The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Division of Health Care Quality
99 Chauncy Street, Boston, MA 02111
617-753-8000

MITT ROMNEY
GOVERNOR
KERRY HEALEY
LIEUTENANT GOVERNOR
TIMOTHY R. MURPHY
SECRETARY
PAUL J. COTE, JR.
COMMISSIONER	
Circular Letter: DHCQ # 05-11-454

TO:	 Hospital Chief Executive Officers

FROM:   	Paul I. Dreyer, Ph.D.

RE:		Trauma Center Designation

DATE:	December 22, 2005

The Department of Public Health (DPH or the Department) promulgated hospital licensure regulations for Trauma Center Designation (105 CMR 130.850-.854), effective March 12, 2004, and issued Advisory Bulletin DHCQ 08-04-443 for Trauma Center Designation dated August 18, 2004.  In response to concerns regarding compliance timelines, in December 2004 the Department amended 
105 CMR 130.851 and extended the timelines for filing an application with the American College of Surgeons (ACS) for Trauma Center verification for hospitals that were identified in regional Emergency Medical Services (EMS) trauma point-of-entry plans as of March 12, 2004.  Please refer to the attached copy of the revision of 105 CMR 130.851 (Attachment A).  

Pursuant to hospital licensure regulation 105 CMR 130.853, a hospital may not use the terms “trauma facility,” “trauma center,” or similar terminology in its signs or advertisements or in the printed materials and information it provides to the public, unless it provides a trauma service as a DPH Designated Trauma Center. 

Prerequisites for DPH Trauma Center Designation

The prerequisites for DPH Trauma Center designation include the following: 
 
1) A hospital must have been recognized as a level 1, 2 or 3 adult or level 1 or 2 pediatric trauma center in the regional EMS trauma point-of-entry plan by March 12, 2004; and
2) A hospital must be ACS-verified or be in the process of ACS verification as a level 1, 2 or 3 adult trauma center or a level 1 or 2 pediatric trauma center; and
3) A hospital must submit an Application for DPH Trauma Center Designation and document the hospital(s) with which it has a transfer agreement as required by 105 CMR 130.851(C).

A copy of the hospital’s current ACS Certificate of Verification is required to document ACS Verification.  The Department will request periodic reports to document ongoing progress toward ACS verification for hospitals not currently ACS-verified.

DPH Letter of Designation

Hospitals that are included in regional EMS trauma point-of-entry plans, are ACS-verified, and have submitted an Application for Trauma Center Designation with the Department will receive a letter of designation as a Trauma Center from the Department.  

Application for Designation

If your hospital was in the regional EMS trauma point-of-entry plan on March 12, 2004 (see Attachment B), you must complete the enclosed Application for Trauma Center Designation (Attachment C) and be designated by the Department in order to maintain status in regional EMS trauma point-of-entry plans.  

All hospitals must complete Part One of Attachment C (two pages).  Hospitals that are currently ACS-verified as a Level 1, 2, or 3 adult trauma center or a Level 1 or 2 pediatric trauma center should also complete Part Two of Attachment C (one page).   Hospitals that are in the process of ACS verification as a Level 1, 2, or 3 adult trauma center or a Level 1 or 2 pediatric trauma center should, in addition to Part One, also complete Part Three of Attachment C (two pages).  The ACS requires a period of program development and data collection before an on-site visit can be scheduled.  You may review ACS trauma program information on the ACS website at www.facs.org/trauma.  Informational packets available from the ACS include the reference publication Resources for Optimal Care of the Injured Patient:1999 (“Gold Book”) and subsequent amendments, information and instructions for filing an application and scheduling a site visit, data collection requirements, and other related material.

Change of Designation Status

In accordance with 105 CMR 130.854, “any Designated Trauma Center that plans to change its ACS verification status or take action that will result in a loss of designation as a Trauma Center shall notify its Regional EMS Council as defined in 105 CMR 170.020, and the Department 90 days prior to the proposed effective date of such change”.   Please note that the Department will request periodic ACS verification and hospital transfer agreement status reports.

Please return the application and related documents to the Department no later than January 20, 2006.  Send materials to the attention of:

Dennis Corbett
Massachusetts Department of Public Health
Division of Health Care Quality
99 Chauncy Street
Boston, MA 02111

If you have any questions about this correspondence, please contact Dennis Corbett at 617-753-8016 or by email at dennis.corbett@state.ma.us.

cc:	EMS Regional Directors
	Louise Goyette, Director, DPH, Office of Emergency Medical Services

COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF PUBLIC HEALTH
DIVISION OF HEALTH CARE QUALITY
99 CHAUNCY STREET
BOSTON, MA 02111-1212

Application for Trauma Center Designation

Attachment C

                                                                           

Instructions:    All applicants complete Part One.  Please complete a separate application for each hospital campus.

