# 6 CCR 1015-4: STATEWIDE EMERGENCY MEDICAL AND TRAUMA CARE SYSTEM

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## Section

- **Citation:** 6 CCR 1015-4
- **Heading:** STATEWIDE EMERGENCY MEDICAL AND TRAUMA CARE SYSTEM
- **Jurisdiction:** Colorado
- **Kind:** Regulations
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Code of Colorado Regulations / 1000 Department of Public Health and Environment / 1011 Health Facilities and Emergency Medical Services Division (1011, 1015 Series) / 6 CCR 1015-4

## Text

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DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
Health Facilities and Emergency Medical Services Division
STATEWIDE EMERGENCY MEDICAL AND TRAUMA CARE SYSTEM
6 CCR 1015-4
[Editor’s Notes follow the text of the rules at the end of this CCR Document.]
_________________________________________________________________________
Adopted by the Board of Health on April 15, 2020. Effective June 14, 2020.
CHAPTER ONE – STATE EMERGENCY MEDICAL AND TRAUMA CARE SYSTEM STANDARDS
Index to Sections
100.
Definitions
101.
Prehospital Care
102.
Transport Protocols
103.
Hospital/Facility Care
104.
Rehabilitative Care
105.
Injury Prevention
106.
Education and Research
107.
State Trauma Registry and Epidemiology
108.
Disaster Medical Care
109.
Trauma Communications
110.
Regional Emergency Medical and Trauma Advisory Councils
111.
Trauma Care for Pediatrics
Exhibit A
Prehospital Trauma Triage Algorithm Adult Patients
Exhibit B
Prehospital Trauma Triage Algorithm Pediatric Patients
100.
Definitions
1.
Adult – Any patient age 15 and older is considered an adult in the trauma system.
2.
Advisory – The trauma facility is experiencing a specific resource limitation.
3.
Bypass – EMS transport of a trauma patient past a routinely used or closer receiving facility for
the purpose of accessing a higher level of trauma or specialty care.
4.
Department – The Colorado Department of Public Health and Environment.
5.
Designated – A status that the Department assigns to a health care facility based on the level of
trauma services the facility is capable of and committed to providing to injured persons.
Designation levels include Levels I through V, as defined in 25-3.5-703(4)(a)-(e), C.R.S.,
Regional Pediatric Trauma Centers as defined in 25-3.5-703(4)(f), and nondesignated facilities.
Code of Colorado Regulations
Secretary of State
State of Colorado

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and committed to providing to injured persons.
Designation levels include Levels I through V, as defined in 25-3.5-703(4)(a)-(e), C.R.S.,
Regional Pediatric Trauma Centers as defined in 25-3.5-703(4)(f), and nondesignated facilities.
Code of Colorado Regulations
Secretary of State
State of Colorado

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6.
Disaster Medical Care – Medical care provided during the occurrence or imminent threat of
widespread or severe damage, injury, illness, or loss of life resulting from an epidemic or a
natural, man-made, technological, or other cause.
7.
Divert Status – The facility cannot currently accept EMS traffic. EMS shall transport trauma
patients to an alternative designation in accordance with the prehospital trauma triage algorithm.
8.
Facility – For purposes of these rules, any designated health care facility, Regional Pediatric
Trauma Center (RPTC), or nondesignated health care facility.
9.
Interfacility Transfer – The movement of a trauma patient from one licensed health care facility
participating in the trauma system to another licensed health care facility participating in the
trauma system.
10.
Nondesignated – A facility that has not met the criteria of Levels I-V or RPTC, but that receives
and is accountable for injured persons, including having a transfer agreement to transfer persons
to Level to V or RPTC facilities as set forth in Section 25-3.5-703(4)(a.5)-(f), C.R.S. and these
rules. “Nondesignated” is considered a designation level pursuant to Section 25-3.5-703(4)(a),
C.R.S.
11.
Pediatric – Any patient from birth through age 14 is considered a pediatric patient in the trauma
system.
12.
Prehospital Transport – Transport by air or ground ambulance service of a trauma patient to the
most appropriate receiving facility consistent with the Regional Emergency Medical and Trauma
Services Advisory Council (RETAC) destination protocols and guidelines and the best interest of
the patient.
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Any patient from birth through age 14 is considered a pediatric patient in the trauma
system.
12.
Prehospital Transport – Transport by air or ground ambulance service of a trauma patient to the
most appropriate receiving facility consistent with the Regional Emergency Medical and Trauma
Services Advisory Council (RETAC) destination protocols and guidelines and the best interest of
the patient.
13.
Regional Emergency Medical and Trauma Services Advisory Council (RETAC) – The
representative body appointed by the governing bodies of counties or cities and counties for the
purpose of providing recommendations concerning regional area emergency medical and trauma
service plans for such counties or cities and counties.
14.
Trauma Transport Protocols – Written standards adopted by the State Board of Health that
address the use of appropriate resources to move trauma victims from one level of care to
another on a continuum of care.
15.
Trauma Care System – An organized approach to providing quality and coordinated care to
trauma victims throughout the state on a twenty-four-hour per day basis by transporting a trauma
victim to the appropriate designated facility.
101.
Prehospital Care
1.
Prehospital Algorithms
A.
Adult patients: Scene transport for adults with trauma or suspected trauma shall be in
accordance with national best practice guidelines, the algorithm found in Exhibit A of
these rules, and applicable RETAC protocols.
B.
Pediatric patients: Scene transport for pediatric patients with trauma or suspected trauma
shall be in accordance with national best practice guidelines, the algorithm found in
Exhibit B of these rules, and applicable RETAC protocols.

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2.
Facility Divert Status
A.
Facilities may go on to divert status for the following reasons:
(1)
Lack of critical equipment
(2)
Operating room saturation
(3)
Emergency department saturation
(4)
Intensive care unit saturation
thm found in
Exhibit B of these rules, and applicable RETAC protocols.

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2.
Facility Divert Status
A.
Facilities may go on to divert status for the following reasons:
(1)
Lack of critical equipment
(2)
Operating room saturation
(3)
Emergency department saturation
(4)
Intensive care unit saturation
(5)
Facility structural compromise
(6)
Internal/external disaster
(7)
Lack of equipment/staff necessary to safely and adequately care for the trauma
patient.
B.
When a trauma center is on divert status, destination of the trauma patient shall be in
accordance with the prehospital trauma triage algorithms (Exhibits A and B).
C.
Trauma facilities must keep a record of times and reasons for going on divert status for at
least 3 years. This information must be made available for RETAC and/or department
audit upon request.
D.
Trauma facilities must notify impacted EMS agencies and impacted local facilities of
divert status in a manner consistent with RETAC protocols.
3.
Bypass for Trauma Patients
A.
At times, the best interests of the patient and the prehospital trauma triage algorithms
(Exhibits A and B) may require that prehospital providers bypass the nearest facility to
transport the patient to a higher level trauma center of specialty care.
B.
Whether bypass is necessary must initially be determined by the criteria in the
algorithms. However, deviations from the algorithms may occur due to the patient's
emergency conditions, excessive transport time to the nearest trauma center, specific
medical direction, or if it is determined that air transport is the most appropriate option for
the patient.
4.
Advisory for Trauma Patients
The trauma facility may issue an advisory when it is experiencing specific resource limitations but
is able to accept trauma patients who do not require the limited resource
emergency conditions, excessive transport time to the nearest trauma center, specific
medical direction, or if it is determined that air transport is the most appropriate option for
the patient.
4.
Advisory for Trauma Patients
The trauma facility may issue an advisory when it is experiencing specific resource limitations but
is able to accept trauma patients who do not require the limited resource. Ambulance agencies
are advised to consider transport to other trauma facilities as time and conditions allow for
patients impacted by the specific advisory.
102.
Transport Protocols
1.
When an air or ground ambulance service transports a trauma patient to a receiving facility, its
determination of what constitutes the most appropriate receiving facility must conform with:
A.
The applicable RETAC plan assessment of regional considerations as required by
Chapter Four, 6 CCR 1015-4, Section 405.3.B.(1); and

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B.
The RETAC trauma destination protocol as required by 6 CCR 1015-4, Chapter Four,
Section 406 and Chapter One, Exhibits A and B.
2.
Each designated and nondesignated facility shall meet the transfer requirements, including
transfer agreements as required by statute and in rule, appropriate to its designation level, as set
forth in 6 CCR 1015-4, Chapter Three.
3.
Every licensed health care facility that participated in the trauma system shall develop and
implement protocols that, at a minimum, address the following components of the trauma system
as set forth in 6 CCR 1015-4, Chapter Three:
A.
When a patient arrives at a facility, the facility will provide the patient with the appropriate
available care based on the patient's injury, which may include stabilization before
transferring to a higher level of care or specialty care;
B
hall develop and
implement protocols that, at a minimum, address the following components of the trauma system
as set forth in 6 CCR 1015-4, Chapter Three:
A.
When a patient arrives at a facility, the facility will provide the patient with the appropriate
available care based on the patient's injury, which may include stabilization before
transferring to a higher level of care or specialty care;
B.
If the patient requires a higher level of care or specialty care that is not available, the
facility shall transfer the patient as soon as medically feasible to the appropriate facility,
which may be in or out of state; and
C.
When determining what receiving facility is the most appropriate trauma facility for the
injured person, the sending facility shall consider, at a minimum:
(1)
Accessibility to the receiving facility by ground or air transport,
(2)
Transport time to the receiving facility by ground or air transport,
(3)
Treatment options and transport modes that best meet the needs of the patient
during ground or air transport, and
(4)
Whether the best interests of the patient require the attending physician at the
sending facility to exercise his or her discretion to bypass a closer facility.
103.
Hospital/Facility Care
Hospital/facility care includes all care provided to the trauma patient in licensed healthcare
facilities that are governed by the rules and regulations of 6 CCR 1015-4, Chapter Three and 6
CCR 1015-4, Chapter Four, Section 406.
104.
Rehabilitative Care
Each facility shall meet the rehabilitative care requirements appropriate to its designation level, as
set forth in 6 CCR 1015-4, Chapter Three.
105.
Injury Prevention
Each facility shall meet the injury prevention program requirements appropriate to its designation
level, as required by 6 CCR 1015-4, Chapter Three and 6 CCR 1015-4, Chapter Four.
106
ter Four, Section 406.
104.
Rehabilitative Care
Each facility shall meet the rehabilitative care requirements appropriate to its designation level, as
set forth in 6 CCR 1015-4, Chapter Three.
105.
Injury Prevention
Each facility shall meet the injury prevention program requirements appropriate to its designation
level, as required by 6 CCR 1015-4, Chapter Three and 6 CCR 1015-4, Chapter Four.
106.
Education and Research
Each facility shall meet the requirements pertaining to public information, education, and research
(as applicable) appropriate to its designation level, as required by 6 CCR 1015-4, Chapter Three.

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107.
State Trauma Registry and Epidemiology
Each facility shall meet the State registry requirements appropriate to its designation level, as
required by 6 CCR 1015-4, Chapter Two.
108.
Disaster Medical Care
1.
Each facility must provide trauma patients with appropriate access to disaster medical care to the
extent necessary and subject to each facility's capabilities and resources. Facilities shall
collaborate with and coordinate their planning and provision of disaster medical care with local,
regional, and state emergency medical and trauma organizations, and any other entities involved
in disaster response.
2.
For purposes of these rules, "Disaster Medical Care" is defined in Section 100.6 of these rules.
109.
Trauma Communications
1.
Each facility shall meet the trauma communications requirements appropriate to its designation
level, as required by 6 CCR 1015-4, Chapter Three.
2.
Each RETAC biennial plan shall ensure access to emergency medical and trauma services
through the 911 telephone system or its local equivalent, and include adequate provisions for
services, as required by 6 CCR 1015-4, Chapter Four.
110.
Regional Emergency Medical and Trauma Advisory Councils
1.
The rules governing RETACS in the trauma system are set forth in 6 CCR 1015-4, Chapter Four.
2
hree.
2.
Each RETAC biennial plan shall ensure access to emergency medical and trauma services
through the 911 telephone system or its local equivalent, and include adequate provisions for
services, as required by 6 CCR 1015-4, Chapter Four.
110.
Regional Emergency Medical and Trauma Advisory Councils
1.
The rules governing RETACS in the trauma system are set forth in 6 CCR 1015-4, Chapter Four.
2.
Each facility shall meet the RETAC requirements as set forth in 6 CCR 1015-4, Chapters Three
and Four.
111.
Trauma Care for Pediatrics
1.
Each facility shall meet the requirements pertaining to the care of pediatric patients that is
appropriate to its designation level, as required by 6 CCR 1015-4, Chapter Three.
2.
Scene transport, diversion, bypass, and RETAC destination protocols pertaining to pediatric
patients shall be in accordance with this chapter and as outlined in Exhibit B.

