Ill. Admin. Code tit. 77, pt. 515, subpt. K, app A
a) Name and address of hospital (typed)
__________________________
__________________________
__________________________
____________________________________________________________________
1) Check the designation level(s) for which your hospital is applying:
________ Level I
________ Level II
________ Level I Pediatric
________ Level II Pediatric
2) The above named facility certifies that each requirement listed in this Request for Designation is met and will be operational by the date of designation.
__________________________________________________________
Typed name CEO/Administrator
______________________________________________________________
Signature CEO/AdministratorDate
__________________________________________________________
Typed name Trauma Director
__________________________________________________________
Signature Trauma DirectorDate
__________________________________________________________
Contact person and phone
b) Level I Designation Criteria
Provide a Trauma Plan that explains how each of the requirements will be met. Options include provision of services in-house, by transfer agreement or by waiver. Requests for waiver must include the requirement or standards with which it considers compliance to be a hardship and demonstrate how there will be no reduction in the standards of medical care. (Section 3.185 of the Act) The Trauma Plan must be submitted in the order listed in this Appendix A, subsection (b). Each section of the Plan must be referenced by the applicable portion of this Part by subsection number (e.g., the subsections referenced in this subsection (b)).
1) Table of Organization
A) Board of Directors
B) Chief Executive Officer
C) Department of Surgery
D) Trauma Service
E) Department of Medicine
F) Department of Radiology
G) Emergency Medicine
H) Rehabilitation Department, including Occupational Therapy, Speech Therapy, and Physical Therapy
I) Social Services
J) Dietary
K) Department of Psychiatry
2) Review the requirements in Section 515.2030(a) and (b) for the Trauma Director. Submit a curriculum vitae for the Trauma Director.
3) Review the criteria in Section 515.2030(c)(1) for all general and trauma surgeons. Complete Appendix G.
4) Review requirements in Section 515.2030(c)(2)-(6) for resident coverage. If residents are used, submit documentation to substantiate this requirement. Otherwise, submit a statement that residents are not used.
5) Review requirements in Section 515.2030(c)(7) for treatment of isolated injuries. Submit documentation to substantiate this requirement.
6) Review requirements in Section 515.2030(d)(1)(A)-(C) for physicians to be on call to arrive at the hospital within 30 minutes after notification that their services are needed at the hospital. Submit documentation to substantiate this requirement.
7) Review requirements in Section 515.2030(d)(2)(A)-(I) for on-call physicians to arrive at the hospital to treat the patient within 60 minutes. Submit documentation to substantiate this requirement.
8) Review requirements in Section 515.2030(d)(3)(A) and (B) for burn care and acute spinal cord injury. Submit documentation to substantiate this requirement.
9) Review criteria for Emergency Physicians in Section 515.2030(e)(1)(A)(i) and (ii) and (B). Submit Appendix H.
10) Review criteria in Section 515.2030(e)(2)(A)-(C) for Anesthesiology Services. Submit documentation to substantiate this requirement.
11) Review criteria in Section 515.2030(e)(3)(A) and (B) for Radiology. Submit documentation to substantiate this requirement.
12) Review criteria in Section 515.2030(e)(4)(A) for Intensive Care Unit physician coverage. Submit documentation to substantiate this requirement.
13) Review criteria in Section 515.2030(e)(4)(B) for ICU nurse coverage. Submit documentation to substantiate this requirement.
14) Review the ICU equipment list in Section 515.2030(e)(4)(C)(i) -(xii). Submit a statement that the trauma center maintains that ICU equipment.
15) Review the Laboratory requirements in Section 515.2030(e)(5)(A)-(G). Submit a statement that the trauma center meets the Laboratory requirements.
16) Review Cardiology requirement in Section 515.2030(e)(6). Submit documentation to substantiate this requirement.
17) Review Internal Medicine requirement in Section 515.2030(e)(7). Submit documentation to substantiate this requirement.
18) Review requirement for Pediatrics in Section 515.2030(e)(9). Submit documentation to substantiate this requirement.
19) Review requirement in Section 515.2030(e)(9) for Postanesthetic Recovery. Submit documentation to substantiate this requirement.
20) Review requirement in Section 515.2030(e)(10) for Acute Hemodialysis capability in-house 24 hours a day. Submit documentation to substantiate this requirement.
