Trauma Center Designation
To be eligible for approval as a Level I, Level II or a pediatric trauma center, a hospital must complete the applicable application and submit all requested information to the Department of Health (DOH), Division of Emergency Preparedness and Community Support, Bureau of Emergency Medical Oversight, Trauma Section, for review. The following must be used to complete this application: Level I Trauma Center Application Manual, January 2010; Level II Trauma Center Application Manual, January 2010; and Pediatric Trauma Center Application Manual, January 2010; as well as the Trauma Center Standards, DOH Pamphlet 150-9, January 2010,” and the application requirements of Chapter 395, Part II, Florida Statutes, and Florida Administrative Code Rule 64J-2.
Certificate of Approval
Each hospital approved as a trauma center shall be issued certificates of approval, which are incorporated by reference and available from the DOH, as defined by Florida Administrative Code Rule 64J-2.001(4). The certificates shall include:
DH Form 2032-Z, January 2010, Level I Trauma Center Certificate of Approval
DH Form 2043-Z, January 2010, Level II Trauma Center Certificate of Approval
DH Form 1721-Z, January 2010, Pediatric Trauma Center Certificate of Approval
At least 14 months prior to the expiration of the trauma center’s certification, the DOH shall send, to each trauma center that is eligible to renew, a blank DH Form 2032R, January 2010. Within 15 calendar days after receipt, the trauma center choosing to renew its certification shall submit to the DOH, the completed DH Form 2032R. All renewing trauma centers shall receive an on-site survey after the DOH’s receipt of the completed DH Form 2032R, January 2010.
Trauma centers within the state of Florida are subject to on-site evaluations to determine whether the hospital is in compliance with standards published in the DOH Pamphlet 150-9, January 2010, and to determine the quality of trauma care provided by the hospital. The on-site evaluation is conducted by a review team of out-of-state reviewers with knowledge of trauma patient management as evident by experience in trauma care at a trauma center approved by the governing body of the state in which they are licensed. The DOH notifies each trauma center of the results of the site survey within 30 working days from completion of the site visit. The hospital has 30 calendar days to respond to the DOH. Patient charts to be reviewed shall be selected by the DOH from cases meeting the criteria listed in Standard XVIII B.2., published in the DOH Pamphlet 150-9.
Between six and nine months prior to the date of the on-site survey, the trauma center will be notified by the DOH of the date of the survey. Following the notification of the date of the survey, the trauma center’s CEO, trauma medical director and trauma program manager will be provided a package containing information to help guide the trauma center in preparation for the survey. The following are samples of the documentation sent:
- Notification Letter
- Additional Information Document
- Day Agenda
- Survey Team*
- Survey Team’s CVs*
- Schematic Site Survey Set-Up
*Team assignment will be provided when the site survey is secured.
The following tools are used by the out-of-state survey team to determine whether the hospital is in compliance with standards published in the DOH Pamphlet 150-9, January 2010:
- Level I Site Survey Report
- Level II Site Survey Report
- Pediatric Site Survey Report
- Trauma Surgeon Medical Record Review Tool
- Neurosurgeon Medical Record Review Tool
- Emergency Physician Medical Record Review Tool
- Trauma Nurse Medical Record Review Tool
- Trauma Quality Management Worksheet
Trauma Center Standards, Department of Health Pamphlet 150-9, January 2010
Section 395.401(2) and (3), Florida Statutes, directs the DOH to adopt by rule, standards for approval and verification of trauma centers. The DOH Pamphlet 150-9, January 2010, contains the trauma center standards referenced in Florida Administrative Code Rule 64J-2.011.
Electronic Pre-Survey Questionnaire
The electronic pre-survey questionnaire (EPSQ) is sent to the renewal trauma centers roughly six months prior to the on-site survey. The trauma center is required to complete the EPSQ and return to the DOH roughly six weeks prior to the survey. The DOH sends the EPSQ to the out-of-state survey team for their review a month prior to the survey.
The EPSQ is a gathering tool of information shared with the survey team prior to going on-site. The information gathered includes trauma services, outreach, research, disaster planning, demographics, quality management, physician credentials and nursing education.
The survey team and DOH staff meet prior to the survey to discuss the contents of the EPSQ.
It is imperative that the trauma center staff follows the instructions on how to complete the document in its entirely. It is very important to be aware of the staffing Excel spreadsheet headings pertaining to the physician credential and nursing education. An incomplete questionnaire may result in unnecessary deficiencies on the day of the survey.
The link below contains the EPSQ zip file, which holds the following:
- Instructions on how to complete the EPSQ
- EPSQ document
- File folder for documents requested in the EPSQ