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Adult Trauma: Trauma Diversion (5.1.9)

Adult Trauma: Trauma Diversion (5.1.9) - Policies, Clinical, UW Health Clinical, Emergency Response/Management

5.1.9


UW HEALTH CLINICAL POLICY 1
Policy Title: Adult Trauma: Trauma Diversion
Policy Number: 5.1.9
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 University Hospital 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 University Hospital w ill w ork to avoid trauma diversion. As the only 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 internal disaster mode or there are extenuating circumstances that w ould prohibit the hospital from
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
“trauma divert” status has been declared. 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 to a trauma
patient. This is independent of the Emergency Department’s (ED) ability to
resuscitate and stabilize trauma patients prior to transferring them to other
trauma centers.
2. Consideration 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 or 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. Trauma diversion status can only be enacted follow ing a conversation betw een the Medical
Director of Trauma, the Attending Trauma Surgeon on call, the ED MD Administrator on call, and
the Hospital Administrator Senior Leadership Team on call. The Trauma Program Manager is
available for consultation.
a. Hospital diversion
1. Senior Leadership Team on call, defined as the Hospital Administrator on call
and Nursing Administrator on call w ill determine hospital diversion status.
2. If there are admissions from the ED, call the closest appropriate Level I or II
trauma center to check ED and bed availability.
3. Options for other trauma center transfers are:
Froedtert Memorial Hospital-Milw aukee: Level I: 414-805-6717
b. Complete ED and Hospital diversion
1. In addition to all steps in Hospital diversion, the Director of Emergency Services
should be contacted to problem solve capacity and/ or staff ing issues.
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.



UW HEALTH CLINICAL POLICY 2
Policy Title: Adult Trauma: Trauma Diversion
Policy Number: 5.1.9

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 Trauma Medical Director, Nursing Administrator on call and Emergency Department Attending
on call w ill review the ongoing diversion status to determine w hen the diversion can be stopped.
ii. When UW is able to accept trauma patients, the Trauma Medical Director, w ith the help of the
Nursing Coordinator w ill inform the Trauma Surgeon on call, ED Attending, MedFlight, and Access
Center respectively that UW 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 UW can accept trauma
patients.
vi. The ED CTL w ill notify Dane County Communications that UW 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: Adult Trauma Program Manager
Senior Management Sponsor: SVP, Medical Affairs
Review ers: Adult Trauma Medical Director; Director of Surgical and Psych Nursing; Pediatric Trauma
Program Manager; VP AFCH Clinical Operations
Approval committees: Adult Trauma Operations Committee; UW Health Clinical Policy Committee; Medical
Board
UW Health Clinical Policy Committee Approval: February 15, 2016

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




UW HEALTH CLINICAL POLICY 2
Policy Title: Adult Trauma: Trauma Diversion
Policy Number: 5.1.9

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 #8.11