21) Review criteria in Section 515.2030(e)(11). Submit documentation to substantiate this requirement.
22) Review criteria in Section 515.2030(f)(1) for Emergency Department Director. Submit a curriculum vitae.
23) Review criteria in Section 515.2030(f)(2) for Trauma Nurse Specialists. Submit documentation to substantiate this requirement.
24) Review criteria in Section 515.2030(f)(3) for a full time Trauma Coordinator. Submit documentation to substantiate this requirement.
25) Review criteria in Section 515.2030(f)(4) for Operating Room. Submit documentation to substantiate this requirement.
26) Review criteria in Section 515.2030(f)(5) for additional facility staff (Occupational Therapy, Speech Therapy, Physical Therapy, Social Service, Dietary, and Psychiatry). Submit documentation to substantiate this requirement for each of these services.
27) Review criteria in Section 515.2030(g)(1)-(5) for a professional staff competency plan. Submit documentation to substantiate this requirement.
28) Review the trauma center equipment list in Section 515.2030(h)(1)-(12). Submit a statement that the trauma center maintains that equipment.
29) Review helicopter landing requirements in Section 515.2030(i)(1)-(4). Submit a statement regarding the helicopter landing.
30) Review requirements in Section 515.2030(j)(1)-(4) for trauma center focused outcome analysis. Submit documentation to substantiate this requirement.
31) Review policies in Section 515.2030(k)(1) for treating patients. Submit documentation to substantiate this requirement.
32) Review criteria in Section 515.2030(k)(2) for clinical protocols. Submit a statement that the trauma center will keep clinical protocols for management of trauma patients on site.
33) Review the transfer criteria in Section 515.2030(k)(3). Submit documentation to substantiate this requirement.
34) Review criteria in Section 515.2030(k)(5) regarding Trauma Nurse Specialist suspension.
35) Review criteria in Section 515.2030(k)(6) for a professional staff competency plan. Submit documentation to substantiate this requirement.
36) Review criteria in Section 515.2030(l) regarding trauma plan approval by the Department. Submit a statement that the trauma center will receive approval on changes to the Trauma Plan before implementing.
37) Review the requirement in Section 515.2030(m) for the practices of the Trauma Center to reflect the protocols of the EMS Region and Trauma Center plan. Submit a statement that the practices of the Trauma Center reflect the protocols of the EMS Region and Trauma Center plan.
38) Review the Trauma Flow Sheet criteria in Section 515.2030(n). Submit a Trauma Flow Sheet.
39) Review criteria in Section 515.2030(o) for the Trauma Center Medical Director job description. Submit a job description.
40) Review criteria in Section 515.2030(p) for the Trauma Coordinator job description. Submit job description.
41) Review the criteria in Section 515.2030(q) for the trauma service to be supported in the facility budget. Submit documentation to substantiate this requirement.
42) Review resource limitation criteria in Section 515.2030(r)(1) and (2)(A)-(C). Submit documentation to substantiate this requirement.
43) Review the criteria for public information and education in Section 515.2030(s). Submit documentation to substantiate this requirement.
44) Review the criteria in Section 515.2050(a) for computer software. Submit documentation to substantiate this requirement.
45) Review reporting schedule data in Section 515.2050(d). Submit documentation to substantiate this requirement.
46) Review the criteria for archiving data in Section 515.2050(e). Submit documentation to substantiate this requirement.
c) Level I Pediatric Trauma Center Designation Criteria, Section 515.2035
Provide a Trauma Plan that explains how each of the requirements will be met. Options include provision of services in-house, by transfer agreement or by waiver. Requests for waiver must include the requirement or standards with which it considers compliance to be a hardship and demonstrate how there will be no reduction in the standards of medical care. (Section 3.185 of the Act) The Trauma Plan must be submitted in the order listed in this Appendix A, subsection (c). Each section of the Plan must be referenced by the applicable portion of this Part by subsection number (e.g., the subsections referenced in this subsection (c)).
