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Frequently Asked Questions

Stroke and STEMI Frequently Asked Questions


My facility is an in-state verified hospital, what standards should we utilize?
Michigan verifies trauma programs using the criteria outlined in "Resources For Optimal Care of the Injured Patient (2014 Standards)". Michigan is planning to undertake a review of that criteria (Level III and IV) in 2024 to determine what if any revisions are needed. When the new Michigan standards are released, hospitals will receive ample notice about the revisions and time to make program adjustments. More information on the Michigan virtual verification process can be found here

My facility is an ACS verified hospital, what standard should we utilize?
ACS verified hospitals should inquire with the ACS on what standards their hospital will be verified under. More information on the ACS verification process can be found here

What are the essential components of a Level IV trauma facility's multidisciplinary peer review committee?
Click here to for guidance on the components of the multidisciplinary peer review committee for a level IV trauma facility. Please note, beginning with site visits that occur after January 1, 2021, the guidance will become required minimum standards.

What are the Advanced Trauma Life Support (ATLS) requirements for trauma care providers?

  • Emergency Department midlevel providers that function as a member of the team caring for trauma activation patients via assessment or interventions must be current in ATLS. If the ED midlevel's only role is as a scribe or entering orders they would not need to meet the ATLS requirement.
  • The Trauma Medical Director must be current in ATLS (Level III only).
  • General surgeons treating trauma patients must have taken ATLS once.
  • Emergency Medicine physicians who are board certified in emergency medicine must have taken ATLS once.
  • Physicians who work in the emergency department and are board certified in something other than emergency medicine, for example family practice, internal medicine, etc., must be current in ATLS.

The American College of Surgeons (ACS) has a six month grace period after a provider's ATLS expires. Does the state of Michigan honor that grace period?
Yes, like the ACS, providers have up to six months after their status expires to take the Student Refresher course.

What are the minimum number of meetings a level III trauma facility is required to have for the multidisciplinary peer review committee?
A level III trauma facility must have a minimum of six multidisciplinary peer review committee meetings a year.

What level of review should transfers receive at a level IV trauma facility?
All transfers must have, at a minimum, a secondary review (TPM + TMD) at level IV trauma facilities.

What level of review should mortalities receive at a level IV trauma facility?
All mortalities must have, at minimum, a secondary review (TPM + TMD) at level IV trauma facilities. Mortalities with opportunities for improvement must be reviewed at the tertiary level. 

CD 11-83 states, "In Level III centers, the blood bank must have an adequate supply of packed red blood cells and fresh frozen plasma available within 15 minutes." What does adequate mean and does the blood have to be thawed within 15 minutes?

An adequate supply will be determined by performance improvement. This criteria is about having the resource available (blood onsite). The blood does not have to be thawed, but must be available to the patient.

CD 18-3 states, "Universal screening for alcohol use must be performed for all injured patients and must be documented." Do I really need to screen all injured patients?
No, the ACS provided clarification on this deficiency. It was changed from "All = 100%" to at least 80% of trauma patients who are admitted with a stay > 24 hours must receive an alcohol screening. The requirement is applicable to eligible patients (alive and participatory), regardless of activated or non-activated, who have been admitted and meet inclusion criteria with a hospital stay of >24 hours. Eighty percent of these patients must be screened. This includes patients admitted to the orthopaedic and neurosurgery services. 

If a Level IV trauma facility has the same team responding to all activations, is it necessary to have more than one level of activation?
Yes, all trauma facilities are required to have at least two levels of activation for trauma patients. To meet this requirement, most trauma facilities have a multitiered trauma team acvitation protocol. Click here for more information.

Can a trauma facility have more than one Trauma Medical Director?
No, having more than one Trauma Medical Director will result in an automatic critical deficiency. One Trauma Medical Director is required to manage all aspects of trauma care.

Is the Trauma Medical Director at a level IV trauma facility required to work in a clinical setting?
Yes, the Trauma Medical Director is required to participate in the care of trauma patients at the facility.

Is a physician anesthesiologist required to be the liaison to the trauma program in a level III trauma facility?
The Bureau of EMS, Trauma and Preparedness and State Trauma Advisory Committee have approved revised criteria for the anesthesia liaison. CD 11-3 now states, "In Level III trauma facilities, a qualified and dedicated provider of anesthesia must be designated as the liaison to the trauma program."

If a Level IV trauma facility has continuous surgical and orthorpaedic coverage, and is capable of stabilizing, treating, and admitting severely injured patients, can patients be admitted vs. transfer?
Yes, if the Level IV trauma facility has the resources. The care must be evaluated through performance improvement.

