Trauma: Wisconsin Admin. Code ch. DHS 118

Wisconsin Admin. Code ch. DHS 118 updates the standards used to classify hospitals as to their emergency care capabilities and updates the standards to be based on the most recent standards developed by the American College of Surgeons. The new standards went into effect on Oct. 1, 2021.

For an overview of how the standards have changed, please review the Trauma Care Facilities Standards Comparison, P-02967.

During the transition period to Wis. Admin. Code. ch. DHS 118, trauma care facilities that undergo a site visit and are unable to meet the new standards may receive a provisional certificate. A provisional certificate requires the facility to either submit additional documentation or host a focused on-site re-visit to show compliance or progress toward compliance. More information can be found in the frequently asked questions section of this page.

Site review resources

Site review documents

Site review tips

Pre-review questionnaire
  • This is a living document that can be updated as needed.
  • By typing rather than handwriting information, the document can be updated more easily.
  • Several people should review the document for accuracy and spelling.
  • It can be used as an orientation tool for new trauma coordinators or registrars.
Chart review
  • Plan for the trauma medical director and trauma coordinator to attend the chart review.
  • Select your charts in advance.
  • Print the required documents and place in order in a designated folder. It is helpful to have them divided into sections (prehospital, emergency department, transfer, inpatient, etc.).
  • Place all performance improvement documentation, such as checklists or multidisciplinary meeting minutes, pertaining to that issue in the patient-specific folder.

Frequently asked questions

Type 1 and type 2 criteria

If any type 1 criteria or more than three type 2 criteria are not demonstrated at the time of the initial classification site visit or at the initial site visit for any subsequent renewal of classification, the hospital’s application may not be approved. If all type 1 criteria are demonstrated but one to three type 2 criteria are not demonstrated at the time of a site visit, then a one-year provisional certificate of classification may be issued and another review shall be required before the hospital’s application may be approved. This second review must occur within one year from the date of notification and may include an on-site re-visit or a review of documents submitted by the hospital to DHS. If the trauma care facility successfully corrects the deficiencies, the period of classification will be extended to three years from the date of the initial site visit.

Type of criteria, status, and hospital responsibility
Criteria Status Hospital responsibility
All criteria met Classified Continue to do great work
All type 1 criteria met or one to three type 2 criteria not met One-year provisional certificate Request re-review within one year
Any type 1 criteria not met Not classified Reapply
More than three type 2 criteria not met Not classified Reapply


Updated 4/22/2021

Advanced Trauma Life Support (ATLS)

  • Trauma medical director must be current in ATLS.
  • Emergency physicians and providers:
    • If board certified in emergency medicine, must have successfully completed the ATLS course at least once
    • If not emergency medicine board certified, must be current in ATLS
    • If the physician is in the alternate pathway, must be current as an ATLS instructor or provider
    • The Rural Trauma Team Development Course does not fulfill this requirement.
  • General Surgeons
    • If board certified in general surgery, must have successfully completed the ATLS course at least once
    • If not board certified in general surgery, must be current in ATLS
    • If in the alternate pathway, must be current as an ATLS instructor or provider
  • Emergency Advanced Practice Providers
    • Advanced practice providers and midlevel providers practicing in the emergency department must be current in ATLS, unless their only function is entering orders or a scribe.
    • In a Level IV facility, this requirement may be fulfilled by the Comprehensive Advanced Life Support program if the program includes the mobile trauma module skills station and the provider is re-verified every four years.
  • Neurosurgery and Orthopedic Surgery
    • If in the alternate pathway, must be current as an ATLS instructor or provider

We understand that training has been a problem. For site reviews falling between October 1, 2021, and June 30, 2022, Advanced Practice Providers who have been unable to obtain the required training will be noted on the facilities' final report as an opportunity for improvement. For site reviews held on or after July 1, 2022, Advanced Practice Providers who have been unable to obtain the required training will be noted on the facilities' final report as a type 2 criterion deficiency (see table above for implications of a type 2 criterion deficiency).

Updated 7/30/2021

Contingency Plan/Credentialing

All general surgeons and emergency providers must be credentialed to provide initial evaluation and stabilization of the trauma patient.

Updated 4/22/2021

Ongoing Professional Practice and Focused Professional Practice Evaluation

The trauma medical director must perform an Ongoing Professional Practice or Focused Professional Practice Evaluation on an annual basis and recommend changes based on this evaluation. For example, if a provider is not following ATLS guidelines, the trauma medical director has the authority to request corrective action up to removing the provider from care of any trauma patient.