1) Table of Organization
A) Board of Directors
B) Chief Executive Officer
C) Department of Pediatric Surgery
D) Trauma Service
E) Department of Pediatrics
F) Department of Radiology
G) Emergency Medicine
H) Rehabilitation Department, including Occupational Therapy, Speech Therapy, and Physical Therapy
I) Social Services
J) Dietary
K) Department of Psychiatry
2) Review the criteria in Section 515.2035(a) and (b)(1) and (2) for the Pediatric Trauma Director. Submit a curriculum vitae.
3) Review the criteria in Section 515.2035(c) for the Pediatric Trauma/General Surgeons. Submit documentation to substantiate this requirement.
4) Review requirements in Section 515.2035(c)(1)-(4) for resident coverage. Submit documentation to substantiate this requirement if residents are used. Otherwise, submit a statement that residents are not used.
5) Review criteria in Section 515.2035(c)(6) for physician competency. Submit documentation to substantiate this requirement.
6) Review requirements in Section 515.2035(c)(7) for treatment of isolated injuries. Submit documentation to substantiate this requirement.
7) Review requirements in Section 515.2035(d)(1)(A) and (B) for physicians to be on call to arrive at the hospital within 30 minutes or provide the service by transfer agreement. Submit documentation to substantiate this requirement.
8) Review requirements in Section 515.2035(d)(2)(A)-(I) for on-call physicians to arrive at the hospital to treat the patient within 60 minutes. Submit documentation to substantiate this requirement.
9) Review requirements in Section 515.2035(d)(3)(A)-(B) for burn care and acute spinal cord injury. Submit documentation to substantiate this requirement.
10) Review the criteria in Section 515.2035(e)(1) for Department of Pediatrics. Submit documentation to substantiate this requirement.
11) Review the criteria in Section 515.2035(e)(2) for Emergency Physicians. Submit Appendix J.
12) Review criteria in Section 515.2035(e)(2)(A)-(C) for Anesthesiology Services. Submit documentation to substantiate this requirement.
13) Review criteria in Section 515.2035(e)(4)(A)-(C) for Radiology. Submit documentation to substantiate this requirement.
14) Review criteria in Section 515.2035(e)(5)(A) for Intensive Care Unit physician coverage. Submit documentation to substantiate this requirement.
15) Review criteria in Section 515.2035(e)(5)(B) for ICU nurse coverage. Submit documentation to substantiate this requirement.
16) Review the ICU equipment list in Section 515.2035(e)(5)(C)(i)-(xi). Submit a statement that the trauma center maintains that ICU equipment.
17) Review the Laboratory requirements in Section 515.2035(e)(6)(A)-(G). Submit a statement that the trauma center meets the laboratory requirements.
18) Review requirement in Section 515.2035(e)(7) for board certified pediatrician to be available in 60 minutes. Submit documentation to substantiate this requirement.
19) Review Pediatric Cardiology requirement in Section 515.2035(e)(8). Submit documentation to substantiate this requirement.
20) Review requirement in Section 515.2035(e)(9) for Postanesthetic Recovery, which may be fulfilled by ICU. Submit documentation to substantiate this requirement.
21) Review requirement in Section 515.2035(e)(10) for Acute Hemodialysis capability 24 hours a day. Submit documentation to substantiate this requirement.
22) Review requirement in Section 515.2035(e)(11) for Open Heart capability. Submit documentation to substantiate this requirement.
23) Review criteria in Section 515.2035(f)(1) for Emergency Department Director. Submit a curriculum vitae.
24) Review criteria in Section 515.2035(f)(2) for Trauma Nurse Specialists. Submit documentation to substantiate this requirement.
25) Review criteria in Section 515.2035(f)(3) for a full-time Trauma Coordinator. Submit documentation to substantiate this requirement.
26) Review criteria in Section 515.2035(f)(4) for Operating Room. Submit documentation to substantiate this requirement.
27) Review criteria in Section 515.2035(f)(5) for additional facility staff (Occupational Therapy, Speech Therapy, Physical Therapy, Social Service, Child Protective Services, Nutrition and Pediatric Psychiatry). Submit documentation to substantiate this requirement for each of these services.
28) Review criteria in Section 515.2035(g)(1)-(5) for a professional staff competency plan. Submit documentation to substantiate this requirement.
29) Review the trauma center equipment list in Section 515.2035(h)(1)-(13). Submit a statement that the trauma center maintains that equipment.
30) Review budget requirements in Section 515.2035(i). Submit documentation to substantiate this requirement.
