/policies/,/policies/clinical/,/policies/clinical/uw-health-clinical/,/policies/clinical/uw-health-clinical/emergency-response/,

/policies/clinical/uw-health-clinical/emergency-response/5112.policy

20160374

page

100

UWHC,UWMF,

Policies,Clinical,UW Health Clinical,Emergency Response/Management

Pediatric Trauma: Trauma Diversion (5.1.12)

Pediatric Trauma: Trauma Diversion (5.1.12) - Policies, Clinical, UW Health Clinical, Emergency Response/Management

5.1.12


UW HEALTH CLINICAL POLICY 1
Policy Title: Pediatric Trauma: Trauma Diversion
Policy Number: 5.1.12
Category: UW Health
Type: Inpatient
Effective Date: March 10, 2016

I. PURPOSE

To provide guidance that w ill determine w hen to place the Level I trauma center at American Family
Children’s Hospital (AFCH) on “divert status” and define the communications pathw ay so that all involved
parties are aw are of the status of the trauma center w ith respect to accepting new patients.

II. POLICY ELEMENTS

The Level I trauma center at AFCH w ill w ork to avoid trauma diversion. As the only Pediatric Level I trauma
center in the region, Emergency Medical Services (EMS) and referring hospitals look to us to care for their
injured patients on a daily basis. Trauma diversion ultimately does not occur unless the institution is in under
conditions that w ould prohibit providing necessary care to trauma patients.

III. PROCEDURE

A. Determining Trauma Diversion Status
i. The trauma center w ill be open and available for the acceptance of all trauma patients unless a
specif ic “trauma divert” status has been declared by the Hospital Administrator on call and the
Nursing Administrator on call after communication w ith the AFCH Medical Director or designee and
the AFCH Director of Pediatric Nursing or designee. The level of Divert status w ill be classif ied as
one of the follow ing:
a. Hospital diversion:
1. The hospital has been determined to be unable to admit trauma patients due to
circumstances that prohibit the ability to provide the necessary care, this is
independent of the Emergency Department’s (ED) ability to resuscitate and
stabilize trauma patients prior to transferring them to other trauma centers. (Refer
to UWHC Administrative Policy 7.44 American Family Children’s Hospital
Admissions for guidance on procedures for times of high census)
2. Consideration by the Hospital Administrator on call and the Nursing Administrator
on call after consultation w ith the AFCH Medical Director or designee, and The
Director of Pediatric Nursing or designee, should be made for the diversion of
non-trauma patients to another facility in order to secure a bed for a trauma
patient.
3. The ED is able to resuscitate and stabilize a patient but the patient may be
transferred to another Level I or II trauma center for inpatient care.
b. Complete ED and Hospital diversion:
1. No trauma patients can be accepted to the ED or hospital.
2. Patients are diverted to the closest appropriate trauma center.
ii. Pediatric Trauma diversion status both Complete (ED and Hospital), and Hospital Diversion can
only be enacted follow ing a conversation betw een the Medical Director of Pediatric Trauma or
designee, the Attending Pediatric Trauma Surgeon on call, the ED MD Administrator on call, the
Director of Pediatric Inpatient Nursing or the AFCH Vice President of Clinical Operations, the AFCH
Medical Director, the Hospital Administrator on call, and the Nursing Administrator on call. The
Pediatric Trauma Program Manager is available for consultation.
a. Hospital diversion
1. The Director of Nursing Operations and Support, in communication w ith the
Associate Chief Nursing Officer or Chief Nursing Officer, the Director of Pediatric
Inpatient Nursing or the AFCH Vice President of Clinical Operations, and the
AFCH Medical Director or designee, w ill determine hospital diversion status.
2. If there are admissions from the ED, call the closed appropriate Level I or II
trauma center to check ED and bed availability.
3. Options for other trauma center transfers are:
Children’s Hospital of Wisconsin- Milw aukee: Level 1: 414-266-2460
b. Complete ED and Hospital diversion



UW HEALTH CLINICAL POLICY 2
Policy Title: Pediatric Trauma: Trauma Diversion
Policy Number: 5.1.12

