Frequently Asked Questions

Yes, like the ACS, providers have up to six months after their status expires to take the Student Refresher course.

A level III trauma facility must have a minimum of six multidisciplinary peer review committee meetings a year.

All transfers must have, at a minimum, a secondary review (TPM + TMD) at level IV trauma facilities.

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.

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.

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 orthopedic and neurosurgery services. 

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.

Yes, the Trauma Medical Director is required to participate in the care of trauma patients at the 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."

Yes, if the Level IV trauma facility has the resources. The care must be evaluated through performance improvement.

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.

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.

Yes, other software systems can be used, however all data must be imported into ImageTrend quarterly for designation. 

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.

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.

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.

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.

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.

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.

Brief is considered 250 characters or less.

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.

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.