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DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
Health Facilities and Emergency Medical Services Division
STATEWIDE EMERGENCY MEDICAL AND TRAUMA CARE SYSTEM
6 CCR 1015-4
_________________________________________________________________________
Adopted by the Board of Health on April 21, 2021.
CHAPTER TWO – THE TRAUMA REGISTRY
200.
Definitions
1.
Admission – Inpatient or observation status for a principal diagnosis of trauma.
2.
Blunt injury – Any injury other than penetrating or thermal.
3.
Community Clinic Providing Emergency Services – Facilities as licensed by the Department
under 6 CCR 1011-1, Chapter 9.
4.
Department – The Colorado Department of Public Health and Environment.
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1.
CHAPTER TWO – THE TRAUMA REGISTRY
200.
Definitions
1.
Admission – Inpatient or observation status for a principal diagnosis of trauma.
2.
Blunt injury – Any injury other than penetrating or thermal.
3.
Community Clinic Providing Emergency Services – Facilities as licensed by the Department
under 6 CCR 1011-1, Chapter 9.
4.
Department – The Colorado Department of Public Health and Environment.
5.
Facility – A health facility licensed by the Department that receives ambulances such as a
hospital, hospital unit, Critical Access Hospital (CAH), Freestanding Emergency Department
(FSED), or Community Clinic Providing Emergency Services.
6.
Injury type – Can be blunt, penetrating, or thermal and is based on the mechanism of injury.
7.
Interfacility transfer – The movement of a trauma patient from one facility as defined by these
rules to another facility. Transfers may occur between the emergency department of one facility
and a second facility, or from inpatient status at one facility to a second facility.
8.
Penetrating injury – Any wound or injury resulting in puncture or penetration of the skin and either
entrance into a cavity, or for the extremities, into deeper structures such as tendons, nerves,
vascular structures or deep muscle beds.
9.
Readmission – A patient who is readmitted (for greater than 12 hours) to the same or to a
different facility within 30 days of discharge from inpatient status for missed diagnoses or
complications from the first admission. Readmission does not include subsequent hospitalizations
that are part of routine care for a particular injury (such as removal of orthopedic hardware, skin
grafts, colostomy takedowns, etc.)
10.
Severity – An indication of the likelihood that the injury or all injuries combined will result in a
significant decrease in functionality or loss of life.
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es or
complications from the first admission. Readmission does not include subsequent hospitalizations
that are part of routine care for a particular injury (such as removal of orthopedic hardware, skin
grafts, colostomy takedowns, etc.)
10.
Severity – An indication of the likelihood that the injury or all injuries combined will result in a
significant decrease in functionality or loss of life.
11.
State Emergency Medical and Trauma Services Advisory Committee (SEMTAC) – A council
created in the Department pursuant to Section 25-3.5-104, C.R.S., which advises the Department
on all matters relating to emergency medical and trauma services.

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12.
Statewide trauma registry – The statewide trauma registry means a statewide database of
information concerning injured persons and licensed facilities receiving injured persons, which
information is used to: evaluate and improve the quality of patient management, facilitate trauma
education, conduct research and promote injury prevention programs.
13.
Thermal injury – Any trauma resulting from the application of heat or cold, such as thermal burns,
scald, chemical burns, electrical burns, lightning, or radiation.
14.
Traumatic injury – A blunt, penetrating or thermal injury or wound to a living person caused by the
application of an external force or by violence. Injuries that are not considered to be trauma
include such conditions as: injuries due to repetitive motion, pathological fractures as determined
by a physician and scheduled elective surgeries.
201.
Reporting of Trauma Data by Facilities
1.
Facilities designated as Level I, II, III or Regional Pediatric Trauma Centers , as defined in
Section 25-3.5-703(4), C.R.S., shall submit data as defined by the Department based on
recommendations by SEMTAC or a committee thereof. These data elements include but are not
limited to:
A
ures as determined
by a physician and scheduled elective surgeries.
201.
Reporting of Trauma Data by Facilities
1.
Facilities designated as Level I, II, III or Regional Pediatric Trauma Centers , as defined in
Section 25-3.5-703(4), C.R.S., shall submit data as defined by the Department based on
recommendations by SEMTAC or a committee thereof. These data elements include but are not
limited to:
A.
The data for discharges, inpatients, transfers, readmits, and deaths in a particular month
shall be submitted as an electronic data file to the Department within 60 days of the end
of that month. These data elements include but are not limited to:
(1)
Patient information: name; date of birth; gender; race/ethnicity; address; pre-
existing medical diagnoses; medical record number;
(2)
Injury information: date, time and location of injury; cause of injury; injury
circumstances; whether or not protective devices were used by the patient;
evidence of alcohol or other intoxication;
(3)
Prehospital information: transport mode from the injury scene; name of agency
providing transport to the facility; physiologic and anatomic conditions; times of
notification, arrival at scene, departure from scene and arrival at destination;
(4)
Emergency department information: clinical data upon arrival; procedures;
providers; response times; disposition from the emergency department;
(5)
Interfacility transfer information: transfer mode from the referring facility; name of
the referring facility; arrival and discharge times from the referring facility;
whether the patient was seen in the emergency department only or was admitted
as an inpatient at the referring hospital;
inical data upon arrival; procedures;
providers; response times; disposition from the emergency department;
(5)
Interfacility transfer information: transfer mode from the referring facility; name of
the referring facility; arrival and discharge times from the referring facility;
whether the patient was seen in the emergency department only or was admitted
as an inpatient at the referring hospital;
(6)
Inpatient care information: name and address of the facility; admission date and
time; admission service; surgical procedures performed; date and time of all
surgical procedures; co morbid factors; total days in the Intensive Care Unit
(ICU); date and time of discharge; discharge disposition; payer source; discharge
diagnoses, including International Classification of Disease (ICD) codes,
Abbreviated Injury Scale (AIS), body region, diagnosis description and Injury
Severity Score (ISS);
(7)
Readmission information: patient’s name, date of birth, gender, address; medical
record number, name of facility and the date of admission at the original facility;
and medical record number, name of facility, date of readmission and the reason
for admission at the readmitting facility;

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(8)
Death information: patient’s name, date of birth, gender and address; patient’s
injury type, diagnostic codes, severity and cause; the time and date of arrival at
the facility; the date of the death; autopsy status if performed (i.e. complete,
pending, not done).
2.
Level IV, V, and nondesignated facilities, as defined in Section 25-3.5-703(4), C.R.S., shall
submit data as defined by the Department based on recommendations by SEMTAC or a
committee thereof.
A.
Data shall be submitted to the Department for all discharges, transfers, and deaths on a
quarterly basis within 60 days of the end of that quarter. These data elements include but
are not limited to:
2.
Level IV, V, and nondesignated facilities, as defined in Section 25-3.5-703(4), C.R.S., shall
submit data as defined by the Department based on recommendations by SEMTAC or a
committee thereof.
A.
Data shall be submitted to the Department for all discharges, transfers, and deaths on a
quarterly basis within 60 days of the end of that quarter. These data elements include but
are not limited to:
(1)
Inpatient information: name, age, gender, zip code of residence, medical record
number, admission date, discharge date, injury type, and cause;
(2)
Interfacility transfer information, whether from the emergency department or after
inpatient admission: the patient’s name, age, gender, and zip code of residence;
(3)
Readmission information: patient’s name, age, gender and zip code of residence;
medical record number, name of facility and the date of admission at the original
facility; medical record number, name of facility, date of readmission, and the
reason for admission at the readmitting facility;
(4)
Death information: patient’s name, age, gender and zip code of residence;
patient’s injury type and cause; the time and date of arrival at the facility; the date
of the death.
B.
Level IV, V, and nondesignated facilities shall fulfill the reporting requirement by
participating in a reporting system approved by the Department with submission dates
determined by the data system operator.
3.
All facilities shall submit to the Department such additional information regarding the care,
medical evaluation and clinical course of specified individual patients with trauma as requested by
the Department for the purpose of evaluating the quality of trauma management and care. Such
information shall be defined by the Department based on recommendations by SEMTAC or a
committee thereof.
202
3.
All facilities shall submit to the Department such additional information regarding the care,
medical evaluation and clinical course of specified individual patients with trauma as requested by
the Department for the purpose of evaluating the quality of trauma management and care. Such
information shall be defined by the Department based on recommendations by SEMTAC or a
committee thereof.
202.
Provision of Technical Assistance and Training
The Department may contract with any public or private entity to perform its duties concerning the
statewide trauma registry including, but not limited to, duties of providing technical assistance and training
to facilities within the state or otherwise facilitating reporting to the registry.
203.
Confidentiality
1.
Any data maintained in the trauma registry that identifies patients or physicians or is part of the
patient’s medical record shall be strictly confidential pursuant to Section 25-3.5-704(2)(f)(III),
C.R.S., whether such data is recorded on paper or stored electronically. The data shall not be
admissible in any civil or criminal proceeding.
2.
The data in the trauma registry may not be released in any form to any agency, institution, or
individual if the data identifies patients or physicians.

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3.
The Department may establish procedures to allow access by outside agencies, institutions, or
individuals to information in the registry that does not identify patients or physicians. These
procedures are outlined in the Colorado Trauma Registry Data Release Policy and other
applicable Department data release policies.

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tablish procedures to allow access by outside agencies, institutions, or
individuals to information in the registry that does not identify patients or physicians. These
procedures are outlined in the Colorado Trauma Registry Data Release Policy and other
applicable Department data release policies.

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DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
Health Facilities and Emergency Medical Services Division
STATEWIDE EMERGENCY MEDICAL AND TRAUMA CARE SYSTEM
6 CCR 1015-4
_________________________________________________________________________
Adopted by the Board of Health on April 21, 2021.
CHAPTER THREE – DESIGNATION OF TRAUMA FACILITIES
Purpose and Authority for Rules
These rules address the designation process for trauma facilities, the enforcement and disciplinary
procedures applicable to trauma facilities, and the designation criteria for Level I through V trauma
facilities. The authority for the promulgation of these rules is set forth in Section 25-3.5-701 et seq.,
C.R.S.
Index to Sections
300.
Definitions
301.
Nondesignation and Designation Processes
302.
Enforcement and Disciplinary Process
303.
Trauma Facility Designation Criteria – Level I and II
304.
Trauma Quality Improvement Programs for Designated Trauma Centers Levels III-V
305.
Scope of Care for Designated Trauma Centers Level III-V
306.
Trauma Facility Designation Criteria – Level III
307.
Trauma Facility Designation Criteria – Level IV and V
308.
Burn Unit Referral Criteria
309.
Trauma Facility Designation Criteria – Regional Pediatric Trauma Centers
300.
Definitions
1.
Advanced Trauma Life Support (ATLS) or equivalent – The training provided in accordance with
the American College of Surgeons curriculum for Advanced Trauma Life Support. An equivalent
program is one which has been approved by the Department. The burden shall be upon the
applicant to prove that the program is equivalent to ATLS.
2
on Criteria – Regional Pediatric Trauma Centers
300.
Definitions
1.
Advanced Trauma Life Support (ATLS) or equivalent – The training provided in accordance with
the American College of Surgeons curriculum for Advanced Trauma Life Support. An equivalent
program is one which has been approved by the Department. The burden shall be upon the
applicant to prove that the program is equivalent to ATLS.
2.
Consultation – Telephone or telemedicine, as specified in this chapter, to determine the necessity
of transfer and the circumstances of transfer including, but not limited to, additional
diagnostic/therapeutic issues, availability of resources, and weather conditions. Consultation
occurs between the attending trauma surgeon, or physician in a Level IV or V facility, of a
referring facility and an appropriate attending physician from the trauma service at a receiving
trauma center with the resources necessary to meet the patient's needs. Trauma consultation
shall include written documentation completed by staff at both facilities. Disagreements as to
patient disposition will be documented at both facilities for Department review.