Note: Recommend working with medical staff and credentialing office

Updated 4/22/2021

Prehospital PIPS program representative

The Performance Improvement Patient Safety (PIPS) representative may be from the hospital, not just the emergency department. However, information about trauma must be communicated with the trauma medical director. For example, a nurse from the inpatient unit may be an emergency medical technician and may serve as the representative.

Updated 4/22/2021

Registry training

This requirement will take effect on January 1, 2022.

At least one staff trauma registrar at each trauma care facility must either have previously attended the following two courses or attend the following two courses within 12 months of being hired:

  • The American Trauma Society’s two-day, in person, or virtual, trauma registry course or equivalent provided by a state trauma program
  • The Association of the Advancement of Automotive Medicine’s Abbreviated Injury Scale and Injury Scoring: Uses and Techniques course

Note: More information, including registration information, regarding the American Trauma Society’s trauma registry course can be found on the American Trauma Society’s webpage. More information, including registration information, regarding the Association of Advancement of Automotive Medicine’s Abbreviated Injury Scale and Injury Scoring: Uses and Techniques course can be found on the Association of Advancement of Automotive Medicine’s webpage.

Updated 4/22/2021

Identification of events for review

Events can be identified across all settings that care for injured patients, including (but not exclusive) the emergency department, intensive care unit, general inpatient unit, outpatient, laboratory, imaging, operating room, EMS (both scene and transferring agency) or the accepting facility. The sources of event identification can be written documentation or verbal report from any area or individual that cared for the patient, the hospital quality department, registry data, daily rounds, patient and family feedback, risk management reports, or autopsies.

Resource: Trauma Outcome and Performance Improvement Course (TOPIC)

Updated 4/22/2021

Surgeon response time

The maximum acceptable surgeon response time, with notification from the field and tracked from patient arrival, is 30 minutes for the highest level of trauma activation. This response time must be met for at least 80 percent of trauma activations. The surgeon must be activated for all highest level activations regardless of impending transfer or other scenario.

The clock start time depends on the patient method of arrival:

  • If a patient is being transported in via EMS and EMS activates them, the clock starts once the patient hits the facility doors. Ideally, the surgeon should be at the bedside prior to patient arrival.
  • If a patient arrives at the facility on their own, the clock starts once the patient is examined and activated.

In the instance that the surgeon is on site performing a surgery during a trauma activation, and is therefore unavailable to respond to the bedside, the backup plan needs to be activated (e.g., call in another surgeon or rapid transfer out). Anytime the backup plan is activated, it should be clearly documented why it was activated, why the surgeon couldn't respond, and the reason for rapid transfer. The activation backup plan should be thoroughly reviewed in the PIPS program with evidence of clear loop closure. An activation of the backup plan counts as a non-response. The response time must be met for at least 80 percent of trauma activations.

During the site review, the surgeon and trauma team response time will be evaluated. If the response time is not documented in the patient medical record, please pull any data or documentation to support the response time.

Updated 7/30/2021

Bypass vs. diversion

  • Bypass: Facility is no longer accepting patients.
  • Diversion: Patient acceptance is on an individual case-by-case basis.

Regardless of the terminology used, facilities need to have contingency plans and review within the PIPS program.

The facility does not need to monitor a bypass implemented by EMS decision.

Updated 7/30/2021

Alcohol screening

In relation to criteria 17(c), DHS aligns with the American College of Surgeons' clarification that “all” refers to at least 80% of trauma patients who are admitted or discharged from the emergency department. This is only for patients who meet inclusion criteria. These patients must receive a screening only. DHS does not define the type of screening performed, as this is up to the facility. In the registry, the National Trauma Data Bank (NTDB)-required alcohol screen question is in relation to Blood Alcohol Content (BAC) and the respective value. Should you wish to track other validated screening options in the trauma registry, these can be added as facility-specific questions. If you need assistance to add facility-specific questions, please email DHS Trauma.

Updated 5/19/2022

Orthopedic coverage

Per criteria 9(d), a level III facility must have an orthopedic surgeon on call and promptly available 24 hours a day, 7 days a week. If the on-call surgeon is not able to respond due to being encumbered at another facility, responding to a case at the same facility, or other extenuating circumstances, the level III facility must have a contingency plan. Per criteria 9(f), this contingency plan must include a published back-up call schedule or guidelines to transfer.

Updated 5/19/2022

Consent of trauma service

Clinical consent includes written guidelines for specific clinical situations or documentation in the medical chart about the conversation had with the trauma team.

Trauma service includes any surgeon currently involved in the care and management of the patient.

