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 will go into effect on October 1, 2021. The Legislative Reference Bureau will publish Wis. Admin. Code. ch. DHS 118 on May 31, 2021, but it is currently available on the Department of Health Services (DHS) website. While formatting of the rules may change prior to the formal publishing date, the language and content will not change. Trauma care facilities with upcoming site reviews are encouraged to review Wis. Admin. Code ch. DHS 118 prior to October 1, 2021.
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.
Wis. Admin. Code ch. DHS 118 Timeline
- DHS 118 Advisory Committee Meeting: 09/29/16
- DHS 118 Advisory Committee Meeting: 10/21/16
- DHS 118 Advisory Committee Meeting: 11/14/16
- Comments on economic impact: 12/03-17/18
- Clearinghouse submittal: 6/20/19
- Public hearing held: 10/11/19
- Governor's Office proposed rule order submittal: 01/07/20
- Legislature submission: 01/29/20
- Legislative review: Completed CR 19-086
- Legislative Reference Bureau submission and publication: 05/31/2021*
- Wis. Admin. Code ch. DHS 118 in effect: 10/01/2021
* The Legislative Reference Bureau will publish Wis. Admin. Code ch. DHS 118 on May 31, 2021, but it is currently available on the DHS website. While formatting of the rules may change prior to the formal publishing date, the language and content will not change. Hospitals with upcoming site reviews are encouraged to review Wis. Admin. Code ch. DHS 118 prior to October 1, 2021.
Site Review Resources
Site review documents
Site review tips
- 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.
- 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.
|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|
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
- Advanced practice providers and midlevel providers must be current in ATLS.
- 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.
- 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
We understand that training has been a problem and will be providing conditional approval for facilities that are unable to meet the requirement and have a review prior to July 2022. The conditional approval will require that facilities submit documentation of training when it is completed. If it is not completed by July of 2022, it will become a type 2 deficiency.
All general surgeons and emergency providers must be credentialed to provide initial evaluation and stabilization of the trauma patient.
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
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.
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.
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.