Center (RTC) to analyze trauma registry data and patient care reports (PCRs) to identify potential problems and opportunities for improvement, make quality improvement recommendations for trauma care to the hospitals in its region, and to analyze issues identified by the Department during routine analysis of regional state trauma registry data.

To that end, the Department has contracted with Image Trend to serve as the state trauma registry and PCR repository, and granted access to regional trauma registry data to the trauma program managers and performance improvement coordinators at each RTC. The accounts that have been created are password protected and each account group allows access to specific information required to conduct regional performance improvement activities. The Image Trend system also tracks users and any reports generated requires a reason for the creation of the report which will be monitored by the Department.

Access to regional data will enable data-driven decisions and an ability to monitor the effect of any change in regional protocols, improvements in the transfer process, injury prevention efforts or any other process improvement effort undertaken by the region. Audit filters will include: total number of trauma admissions/year; total number of trauma admissions/year to non-trauma centers; patient transfers; time to transfer; patterns of injury, length of stay; readmission rates and registry data quality. It is the Department’s expectation that your facility will participate in regional activities, as your facility’s involvement in these efforts will be crucial in moving the system forward and in improving patient care in your region.

Thank you.


Lee Burns, Director
Bureau of Emergency Medical Services
and Trauma Systems