Figure: 25 TAC §157.125(y)(2)
Basic (Level IV) Trauma Facility
1. Absence of an EMS report on the medical record for a patient transported by pre-hospital EMS personnel.
2. EMS scene time of greater than 20 minutes.
3. Absence of pre-hospital essential data items on EMS patient care report.
4. No, or absence of documentation of, trauma team activation for a potential major or severe trauma patient per protocol.
5. Trauma team member response times of greater than 10 minutes for those in-house or greater than 30 minutes for those off-site.
6. Absence of a trauma flow sheet.
7. Absence of documentation of trauma team response times, mechanism of injury, assessments, interventions, and response to interventions.
8. Absence of at least hourly documentation of blood pressure, pulse, respirations, Glasgow coma scale (GCS), and fluid intake and output for a major or severe trauma patient, beginning with arrival in the emergency department (ED), including time spent in radiology, up to admission, death, or transfer.
9. Absence of documented temperature on arrival, discharge and when indicated.
10. Resuscitation protocol, treatment protocols, and/or standards of care not followed.
11. A comatose patient (GCS of 8 or less) leaving the ED before a definitive airway is established.
12. Required equipment, which is shared with in-house departments (e.g. fluid warmer), not readily available when requested.
13. Absence of physician notes.
14. Patient admitted to surgery or ICU.
15. All delays in identification of injuries.
16. Patient transferred to another health-care facility after spending greater than 2 hours in the ED.
17. Patient admitted to the hospital then transferred to a higher level of care.
18. Major or severe (hemodynamically unstable) trauma patient transferred-out when a general surgeon was on-call to the ED.
19. Denial of acceptance by a higher level of care facility.
20. Major or severe trauma patient transferred to a non-designated facility.
21. Diversion of major or severe trauma patients.
22. All trauma deaths.
23. Patient admitted without being examined by a physician.