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3.
Core group – The core group of surgeons is comprised of those surgeons identified by the
Trauma Medical Director who provide coverage for at least 60 percent of the trauma call
schedule.
4.
Department – The Colorado Department of Public Health and Environment, unless the context
requires otherwise.
5.
Divert – The facility cannot currently accept EMS traffic. EMS shall transport trauma patients to
an alternate destination in accordance with the prehospital trauma algorithm.
6.
Emergent Intervention – Provision of medical services that can be undertaken to address: 1)
uncontrolled bleeding; 2) Physiologic criteria as outlined in Chapter One, Exhibit A or B of the
prehospital trauma triage algorithm; or 3) a traumatic injury that requires emergency surgery.
7
hall transport trauma patients to
an alternate destination in accordance with the prehospital trauma algorithm.
6.
Emergent Intervention – Provision of medical services that can be undertaken to address: 1)
uncontrolled bleeding; 2) Physiologic criteria as outlined in Chapter One, Exhibit A or B of the
prehospital trauma triage algorithm; or 3) a traumatic injury that requires emergency surgery.
7.
Emergent Surgery – A surgical procedure for which it has been determined that no alternative
therapy is available and for which the delay could result in death or permanent impairment of
health.
8.
Expanded Scope of Care – An expanded scope of care is any specialty or service line that
provides treatment at a trauma center beyond the minimum requirements of the trauma center’s
designation level, either on a part-time or full-time basis.
9.
Focused Review – A type of interim trauma designation review focusing on the areas of concern
from a previous review or plan of correction. Both the application and the review process may be
shortened to focus on previous deficits.
10.
Key Resource Facilities – Level I and II certified trauma facilities which have an expanded
responsibility in providing on-going consultation, education, and technical support to referring
facilities, individuals, or RETACS.
11.
Met with Reservations – Evidence of some degree of compliance with regulatory standards, but
where further action is required for full compliance.
12.
Morbidity and Mortality Review – A case presentation of all complications, deaths, and cases of
interest for educational purposes to improve overall care to the trauma patient. Case
presentations shall include all aspects and contributing factors of trauma care from prehospital
care to discharge or death. The multi-disciplinary group of health professionals shall meet on a
regular basis, but not less than every two months, or every quarter for Level IV and V facilities
, deaths, and cases of
interest for educational purposes to improve overall care to the trauma patient. Case
presentations shall include all aspects and contributing factors of trauma care from prehospital
care to discharge or death. The multi-disciplinary group of health professionals shall meet on a
regular basis, but not less than every two months, or every quarter for Level IV and V facilities.
The documentation of the review shall include date, reason for review, problem identification,
corrective action, resolution, and education. Documented minutes shall be maintained on site and
readily available.
13.
Multidisciplinary Trauma Committee – This committee is responsible for the development,
implementation, and monitoring of the trauma program at each designated trauma center.
Functions include, but are not limited to: establishing policies and procedures; reviewing process
issues, e.g., communications; promoting educational offerings; reviewing systems issues, e.g.,
response times and notification times; and reviewing and analyzing trauma registry data for
program evaluation and utilization. Attendance requirements will be established by the
committee. Membership will be established by the facility.
14.
Multisystem Trauma – Two or more body regions or systems that are injured with physiologic
criteria or the potential for physiologic compromise, as defined in Chapter One Exhibits A and B
of the prehospital trauma triage algorithm.

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the
committee. Membership will be established by the facility.
14.
Multisystem Trauma – Two or more body regions or systems that are injured with physiologic
criteria or the potential for physiologic compromise, as defined in Chapter One Exhibits A and B
of the prehospital trauma triage algorithm.

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15.
Outreach – The act of providing resources to other facilities in order to improve response to the
injured patient. These resources shall include, but not be limited to, clinical consultation and
public and professional education. Trauma centers shall be centers of excellence and shall share
this expertise with other trauma centers and nondesignated facilities. Timely and appropriate
communication, consultation, and feedback are imperative to patient outcome.
16.
Plan of Correction – Identifies how the facility plans to correct deficiencies or standards identified
as met with reservations cited in the Department’s written notice to the facility, within an identified
timeline. A plan of correction may also be required to meet a waiver request or fulfill a request
from the Department to address a temporary issue identified by the Department or the facility.
17.
Promptly Available – Unless otherwise specified, promptly available shall be a facility-defined
timeframe based on current standards of clinically appropriate care.
18.
Quality/Performance Improvement Program – A defined plan for the process to monitor and
improve the performance of a trauma program is essential. This plan shall address the entire
spectrum of services necessary to ensure optimal care to the trauma patient, from prehospital to
rehabilitative care. This plan may be parallel to, and interactive with, the hospital-wide quality
improvement program but shall not be replaced by the facility process
fined plan for the process to monitor and
improve the performance of a trauma program is essential. This plan shall address the entire
spectrum of services necessary to ensure optimal care to the trauma patient, from prehospital to
rehabilitative care. This plan may be parallel to, and interactive with, the hospital-wide quality
improvement program but shall not be replaced by the facility process. In Level IV-V facilities, this
plan may be part of the hospital-wide quality improvement program, but must have facility-
defined, trauma-related indicators and components. Implementation of the plan is overseen by
the Trauma Medical Director. Trauma-related issues must be documented separately, and the
TMD has authority over any trauma issues.
19.
Regional Emergency Medical and Trauma Advisory Council (RETAC) – The representative body
appointed by the governing bodies of counties or cities and counties for the purpose of providing
recommendations concerning regional area emergency medical and trauma service plans for
such counties or cities and counties.
20.
Resources or Necessary Resources – As used in this 6 CCR 1015-4, Chapter Three are the
instruments, equipment, medications, training, and qualified personnel required to provide
appropriate care for the patient.
21.
Scope of Care – A scope of care is a description of the facility’s capabilities to manage the
trauma patient. This description must include administrative support and specialty availability that
ensures continuity of care for all admitted patients.
22.
State Emergency Medical and Trauma Services Advisory Council (SEMTAC) – Pursuant to
Section 25-3.5-104(4), C.R.S., the State Emergency Medical and Trauma Services Advisory
Council is a board appointed by the governor that advises and makes recommendations to the
Department on all matters relating to emergency medical and trauma services.
23.
Special Audit for Trauma Deaths – All trauma deaths shall be audited
ncy Medical and Trauma Services Advisory Council (SEMTAC) – Pursuant to
Section 25-3.5-104(4), C.R.S., the State Emergency Medical and Trauma Services Advisory
Council is a board appointed by the governor that advises and makes recommendations to the
Department on all matters relating to emergency medical and trauma services.
23.
Special Audit for Trauma Deaths – All trauma deaths shall be audited. A comprehensive review
audit shall be initiated by the Trauma Medical Director in Levels I, II, III facilities and by the
appropriate personnel designated by the Level IV and V facilities. The trauma nurse coordinator
shall participate in these audits. A written critique shall be used to document the process to
include the assessment, corrective action, and resolution.
24.
Transfer Agreement – A written agreement with one or more hospitals or healthcare institutions
for the transfer of patients from one to another.

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25.
Trauma Nurse Coordinator – The terms “trauma nurse coordinator,” “trauma coordinator” and
“trauma program manager” are used interchangeably in these regulations (6 CCR 1015). The
trauma nurse coordinator (TNC) works to promote optimal care for the trauma patient through
participation in clinical programs, administrative functions, and professional and public education.
The TNC shall be actively involved in the state trauma system. The essential responsibilities of
the TNC include maintenance of the trauma registry, continuous quality improvement in trauma
care, educational activities, and injury prevention.
26.
Trauma Nurse Core Course (TNCC) or equivalent – the training provided in accordance with the
Emergency Nurses Association curriculum. An equivalent program is one that has been approved
by the Department. The burden shall be upon the applicant to prove that the program is
equivalent to the TNCC.
27
y, continuous quality improvement in trauma
care, educational activities, and injury prevention.
26.
Trauma Nurse Core Course (TNCC) or equivalent – the training provided in accordance with the
Emergency Nurses Association curriculum. An equivalent program is one that has been approved
by the Department. The burden shall be upon the applicant to prove that the program is
equivalent to the TNCC.
27.
Trauma Service – The Trauma Service is an organized, identifiable program which includes: a
Trauma Medical Director, a Trauma Nurse Coordinator, a Multidisciplinary Trauma Committee, a
Quality Improvement Program, Injury Prevention and Data Collection/Trauma Registry.
28.
Trauma Medical Director (TMD) – The Trauma Medical Director is a board certified general
surgeon who is responsible for: service leadership, overseeing all aspects of trauma care, and
administrative authority for the hospital trauma program including: trauma multidisciplinary
committee, trauma quality improvement program, physician appointment to and removal from
trauma service, policy and procedure enforcement, peer review, trauma research program, and
key resource facility functions, if applicable; participates in the on-call schedule; practices at the
facility for which he/she is medical director on a full time basis; and participates in all facility
trauma-related committees. In Level I facilities, the Trauma Medical Director shall participate in an
organized trauma research program with regular meetings with documented evidence of
productivity. In Level IV and V, the Trauma Medical Director may be a physician so designated by
the facility who takes responsibility for overseeing the program.
29.
Trauma Team – A facility-defined team of clinicians and ancillary staff, including those required
by these rules.
30.
Trauma Team Activation – A facility-defined method (protocol) for notification of the trauma team
of the impending arrival of a trauma patient based on the prehospital trauma triage algorithms as
set forth in 6 CCR 1015-4, Chapter One.
31
ponsibility for overseeing the program.
29.
Trauma Team – A facility-defined team of clinicians and ancillary staff, including those required
by these rules.
30.
Trauma Team Activation – A facility-defined method (protocol) for notification of the trauma team
of the impending arrival of a trauma patient based on the prehospital trauma triage algorithms as
set forth in 6 CCR 1015-4, Chapter One.
31.
Waiver – A waiver is an exception to the trauma rules approved by the Department. The request
for a waiver shall demonstrate that the alternative meets the intent of the rule. Waivers are
generally granted for a limited term and shall be granted for a period no longer than the
designation cycle. Waivers cannot be granted for any statutory requirement under state or federal
law, requirements under state licensing, federal certification or local safety, fire, electrical,
building, zoning, or similar codes.
301.
Nondesignation and Designation Processes
1.
General Provisions
A.
Any Colorado facility receiving trauma patients by ambulance or other means shall follow
the process for designation or nondesignation based upon its operational status as set
forth in 301.2.A.
B.
Healthcare facilities shall have state licensure before obtaining designation as a trauma
center.