Can a facility have a Type I Criteria Deficiency and still be verified and designated?
No, if a facility has a type I criteria deficiency, they will not be verified or designated. If three or fewer type II criteria deficiencies are present at the time of the site visit with no type I criteria deficiencies, the facility will receive a one year verification/designation with a focused review. Click here to read the Focused Review Policy.

My facility was denied designation, when can we re-apply for designation?
Your facility must have 12 months of new charts in the reporting year to re-apply. The reviewers cannot look at charts from the previous designation visit. A new reporting year is required. Therefore, waiting 12 months before re-applying will ensure there are new charts for the next site visit.

My facility submitted a Request for Verification to MDHHS and received the date confirmation for our in-state site visit, now the date will not work for my facility. Can the date be changed?
If the in-state site visit date scheduled is no longer feasible, then your facility visit will be pulled from the scheduling queue.  When your facility is ready for a site visit you must follow the published procedure and submit a new Request for Verification, PRQ, and Designation Application. Visits will be scheduled at least 90 days from the submission of the Request for Verification.  Please note: The new Request for Verification may change the reporting year and review period for charts. Scheduling site visits is a complex, labor intensive process, which is why you must notify the State Trauma Designation Coordinator when the Request for Verification is submitted if there is a timeframe that your facility is not available for an in-state site visit.


Michigan Trauma Registry:

How do I submit data into the state trauma registry? 
Click here to find instructions for importing data and directly entering data into the registry. All ImageTrend® users must be assigned usernames, password and privileges before this can occur.

Where can I find information on the National Trauma Data Bank Data (NTDB)?
Access this information at

Can I use another software system to collect trauma data?
Yes, other software systems can be used, however all data must be imported into ImageTrend quarterly for designation. 

Should only complete cases be entered into the registry?
The ACS requires that trauma registries for Level I, II, and III facilities be concurrent, at a minimum, 80 percent of cases must be entered within 60 days of discharge.The State recommends following the ACS guidelines. Cases not complete should be entered in the registry when complete.

Do Level IV facilities need to have a dedicated trauma data entry person?
No, it is expected that with limited resources this is not always feasible. However every effort must be made to ensure someone in every facility is trained to ensure trauma data is entered into the registry in an accurate, timely fashion.

While I am waiting for designation, do I need to continue to submit data?
Yes, you should submit data quarterly after the initial 12 month data submission on the following dates March 15, June 15, September 15, and December 15.. Level III and Level IV facilities planning an in-state review should have 12 months of data submitted before a site review is scheduled.



How do I demonstrate participation in Regional Trauma Network performance improvement work plan and initiatives?
Some examples of participation include: accessing the Regional Trauma Network work plan under Regional Trauma Networks on this site and volunteering to work on the SMART objectives each region is developing to address region specific performance improvement. Participating in training or education designed to address a regional performance improvement initiative, participation in the Regional Professional Standards Review Organization, actively engaged in the collection of quality regional data, benchmarking, and report writing. Implementing initiatives in your facility that address system performance for example; expedited transfers, limited ED stays, and others.

I'm planning to become a Level IV facility and I don't have all the elements of a PI program will I not be designated?
You must have a written PI plan that covers all the elements listed on the Michigan Criteria Quick Reference Guide to be considered for verification and designation.


How do I demonstrate participation in Regional Trauma injury prevention?
Some examples of regional injury prevention participation include: accessing the Regional Trauma Network work plan under Regional Trauma Networks on this site and volunteering to work on the SMART objectives each region is developing to address region specific injury prevention, collaborating with regional partners on injury prevention initiatives, using regional injury data to prioritize injury initiatives and evaluate project outcomes.

The application for designation says to send in a brief description of injury prevention initiatives how long is brief?
Brief is considered 250 characters or less.



Does my facility have to submit two names and what if they are the same credential level i.e. two physician assistants?
Yes, two names must be submitted and the candidates should include one physician, either a surgeon or an emergency physician and at least one trauma nurse manager/coordinator, or one trauma quality improvement RN, or one mid-level provider (physician assistant, nurse practitioner, advanced practice nurse) with trauma experience. The Administrative Rules are clear about supporting the verification and designation of Level III and Level IV facilities. An effective review team should have a well-rounded skill set and the ability to review, guide and direct the facility under review so that they understand the gaps strengths and needs of their program. It is acknowledged that this program is new and once executed the team composition will be reviewed.

What role do I have as a possible Level III or Level IV facility in this process?
Just like the ACS process you are responsible for program development, data collection and submission and completing the PRQ. In addition, ensure staff is actively engaged in the site review process.