(CQI). 19. Trauma Alert An alert (notification) made by an EMS provider informing a hospital or trauma center that they are en route with a patient meeting department-approved triage criteria consistent with trauma alert scorecard criteria as provided in Rules 64J-2.004 and 64J-2.005, Florida Administrative Code. 20. Trauma Call Block(s) of time within a 24-hour period in which designated trauma team members shall be available to arrive promptly to a specified area within the trauma center when summoned (for example, via voice page, telephone, or beeper) to provide evaluation, consultation, treatment, or other defined services. 21. Trauma Program Manager A registered nurse who meets the requirements delineated in Standard II.D.2. 22. Trauma Nursing Core Course (TNCC) A course developed and presented by the Emergency Nurses Association that in part will meet the minimum educational standard for a nurse requiring trauma specific education. 23. Trauma Quality Management Committee A multidisciplinary committee established to monitor, evaluate, and improve the quality of trauma patient care. 24. Trauma Registrar An individual who demonstrates the ability to accurately perform hospital-based coding and injury scaling and who provides trauma-related data to the trauma service. 25. Trauma Service A dedicated and defined service within the organizational structure of the hospital designed to coordinate trauma patient care, trauma-related training, and trauma quality management. 26. Trauma Medical Director A physician who meets the requirements delineated in Standard II.D.1. 27. Trauma Surgeon A physician who meets the requirements delineated in Standard III.A.2 and 3. 28. Trauma System A system of organized patterns of trauma readiness and response services based on public and private agreements and operational procedures, in accordance with approved local trauma plans, as provided in section 395.401(2)(a)(c), Florida Statutes (1997). 1.4 29. Trauma Team A group of health care practitioners available for the resuscitative phase of trauma patient care. INTRODUCTION: Although the trauma center is a key component of acute care for the critically injured trauma patient, an effective trauma system encompasses all phases of care, from prehospital to reintegration into society. By providing multidisciplinary educational opportunities and becoming actively involved in the formulation of community approaches to trauma care, the trauma center will aid in attaining the goal of optimal care for all injured patients. It is desirable that the trauma center coordinate their outreach activities with the local or regional trauma agency, if one exists. Finally, the trauma center should consider developing these programs in response to identified, targeted local problems. Use of national injury prevention programs are recommended to avoid replication and eliminates the need to spend resources to develop a quality program when one has already been developed and tested. A. The trauma service shall have written evidence documenting active involvement in at least two public education programs and two public trauma prevention programs per calendar year. 1. Injury prevention programs shall be chosen based upon the epidemiologic needs of the community served by the trauma center. 2. Hospital-specific evaluation methods shall be implemented to determine the effectiveness of the injury prevention programs. B. The trauma service shall provide consultations or feedback to EMS or the transferring hospital regarding any patient admitted to the intensive care unit when performance improvement issues related to prehospital care are applicable. C. The trauma service shall provide 24-hour availability of telephone consultation with members of the hospital’s trauma team and physicians of the community and outlying areas. Scheduled on-site consultations with members of the hospital’s trauma team shall be available with physicians of the community and outlying areas. Evidence of these consultations shall be documented. D. Evidence of contact with referring physicians regarding patient transfers shall be documented in all cases. E. There shall be evidence of a minimum of 10 multidisciplinary conferences conducted per year to provide trauma case review for the purpose of case management and education. 1. The conference shall include the review of the following: a. The local and regional emergency medical service system. b. Individual case management. 3.28 c. The trauma center or system. d. Solution of specific problems, including organ procurement and donation. e. Trauma care education. 2. In order to be considered a multidisciplinary conference, there shall be at least one representative from the following departments: a. Trauma service b. Emergency department c. Neurosurgery d. Orthopedics e. Nursing f. Social work g. Rehabilitation medicine h. Laboratory i. X-ray j. Prehospital providers k. Hospital administration STANDARD XVIII – QUALITY MANAGEMENT INTRODUCTION: The goals of a trauma quality improvement program are to monitor the process and outcome of patient care, to ensure the quality and timely provision of such care, to improve the knowledge and skills of the trauma care providers, and to provide institutional structure and organization to