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C.
A separate designation or nondesignation agreement is required for each distinct
physical location where a facility provides trauma care services.
2.
Process to be Applied
A.
The current operational status of the facility will determine the designation process to be
applied. The four types of operational statuses are:
(1)
Nondesignated facility – A hospital, freestanding emergency department (FSED),
community clinic providing emergency services, or other licensed facility that
receives and is accountable for injured persons but chooses not to seek trauma
center designation.
urrent operational status of the facility will determine the designation process to be
applied. The four types of operational statuses are:
(1)
Nondesignated facility – A hospital, freestanding emergency department (FSED),
community clinic providing emergency services, or other licensed facility that
receives and is accountable for injured persons but chooses not to seek trauma
center designation.
(2)
New facility – A hospital, FSED, community clinic providing emergency services,
or other licensed facility that is seeking trauma center designation for the first
time or seeking to change to a different level of designation.
(3)
Replacement facility – An existing trauma center requesting designation at the
current level for a new physical location and not retaining trauma center status at
the old location.
(4)
Existing facility renewal – A currently designated trauma center seeking renewal
at the same designation level.
B.
The specific administrative and clinical criteria for each of the Level I-V and RPTC
designations are set forth in Section 303 through Section 307 and Section 309 of this
chapter.
C.
Applications for designation are public documents. The facility is responsible for
identifying any proprietary information. Proprietary documents are defined here as those
that are protected by copyright, or are used, produced, or marketed under exclusive legal
right of the facility.
D.
At any time, the Department may move to revoke, suspend, or otherwise limit a facility’s
designation consistent with the enforcement and disciplinary process contained in
Section 302 of this chapter.
3.
Nondesignated Facilities
A.
A facility requesting nondesignation status shall file a nondesignation agreement that, at
a minimum, states the following:
(1)
The facility chooses not to seek such designation.
(2)
The facility acknowledges and agrees that it may only admit patients with single
system injuries that are not threatening to life or limb and whose care is not
complicated by co-morbid conditions.
gnated Facilities
A.
A facility requesting nondesignation status shall file a nondesignation agreement that, at
a minimum, states the following:
(1)
The facility chooses not to seek such designation.
(2)
The facility acknowledges and agrees that it may only admit patients with single
system injuries that are not threatening to life or limb and whose care is not
complicated by co-morbid conditions.
(3)
The facility acknowledges and agrees that it shall triage and treat patients
according to the following:

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Patient Condition
Time Frame
Required Action
Traumatic injury requiring
emergent intervention

One hour
Initiate resuscitation and transfer to a trauma
center with the resources necessary to meet
the patient's emergent needs. Transfer must
be initiated but need not be completed within
one hour. Transfer shall not be encumbered by
restrictions to keep patients within a particular
healthcare organization.
Any non-emergent traumatic
injury meeting mandatory
transfer or consult criteria as
described in 6 CCR 1015-4,
Chapter Three, Section 305.
Two hours
Initiate resuscitation and transfer to a trauma
center with the resources necessary to meet
the patient's needs. Transfer must be initiated
but need not be completed within two hours.
Any non-emergent trauma
patient that has experienced
a significant injury or
mechanism as defined in 6
CCR 1015-4, Chapter One,
prehospital algorithms, or
requiring care beyond the
resources of the facility.
Two hours
Initiate resuscitation and transfer to a trauma
center with the resources necessary to meet
the patient's needs. Transfer must be initiated
but need not be completed within two hours.
Decisions regarding transfer shall include
consideration of co-morbid conditions, potential
complications, etc.
(4)
The facility has identified key resource facilities for adult, pediatric, and specialty
care patients.
itiate resuscitation and transfer to a trauma
center with the resources necessary to meet
the patient's needs. Transfer must be initiated
but need not be completed within two hours.
Decisions regarding transfer shall include
consideration of co-morbid conditions, potential
complications, etc.
(4)
The facility has identified key resource facilities for adult, pediatric, and specialty
care patients.
(5)
The facility has established transfer agreements as required by Section 25-3.5-
703(4)(a), C.R.S.
(6)
Nondesignation agreements shall be renewed on a triennial basis.
B.
Upon initiation or renewal of a nondesignation agreement, each nondesignated facility
shall contact its RETAC. The communication will be documented and a copy of the
documentation shall accompany the signed nondesignation agreement described in
Section 301.6.A. The documentation shall demonstrate that the following was discussed:
(1)
Key resource facilities identified by the RETAC per CCR 1015-4, Chapter Four,
401.10.
(2)
Trauma system resources available for all types of trauma patients, including
specialty services such as burns, reimplantation, and pediatric care. Such
resources may be located within or outside the RETAC.
(3)
Communication systems available within the RETAC, system capabilities, and
how to integrate with those systems.
(4)
Resources available for prehospital and interfacility transport.
4.
New Facility
A.
Application Procedure

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(1)
A new facility shall submit a written notice to the Department at least 180 days in
advance of either the anticipated date of opening or commencement of operation
at a higher designation level. Facilities moving to a lower level of designation
shall provide notice no later than 90 days in advance. The notice shall state the
level of designation the facility is requesting.
Services Division

18
(1)
A new facility shall submit a written notice to the Department at least 180 days in
advance of either the anticipated date of opening or commencement of operation
at a higher designation level. Facilities moving to a lower level of designation
shall provide notice no later than 90 days in advance. The notice shall state the
level of designation the facility is requesting.
(2)
The facility shall complete a trauma designation application for new facilities on
the Department’s form and submit it along with the designation fee before the site
visit according to the deadline specified by the Department.
(3)
After an initial assessment of the application by the Department, the facility shall
have ten (10) calendar days to respond to written notice of any application
deficiency.
(4)
If a facility does not correct application deficiencies in a timely manner, the
Department may delay or cancel the review process. The Department may also
consider the facility’s failure to respond in a timely manner as grounds for denial
of designation.
B.
Fee Structure
(1)
Facilities seeking simultaneous verification or consultation by the American
College of Surgeons (ACS) shall pay any fees associated with the verification
directly to the ACS, and the state fees identified below will be paid to the
Department. If the ACS is unable to supply all required team members for the
state review, the facility shall pay the state an additional $3,000 per reviewer
obtained by the state.
(2)
The facility shall submit the non-refundable state designation fee with its
application. The new facility designation fee is:

Level I/RPTC:
$17,500
Level II:
$17,500
Level III:
$11,300
Level IV/V:
$8,500
C.
Site Review Procedure
(1)
Any facility requesting a new Level I through V designation shall undergo an on-
site review. The Department will set a review date no more than ninety (90) days
before the new facility opens or commencement of operation at the new
designation level.
ion. The new facility designation fee is:

Level I/RPTC:
$17,500
Level II:
$17,500
Level III:
$11,300
Level IV/V:
$8,500
C.
Site Review Procedure
(1)
Any facility requesting a new Level I through V designation shall undergo an on-
site review. The Department will set a review date no more than ninety (90) days
before the new facility opens or commencement of operation at the new
designation level.
(2)
All equipment and policies for the requested designation level as currently
required by Section 303 through Section 307 and Section 309 of this chapter
shall be in place for inspection or evidence of their placement shall be provided
to the Department before the facility’s opening or commencement of operation at
the new designation level.
(3)
All personnel for the requested designation level as currently required by Section
303 through Section 307 and Section 309 of this chapter shall be identified and
available for interview.
(4)
The Department will select the new facility review team according to the following
specifications:

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a.
Level I-II facilities:
i.
A minimum of one trauma surgeon and one trauma nurse who
live and work outside the State of Colorado,
ii.
One state observer,
iii.
Departmental discretion to designate additional reviewers up to a
full team as set forth in 301.6.C.(1)a. of this Section.
b.
Level III facilities:
i.
A minimum of one trauma surgeon and one trauma nurse who
live and work outside the facility’s RETAC area,
ii.
One state observer,
iii.
Departmental discretion to designate additional reviewers up to a
full team as set forth in 301.6.C.(1)b. of this Section.
c.
Level IV-V facilities:
i.
A minimum of one emergency physician or trauma surgeon and
one trauma nurse who live and work outside the facility’s RETAC
area,
ii.
One state observer,
iii.
Departmental discretion to designate additional reviewers up to a
full team as set forth in 301.6.C.(1)c. of this Section.
nate additional reviewers up to a
full team as set forth in 301.6.C.(1)b. of this Section.
c.
Level IV-V facilities:
i.
A minimum of one emergency physician or trauma surgeon and
one trauma nurse who live and work outside the facility’s RETAC
area,
ii.
One state observer,
iii.
Departmental discretion to designate additional reviewers up to a
full team as set forth in 301.6.C.(1)c. of this Section.
(5)
All review team members shall also meet the following criteria:
a.
Physician reviewers shall be certified by the American Board of Medical
Specialties or the American Board of Osteopathic Medicine,
b.
Physician reviewers shall be board certified in the specialty they are
representing,
c.
Be currently active in trauma care at the level being reviewed or above,
d.
Have no conflict of interest with the facility under review, and
e.
Live and work outside the facility’s RETAC area.
(6)
The Department will provide the applicant with the names of the on-site
reviewers once they have been selected.
(7)
If the applicant believes that a potential reviewer has a financial, professional or
personal bias that may adversely affect the review, the facility shall notify the
Department, in writing, no later than seven (7) calendar days after the
Department’s announcement of the proposed team members. Such notice shall
contain all details of any alleged bias along with supporting documentation. The
Department shall consider such notice and make a decision concerning
replacement of the reviewer in question.

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en (7) calendar days after the
Department’s announcement of the proposed team members. Such notice shall
contain all details of any alleged bias along with supporting documentation. The
Department shall consider such notice and make a decision concerning
replacement of the reviewer in question.

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(8)
The review may consist of, but is not limited to, consideration of the following:
a.
Review of application,
b.
Equipment check throughout the facility,
c.
Review of all policies and procedures,
d.
Review of quality improvement plans and other quality improvement
documentation as may be appropriate,
e.
Physical inspection of facility,
f.
Interviews with staff,
g.
Transfer protocols,
h.
Call schedules,
i.
Credentials of staff,
j.
Review of the facility’s planned interaction with prehospital transport, and
k.
Other documents deemed appropriate by the Department.
(9)
The review team shall provide a verbal report of its findings to the applicant
before leaving the facility.
D.
Designation Decision Procedure
(1)
The Department shall present a summary of the Level I-II and RPTC results to
SEMTAC or a summary of the Level III-V results to the Designation Review
Committee (DRC) for a recommendation on the new facility designation.
(2)
The Department shall consider all evidence and notify the applicant in writing of
its decision within thirty (30) calendar days of receiving the recommendation.
(3)
The Department’s final determination regarding each application shall be based
upon consideration of all pertinent factors including, but not limited to, the
application, the evaluation and recommendations of the on-site review team, the
recommendation from SEMTAC or DRC, the best interests of trauma patients,
and any unique attributes or circumstances that make the facility capable of
meeting particular or special community needs.
n regarding each application shall be based
upon consideration of all pertinent factors including, but not limited to, the
application, the evaluation and recommendations of the on-site review team, the
recommendation from SEMTAC or DRC, the best interests of trauma patients,
and any unique attributes or circumstances that make the facility capable of
meeting particular or special community needs.
(4)
If the Department denies new facility designation, the provisions of Section 302.4
of this chapter shall apply.
E.
Period of Designation
(1)
A new facility designation is a one-time designation valid for 18 months.
(2)
Once a new facility designation is issued, the facility will coordinate with the
Department to schedule a full review within 12-14 months.

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(3)
Prior to the full review, the facility shall follow the application procedures
described in 301.6.A.(2) through (4).
(4)
The subsequent site review and designation decision procedures shall follow
those described for renewal of existing facilities at 301.6.B. through D.
(5)
Designation following the full review will mark the beginning of a full three-year
designation cycle.
5.
Replacement Facility
A.
Application Procedure
(1)
A trauma designation review is required when the Department issues a new
hospital, FSED, or community clinic providing emergency services license based
upon a change of location.
(2)
A replacement facility shall submit a written notice to the Department at least 180
days in advance of the anticipated date of opening.
(3)
The facility shall provide the Department with a copy of its last renewal
application along with updated statistical data and information on any policy
changes. The facility shall submit the application, designation fee, and additional
information to the Department before the site visit according to the specified
deadline.
rtment at least 180
days in advance of the anticipated date of opening.
(3)
The facility shall provide the Department with a copy of its last renewal
application along with updated statistical data and information on any policy
changes. The facility shall submit the application, designation fee, and additional
information to the Department before the site visit according to the specified
deadline.
(4)
After an initial assessment of the application and updated information by the
Department, the facility shall have ten (10) calendar days to respond to written
notice of any application deficiency.
(5)
If a facility does not correct application deficiencies in a timely manner, the
Department may delay or cancel the review process. The Department may also
consider the facility’s failure to respond in a timely manner as grounds for denial
of designation.
(6)
The facility will coordinate with the Department to schedule a date for the
replacement review to occur no sooner than the move to the replacement
physical plant and no later than thirty (30) calendar days after the move.
(7)
The facility’s existing trauma designation continues until a replacement review
occurs and the Department makes a decision on the replacement facility
application.
B.
Fee Structure
The facility shall submit the non-refundable designation fee with its application. The
replacement facility designation fee is:

Level I/RPTC:
$6,500
Level II:
$6,500
Level III:
$1,800
Level IV/V:
$1,800

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C.
Site Review Procedure
(1)
Any facility requesting replacement designation at the same level for a new
physical plant shall undergo an on-site review at the new location.
(2)
All equipment and policies required by the facility’s current designation level shall
be in place for inspection at the replacement facility.
ATIONS
6 CCR 1015-4
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22
C.
Site Review Procedure
(1)
Any facility requesting replacement designation at the same level for a new
physical plant shall undergo an on-site review at the new location.
(2)
All equipment and policies required by the facility’s current designation level shall
be in place for inspection at the replacement facility.
(3)
The Department will select the site review team for the replacement facility
according to the following specifications:
a.
Level I-II facilities:
i.
A minimum of one trauma surgeon and one trauma nurse who
live and work outside the State of Colorado,
ii.
One state observer,
iii.
Departmental discretion to designate additional reviewers up to a
full team as set forth in 301.6.C.(1)a.
b.
Level III-V facilities:
i.
A minimum of one trauma nurse who lives and works outside the
facility’s RETAC area,
ii.
One state observer,
iii.
Departmental discretion to designate additional reviewers up to a
full team as set forth in 301.6.C.(1)b. and c.
(4)
All review team members shall also meet the following criteria:
a.
Physician reviewers shall be certified by the American Board of Medical
Specialties or the American Board of Osteopathic Medicine,
b.
Physician reviewers shall be board certified in the specialty they are
representing,
c.
Be currently active in trauma care at the level being reviewed or above,
d.
Have no conflict of interest with the facility under review, and
e.
Live and work outside the facility’s RETAC area.
(5)
The Department will provide the applicant with the names of the on-site
reviewers once they have been selected.
b.
Physician reviewers shall be board certified in the specialty they are
representing,
c.
Be currently active in trauma care at the level being reviewed or above,
d.
Have no conflict of interest with the facility under review, and
e.
Live and work outside the facility’s RETAC area.
(5)
The Department will provide the applicant with the names of the on-site
reviewers once they have been selected.
(6)
If the applicant believes that a potential reviewer has a financial, professional, or
personal bias that may adversely affect the review, the facility shall notify the
Department, in writing, no later than seven (7) calendar days after the
Department’s announcement of the proposed team members. Such notice shall
contain all details of any alleged bias along with supporting documentation. The
Department shall consider such notice and make a decision concerning
replacement of the reviewer in question.

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(7)
The on-site review may consist of, but is not limited to, consideration of the
following:
a.
Equipment check throughout the facility,
b.
Physical inspection of facility,
c.
Review of all policies and procedures,
d.
Interviews with staff,
e.
Review of effects of the facility move on prehospital transport protocols,
and
f.
Other documents deemed appropriate by the Department.
(8)
The team shall provide a verbal report of its findings to the applicant before
leaving the facility.
D.
Designation Decision Procedure
The designation decision procedure shall follow the one described for existing facility
renewal at Section 301.6.D of this chapter.
E.
Designation Period
Designation following the replacement review will continue until the end of the facility’s
existing designation cycle.
6.
Renewal of Existing Facility
A.
Application Procedure
plicant before
leaving the facility.
D.
Designation Decision Procedure
The designation decision procedure shall follow the one described for existing facility
renewal at Section 301.6.D of this chapter.
E.
Designation Period
Designation following the replacement review will continue until the end of the facility’s
existing designation cycle.
6.
Renewal of Existing Facility
A.
Application Procedure
(1)
Existing facilities shall submit a letter of intent to maintain their current trauma
level designation to the Department no later than 120 days before the current
designation expiration date.
(2)
The facility shall complete a trauma designation application for renewal of
existing facilities on the Department’s form and submit it to the Department
before the site visit according to the deadline specified by the Department.
(3)
After an initial assessment of the application by the Department, the facility shall
have ten (10) calendar days to respond to written notice of any application
deficiency.
(4)
If a facility does not correct application deficiencies in a timely manner, the
Department may delay or cancel the review process. The Department may also
consider the facility’s failure to respond in a timely manner as grounds for denial
of designation.
B.
Fee Structure
(1)
Facilities seeking state designation only:

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a.
The facility shall submit the required annual designation fee in the
manner specified by the Department. The renewal of existing facility
designation fee is:

Level I/RPTC:
$12,300
Level II:
$12,300
Level III:
$7,000
Level IV/V: Emergency Department Visits
> 15,000 per year
$5,000
Level IV/V: Emergency Department Visits
between 5,000 - 15,000 per year
$4,000
Level IV/V: Emergency Department Visits
< 5,000 per year
$3,000
t the required annual designation fee in the
manner specified by the Department. The renewal of existing facility
designation fee is:

Level I/RPTC:
$12,300
Level II:
$12,300
Level III:
$7,000
Level IV/V: Emergency Department Visits
> 15,000 per year
$5,000
Level IV/V: Emergency Department Visits
between 5,000 - 15,000 per year
$4,000
Level IV/V: Emergency Department Visits
< 5,000 per year
$3,000
(2)
Facilities seeking state designation and simultaneous ACS verification must pay
each of the following fees separately:
a.
Facilities seeking verification by the ACS shall pay any fees associated
with the verification by the ACS directly to the ACS and the state fees
identified below.
b.
Facilities requesting simultaneous verification by the ACS at the time of
the Colorado state trauma designation survey shall pay the following
annual fee to the Department for the state designation process only:

LEVEL I/RPTC:
$8,100
LEVEL II:
$8,100
LEVEL III:
$5,000
LEVEL IV/V:
N/A
c.
If the ACS is unable to supply all required team members for the
designation review, the facility shall pay the Department an additional
$3,000 per reviewer obtained by the state.
(3)
The new fees shall be in effect on July 1, 2017, and the first annual payment
shall be due on July 1 of the state fiscal year in which the current state
designation expires.
C.
Site Review Procedure
(1)
The Department will select the site review members for renewal of an existing
facility designation according to the following specifications:

a.
Level I-II facilities – An out-of-state multidisciplinary team consisting of
two trauma surgeons, one trauma nurse coordinator or RN involved in
trauma program management, one emergency physician, and one state
observer.
b.
Level III facilities – A team consisting of one trauma surgeon, one
emergency physician, one trauma nurse coordinator or registered nurse
involved in trauma program management, and one state observer.

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r or RN involved in
trauma program management, one emergency physician, and one state
observer.
b.
Level III facilities – A team consisting of one trauma surgeon, one
emergency physician, one trauma nurse coordinator or registered nurse
involved in trauma program management, and one state observer.

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c.
Level IV-V facilities – A team consisting of one emergency physician or
trauma surgeon, one trauma nurse coordinator or registered nurse
involved in trauma program management, and one state observer.
(2)
All review team members shall also meet the following criteria:
a.
Physician reviewers shall be certified by the American Board of Medical
Specialties or the American Board of Osteopathic Medicine,
b.
Physician reviewers shall be board certified in the specialty they are
representing,
c.
Be currently active in trauma care at the level being reviewed or above,
d.
Have no conflict of interest with the facility under review, and
e.
Live and work outside the facility’s RETAC area.
(3)
The Department will provide the applicant with the names of the on-site
reviewers once they have been selected.
(4)
If the applicant believes that a potential reviewer has a financial, professional, or
personal bias that may adversely affect the review, the facility shall notify the
Department, in writing, no later than seven (7) calendar days after the
Department’s announcement of the proposed team members. Such notice shall
contain all details of any alleged bias along with supporting documentation. The
Department shall consider such notice and make a decision concerning
replacement of the reviewer in question.
may adversely affect the review, the facility shall notify the
Department, in writing, no later than seven (7) calendar days after the
Department’s announcement of the proposed team members. Such notice shall
contain all details of any alleged bias along with supporting documentation. The
Department shall consider such notice and make a decision concerning
replacement of the reviewer in question.
(5)
The on-site review team shall evaluate the capability of the facility to meet the
responsibilities, required equipment, and performance criteria appropriate to its
designation level as identified in these rules through the following:
a.
Review of application,
b.
Physical inspection of the facility,
c.
Review of trauma patient medical records,
d.
Review of patient discharge summaries,
e.
Review of patient care logs,
f.
Review of quality improvement/management/assurance records and
meeting minutes,
g.
Review of rosters, schedules, and meeting minutes,
h.
Interviews with appropriate facility personnel and other medical
providers,
i.
Review of research, prevention, and educational programs as applicable,
and
j.
Review of other documents as deemed appropriate by the team.

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(6)
The review team shall provide a verbal report of its findings to the applicant
before leaving the facility.
D.
Designation Decision Procedure
(1)
The Department shall present a summary of the Level I-II or RPTC results to
SEMTAC or a summary of the Level III-V results to the Designation Review
Committee (DRC) for a recommendation to the Department on the facility
designation.
(2)
If the Department determines that a plan of correction is appropriate, the facility
shall follow the process set forth in Section 302.2 of this chapter.
(3)
The Department shall notify the applicant in writing of its decision within thirty
(30) calendar days of receiving the recommendation.
e Designation Review
Committee (DRC) for a recommendation to the Department on the facility
designation.
(2)
If the Department determines that a plan of correction is appropriate, the facility
shall follow the process set forth in Section 302.2 of this chapter.
(3)
The Department shall notify the applicant in writing of its decision within thirty
(30) calendar days of receiving the recommendation.
(4)
The Department’s final determination regarding each application shall be based
upon consideration of all pertinent factors, including, but not limited to, the
application, the evaluation and recommendations of the on-site review team, the
recommendation from SEMTAC or DRC, compliance history, the best interests of
trauma patients, and any unique attributes or circumstances that make the facility
capable of meeting particular or special community needs.
(5)
If the Department denies renewal of existing facility designation, the provisions of
Section 302.4 of this chapter shall apply.
E.
Period of Designation
(1)
Renewal of existing facility designation will be valid for three years from the prior
expiration date, unless voluntarily relinquished by the facility, revoked,
suspended, or otherwise sanctioned pursuant to these rules.
7.
Waivers
A.
The Department may grant a waiver from one or more criteria that are established in this
chapter for Level I-V trauma centers.
B.
Facilities seeking a waiver shall submit a completed waiver application on the
Department’s form. The Department may require the applicant to provide additional
information, and the application will not be considered complete until the required
information is provided.
C.
The facility seeking the waiver shall also post notice of the waiver application and a
meaningful description of the substance of the request at all public entrances to the
facility and in at least one area commonly used by the patients. The notice shall be
posted no later than the application’s submission date and shall remain posted for at
least thirty (30) calendar days.
D
ation is provided.
C.
The facility seeking the waiver shall also post notice of the waiver application and a
meaningful description of the substance of the request at all public entrances to the
facility and in at least one area commonly used by the patients. The notice shall be
posted no later than the application’s submission date and shall remain posted for at
least thirty (30) calendar days.
D.
The notice shall describe where to send comments within that 30-day period. Comments
should be directed to:

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EMTS Branch
ATTN: Branch Chief
CDPHE, HFEMSD
4300 Cherry Creek Drive South
Denver, CO 80246
E.
At the same time the notice is posted in the facility, the facility shall also distribute a copy
of the notice to prehospital emergency medical service providers active in the community
served by the facility.
F.
The completed waiver application shall be submitted to the Department at least thirty (30)
calendar days before a SEMTAC meeting in order to be placed on the next agenda.
Applications completed less than thirty (30) calendar days in advance will be placed on
the subsequent agenda.
G.
The Department shall distribute a copy of the public notice of the SEMTAC meeting
regarding the waiver to all other designated trauma centers.
H.
SEMTAC shall review the request and make recommendations to the Department. The
Department shall make a decision and send notice of that decision to the facility
administrator within thirty (30) calendar days of the recommendation.
(1)
If the waiver is granted, the Department may:
a.
Specify the terms and conditions of the waiver.
b.
Specify the duration of the waiver. Under no circumstances shall a
waiver be granted for a period longer than the designation cycle for that
facility.
(2)
The Department may require the submission of progress reports from any facility
granted a waiver.
y (30) calendar days of the recommendation.
(1)
If the waiver is granted, the Department may:
a.
Specify the terms and conditions of the waiver.
b.
Specify the duration of the waiver. Under no circumstances shall a
waiver be granted for a period longer than the designation cycle for that
facility.
(2)
The Department may require the submission of progress reports from any facility
granted a waiver.
(3)
If the waived rule is amended or repealed, obviating the need for the waiver, the
waiver shall expire on the effective date of the rule change.
I.
A facility shall notify the Department prior to any change of ownership of the facility as
defined in 6 CCR 1011-1, Chapter 2 – General Licensure Standards, Part 2.6.
J.
Facilities wishing to maintain a waiver beyond its expiration shall submit a new waiver
application to the Department no less than ninety (90) days prior to the expiration of the
waiver.
K.
The Department may revoke or suspend a waiver if it determines:
(1)
That its continuation jeopardizes the health, safety, and/or welfare of the patients,
(2)
The applicant has provided false or misleading information in the waiver
application,
(3)
The applicant has failed to comply with conditions of the waiver, or
(4)
The Department determines that a change in federal or state law prohibits
continuation of the waiver.