Updated 7/30/2021

Data protection language

Sample data protection language:

All information documented on this form is privileged to the fullest extent under Wis. Stat. §§ 146.37 and 146.38, any amendments thereto, and all applicable federal law.

Updated 7/30/2021


Additional FAQs

How does a facility fulfill the prehospital performance improvement criteria if the facility does not serve as medical direction for the prehospital service and hasn't been invited to any prehospital performance improvement activities, despite efforts?

Strengthening relationships with EMS agencies is an opportunity for improvement for most facilities. The reviewers understand that most communities have multiple EMS agencies bringing patients to the hospital, and relationship development takes time. Involvement in the PIPS program can be done in a variety of ways, with multiple communication forms. It can be documented that feedback was provided about improvement events and through monitoring, repeat events improved, or if events continued to occur, some form of escalation of feedback was involved. There should be evidence that communication occurred with station supervisor and/or medical director.

Private vehicle transfers are currently optional to put into the trauma registry. What should the facility put if it does not currently track this?

The facility does not need to track private vehicle transfers but should acknowledge that the inclusion criteria was followed.

Is a facility able to transfer a patient from a level III facility without neurosurgery to a level III or IV facility with neurosurgery?

Ideally, multisystem injured patients should be transferred to Level I and Level II ACS verified centers with neurosurgery. Patients with isolated neurological trauma can be admitted or transferred to classified facilities with 24/7 neurosurgery coverage. The facility must develop a transfer out guideline for neurologically injured patients. This guideline should be developed in collaboration with the classified receiving facilities. In addition, neurosurgery must be actively involved in the trauma PIPS process, and the PIPS process should review the appropriateness of admission and transfers.

What method is acceptable for over and under triage?

Any method that works best for the facility and maintains integrity among the data is acceptable.

Can the liaison to the multidisciplinary meeting be a non-physician as long as there is a physician liaison to trauma and a plan for communication?

The liaison must be a physician who has at least a 50 percent meeting attendance rate.

Is a step down unit or progressive care unit in place of an intensive care unit acceptable for Level III criteria?

This is acceptable if the facility is providing care at the level of an intensive care unit, as defined by Resources for Optimal Care of the Injured Patient 2014 (6th edition).

Can patients go from the operating room back to the emergency department while awaiting transport to a higher level of care?

This is acceptable if the facility determines that this is the most appropriate place for the patient to await transfer. PIPS review process is necessary in these situations.

Is it acceptable to notify the trauma medical director after a diversion, as opposed to before a diversion (for example, a Level IV facility diverts a patient but the trauma medical director is not working)?

The trauma medical director needs be a part of the diversion policy development. The trauma surgeon on call needs to be notified during the event. The trauma medical director can be notified after the PIPS process review of the event.

At some facilities, it takes 20 minutes to thaw fresh frozen plasma, though the requirement says that facilities must have an adequate supply of packed red blood cells and fresh frozen plasma available within 15 minutes. How should these facilities proceed to meet this requirement?

The site reviewers are less concerned about the actual time to thaw. Rather, facilities need to ensure that they have a thorough transfusion protocol, that patients are able to receive plasma in a timely manner, and that the 1:1:1 ratio (one each of red blood cells, frozen plasma, and platelets) is being met.

For a Level IV facility, is a rapid transfuse needed, or does a pressure bag suffice?

Best practice indicates that a pressure bag will suffice as long as the facility has a heating system to use with it.

Does the trauma surgeon or general surgeon have to be consulted on all admitted trauma cases? For example, if the orthopedic surgeon is consulted due to an orthopedics injury, does the trauma surgeon or general surgeon still need to be consulted?

No, just the most appropriate surgeon needs to be consulted. If it is a low mechanism of injury and an isolated orthopedics injury, only the orthopedic surgeon should be notified. If it is a poly-system injury, then the general and orthopedic surgeons should be notified. Have a written policy regarding this and utilize your PIPS program to monitor it.

Does the orthopedic surgeon need to see a patient with an isolated hip injury?

If the patient is being admitted for operative care, then yes, the orthopedic surgeon should see the patient. If the patient is being transferred out, then it might not be necessary.

Does neurosurgery need to see a patient admitted for comfort measures due to subdural hemorrhage (SDH)?

At the facility’s discretion, if the advanced directive is very specific, follow the facility’s policies or guidelines and use best judgment. The neurosurgeon should review scans and assessments, and document findings in the patient’s chart. The neurosurgeon should consider seeing the patient, but it might not be necessary. Utilize PIPS review when necessary.

Updated 7/30/2021


Last Revised: August 9, 2022