Introduction of Criteria Highlights:
Welcome to the first trauma care facility criteria highlight! These highlights are intended to provide clarification to frequently asked questions or recently cited deficiencies. These criteria highlights are applicable to State of Wisconsin Department of Health Services classified level III and/or level IV trauma care facilities.
Criteria 2(o):
Applicable to level III and IV facilities, type 2 deficiency
Criteria: The Trauma Multidisciplinary Peer Review Committee must: (1) Meet at least quarterly to ensure cases are being reviewed in a timely fashion. (2) Review systemic and care provider issues and propose improvements to the care of the injured patient. (3) Include the Trauma Program Manager (TPM), Trauma Medical Director (TMD) and other key staff and departments involved with care of the trauma patient as members of the committee. (4) Have representation from general surgery, including all general surgeons taking trauma call. (5) Have liaisons from emergency medicine, orthopedics, anesthesiology, critical care, and the ICU. (6) Have liaisons from all the specialty care services, such as neurosurgery and radiology, provided by the Trauma Care Facility (TCF). (7) Require 50% attendance of its continuous members and document attendance. (8) Systematically review mortalities, significant complications and process variances associated with unanticipated outcomes and determine opportunities for improvement, as evidenced by documented meeting minutes. (9) Review selected cases involving multiple specialties, mortality data, adverse events and problem trends. If a designated liaison is unable to attend, another representative from the same service team may participate in their place. The TCF may determine which members of the Trauma Multidisciplinary Peer Review Committee are continuous versus ad hoc.
Clarification:
- Trauma Multidisciplinary Peer Review Committee must meet at least quarterly.
- TPM and TMD should be present at all meetings.
- All general surgeons taking trauma call must attend at least 50% of meetings on an annual basis as a continuous member.
- Liaisons from emergency medicine, orthopedics, anesthesiology, critical care, and ICU must attend at least 50% of meetings on an annual basis as a continuous member.
- The liaison should be a physician or person of leadership position.
- If a designated liaison is unable to attend, another representative from the same service team may participate in their place.
- If the TCF provides other specialty care, such as neurosurgery or radiology, those departments should have a liaison representative present for at least 50% of meetings on an annual basis as a continuous member.
- The liaison should be a physician or person of leadership position.
- If a designated liaison is unable to attend, another representative from the same service team may participate in their place.
- Other departments (examples could include, palliative care, hospital medicine, lab, nursing, quality department, legal, hospital administration, rehabilitation specialist, physical therapy, occupational therapy, injury prevention, EMS) may join on an ad-hoc basis, as deemed by the TCF.
- Meeting attendance must be documented and available during site review.
- Cases for review should include all deaths, significant complications, unanticipated or adverse outcomes, multiple specialties, problem trends and/or other define audit filters. Ensure documentation in the meeting minutes and minutes are available during the site review.
Resources for Multidisciplinary Meetings:
For questions or further clarification, please email the DHS Trauma Team.
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