31) Review requirements for Level I, Section 515.2030(i)-(s). Submit policies for each.
d) Level II Designation Criteria, Section 515.2040
Provide a Trauma Plan that explains how each of the requirements will be met. Options include provision of services in-house, by transfer agreement, or by waiver. Requests for waiver must include the requirement or standards with which it considers compliance to be a hardship and demonstrate how there will be no reduction in the standards of medical care. (Section 3.185 of the Act) The Trauma Plan must be submitted in the order listed in this Appendix A, subsection (d). Each section of the Plan must be referenced by the applicable portion of this Part by subsection number (e.g., the subsections referenced in this subsection (c)).
1) Table of Organization
A) Board of Directors
B) Chief Executive Officer
C) Department of Surgery
D) Trauma Service
E) Department of Medicine
F) Department of Radiology
G) Emergency Medicine
H) Rehabilitation Department, including Occupational Therapy, Speech Therapy, and Physical Therapy
I) Social Services
J) Dietary
K) Department of Psychiatry
2) Review the requirements in Section 515.2040(a) and (b) for the Trauma Director. Submit a curriculum vitae.
3) Review the criteria in Section 515.2040(c)(1) for all General and Trauma Surgeons. Complete Appendix G.
4) Review requirements in Section 515.2040(c)(2)-(5) for resident coverage. Submit documentation to substantiate this requirement if residents are used. Otherwise, submit a statement that residents are not used.
5) Review the requirement in Section 515.2040(c)(6) for a physician competency plan. Submit documentation to support this requirement.
6) Review the requirement in Section 515.2040(c)(8) for a call schedule. Submit documentation to substantiate this requirement.
7) Review the requirements in Section 515.2040(c)(9) for treatment of isolated injuries. Submit documentation to substantiate this requirement.
8) Review requirements in Section 515.2040(d)(1)-(4) for physicians to be on call to arrive at the hospital within 60 minutes after notification that their services are needed at the hospital. Submit documentation to substantiate this requirement.
9) Review requirements in Section 515.2040(e)(1)-(9) for on-call physicians to arrive at the hospital to treat the patient within 60 minutes or provide the service by transfer agreement. Submit documentation to substantiate this requirement.
10) Review criteria in Section 515.2040(f)(1)(A)(i) and (ii) and (B) for Emergency Physicians. Submit Appendix H.
11) Review criteria in Section 515.2040(f)(2)(A) and (B) for Anesthesiology Services. Submit documentation to substantiate this requirement.
12) Review the Laboratory requirements in Section 515.2040(f)(3)(A)-(G). Submit a statement that the trauma center meets the Laboratory requirements.
13) Review criteria in Section 515.2040(f)(4)(A) and (B) for Radiology. Submit a policy.
14) Review criteria in Section 515.2040(f)(5) for Cardiology. Submit documentation to substantiate this requirement.
15) Review criteria in Section 515.2040(f)(6) for Internal Medicine. Submit documentation to substantiate this requirement.
16) Review criteria in Section 515.2040(f)(7) for Postanesthetic Recovery. Submit documentation to substantiate this requirement.
17) Review criteria in Section 515.2040(f)(8)(A) for Intensive Care Unit physician coverage. Submit documentation to substantiate this requirement.
18) Review criteria in Section 515.2040(f)(8)(B) for ICU nurse coverage. Submit documentation to substantiate this requirement.
19) Review the ICU equipment list in Section 515.2040(f)(8)(C)(i)-(ix). Submit a statement that the Trauma Center maintains that ICU equipment.
20) Review requirement for Pediatrics in Section 515.2040(f)(9). Submit documentation to substantiate this requirement.
21) Review requirement in Section 515.2040(f)(10) for Acute Hemodialysis capability in-house 24 hours a day. Submit documentation to substantiate this requirement.
22) Review criteria in Section 515.2040(g)(1) for Emergency Department Director. Submit a curriculum vitae.
23) Review criteria in Section 515.2040(g)(2) for Trauma Nurse Specialists. Submit documentation to substantiate this requirement.
24) Review criteria in Section 515.2040(g)(3) for a full time Trauma Coordinator. Submit a job description.
25) Review criteria in Section 515.2040(g)(4) for Operating Room. Submit documentation to substantiate this requirement.