                                                                       PART ONE

Hospital Name								Campus Name:

Address: Number		 Street Name					Address: Number		 Street Name

City/Town			State		Zip Code			City/Town			State		Zip Code

Telephone Number (__ __ __) __ __ __-__ __ __ __				Telephone Number (__ __ __) __ __ __-__ __ __ __		

Fax Number (__ __ __)__ __ __ - __ __ __ __					Fax Number (__ __ __)__ __ __ - __ __ __ __

										Campus Mailing Address (if different from location above)
Hospital Website Address							
Address: Number/PO Box		 Street Name					
										City/Town			State		Zip Code
Contact Person
Designee for Hospital who will serve as the official liaison between the Hospital and the Massachusetts Department of Public Health on Trauma Center Designation: 

First Name						Last Name				        Title

Telephone Number (__ __ __) __ __ __-__ __ __ __		Fax Number (__ __ __)__ __ __ - __ __ __ __

E-mail address

																Page 1 of 5

In accordance with the Licensure Rules and Regulations for Hospitals in the Commonwealth of Massachusetts, the undersigned requests Trauma Center Designation as set forth under provisions of 105 CMR 130.850 through 130.854.  The undersigned attests that:

•	this hospital/campus is recognized in the regional Emergency Medical Services (EMS) point-of-entry plan (as of March 12, 2004) as a  Level 1, 2, or 3 Adult Trauma Center or a Level 1 or 2 Pediatric Trauma Center;
•	the Department of Public Health’s American College of Surgeons (ACS) Trauma Center Verification Status Report form is complete and attached to this request (including a copy of the hospital/campus’s current, non-expired ACS Certificate of Verification, if applicable); and
•	pursuant to 105 CMR 130.851 (C), this hospital/campus has written transfer agreements to send and receive patients with the higher level trauma centers, if applicable, and the lower level trauma centers or hospitals listed below:

TRANSFER AGREEMENT(S) TO SEND TRAUMA PATIENTS TO:
(Attach separate sheets if necessary for additional hospitals)

Hospital Name:

Chief of Trauma Service:						Medical Director of Emergency Department:

Date Agreement Signed:						Name of Signee:

Hospital Name:

Chief of Trauma Service:						Medical Director of Emergency Department:

Date Agreement Signed:						Name of Signee:

TRANSFER AGREEMENTS(S) TO RECEIVE TRAUMA PATIENTS FROM:
(Attach separate sheets if necessary for additional hospitals)

Hospital Name:

Chief of Trauma Service:						Medical Director of Emergency Department:

Date Agreement Signed:						Name of Signee:

Hospital Name:

Chief of Trauma Service:						Medical Director of Emergency Department:

Date Agreement Signed:						Name of Signee:

NAME OF CEO OR DESIGNEE

First Name						Last Name						Title

Signature of CEO or Designee:							Date:							Page 2 of 5
DPH American College of Surgeons Trauma Center Verification Status Report

Instructions:    Only facilities with current American College of Surgeons (ACS) verification must complete Part Two.  For facilities in the process of seeking ACS verification, please skip to Page 4 and complete Part Three.

PART TWO

If this hospital/campus is currently ACS-verified, please check this box        and circle below as appropriate:

	Adults Only
	Pediatric Only
	Adult and Pediatric

	Level I
	Level II
	Level III
	Level IV

Please indicate Trauma Registry Software used:

Name of Trauma Registrar or Coordinator who oversees Trauma data collection:

First Name						Last Name						

Telephone Number (__ __ __) __ __ __-__ __ __ __		Fax Number (__ __ __)__ __ __ - __ __ __ __

E-mail address

Checklist for Application Completion by ACS-Verified Facilities:
⁪	Part One Massachusetts Application for Trauma Center Designation
⁪	Part Two DPH ACS Trauma Center Verification Status Report Form
⁪	Copy of ACS Certificate of Verification

Please review the application to assure all of the above checklist items have been completed.  Mail this application and required attachments by  January 20, 2006 to:	ATTN:   Dennis Corbett
				Massachusetts Department of Public Health
				Division of Health Care Quality
				99 Chauncy Street
				Boston, MA 02111
				Phone:  617-753-8016
				Email:  Dennis.Corbett@state.ma.us								Page 3 of 5

