Trauma Protocol Information

Each Ohio hospital is required to have the following as applicable:

Hospitals that are not trauma centers. Must adopt protocols for adult and pediatric trauma care provided in or by that hospital.

Hospitals that are adult trauma centers and not Level I or Level II pediatric trauma centers. Must adopt protocols for pediatric trauma care provided in or by that hospital.

Hospitals that are pediatric trauma center and not Level I or Level II adult trauma centers. Must adopt protocols for adult trauma care provided in or by that hospital.

Trauma Protocols Requirements

The protocols must consider the guidelines for trauma care established by the American College of Surgeons, the American College of Emergency Physicians, and the American Academy of Pediatrics.

The protocols must be in writing;

The protocols must comply with applicable federal and state laws;

The protocols must include policies and procedures with respect to all of the following:

1. Evaluation of trauma patients, including criteria for prompt identification of trauma patients who require a level of adult or pediatric trauma care that exceeds the hospital's capabilities;

2. Emergency treatment and stabilization of trauma patients prior to transfer to an appropriate adult or pediatric trauma center;

3. Timely transfer of trauma patients to appropriate adult or pediatric trauma centers based on a patient's medical needs. Trauma patient transfer protocols shall specify all of the following:

   1. Confirmation of the ability of the receiving trauma center to provide prompt adult or pediatric trauma care appropriate to a patient's medical needs;

   2. Procedures for selecting an appropriate alternative adult or pediatric trauma center to receive a patient when it is not feasible or safe to transport the patient to a particular trauma center;

   3. Advance notification and appropriate medical consultation with the trauma center to which a trauma patient is being, or will be, transferred;

   4. Procedures for selecting an appropriate method of transportation and the hospital responsible for arranging or providing the transportation;

   5. Confirmation of the ability of the persons and vehicle that will transport a trauma patient to provide appropriate adult or pediatric trauma care;

   6. Assured communication with, and appropriate medical direction of, the persons transporting a trauma patient to a trauma center;

   7. Identification and timely transfer of appropriate medical records of the trauma patient being transferred;

   8. The hospital responsible for care of a patient in transit;

   9. The responsibilities of the physician attending a patient and, if different, the physician who authorizes a transfer of the patient;

   10. Procedures for determining, in consultation with an appropriate adult or pediatric trauma center and the persons who will transport a trauma patient, when transportation of the patient to a trauma center may be delayed for either of the following reasons:

       1. Immediate transfer of the patient is unsafe due to adverse weather or ground conditions.

       2. No trauma center is able to provide appropriate adult or pediatric trauma care to the patient without undue delay.

4. Peer review and quality assurance procedures for adult and pediatric trauma care provided in or by the hospital.

Note that the trauma care protocols must be made available for public inspection during normal working hours. The hospital must furnish a copy of the protocols upon request and may charge a reasonable and necessary fee for doing so (except when such protocols are requested by the Ohio Department of Health).