The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Center for Quality Assurance and Control
10 West Street, Boston, MA 02111
617-753-8000
MITT ROMNEY
GOVERNOR
KERRY HEALEY
LIEUTENANT GOVERNOR
RONALD PRESTON
SECRETARY
CHRISTINE C. FERGUSON
COMMISSIONER	
CIRCULAR LETTER:  DHCQ 08-04-443

TO:  	Chief Executive Officers
Acute Care Hospitals 

FROM:  	Paul I. Dreyer, Ph.D.
              	Director
DATE:   	August 17, 2004
RE:        	Advisory Bulletin: Trauma Service 
The Department of Public Health recently promulgated hospital licensure regulations for Trauma Center Designation (see Attachment A).   Under the new regulations, which became effective March 12, 2004, a hospital may hold itself out or advertise itself as a trauma center or a trauma facility, only if it provides trauma services as a Designated Trauma Center.

In order for the Department to designate a hospital as a Designated Trauma Center, a hospital must complete the enclosed form (Attachment B), and submit it to the Department with documentation that:

1.	The hospital has been verified by the American College of Surgeons (ACS) as a trauma center, at a particular level of designation (i.e., the hospital must indicate if it has Level 1, 2 or 3 adult trauma, or Level 1 or 2 pediatric trauma designation) 

or

2.	The hospital was recognized, at a particular level of designation, as a trauma center in a regional point-of-entry plan for Emergency Medical Services (EMS) as of March 12, 2004, and it has a verification application pending with ACS. 

Hospitals that meet either of these two criteria must submit the attached form and supporting documentation to the Department by September 8, 2004. The Department will designate a hospital as a Designated Trauma Center at the level at which the hospital is currently verified by ACS, or for which the hospital has applied for verification by ACS. 

Please note that hospitals designated as Trauma Centers in regional point-of-entry plans as of March 12, 2004, that are not ACS-verified trauma centers, or do not have a verification application pending with ACS as of March 12, 2005, will be removed from regional point-of-entry plans as designated trauma centers as of that date.  In order to facilitate application management and EMS planning, the Department requests that those hospitals that have decided not to seek ACS verification, or have not yet applied for ACS, submit the enclosed form to the Department and indicate their intention in this regard. 

In addition, the Department requests all hospitals to identify the higher level trauma centers and the lower level trauma centers or hospitals with which they have transfer agreements.  Under the new regulations, a hospital may provide trauma services as a Designated Trauma Center, or may provide trauma services as part of it’s license to provide emergency services, however, all hospitals providing trauma services must have transfer agreements with hospitals having other levels of trauma services.

If you have any questions regarding the enclosed material, please contact 
Mr. Dennis Corbett at 617-753-8220, or email Dennis.Corbett@state.ma.us

Please return the completed application to:

Mr. Dennis Corbett
Department of Public Health
Division of Health Care Quality
10 West Street, 5th Floor
Boston, MA 02111

Attachment A
Final Amendment for Trauma System Implementation
105 CMR 130.000: Hospital Licensure Regulations

130.020:  Definitions:

Essential Services:

Add to the excluded services list:

	G. Trauma service as a designated trauma center as defined in 130.851

Trauma: Tissue injury due to the direct effects of externally applied mechanical, thermal, electrical, electromagnetic or nuclear energy, as further defined in the Statewide Treatment Protocols established under 105 CMR 170.000. Trauma shall not mean toxic ingestion, poisoning or foreign body ingestion. 

Add to the definition of “Service”

(Z) Designated Trauma Center: A hospital that has been verified by the American College of Surgeons as a level 1, 2 or 3 adult trauma center, or a level 1 or 2 pediatric trauma center, as defined in the document ‘Resources for Optimal Care of the Injured Patient: 1999’  by the Trauma Subcommittee of the American College of Surgeons (ACS) and its successors; and meets applicable Department standards for designation, or a hospital that has applied for and is in the process of verification as specified in 130.851 and meets  applicable Department standards for designation.

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 has a verification application pending with ACS as of March 12, 2005, provided, however, that no such hospital may continue to provide trauma service as a designated trauma center pursuant to 105 CMR 130.851(B) after March 12, 2006.

C.	The hospital enters into transfer agreements and provides consultation to lower level trauma centers and/or system hospitals,

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 Services 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.

Attachment B

Designated Trauma Center Informational Form 

The Department of Public Health requests all hospitals with licensed Emergency Services to complete the following document.  For hospitals with multi-campuses, please complete a separate document for each campus.

NAME OF HOSPITAL:							

ADDRESS:							
		    Street			    	City/Town			              Zip Code

NAME OF CONTACT PERSON: 

TELEPHONE NUMBER:				          EMAIL ADDRESS:   			

	Yes	No			
1			The hospital has been verified by the American College of Surgeons (ACS), as a Level 1, 2 or 3 Adult Trauma Center, or Level 1 or 2 Pediatric Trauma Center.	Identify designation level ____________________

Attach copy of current designation _____________	
	
Yes	
No	
OR

	
2			a)  The hospital was recognized, as a Level 1, 2, or 3 Adult Trauma Center, or Level 1 or 2 Pediatric Trauma Center, in regional point-of-entry plan(s) for Emergency Medical Services (EMS) as of March 12, 2004, and

b) a verification application is pending with the American College of Surgeons.	Attach relevant portions of regional point-of-entry plan(s)

Identify level in point-of-entry plan _____________

Date verification application filed ______________

Yes	
No	
OR

		
3			The hospital will apply for American College of Surgeons verification by March, 2005.	Projected date of application __________________	
	
Yes	
No			
4			Written transfer agreement(s) have been established with one or more hospitals.	Name of Hospital                                  Date Signed
__________________________           __________

__________________________           __________

__________________________          __________	

PLEASE CHECK THE APPROPRIATE BOX BELOW, SIGN AND DATE:

•	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 to 130.854.

•	The undersigned does not request Trauma Center Designation at this time.

NAME OF CEO or DESIGNEE:  ___________________________________	

SIGNATURE OF CEO or DESIGNEE:  _____________________________	     DATE:  _________________

Enclosures (Attachments A&B)

Hosp:  TraumaServiceInfo.081704