26) Review criteria in Section 515.2040(g)(5) for additional facility staff (Occupational Therapy, Speech Therapy, Physical Therapy, Social Service, Dietary, and Psychiatry). Submit a policy for each of these services.
27) Review the trauma center equipment list in Section 515.2040(h)(1)-(12). Submit a statement that the trauma center maintains that equipment.
28) Review helicopter landing requirements in Section 515.2040(j)(1)-(3). Submit a statement regarding the helicopter landing.
29) Review requirements in Section 515.2040(k)(1)-(4) for Trauma Center focused outcome analysis. Submit documentation to substantiate this requirement.
30) Review policies in Section 515.2040(l)(1) for policies for treating patients. Submit documentation to substantiate this requirement.
31) Review criteria in Section 515.2040(l)(2) for clinical protocols. Submit a statement that the trauma center will keep clinical protocols for management of trauma patients on site.
32) Review the transfer criteria in Section 515.2040(l)(3). Submit documentation to substantiate this requirement.
33) Review criteria regarding Trauma Nurse Specialist suspension in Section 515.2040(l)(5). Submit documentation to substantiate this requirement.
34) Review criteria in Section 515.2040(h) regarding professional staff competency plan. Submit documentation to substantiate this requirement.
35) Review criteria in Section 515.2040(m) regarding Trauma Plan approval by the Department. Submit a statement that the Trauma Center will receive approval on changes to the Trauma Plan before implementing.
36) Review the requirement in Section 515.2040(n) for the practices of the Trauma Center to reflect the protocols of the EMS Region and Trauma Center plan. Submit a statement that the practices of the Trauma Center reflect the protocols of the EMS Region and Trauma Center plan.
37) Review the Trauma Flow Sheet criteria in Section 515.2040(o). Submit a Trauma Flow Sheet.
38) Review criteria in Section 515.2040(p) for the Trauma Center Medical Director job description. Submit a job description.
39) Review criteria in Section 515.2040(q) for the Trauma Coordinator job description. Submit job description.
40) Review the criteria in Section 515.2040(r) for the Trauma Service to be supported in the facility budget. Submit documentation to substantiate this requirement.
41) Review resource limitation criteria in Section 515.2040(s). Submit documentation to substantiate this requirement.
42) Review the criteria for public information and education in Section 515.2040(t). Submit documentation to substantiate this requirement.
43) Review the criteria in Section 515.2050(a) for computer software. Submit documentation to substantiate this requirement.
44) Review reporting data schedule in Section 515.2050(d). Submit documentation to substantiate this requirement.
45) Review the criteria for archiving data in Section 515.2050(e). Submit documentation to substantiate this requirement.
e) Level II Pediatric Trauma Center Designation Criteria, Section 515.2045
Provide a Trauma Plan that explains how each of the requirements will be met. Options include provision of services in-house, by transfer agreement or by waiver. Requests for waiver must include the requirement or standards with which it considers compliance to be a hardship and demonstrate how there will be no reduction in the standards of medical care. (Section 3.185 of the Act) The Trauma Plan must be submitted in the order listed in this Appendix A, subsection (e). Each section of the Plan must be referenced by the applicable portion of this Part by subsection number (e.g., the subsections referenced in this subsection (e)).
1) Table of Organization
A) Board of Directors
B) Chief Executive Officer
C) Department of Pediatric Surgery
D) Trauma Service
E) Department of Pediatric Medicine
F) Department of Radiology
G) Emergency Medicine
H) Rehabilitation Department, including Occupational Therapy, Speech Therapy, and Physical Therapy
I) Social Services
J) Dietary
K) Department of Psychiatry
2) Review the criteria in Section 515.2045(a) and (b)(1) and (2)(A) and (B) for the Pediatric Trauma Director. Submit a curriculum vitae.
3) Review the criteria in Section 515.2045(c) for the Pediatric Trauma/General Surgeons. Submit documentation to substantiate this requirement.
4) Review requirements in Section 515.2045(c)(1)-(4) for resident coverage. Submit documentation to substantiate this requirement if residents are used. Otherwise, submit a statement that residents are not used.
5) Review requirements in Section 515.2045(c)(7) for primary and back-up call schedule.
