Introduction to Criteria Highlights
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. For suggested future editions, please email DHS Trauma Team.
Criteria 3(h)
Applicable to level III and IV facilities, type 2 deficiency
Criteria: When a Trauma Care Facility (TCF) is required to divert for trauma related occurrences it must: (1) Notify other TCFs of divert or advisory status. (2) Maintain a divert log. (3) Review all diverts and advisories to the trauma PIPS program.
Clarification
Notifying other TCFs:
- You must change your Emergency Department status and create a general announcement event for your region to meet the criteria 3(h)(1) utilizing EMResource.
- You should consider subscribing for alerts related to status changes for hospitals within your region.
Status change notifications are useful for charge nurses, EMS providers, dispatch centers, and other health care users that do not actively log in and report in the EMResource system but still need to receive real-time diversion notifications and situational awareness.
- You must call and log the diversion notification to surrounding hospitals if you are not utilizing EMResource.
Maintain a divert log:
- You can run a “Status Type” report in EMResource that generates a log on Emergency Department status changes during a specific time.
- The trauma program should retain divert logs, which are available upon request during your trauma care facility site review.
Review all diverts and advisories to the trauma PIPS program:
- TPM and TMD should review all diverts.
- You should consider having a discussion at the trauma multidisciplinary committee meeting if an audit filter is flagged or there is a potential system issue.
Please note, facilities must also have a process to notify dispatch and EMS agencies. This is outlined in criteria 3(d). Consider encouraging your EMS agencies to utilize this alerting system as well.
Additional EMResource status information:
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No ED: no ED at facility
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Open: open to all ambulance traffic
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Peak Census: ED at peak bed capacity; still accepting ambulances—expect delays
Provide details in comments section
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Limited Divert: specify most appropriate reason—enter details in comment section
- No ICU beds available
- ED Boarders/new admissions pending due to lack of inpatient bed
- Equipment Failure: please indicate
- Specialty Care Limitation: please indicate
- Other: provide comments
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Bypass: The ED is closed to inbound EMS patients. Caution, only to be used when hospital has sustained a major internal emergency (structural damage, environmental, HAZMAT, utilities failure, etc.)
Resources:
To access the EMResource system, email DHSEMSystems.
For questions or further clarification, please email the DHS Trauma Team.
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