DPH American College of Surgeons Trauma Center Verification Status Report

Instructions:    All facilities in the process of seeking ACS verification must complete the remainder of this application, Part Three.
PART THREE

1.   Identify Trauma Center Verification sought:  
                                 (circle below as appropriate)
Adults only
Pediatric only
Adult and Pediatric 

Level I
Level II
Level III
Level IV 		
2.   Has the hospital contacted the ACS and received information about the process to apply for ACS verification as a trauma center?	Yes                    No	
3.   Has the hospital established a trauma data registry?
            
a)	Has the hospital obtained and installed software for a trauma data registry?

b)	Has the hospital assigned staff (a “Registrar”) to enter data?

c)	If the hospital is currently collecting trauma data, please indicate:

             the start date of data collection

             Trauma Registry Software

d)	If the hospital is not yet collecting trauma data, when do you anticipate data
             collection will begin?	Yes                    No                           Date

Yes                    No

Yes                    No

Name                                            Title

Start Date

Trauma Registry Software

Date	
4.   Has the hospital developed a trauma program?

a)	Has the hospital appointed a Trauma Program Medical Director?

b)	Has the hospital appointed a Trauma Program Manager/Coordinator (RN)?

c)	Has the hospital established a Trauma Systems Committee?

If you answered ‘no’ to (a),(b),or (c), when do you anticipate these actions will be completed?	Yes                     No                              Date

Yes                     No                              Date

Yes                    No                               Date

Yes                    No                               Date
 	
																Page 4 of 5

5.   Has the hospital developed a trauma specific performance improvement program under which the hospital establishes a process for identifying system problems and correcting any identified problems?
  
a)	If a trauma specific performance improvement program has not been established,   
when do you anticipate the program will be established?	Yes                     No

Date	
6.   Has the hospital scheduled or participated in an ACS consultative visit?

a)	If yes, please indicate when the visit occurred or is scheduled to occur.

b)	If no, does the hospital intend to schedule an ACS consultative visit?

If a consultative visit has occurred, please attach and submit a copy of the ACS consultative visit report.	Yes                     No

Date

Yes                     No
	
7.   Has the hospital scheduled an ACS verification visit?

a)	If yes, when will it occur?

b)	If no, when do you anticipate scheduling a verification visit?	Yes                     No

Date

Date	
8.   Has an ACS verification visit been conducted?

a)	If yes, please identify the date of the visit.

b)	Has the hospital received a decision or comments from the ACS subsequent to a verification visit?

c)	If yes, what were the results of that visit?  Please attach and submit a copy of the ACS verification visit report.	Yes                     No

Date

Yes                     No

	

Checklist for Application Completion by non-ACS-Verified Facilities:
⁪	Part One Massachusetts Application for Trauma Center Designation
⁪	Part Three DPH ACS Trauma Center Verification Status Report Form
⁪	Copy of ACS Trauma Center Consultative and/or Verification Visit Report, if applicable

Please review the application to assure all of the above checklist items have been completed.  Mail this application and required attachments by January 20, 2006 to:              ATTN:   Dennis Corbett
				Massachusetts Department of Public Health
				Division of Health Care Quality
				99 Chauncy Street
				Boston, MA 02111
				Phone:  617-753-8016
Email:  Dennis.Corbett@state.ma.us	

Attachment B

MASSACHUSETTS TRAUMA CENTERS*

*Note: 	The trauma centers listed below are those hospitals that Massachusetts EMS Regional Directors recognized in their Regional Point of Entry Plan to receive trauma patients and trauma centers that have received verification from the American College of Surgeons (ACS). 

Western Massachusetts EMS Regional One
EMS Regional Director: Linda Moriarty, tel. (413) 586-6065, fax (413) 586-0947
168 Industrial Drive, Northampton, MA 01060
Website: http://wmems.org

REGION ONE TRAUMA CENTERS

Baystate Health Systems (ACS Verified Level 1 Adult & Pediatric Trauma)			HAMPDEN COUNTY
759 Chestnut Street
Springfield, MA 01107
Emergency Dept. Phone (413) 794-3233
Emergency Dept. Fax (413) 794-4006
Contact Person: John Santoro

Berkshire Medical Center (ACS Verified Level 2 Adult & Pediatric Trauma)		BERKSHIRE COUNTY
725 North Street
Pittsfield, MA 01201
Emergency Dept. Phone (413) 447-2834
Emergency Dept. Fax (413) 447-2833
Contact Person: Donna Smith