6) Review requirements in Section 515.2045(c)(8) for treatment of isolated injuries. Submit documentation to substantiate this requirement.
7) Review requirements in Section 515.2045(d)(1)-(4) for physicians to be on call to arrive at the hospital within 60 minutes. Submit documentation to substantiate this requirement.
8) Review requirements in Section 515.2045(e)(1)-(8) for on-call physicians to arrive at the hospital to treat the patient within 60 minutes or provide the service by transfer agreement. Submit documentation to substantiate this requirement.
9) Review the criteria in Section 515.2045(f)(1) for Emergency Physicians. Submit Appendix J.
10) Review criteria in Section 515.2045(f)(2)(A) and (B) for Anesthesiology Services. Submit documentation to substantiate this requirement.
11) Review the Laboratory requirements in Section 515.2045(f)(3)(A)-(G). Submit documentation to substantiate this requirement.
12) Review criteria in Section 515.2045(f)(4) for a Department of Pediatrics. Submit documentation to substantiate this requirement.
13) Review criteria in Section 515.2045(f)(5)(A)-(C) for Radiology. Submit documentation to substantiate this requirement.
14) Review criteria in Section 515.2045(f)(6) for Pediatric Cardiology. Submit documentation to substantiate this requirement.
15) Review requirement in Section 515.2045(f)(7) for Postanesthetic Recovery. Submit documentation to substantiate this requirement.
16) Review criteria in Section 515.2045(f)(8)(A) for Intensive Care Unit physician coverage. Submit documentation to substantiate this requirement.
17) Review criteria in Section 515.2045(f)(8)(B) for ICU nurse coverage. Submit documentation to substantiate this requirement.
18) Review the ICU equipment list in Section 515.2045(f)(8)(C)(i) -(viii). Submit a statement that the trauma center maintains that ICU equipment.
19) Review requirement in Section 515.2045(f)(9) for Acute Hemodialysis capability 24 hours a day. Submit documentation to substantiate this requirement.
20) Review criteria in Section 515.2045(g)(1) for Emergency Department Director. Submit a curriculum vitae.
21) Review criteria in Section 515.2045(g)(2) for Trauma Nurse Specialists. Submit documentation to substantiate this requirement.
22) Review criteria in Section 515.2045(g)(3) for a full-time Trauma Coordinator. Submit a job description.
23) Review criteria in Section 515.2045(g)(4) for Operating Room. Submit documentation to substantiate this requirement.
24) Review criteria in Section 515.2045(g)(5) for additional facility staff (Occupational Therapy, Speech Therapy, Social Service, Child Protective Services and Pediatric Psychiatry). Submit documentation to substantiate this requirement for each of these services.
25) Review the trauma center equipment list in Section 515.2045(i)(1)-(13). Submit a statement that the trauma center maintains that equipment.
26) Review the criteria in Section 515.2045(j) for trauma service to be identified in the facility's budget. Submit documentation to substantiate this requirement.
27) Review helicopter landing requirements in Section 515.2040(j)(1)-(3). Submit a statement regarding the helicopter landing.
28) Review requirements in Section 515.2040(k)(1)-(4) for a focused outcome analysis. Submit documentation to substantiate this requirement.
29) Review criteria in Section 515.2040(l)(2) for clinical protocols. Submit a statement that the trauma center will keep protocols for management of trauma patients on site.
30) Review the criteria in Section 515.2040(m) regarding trauma plan approval by the Department. Submit a statement that the trauma center will receive approval on changes to the trauma plan before implementing.
31) Review the Trauma Flow Sheet criteria in Section 515.2040(o). Submit a Trauma Flow Sheet.
32) Review criteria in Section 515.2040(p) for the Trauma Center Medical Director job description. Submit a job description.
33) Review criteria in Section 515.2040(q) for the Trauma Coordinator job description. Submit job description.
34) Review criteria in Section 515.2040(r) for the trauma service to be supported in the facility budget. Submit documentation to substantiate this requirement.
35) Review resource limitation criteria in Section 515.2040(s). Submit documentation to substantiate this requirement.
36) Review criteria for public information and education in Section 515.2040(t). Submit documentation to substantiate this requirement.
Ill. Admin. Code tit. 77, pt. 515, subpt. K, app A