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L.
If the Department denies, revokes, or suspends a waiver, the pertinent provisions of
Sections 302.4, 302.5, or 302.6 of this chapter shall apply.
8.
Designation Review Committee
A.
The Designation Review Committee (DRC) shall make recommendations to the
Department about the designation of Level III-V facilities and shall report such
recommendations to SEMTAC.
B.
The DRC shall be comprised of nine members. A minimum of five members shall be
current SEMTAC members. The members shall represent the following constituencies
and disciplines:
(1)
One healthcare facility administrator,
Designation Review Committee (DRC) shall make recommendations to the
Department about the designation of Level III-V facilities and shall report such
recommendations to SEMTAC.
B.
The DRC shall be comprised of nine members. A minimum of five members shall be
current SEMTAC members. The members shall represent the following constituencies
and disciplines:
(1)
One healthcare facility administrator,
(2)
One board certified general surgeon;
(3)
One board certified general surgeon with experience as a site reviewer or a
Trauma Medical Director at a Level III-V facility,
(4)
One physician board certified in emergency medicine,
(5)
One physician board certified in emergency medicine with experience as a site
reviewer or a Trauma Medical Director at a Level III-V facility,
(6)
One trauma program manager or trauma nurse coordinator,
(7)
One trauma program manager or trauma nurse coordinator with experience as a
site reviewer or a Level III-V trauma nurse coordinator,
(8)
One member representing the prehospital/EMS community/or public, and
(9)
One member representing a RETAC.
C.
SEMTAC shall make recommendations to the Department on the membership of the
DRC along with the criteria to be used by the DRC.
D.
The DRC meetings shall be public.
E.
The DRC shall have access to a facility’s application with any proprietary material
extracted, a summary of the site review findings, and any plan of correction submitted by
the facility.
302.
Enforcement and Disciplinary Process
1.
Unscheduled or Interim, Focused or Re-Reviews
A.
At any time the Department may require and conduct an unscheduled or interim, focused
or re-review of a currently designated facility based upon, but not limited to, the following
criteria:
(1)
Recent review results,
(2)
A complaint, or

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rocess
1.
Unscheduled or Interim, Focused or Re-Reviews
A.
At any time the Department may require and conduct an unscheduled or interim, focused
or re-review of a currently designated facility based upon, but not limited to, the following
criteria:
(1)
Recent review results,
(2)
A complaint, or

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(3)
Monitoring of the EMTS system.
2.
Plans of Correction
A.
Prior to making a designation decision, or after an unscheduled or interim, focused or re-
review, the Department shall require a plan of correction from any facility with review
deficiencies and/or met with reservations.
B.
A plan of correction shall include, but not be limited to, the following:
(1)
Identification of the problem(s) with the current activity and what the facility will
do to correct each deficiency,
(2)
A description of how the facility will accomplish the corrective action,
(3)
A description of how the facility will monitor the corrective action to ensure the
deficient practice is remedied and will not recur,
(4)
A timeline with the expected implementation and completion date. Completion
date is the date that the facility deems it can achieve compliance.
C.
Completed plans of correction shall be:
(1)
Submitted to the Department in the form and manner required by the
Department,
(2)
Submitted within thirty (30) calendar days after the date of the Department’s
written notice of deficiencies and/or criteria identified as met with reservations
when areas of non-compliance with rules pertaining to the designation of trauma
centers have been identified, and
(3)
Signed by the facility administrator and facility trauma director.
D.
The Department has the discretion to approve, modify, or reject plans of correction.
(1)
If the plan of correction is accepted, the Department shall notify the facility by
issuing a written notice of acceptance within thirty (30) calendar days of receipt of
the plan.
he designation of trauma
centers have been identified, and
(3)
Signed by the facility administrator and facility trauma director.
D.
The Department has the discretion to approve, modify, or reject plans of correction.
(1)
If the plan of correction is accepted, the Department shall notify the facility by
issuing a written notice of acceptance within thirty (30) calendar days of receipt of
the plan.
(2)
If the plan of correction is unacceptable, the Department shall notify the facility in
writing, and the facility shall re-submit changes to the Department within fifteen
(15) calendar days of the date of the written notice.
(3)
If the facility fails to comply with the requirements or deadlines for submission of
a plan or fails to submit requested changes to the plan, the Department may
reject the plan of correction and impose disciplinary sanctions as set forth below.
(4)
If the facility fails to timely implement the actions agreed to in the plan of
correction, the Department may impose disciplinary sanctions as set forth below.
3.
Re-Review Fee Structure
A.
In the event the Department designates a facility with a required interim, focused, or re-
review per Section 302.1.A.(1) above, the facility shall submit the required fee in the

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manner specified by the Department. The methodology used to determine the re-review
fee for an existing facility is:

Levels I and II:
100% of costs of review team, excluding state observer time
Levels III through V:
75% of costs of review team, excluding state observer time
B.
These fees shall apply to all on-site trauma re-reviews conducted subsequent to the
effective date of these rules.
4.
Denials
A.
The Department may deny an application for Level I-V or RPTC designation to a new,
replacement, or existing facility for reasons including, but not limited to, the following:
(1)
The facility does not meet the criteria for designation as set forth in these
regulations,
.
These fees shall apply to all on-site trauma re-reviews conducted subsequent to the
effective date of these rules.
4.
Denials
A.
The Department may deny an application for Level I-V or RPTC designation to a new,
replacement, or existing facility for reasons including, but not limited to, the following:
(1)
The facility does not meet the criteria for designation as set forth in these
regulations,
(2)
The facility’s application or accompanying documents contain a false statement
of material fact,
(3)
The facility refuses any part of an on-site review,
(4)
The facility’s failure to comply with or to successfully complete a plan of
correction, or
(5)
The facility is substantially out of compliance with any of the Department’s
regulations.
B.
If the facility does not meet the level of designation criteria for which it has applied, the
Department may recommend designation at a lesser level. Such action, unless agreed to
by the applicant, shall represent a denial of the application.
C.
If the Department denies an application for designation or waiver, the Department shall
provide the facility with a notice explaining the basis for the denial. The notice shall also
inform the facility of its right to appeal the denial and the procedure for appealing the
denial.
D.
Appeals of Departmental denials shall be conducted in accordance with the State
Administrative Procedure Act, Section 24-4-101, et seq., C.R.S.
5.
Revocation or Temporary Suspension
A.
The Department may revoke the designation of a facility if any owner, officer, director,
manager, or other employee:
(1)
Fails or refuses to comply with the provisions of these regulations,
(2)
Makes a false statement of material fact about facility capabilities or other
pertinent circumstances in any record or in a matter under investigation for any
purposes connected with this chapter,
ension
A.
The Department may revoke the designation of a facility if any owner, officer, director,
manager, or other employee:
(1)
Fails or refuses to comply with the provisions of these regulations,
(2)
Makes a false statement of material fact about facility capabilities or other
pertinent circumstances in any record or in a matter under investigation for any
purposes connected with this chapter,
(3)
Prevents, interferes with, or attempts to impede in any way, the work of a
representative of the Department in implementing or enforcing these regulations
or the statute,

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(4)
Falsely advertises or in any way misrepresents the facility’s ability to care for
trauma patients based on its designation status,
(5)
Is substantially out of compliance with these regulations and has not rectified
such noncompliance,
(6)
Fails to provide reports required by the registry or the state in a timely and
complete fashion, or
(7)
Fails to comply with or complete a plan of correction in the time or manner
specified.
B.
If the Department revokes or temporarily suspends a designation or waiver, it shall
provide the facility with a notice explaining the basis for the action. The notice shall also
inform the facility of its right to appeal and the procedure for appealing the action.
C.
Appeals of Departmental revocations or suspensions shall be conducted in accordance
with the State Administrative Procedure Act, Section 24-4-101, et seq., C.R.S.
6.
Summary Suspension
A.
The Department may summarily suspend a designation or waiver if it finds, after
investigation, that a facility has engaged in a deliberate and willful violation of these
regulations or that the public health, safety, or welfare requires immediate action.
B.
If the Department summarily suspends a designation or waiver, it shall provide the facility
with a notice explaining the basis for the summary suspension
ent may summarily suspend a designation or waiver if it finds, after
investigation, that a facility has engaged in a deliberate and willful violation of these
regulations or that the public health, safety, or welfare requires immediate action.
B.
If the Department summarily suspends a designation or waiver, it shall provide the facility
with a notice explaining the basis for the summary suspension. The notice shall also
inform the facility of its right to appeal and that it is entitled to a prompt hearing on the
matter.
C.
Appeals of summary suspensions shall be conducted in accordance with the State
Administrative Procedure Act, Section 24-4-101, et seq., C.R.S.
7.
Redesignation at a Lesser Level
A.
The Department may determine that a facility be redesignated at a lesser level due to the
facility’s inability to meet the designation criteria at its current level, notwithstanding any
waiver previously granted.
B.
If the Department seeks to redesignate the facility, it shall provide the facility with a notice
explaining the basis for its action. The notice shall also inform the facility of its right to
appeal and the procedure for appealing the action.
C.
Appeals of involuntary redesignation shall be conducted in accordance with the State
Administrative Procedure Act, Section 24-4-101, et seq., C.R.S.
8.
Monetary Penalties
Any facility, provider, or employee of a facility that falsely misrepresents a facility’s designation
level or violates any rule adopted by the board shall be subject to a civil penalty of $500 per
violation. The fee shall be assessed in accordance with Section 25-3.5-707(2), C.R.S.
303.
Trauma Facility Designation Criteria – Level I and II Facilities
1.
Prehospital Trauma Care Integration

CODE OF COLORADO REGULATIONS
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ignation
level or violates any rule adopted by the board shall be subject to a civil penalty of $500 per
violation. The fee shall be assessed in accordance with Section 25-3.5-707(2), C.R.S.
303.
Trauma Facility Designation Criteria – Level I and II Facilities
1.
Prehospital Trauma Care Integration

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A.
The facility shall participate in the development and improvement of prehospital care
protocols and patient safety programs.
B.
The Trauma Medical Director shall be involved in the development of the trauma facility’s
divert protocol as it affects the trauma service.
C.
A trauma surgeon shall be involved in any decision regarding divert as it affects the care
of the trauma patient.
D.
A liaison from the emergency department shall participate in prehospital peer
review/performance improvement.
2.
Interfacility Consultation, Transfer Requirements, and Emergent Surgery
A.
The facility shall provide on-going consultation, education, and technical support to
referring facilities, individuals, or RETACS.
B.
Provisions for direct physician-to-physician contact shall be included in the process of
transferring a patient between facilities.
C.
The decision to transfer a patient shall be based on the clinical needs of the patient.
Physicians shall be allowed to transfer when in the best interest of the patient and shall
not be encumbered by restrictions to keep patients within a particular healthcare
organization or based on the patient's ability to pay.
D.
If the facility does not have a burn service, a reimplantation service, a pediatric trauma
service, or an acute rehabilitation service, the facility shall have written transfer guidelines
for patients in these categories.
E.
All Level I and II trauma centers may perform emergent surgery if appropriate resources
are available
ular healthcare
organization or based on the patient's ability to pay.
D.
If the facility does not have a burn service, a reimplantation service, a pediatric trauma
service, or an acute rehabilitation service, the facility shall have written transfer guidelines
for patients in these categories.
E.
All Level I and II trauma centers may perform emergent surgery if appropriate resources
are available. If after the emergent surgery is performed, the facility does not have the
post-operative resources to care for the patient and for potential complications, the facility
shall transfer to a trauma center with the necessary resources to meet the patient's
needs.
F.
Mandatory Transfers
(1)
Patients of any age with a traumatic injury requiring resources beyond those
available in the facility's scope of care, see 6 CCR 1015-4, Chapter Three,
303.4.B(1), shall be transferred.
(2)
Levels I and II trauma centers that only admit children have a single extremity
orthopedic fracture or minor head trauma, as determined by best practice
guidelines, shall transfer any other pediatric patients, after emergency surgery,
as necessary.
(a)
Transfer shall be to a Regional Pediatric Trauma Center or to a Level I or
II trauma center that admits pediatric trauma patients.
(b)
The receiving trauma center must meet the requirements set forth in 6
CCR 1015-4, Chapter Three, Section 303.9.D and have a pediatric
intensive care area staffed by a board certified or board eligible pediatric
intensivist available for consultation or have a transfer protocol and
transfer agreements for pediatric patients requiring intensive care.