Central Massachusetts EMS Region Two
EMS Regional Director: Edward McNamara, tel. (508) 854-0111, fax (508) 853-3672
361 Holden Street, Holden, MA 01560
Website: http://www.cmemsc.org

REGION TWO TRAUMA CENTERS

Saint Vincent Medical Center (Regional Point of Entry Level 2 Adult Trauma)			WORCESTER COUNTY
25 Winthrop Street
Worcester, MA 01614
Emergency Dept. Phone (508) 363-6025
Emergency Dept. Fax (508) 363-9597
Contact Person: John Benanti

REGION TWO TRAUMA CENTERS (continued)

UMass Memorial Medical Center/University (Regional Point of Entry Level I Adult & Pediatric)	WORCESTER COUNTY
55 Lake Avenue North
Worcester, MA 01614
Emergency Dept. Phone (508) 856-3511
Emergency Dept. Fax (508) 856-6600
Contact Person: Paul MacKinnon

Northeast Massachusetts EMS Region Three
EMS Regional Director: Jonathan Epstein, tel. (781) 224-3344, fax (781) 213-9417
16 DelCarmine Street, Wakefield, MA 01880
Website: http://www.neems.org

REGION THREE TRAUMA CENTERS

Anna Jaques Hospital (ACS Verified Level 3 Adult Trauma)	  				ESSEX COUNTY
25 Highland Avenue
Newburyport, MA 01950
Emergency Dept. Phone (978) 463-1050
Emergency Dept. Fax (978) 463-1163
Contact Person: Diane Wigmore

Beverly Hospital (Regional Point of Entry Level 3 Adult Trauma)					ESSEX COUNTY
(Now kKnown as Northeast Health System’s Beverly Hospital)
85 Herrick Street
Beverly, MA 01915
Emergency Dept. Phone (978) 922-3000 ext. 2770
Emergency Dept. Fax (978) 921-7070
Contact Person: Elliot Cohen

Caritas Holy Family Hospital and Medical Center (ACS Verified Level 3 Adult Trauma)		ESSEX COUNTY
70 East Street
Methuen, MA 01844
Emergency Dept. Phone (978) 687-0151 ext. 2110
Emergency Dept. Fax (978) 794-9259
Contact Person: Mariellen Sharp
REGION THREE TRAUMA CENTERS (continued)

Salem Hospital (Regional Point of Entry Level 3 Adult Trauma) 					ESSEX COUNTY
(Now known as North Shore Medical Center’s Salem Hospital)
81 Highland Avenue
Salem, MA 01970
Emergency Dept. Phone (978) 741-1215 ext. 3500
Emergency Dept. Fax (978) 744-8412
Contact Person: Vinnie Cezus

Lawrence General Hospital (ACS Verified Level 3 Adult Trauma)					ESSEX COUNTY
1 General Street
Lawrence, MA 01842
Emergency Dept. Phone (978) 683-4000 ext. 2500
Emergency Dept. Fax (978) 946-8180
Contact Person: Linda Molchan

Lowell General Hospital (Regional Point of Entry Level 3 Adult Trauma)		     		MIDDLESEX COUNTY
295 Varnum Avenue
Lowell, MA 01854
Emergency Dept. Phone (978) 937-6161
Emergency Dept. Fax (978) 937-6894
Contact Person: Wayne Pasanen

Metropolitan Boston EMS Region Four
EMS Regional Director: John Guidara, tel. (781) 505-4367, fax (781) 272-6967
25 B Street, Suite A, Burlington, MA 01803
Website: http://www.mbemsc.org

REGION FOUR TRAUMA CENTERS

Beth Israel Deaconess Medical Center (ACS Verified Level 1 Adult Trauma)			SUFFOLK COUNTY
330 Brookline Avenue
Boston, MA 02215
Emergency Dept. Phone (617) 754-2400
Emergency Dept. Fax (617) 754-2498
Contact Person: Richard Wolfe
REGION FOUR TRAUMA CENTERS (continued)

Boston Medical Center (ACS Verified Level 1 Adult & Pediatric Trauma)				SUFFOLK COUNTY
840 Harrison Avenue
Boston, MA 02118
Emergency Dept. Phone (617) 414-4075
Emergency Dept. Fax (617) 414-7757
Contact Person: Erwin Hirsch

Brigham & Women’s Hospital (ACS Verified Level 1 Adult Trauma)				SUFFOLK COUNTY
75 Francis Street
Boston, MA 02119
Emergency Dept. Phone (617) 732-5636
Emergency Dept. Fax (617) 734-6722
Contact Person: Judy Perron

