On Oct. 11, the Wisconsin Department of Health Services (DHS) held a hearing to receive feedback on the agency’s proposed rules for hospital trauma designation, DHS 118. The state’s trauma system encompasses the comprehensive care at Wisconsin’s level I trauma centers to the crucial care at level IV trauma hospitals. The DHS rules under consideration would provide a long-overdue update to the 2004 rules that guide level III and IV trauma designation. DHS and Wisconsin’s Trauma Advisory Committee have been working on these rules since 2015. Hospital and health system trauma experts and WHA have been active participants in seeking to update the rules in a manner that strengthens trauma care without making participation in the trauma system of care unnecessarily burdensome for clinical staff caring for trauma patients, or making it unnecessarily difficult for a hospital to gain or maintain its trauma certification.
WHA Chief Medical Officer Mark Kaufman, MD, and WHA Vice President of Workforce and Clinical Practice Ann Zenk testified at DHS’ Oct. 11 hearing, noting WHA’s appreciation for the collaborative approach the state has taken as it considers revisions to DHS 118. The current proposal has changed as a result of WHA feedback on previous drafts of the rule and ongoing discussion among WHA, WHA members and DHS. Dr. Kaufman offered an example in his testimony, noting, “Specialty coverage in rural areas is a challenge. DHS acted on this dynamic when it allowed a medical director for a level III trauma care facility be a specialist other than a general surgeon.”
In their testimony and in WHA’s written comments, Zenk and Dr. Kaufman requested additional revisions to address key remaining issues. WHA convened a workgroup composed of level III and level IV trauma care facilities (TCFs) which identified five key issues and recommendations to resolve:
- Clarification of orthopedic coverage when gaps in call coverage is needed. WHA suggested that having a collaborative treatment and transfer guideline specific to orthopedic surgery should satisfy the requirement for a backup on-call schedule when an orthopedic surgeon is not available.
- The proposed rule applies level III standards to level IV TCFs that have specialty care “capability” without further definition of “capability.” WHA asked that DHS revise the rule so that level IV TCFs offering limited specialty services would not be subject to level III TCF standards.
- The proposed rule would require level III and level IV TCFs to have a formal, written transfer agreement with a higher level TCF in numerous clinical scenarios. The proposed rule also has a requirement for TCFs to have “collaborative treatment and transfer guidelines” which are seen as a more robust and effective way to ensure that trauma patients receive the most appropriate care. WHA asked that DHS remove the requirement for transfer agreements and believes that Wisconsin’s TCFs can collaborate and optimally manage patient transfers without the additional regulatory burden of transfer agreements.
- The proposed rule mandates registrar staffing and education for level III trauma centers with more than 500 trauma patients admitted annually. WHA members work to meet many regulatory and practice standards and need the flexibility to determine staffing levels, staff responsibilities and needed education. WHA asked DHS to remove the staffing and education requirements and instead work with TCFs to ensure adequate training is accessible and cost effective.
- The proposed rule also mandates ICU staffing ratios for trauma patients. WHA asked for removal of the staffing ratios, as they do not take into account the many patient and staffing circumstances that can be weighed and addressed only by the staff at the hospital. Too often, mandated ratios can distract from rather than improve patient care.
Zenk pointed to the trauma expertise available throughout the state and the importance of collaboration in her testimony, stating “Wisconsin has a strong tradition of collaboration for improvement, and WHA stands ready to convene and support our members’ collaboration to strengthen trauma care for patients wherever they are in our state.”