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set forth in 6
CCR 1015-4, Chapter Three, Section 303.9.D and have a pediatric
intensive care area staffed by a board certified or board eligible pediatric
intensivist available for consultation or have a transfer protocol and
transfer agreements for pediatric patients requiring intensive care.

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(c)
The receiving trauma center must have a neurosurgeon on call with
qualifications necessary to manage pediatric neurotrauma.
3.
Performance Improvement Process
A.
General Provisions
(1)
The facility shall demonstrate a clearly defined trauma performance improvement
program that shall be coordinated with the hospital-wide program.
(2)
The facility shall be able to demonstrate that the trauma patient population can
be identified for separate review regardless of the institutional performance
improvement processes.
(3)
Performance improvement shall be supported by a reliable method of data
collection that consistently obtains valid and objective information necessary to
identify opportunities for improvement. The process of analysis shall include
multidisciplinary review and shall occur at regular intervals to meet the needs of
the program. The results of analysis shall define corrective strategies and shall
be documented.
(4)
The facility shall demonstrate that the trauma registry is used to support the
performance improvement program.
(5)
The performance improvement program shall have defined audit filters based
upon a regular review of registry and/or clinical data.
(6)
There shall be appropriate, objectively defined standards to determine the quality
of care.
(7)
If more than 10 percent of injured patients with an Injury Severity Score greater
than or equal to nine (excluding isolated hip fractures) are admitted to non-
surgical services, the trauma facility shall demonstrate the appropriateness of
that practice through the performance improvement program.
.
(6)
There shall be appropriate, objectively defined standards to determine the quality
of care.
(7)
If more than 10 percent of injured patients with an Injury Severity Score greater
than or equal to nine (excluding isolated hip fractures) are admitted to non-
surgical services, the trauma facility shall demonstrate the appropriateness of
that practice through the performance improvement program.
(8)
Identified problem trends shall undergo peer review by the Peer
Review/Performance Improvement Committee.
(9)
The facility shall review any diversion or double transfer (from another facility and
then transferred for additional acute trauma care) of trauma patients.
(10)
The facility shall demonstrate that its graded activation criteria are regularly
evaluated by the performance improvement program.
(11)
Physician availability to the trauma patient in the ICU shall be monitored by the
peer review/performance improvement program.
B.
Multidisciplinary Trauma Committee
(1)
The facility shall have a multidisciplinary committee to address trauma program
operational issues.
(2)
A multidisciplinary trauma committee shall continuously evaluate the trauma
program’s processes and outcomes.

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(3)
The committee shall include, at a minimum, the Trauma Medical Director or
designee and all core surgeons as well as liaisons from orthopedic surgery,
neurosurgery, emergency medicine, radiology, and anesthesia. Each of these
liaisons shall attend at least 50 percent of the meetings.
(4)
The exact format of the committee may be hospital specific, but shall be
multidisciplinary and consist of hospital and medical staff members who work to
identify and correct trauma program system issues.
(5)
The committee minutes shall reflect the review of operational issues and, when
appropriate, the analysis and proposed corrective actions. The process shall
identify problems and shall demonstrate problem resolution.
committee may be hospital specific, but shall be
multidisciplinary and consist of hospital and medical staff members who work to
identify and correct trauma program system issues.
(5)
The committee minutes shall reflect the review of operational issues and, when
appropriate, the analysis and proposed corrective actions. The process shall
identify problems and shall demonstrate problem resolution.
(6)
The committee shall monitor compliance with all required time frames for
availability of trauma personnel including, but not limited to, response times for
general surgery, orthopedics, neurosurgery, anesthesiology, radiology, and
radiology, MRI, or CT techs.
(7)
The availability of anesthesia services and the absence of delays in airway
control or operations shall be monitored.
(8)
Radiologists shall be involved in protocol development and trend analysis that
relate to diagnostic imaging.
(9)
The multidisciplinary committee shall review and address issues related to the
availability of necessary personnel and equipment to monitor and resuscitate
patients in the PACU.
C.
Peer Review/Performance Improvement Committee
(1)
The facility shall have a Peer Review/Performance Improvement Committee
chaired by the Trauma Medical Director or physician designee.
(2)
The committee shall include, at a minimum, the core group of general surgeons
and a physician liaison from orthopedic surgery, neurosurgery, emergency
medicine, radiology, and anesthesia. Each liaison shall attend at least 50 percent
of the meetings.
(3)
Each liaison shall be available to the Trauma Medical Director for committee
issues that arise in his or her department.
(4)
The Peer Review/Performance Improvement Committee shall document
evidence of committee attendance and participation.
(5)
The committee shall review the overall quality of care for the trauma service,
selected deaths, complications, and sentinel events with the objective of
identifying issues and appropriate responses.
a Medical Director for committee
issues that arise in his or her department.
(4)
The Peer Review/Performance Improvement Committee shall document
evidence of committee attendance and participation.
(5)
The committee shall review the overall quality of care for the trauma service,
selected deaths, complications, and sentinel events with the objective of
identifying issues and appropriate responses.
(6)
Trauma patient care may be evaluated initially by individual specialties within
their usual Departmental review structures; however, identified problem trends
shall undergo review within the Peer Review/Performance Improvement
Committee.

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(7)
The facility shall also, in this committee or in another appropriate forum, provide
for morbidity and mortality review of trauma cases. All trauma deaths shall be
systematically reviewed and categorized as preventable, non-preventable, or
potentially preventable or equivalent taxonomy.
(8)
When a consistent problem or inappropriate variation is identified, corrective
actions shall be taken and documented.
(9)
The Trauma Medical Director shall ensure dissemination of committee
information to all non-core general surgeons with documentation.
(10)
The Peer Review/Performance Improvement Committee shall review and monitor
the organ donation rate.
(11)
The committee shall demonstrate that the program complies with required
surgical response times at least 80 percent of the time.
(12)
The peer review/performance improvement program shall monitor changes in
interpretation of diagnostic information.
4.
Facility Organization and the Trauma Program
A.
Facility Governing Body and Medical Staff Commitment
(1)
The facility shall demonstrate the commitment of the facility’s governing body and
medical staff through a written document. The document shall be reaffirmed
every three years and be current at the time of the site review.
am shall monitor changes in
interpretation of diagnostic information.
4.
Facility Organization and the Trauma Program
A.
Facility Governing Body and Medical Staff Commitment
(1)
The facility shall demonstrate the commitment of the facility’s governing body and
medical staff through a written document. The document shall be reaffirmed
every three years and be current at the time of the site review.
(2)
The administrative structure of the hospital/trauma facility shall include, at a
minimum, an administrator, a Trauma Medical Director, and a trauma program
manager.
B.
Trauma Program
(1)
Scope of care: All designated Level I and II trauma centers shall define their
scope of care based on the resources that are available at the facility for adult
and pediatric patients.
(2)
The trauma program members or a representative of the program shall
participate in state and regional trauma system planning, development, and
operation.
(3)
The trauma program shall have authority to address issues that involve multiple
disciplines. The Trauma Medical Director shall have the authority and
administrative support to lead the program.
C.
Trauma Medical Director
(1)
The Trauma Medical Director shall be a board certified (not board eligible)
surgeon, as those boards are defined under the “Clinical Requirements for
General Surgery” as described in Section 303.5.C or shall be a Fellow of the
American College of Surgeons with special interest in trauma care, shall take
trauma call, and shall remain current in ATLS.

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(2)
The Trauma Medical Director shall demonstrate membership and active
participation in state and either regional or national trauma organizations.
ll be a Fellow of the
American College of Surgeons with special interest in trauma care, shall take
trauma call, and shall remain current in ATLS.

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6 CCR 1015-4
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(2)
The Trauma Medical Director shall demonstrate membership and active
participation in state and either regional or national trauma organizations.
(3)
The Trauma Medical Director shall have the authority to correct deficiencies in
trauma care and exclude from taking trauma call all trauma team members who
do not meet required criteria. Through the performance improvement program
and hospital policy, the Trauma Medical Director shall have the responsibility and
authority to determine each general surgeon’s ability to participate on the trauma
panel based on an annual review.
D.
Trauma Resuscitation Team
(1)
The facility shall define criteria for trauma resuscitation team activation.
(2)
The criteria for a graded activation shall be clearly defined and continuously
evaluated by the performance improvement program.
E.
Trauma Service
(1)
A trauma service admission is a patient who is admitted to or evaluated by an
identifiable surgical service staffed by credentialed trauma providers.
(2)
The facility shall demonstrate or provide documentation that the trauma service
has sufficient infrastructure and support to ensure the adequate provision of care.
(3)
The trauma service shall maintain oversight of the admitted patient until trauma
care is no longer necessary.
(4)
Level I only: An adult trauma facility shall demonstrate an annual volume of at
least 320 trauma patients with an Injury Severity Score (ISS) of 16 or greater.
F.
Trauma Program Manager
The trauma program manager shall, at a minimum, be a registered nurse and
demonstrate the following qualifications:
(1)
Administrative ability,
(2)
Evidence of educational preparation, and
(3)
Documented clinical experience.
5.
Clinical Requirements for General Surgery
A.
Role/Availability
at
least 320 trauma patients with an Injury Severity Score (ISS) of 16 or greater.
F.
Trauma Program Manager
The trauma program manager shall, at a minimum, be a registered nurse and
demonstrate the following qualifications:
(1)
Administrative ability,
(2)
Evidence of educational preparation, and
(3)
Documented clinical experience.
5.
Clinical Requirements for General Surgery
A.
Role/Availability
(1)
The on-call attending trauma surgeon shall be in the emergency department on
patient arrival, as set forth below, for the highest level of activation, with
adequate notification from the field. The maximum response time is 15 minutes,
tracked from patient arrival, 80 percent of the time. The Multidisciplinary Trauma
Committee shall monitor compliance of the attending surgeon’s arrival times.
(2)
A resident in postgraduate year four or five may begin resuscitation while
awaiting arrival of the attending surgeon based on facility-defined criteria.

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B.
Equipment/Resources
The facility shall provide all of the necessary resources, including instruments,
equipment, and personnel, for current surgical trauma care.
C.
Qualifications/Board Certification
(1)
Except as provided below in subparagraph 2, all general surgeons on the trauma
panel shall be fully credentialed in critical care and board certified in surgery by
the American Board of Surgery (ABS), the Bureau of Osteopathic Specialists and
Boards of Certification, or the Royal College of Physicians and Surgeons of
Canada; or shall be board eligible, working toward certification, and less than five
years out of residency.
(2)
A foreign-trained, non-ABS boarded surgeon shall have the foreign equivalent of
ABS certification in general surgery, clinical expertise in trauma care, an
unrestricted Colorado license, and unrestricted credentials in surgery and critical
care at the facility.
D.
Clinical Commitment/Involvement
r shall be board eligible, working toward certification, and less than five
years out of residency.
(2)
A foreign-trained, non-ABS boarded surgeon shall have the foreign equivalent of
ABS certification in general surgery, clinical expertise in trauma care, an
unrestricted Colorado license, and unrestricted credentials in surgery and critical
care at the facility.
D.
Clinical Commitment/Involvement
(1)
All general surgeons on the trauma panel shall have general surgical privileges.
(2)
The general surgeon on call shall be dedicated to one trauma facility when taking
trauma call.
(3)
A published general surgery back-up call schedule shall be available. The back-
up surgeon shall be present within 30 minutes of being requested to respond.
(4)
An attending surgeon shall be present at all trauma operations. The surgeon’s
presence shall be documented.
(5)
The performance of all surgeons on the trauma panel shall be reviewed annually
by the Trauma Medical Director.
E.
Education/Continuing Education: All general surgeons on the trauma panel shall remain
current in ATLS.
F.
Participation in Statewide Trauma System
Each Level I and II trauma facility shall provide a qualified surgeon as a state reviewer a
minimum of one day per year, if requested by the Department.
6.
Requirements for Emergency Medicine and the Emergency Department
A.
Role/Availability
(1)
The facility shall have a designated emergency department physician director
supported by additional physicians to ensure immediate care for injured patients.
(2)
A physician shall be present in the emergency department at all times.
(3)
In facilities with emergency medicine residents, an in-house attending emergency
physician shall provide supervision of the residents 24 hours per day.

