DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 7484 (10/06)

STATE OF WISCONSIN

PRE REVIEW QUESTIONNAIRE AND APPLICATION CHECKLIST

Please answer ALL questions appropriate to your trauma care facility level. Do not use abbreviations. Use the “Tab” key to move from question to question. Return no later than one month prior to your site visit. Save this form after completion on your computer hard drive, title file as follows: “Hospital Name - Date”, email the saved file to peckme@dhfs.state.wi.us .

1. Type of Trauma Visit

State designation- first visit

Renewal visit

Date of last visit

2. Level of Review

Level III

Level IV

3. Primary Membership of Regional Trauma Advisory Council (RTAC)

Northeast

Southeast

South central

Southwest

North/Northwest

West Central

Lake Superior

North Central

Fox Valley

4. What is your trauma care facility’s attendance (in percentage) at the RTAC meetings in the 12 months prior to the site visit?

5. Trauma Care Facility Beds

	Year of Site Visit
Number of beds licensed
Number of beds staffed
Average daily census

Data collection date range: From: To:

TRAUMA SERVICE

6. Trauma Roles:

Check all applicable positions and where applicable give name of staff.

Attach job descriptions for the Trauma Coordinator and Trauma Service Medical Director

Trauma Coordinator Name:

Trauma Service Medical Director Name:

Injury Prevention staff Name:

Trauma Registrar (data entry staff) Name:

Other

Be prepared to discuss the Trauma Service: how roles interact on a daily basis, and how issues and problems are handled.

7. Trauma Numbers: Major trauma patients based on Trauma Registry inclusion criteria.

See appendix for definition. All data can be extracted from the Trauma Registry.

Total number of trauma patients

Number admitted to your facility

Number transferred to higher level of trauma care

Number of trauma deaths at your facility

Number of patients ISS>15

Data collection date range: From: To:

EMERGENCY DEPARTMENT

8. What are your criteria for trauma team activation?

Please attach copy. Do not write criteria on application.

9. Members of the Trauma Team

Physician

Nurses (number on team)

ER

ICU

Other

ED MD

If not in house, how do you document response time?

Respiratory Therapy

Social Service/Chaplain

Paramedic/EMT

Anesthesia

Physician Assistant (PA)

Nurse Practitioner (NP)

Other (list)

Other (list)

10. Who has the authority to activate the trauma team (check all applicable)

Physician

Nurse

Pre hospital provider (from the field)

Other: (list)

11. How is the Trauma Team activated? (Check all applicable)

Pager

Telephone

Overhead page

Other

12. Trauma Surgeon is present within 30 minutes of patient arrival for major trauma patients

% of the time.

Not applicable if you do not have surgeons covering the TCF (Level IV)

13. Call Schedules available on site for

Emergency Medicine

Total number of physicians that take call at your TCF

Other level provider:

General Surgery

Not applicable- do not have surgeons covering TCF

Total number of surgeons that take call at your TCF

Anesthesia

Other

Other

14. Trauma Flow Sheet or ED record

Available on site for review

15. Trauma protocols

Available on site

16. Trauma Diversion

Trauma diversion protocol available on site

Date of Occurrence

Length of diversion

Reason