Children’s Hospital Boston (ACS Verified Level 1 Pediatric Trauma)				SUFFOLK COUNTY
300 Longwood Avenue
Boston, MA 02115
Emergency Dept. Phone (617) 355-6611
Emergency Dept. Fax (617) 734-0756
Contact Person: Fran Damian

Lahey Clinic Hospital (ACS Verified Level 2 Adult Trauma)			  		MIDDLESEX COUNTY
41 Mall Road
Burlington, MA 01805
Emergency Dept. Phone (781) 744-8100
Emergency Dept. Fax (781) 744-5213
Contact Person: Malcolm Creighton

Massachusetts General Hospital (ACS Verified Level 1 Adult Trauma and
32 Fruit Street		             ACS Verified Level 1 Pediatric Trauma)				SUFFOLK COUNTY
Boston, MA 02113
Emergency Dept. Phone (617) 724-4100
Emergency Dept. Fax (617) 
Contact Person: Alisdair Conn
REGION FOUR TRAUMA CENTERS (continued)

The Floating Hospital for Children at New England Medical Center (ACS Verified Level 1 Pediatric Trauma)	SUFFOLK COUNTY
750 Washington Street               
Boston, MA 02111
Emergency Dept. Phone (617) 636-5566
Emergency Dept. Fax (617) 964-3422
Contact Person: Mark Lemons

New England Medical Center (Regional Point of Entry Level 2 Adult Trauma)					SUFFOLK COUNTY
750 Washington Street               
Boston, MA 02111
Emergency Dept. Phone (617) 636-5566
Emergency Dept. Fax (617) 964-3422
Contact Person: Mark Lemons

Southeastern Masschusetts EMS Region Five
EMS Regional Director, Frederick Fowler, tel. (508) 946-3960, fax  (508) 946-3961
PO Box 686, 339 Center Street, Suite 36, Middleboro, MA 02346
Website: http://www.semaems.com

NO REGION FIVE ACS VERIFIED OR REGIONAL POINT OF ENTRY TRAUMA CENTERS

Attachment A

Trauma Service Licensure and Designation Regulations 105 CMR 130.850-.854

130.850:   Trauma Service

Licensing regulations 105 CMR 130.850 through 105 CMR 130.854 set forth standards for the licensure and designation of trauma services as mandated by M.G.L. c. 111C, Section 11 (a), which states that the department shall develop a statewide coordinated trauma care system that at a minimum, by regulation and guidelines, shall provide for the designation of trauma centers at various levels.
Hospitals must provide one of two levels of trauma services as described in 105 CMR 130.851 and 130.852 in order to be licensed to provide emergency services.

130.851:   Trauma Service as a Designated Trauma Center

A hospital may provide a trauma service as a designated trauma center if: 

(A)  The hospital has been verified by the American College of Surgeons (ACS) as a level 1, 2 or 3 adult trauma center or a level 1 or 2 pediatric trauma center; or 

(B)  The hospital is recognized as a level 1, 2, or 3 adult trauma center or a level 1 or 2 pediatric trauma center in regional point of entry plans as of March 12, 2004 and is in the process of completing ACS verification as defined in Department guidelines.

(C)  The hospital enters into transfer agreements and provides consultation to lower level trauma centers and/or hospitals that are not Designated Trauma Centers;

(D)  The hospital provides to the Division of Health Care Finance and Policy the designated trauma center data set to be specified in administrative requirements jointly developed by the Department and the Division of Health Care Finance and Policy, and promulgated by the Department, and

(E)  The hospital meets such other standards as the Department may require.

130.852:   Trauma Service at a Hospital That is not a Designated Trauma Center

A hospital that is not a Designated Trauma Center may be licensed to provide emergency services only if: 

 (A)  The hospital provides to the Division of Health Care Finance and Policy the trauma service hospital data set to be specified in administrative requirements jointly developed by the Department and the Division of Health Care Finance and Policy, and 

(B)  The hospital enters into formal written agreements with one or more Designated Trauma Centers that address the transfer of patients to those centers.

130.853:   Trauma Service Advertising

No Hospital may use the terms “trauma facility”, trauma center”, or similar terminology in its signs or advertisements or in the printed materials and information it provides to the public unless it provides a trauma service as a Designated Trauma Center.

130.854:   Change in Designation Status

Any Designated Trauma Center that plans to change its ACS verification status or take action that will result in a loss of designation as a Trauma Center shall notify its Regional EMS Council, as defined in 105 CMR 170.020, and the Department 90 days prior to the proposed effective date of such change.