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38
tional physicians to ensure immediate care for injured patients.
(2)
A physician shall be present in the emergency department at all times.
(3)
In facilities with emergency medicine residents, an in-house attending emergency
physician shall provide supervision of the residents 24 hours per day.

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(4)
The facility shall designate an emergency physician to serve as the emergency
medicine liaison to the trauma service.
B.
Equipment/Resources
The trauma facility shall provide all of the necessary resources, including instruments,
equipment, and personnel, for current emergency trauma care.
C.
Qualifications/Board Certification
(1)
All emergency physicians on the trauma panel shall have successfully completed
ATLS at least once.
(2)
Physicians providing initial resuscitation in the emergency department shall be:
(a)
Board certified in emergency medicine, or
(b)
Have current ATLS.
(3)
Board certification shall be issued by a certifying entity that is nationally
recognized in the United States.
D.
Clinical Commitment/Involvement
(1)
The roles and responsibilities of the emergency physician shall be defined,
agreed on, and approved by the Trauma Medical Director.
(2)
Emergency physicians on the call panel shall be regularly involved in the care of
the injured patient.
(3)
The performance of all emergency physicians on the trauma panel shall be
reviewed annually by the emergency medicine liaison or designated
representative.
E.
Nursing Services
(1)
A qualified nurse shall be available 24 hours per day to provide care for patients
during the emergency department phase of care. Nursing personnel with special
capability in trauma care shall provide continual monitoring of the trauma patient
from hospital arrival to disposition in Intensive Care Unit (ICU), Operating Room
(OR), or Patient Care Unit (PCU).
representative.
E.
Nursing Services
(1)
A qualified nurse shall be available 24 hours per day to provide care for patients
during the emergency department phase of care. Nursing personnel with special
capability in trauma care shall provide continual monitoring of the trauma patient
from hospital arrival to disposition in Intensive Care Unit (ICU), Operating Room
(OR), or Patient Care Unit (PCU).
(2)
The nurse/patient ratio shall be appropriate for the acuity of the trauma patients
in the emergency department.
7.
Clinical Requirements for Neurosurgery
A.
Role/Availability
(1)
The facility shall designate a neurosurgeon to serve as the neurosurgical liaison
to the trauma service.
(2)
The facility shall define criteria for neurosurgical attending response.

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6 CCR 1015-4
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39
(3)
Neurosurgical care must be continuously available for all traumatic brain injury
and spinal cord injury patients and must be present within 30 minutes, based on
the facility's neurosurgical response criteria.
(4)
Compliance with the 30 minute response time to neurosurgical presence shall be
monitored by the trauma program and presented to the multidisciplinary trauma
committee.
(5)
Level I availability:
The facility shall provide a neurosurgical on-call schedule, dedicated only to that
facility, available 24 hours per day, and either a posted backup call schedule or a
contingency plan that includes bypass and transfer guidelines with another
designated Level I, or in the event that no other Level I is available, then to a
Level II facility with the necessary resources to meet the patient's needs.
The facility shall provide a neurosurgical on-call schedule, dedicated only to that
facility, available 24 hours per day, and either a posted backup call schedule or a
contingency plan that includes bypass and transfer guidelines with another
designated Level I, or in the event that no other Level I is available, then to a
Level II facility with the necessary resources to meet the patient's needs.
(6)
Level II availability:
a.
The facility shall provide a neurosurgical on-call schedule, dedicated only
to that facility, available 24 hours per day, and either a posted backup
call schedule or a contingency plan that includes bypass and transfer
guidelines with a designated Level I or II facility with the necessary
resources to meet the patient's needs; or
b.
If neurosurgeons take call at more than one facility (either trauma or non-
trauma) at a time, written primary and backup call schedules are required
and a contingency plan that includes bypass and transfer guidelines with
a designated Level I or II facility.
B.
Equipment/Resources
The facility shall provide all of the necessary resources, including instruments,
equipment, and personnel for current neurotrauma care.
C.
Qualifications
(1)
Neurosurgeons must be:
a.
Board certified in neurosurgery, or
b.
Board eligible and less than seven years from residency, or
c.
Have current ATLS, if no longer boarded or board eligible.
(2)
All board certifications shall be issued by a certifying entity that is nationally
recognized in the United States.
D.
Clinical Commitment/Involvement
(1)
Neurosurgeons shall be credentialed by the hospital with general neurosurgical
privileges.
(2)
Qualified neurosurgeons shall be regularly involved in the care of the head and
spinal cord injured patients.

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40
that is nationally
recognized in the United States.
D.
Clinical Commitment/Involvement
(1)
Neurosurgeons shall be credentialed by the hospital with general neurosurgical
privileges.
(2)
Qualified neurosurgeons shall be regularly involved in the care of the head and
spinal cord injured patients.

CODE OF COLORADO REGULATIONS
6 CCR 1015-4
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40
(3)
The performance of all neurosurgeons on the trauma panel shall be reviewed
annually by the liaison or designated representative.
8.
Clinical Requirements for Orthopedic Surgery
A.
Role/Availability/Specialists
(1)
The facility shall designate an orthopedic surgeon to serve as the orthopedic
liaison to the trauma program.
(2)
The facility shall define criteria for the orthopedic surgeon attending response.
(3)
Orthopedic care must be continuously available for patients and must be present
within 30 minutes based on the facility's orthopedic response criteria.
(4)
Compliance with the 30 minute response time to orthopedic presence shall be
monitored by the trauma program and presented to the multidisciplinary trauma
committee.
(5)
Level I availability:
The facility shall provide an orthopedic on-call schedule, dedicated only to that
facility, available 24 hours per day and either a posted backup call schedule or a
contingency plan that includes bypass and transfer guidelines with another
designated Level I, or in the event that no other Level I is available, then to a
Level II facility with the necessary resources to meet the patient's needs.
y:
The facility shall provide an orthopedic on-call schedule, dedicated only to that
facility, available 24 hours per day and either a posted backup call schedule or a
contingency plan that includes bypass and transfer guidelines with another
designated Level I, or in the event that no other Level I is available, then to a
Level II facility with the necessary resources to meet the patient's needs.
(6)
Level II availability:
a.
The facility shall provide an orthopedic on-call schedule, dedicated only
to that facility, available 24 hours per day and either a posted backup call
schedule or a contingency plan that includes bypass and transfer
guidelines with a designated Level I or II facility with the necessary
resources to meet the patient's needs; or
b.
If orthopedic surgeons take call at more than one facility (either trauma
or non-trauma) at a time, written primary and backup call schedules are
required and a contingency plan that includes bypass and transfer
guidelines with a designated Level I or II facility.
(7)
A fully credentialed spine surgeon shall be promptly available, as defined by the
facility, 24 hours per day.
(8)
Level I only: At least one orthopedic traumatologist with a minimum of six to
twelve months of fellowship training (or equivalent) shall be a part of the trauma
team.
B.
Equipment/Resources
The facility shall provide all of the necessary resources including instruments, equipment,
and personnel for current musculoskeletal trauma care.
C.
Qualifications
(1)
Orthopedic surgeons must be:

CODE OF COLORADO REGULATIONS
6 CCR 1015-4
Health Facilities and Emergency Medical Services Division

41
a.
Board certified, or
b.
Board eligible and less than seven years from residency, or
c.
Have current ATLS, if no longer boarded or board eligible.
(2)
All board certifications shall be issued by a certifying entity that is nationally
recognized in the United States.
D.
Clinical Commitment/Involvement
(1)
Orthopedic surgeons shall be credentialed by the hospital with general
orthopedic privileges.
a.
Board certified, or
b.
Board eligible and less than seven years from residency, or
c.
Have current ATLS, if no longer boarded or board eligible.
(2)
All board certifications shall be issued by a certifying entity that is nationally
recognized in the United States.
D.
Clinical Commitment/Involvement
(1)
Orthopedic surgeons shall be credentialed by the hospital with general
orthopedic privileges.
(2)
Orthopedic surgeons on the call panel shall be regularly involved in the care of
the trauma patient.
(3)
The performance of all orthopedic surgeons on the trauma panel shall be
reviewed annually by the liaison or designated representative.
9.
Pediatric Trauma Care
A.
Pediatric trauma care shall refer to care delivered to children under age 15.
B.
Level I and II adult trauma facilities can and will receive pediatric trauma patients. All
adult Level I and II facilities shall:
(1)
Provide evidence of safe pediatric trauma care to include age-specific medical
devices and equipment as appropriate for the resuscitation and stabilization of
the pediatric patient.
(2)
Assure that the physician and nursing staff providing care to the pediatric patient
demonstrates competency in the care of the injured child appropriate to the type
of injured child.
(3)
Demonstrate oversight of the pediatric care provided through a pediatric-specific
peer review/performance improvement process.
C.
Nonaccidental Trauma
(1)
Pediatric patients with suspected or evidence of nonaccidental trauma requiring
social or clinical care beyond the facility's resources shall be transferred to a
Regional Pediatric Trauma Center or to a Level I or II trauma center with the
necessary resources that admits pediatric trauma patients. The receiving trauma
center must meet the requirements set forth in

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## Nearby sections

- [6 CCR 1011-1 Chapter 22 CHAPTER 22 - BIRTH CENTERS](https://www.frixlaw.com/law-library/statutes/STATE_CO_CCR_6_CCR_1011_1_Chapter_22.md)
- [6 CCR 1011-1 Chapter 24 CHAPTER 24 - MEDICATION ADMINISTRATION REGULATIONS](https://www.frixlaw.com/law-library/statutes/STATE_CO_CCR_6_CCR_1011_1_Chapter_24.md)
- [6 CCR 1011-1 Chapter 25 CHAPTER 25 - RURAL PRIMARY CARE HOSPITALS [Repealed eff. 11/01/2004]](https://www.frixlaw.com/law-library/statutes/STATE_CO_CCR_6_CCR_1011_1_Chapter_25.md)
- [6 CCR 1011-1 Chapter 26 CHAPTER 26 - HOME CARE AGENCIES](https://www.frixlaw.com/law-library/statutes/STATE_CO_CCR_6_CCR_1011_1_Chapter_26.md)
- [6 CCR 1011-3 STANDARDS FOR COMMUNITY INTEGRATED HEALTH CARE SERVICE AGENCIES](https://www.frixlaw.com/law-library/statutes/STATE_CO_CCR_6_CCR_1011_3.md)
- [6 CCR 1011-4 STANDARDS FOR SECURE TRANSPORTATION SERVICES](https://www.frixlaw.com/law-library/statutes/STATE_CO_CCR_6_CCR_1011_4.md)
- [6 CCR 1015-1 EMERGENCY MEDICAL SERVICES ACCOUNT](https://www.frixlaw.com/law-library/statutes/STATE_CO_CCR_6_CCR_1015_1.md)
- [6 CCR 1015-2 IMPLEMENTATION OF CARDIOPULMONARY RESUSCITATION (CPR) DIRECTIVES BY EMERGENCY MEDICAL SERVICE PROVIDERS](https://www.frixlaw.com/law-library/statutes/STATE_CO_CCR_6_CCR_1015_2.md)
- [6 CCR 1015-3 EMERGENCY MEDICAL SERVICES](https://www.frixlaw.com/law-library/statutes/STATE_CO_CCR_6_CCR_1015_3.md)
- [6 CCR 1015-4 STATEWIDE EMERGENCY MEDICAL AND TRAUMA CARE SYSTEM](https://www.frixlaw.com/law-library/statutes/STATE_CO_CCR_6_CCR_1015_4.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_CO_CCR_6_CCR_1015_4. Check the current official text before relying on it. Not legal advice.