In addition to all steps for Hospital diversion:
1. The Pediatric Director of Surgical Services, or designee should be consulted to
explore using the AFCH PACU as a temporary alternative care location
2. The Director of Emergency Services and the Director of Nursing Operations and
Support should be contacted to problem solve capacity and/ or staff ing issues.
The Nursing Administrator on call may also be consulted.
B. Communicating Diversion Status (internal) once a diversion has been determined
i. The ED Attending w ill notify the ED Care Team Leader (ED CTL)
ii. The ED CTL w ill notify the Nursing Coordinator of the diversion status.
iii. The Nursing Coordinator w ill notify the Access Center.
iv. The Access Center to notify Med Flight so the f light team can be aw are of the of the hospital’s
status to accept patients.
v. The Access Center w ill place the diversion status on EM Resource (formerly Know n as WI Trac)
and update it as the situation changes.
C. Communicating Diversion Status External
i. Hospital and ED Diversion
a. The Nursing Coordinator w ill notify Meriter and St. Mary’s Hospitals of the trauma
diversion status and update them as the situation changes.
1. Meriter Hospital- Access Center 608-417-5755 or Emergency Department 608-
417-6206
2. St. Mary’s Hospital- Transfer Center 608-389-2600 or Emergency Department
608-389-3990
b. The ED CTL w ill notify Dane County Communications of the trauma diversion status and
update them as the situation changes. Dane County Communications: 608-266-4135
D. Return to Patient Acceptance
i. The Pediatric Trauma Medical Director or designee, The Pediatric Trauma Surgeon on call, The
Director of Pediatric Inpatient Nursing or the AFCH Vice President of Clinical Operations, The
AFCH Medical Director or designee, Nursing Administrator and Emergency Department Attending
w ill review the ongoing diversion status to determine w hen the diversion can be stopped.
ii. When AFCH is able to accept trauma patients, the Trauma Medical Director or designee, w ith the
help of the Nursing Coordinator w ill inform MedFlight, and Access Center respectively that AFCH is
no longer in diversion status.
iii. The Nursing Administrator on call w ill notify the Associate Chief Nursing Officer or Chief Nursing
Officer and the Hospital Administrator on call w ill notify any additional executive leadership team
members that w ere notif ied of the decision to go on trauma divert status.
iv. The Access Center w ill update the status on EM Resource.
v. The Nursing Coordinator w ill notify the area hospitals listed above that AFCH can accept trauma
patients.
vi. The ED CTL w ill notify Dane County Communications that AFCH can accept trauma patients
vii. The Nursing Coordinator w ill complete the Trauma diversion log. See Appendix A. The conditions
responsible for the trauma divert should be documented appropriately and sent to the Trauma
Support Dept.
viii. All diversions w ill be review ed in the Trauma PIPS processes.

IV. FORMS

Appendix A – Trauma Diversion Log

V. COORDINATION

Author: Pediatric Trauma Program Manager
Senior Management Sponsor: AFCH Vice President of Clinical Operations
Review ers: Pediatric Trauma Medical Director; Adult Trauma Medical Director; Director of Surgical and
Psychiatric Nursing; Adult Trauma Program Manager
Approval committees: AFCH Trauma Management Committee; UW Health Clinical Policy Committee;
Medical Board
UW Health Clinical Policy Committee Approval: February 15, 2016




UW HEALTH CLINICAL POLICY 3
Policy Title: Pediatric Trauma: Trauma Diversion
Policy Number: 5.1.12

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter New comer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

American College of Surgeons Committee on Trauma. Resources for the Optimal Care of the Injured
Patient: 2014. Chicago, IL, American College of Surgeons, 2014.
Surgical Services Departmental policy #2.29, Operative Triage of the Trauma Patient
UW Health Clinical Policy #2.2.2, Massive Transfusion Procedure
UWHC Emergency Operations Plan (EOP)
VIII. REVIEW DETAILS
Version: Original
Next Revision Due: March 10, 2019
Formerly Know n as: Hospital Administrative policy #8.21