# Title 33 — State Department of Health

## Article 33-38 — State Trauma System

## Chapter 33-38-01 — Trauma System Regulation

### § 33-38-01-01. Definitions.

Words defined in North Dakota Century Code chapter 23-01.2 have the same meaning in this
chapter. As used in this chapter:
1. "Advanced trauma life support" means the most current edition of the course as developed by
the American college of surgeons - committee on trauma, or its equivalent, as determined by
the department.
2. "Department" means the state department of health.
3. "Emergency medical services" means the system of personnel who provide medical care from
the time of injury to hospital admission.
4. "Local emergency medical services transport plans" means plans developed by emergency
medical services, medical directors, and hospital officials which establish the most efficient
method to transport trauma patients.
5. "Major trauma patient" means any patient that meets the criteria in step one or two of the field
triage decision scheme provided by the American college of surgeons, committee on trauma,
as published by the most current edition of the Resources for Optimal Care of the Injured
Patient.
6. "Online medical control" consists of directions given over the telephone or by radio directly
from the medical director or designated physician.
7. "Provisional designation" means a state process of designating a facility as a trauma center
based on American college of surgeons or department standards for a period determined by
the department and the state trauma committee or until an American college of surgeons
verification visit or state designation visit is completed.

8. "Trauma" means tissue damage caused by the transfer of thermal, mechanical, electrical, or
chemical energy, or by the absence of heat or oxygen.
9. "Trauma center" means a facility that has made a commitment to serve the trauma patient,
has met the standards of the trauma system, and has obtained designation as a trauma
center.
10. "Trauma code" includes the activation and assembly of the trauma team to provide care to the
major trauma patient.
11. "Trauma quality improvement program" means a system of evaluating the prehospital, trauma
center, and rehabilitative care of trauma patients.
12. "Trauma registry" includes the collection and analysis of trauma data from the trauma system.
13. "Trauma team" includes a group of health care professionals organized to provide care to the
trauma patient.
History: Effective July 1, 1997; amended effective June 1, 2001; July 1, 2010.
General Authority: NDCC 23-01.2-01
Law Implemented: NDCC 23-01.2-01
### § 33-38-01-02. Trauma system.

A statewide trauma system shall be adopted by the state health council. The trauma system shall
consist of the following:
1. Standardized definition of major trauma patient.
2. Trauma code activation protocols.
3. Local emergency medical services transport plans.
4. Trauma center designation process.
5. Revocation of trauma center designation process.
6. Statewide trauma registry.
7. Quality improvement process.
8. State trauma committee.
9. Four regional trauma committees.
10. Injury prevention.
History: Effective July 1, 1997; amended effective July 1, 2010.
General Authority: NDCC 23-01.2-01
Law Implemented: NDCC 23-01.2-01
### § 33-38-01-03. Activation of trauma codes for trauma patients.

Emergency medical services and trauma centers shall assess patients and activate a trauma code.
1. Emergency medical services must activate a trauma code if the trauma patient meets one or
more of the criteria in step one, two, or three of the field triage decision scheme, provided by
the current edition of the American college of surgeons Resources for Optimal Care of the
Injured Patient. Step four of the field triage scheme may be used as discretionary criteria for

activating trauma code. The field triage scheme is used as a minimal standard and additional
activation criteria may be added.
2. A level I, level II, or level III trauma center must follow the minimum criteria for highest level of
activation set by the American college of surgeons committee on trauma.
3. A level IV and level V trauma center must activate a trauma code if the trauma patient meets
one or more of the criteria in step one, two, or three of the field triage decision scheme,
provided by the current edition of the American college of surgeons Resources for Optimal
Care of the Injured Patient. Step four of the field triage scheme may be used as discretionary
criteria for activating trauma code. The field triage scheme is used as a minimal standard and
additional activation criteria may be added.
History: Effective July 1, 1997; amended effective July 1, 2010.
General Authority: NDCC 23-01.2-01
Law Implemented: NDCC 23-01.2-01
### § 33-38-01-04. Emergency medical services.

All emergency medical services licensed or certified by the department shall establish each of the
following:
1. Trauma code activation protocols.
2. Trauma patient care protocols that have been reviewed and approved by a medical director.
3. Local emergency medical services transport plans.
History: Effective July 1, 1997.
General Authority: NDCC 23-01.2-01
Law Implemented: NDCC 23-01.2-01
### § 33-38-01-05. Local emergency medical services transport plans.

Emergency medical services shall develop local emergency medical services transport plans for
the transport of trauma patients meeting the criteria in step one, two, three, or four of the field triage
decision scheme, provided by the current edition of the American college of surgeons Resources for
Optimal Care of the Injured Patient by appropriate means to the nearest designated trauma center.
1. Emergency medical services may bypass the nearest designated trauma center for a higher
level trauma center provided that it does not result in an additional thirty minutes or more of
transport time. If the additional transport time would be greater than thirty minutes, the
transporting emergency medical services personnel must contact online medical direction for
permission to bypass or as defined in the transport protocol.
2. If there are multiple trauma centers in the community, the major trauma patient meeting one or
more of the criteria in step one or two of the field triage decision scheme provided by the
current edition of the American college of surgeons Resources for Optimal Care of the Injured
Patient should be taken to a trauma center per local emergency medical trauma transport
plans approved by the department and state trauma committee.
History: Effective July 1, 1997; amended effective June 1, 2001; July 1, 2010.
General Authority: NDCC 23-01.2-01
Law Implemented: NDCC 23-01.2-01
### § 33-38-01-06. Trauma center designation.

1. Five levels of hospital designation must be established.

2. Hospitals applying for level I, level II, or level III designation shall present evidence of having
current trauma center verification from the American college of surgeons. The department
shall issue designation with an expiration date consistent with the American college of
surgeons verification expiration date.
3. Hospitals applying for level IV and level V trauma center designation must submit an
application to the department. Once the application is approved by the department, an onsite
verification visit shall be conducted by the department or its designee. The verification team
shall compile a report. The application and report will be reviewed by the state trauma
committee. If approved, the department shall issue the designation for up to three years to the
facility.
4. Hospitals without trauma center designation or currently designated as a level IV or level V
trauma center planning to apply for a level I, level II, or level III trauma center designation may
apply for a provisional designation by submitting an application to the department. Once the
application is approved by the department, an onsite visit shall be conducted by a team
designated by the state trauma committee. The team shall compile a report. The application
and report will be reviewed by the state trauma committee. If approved, the department shall
issue a provisional designation for a maximum of twenty-four months. During these
twenty-four months, the facility must complete an American college of surgeons verification
visit.
5. Provisional trauma center designations for level I, level II, or level III trauma centers may be
issued by the department to hospitals with deficiencies identified by the American college of
surgeons and that are partially compliant with the trauma center standards. Hospitals must
submit a plan of correction within one month after notification for deficiencies that are
identified by the verification team. The plan of correction will be reviewed by the state trauma
committee. If approved, the department may issue a provisional designation to the hospital for
up to eighteen months or until another American college of surgeons verification visit is
completed.
6. Provisional trauma center designations for level IV and level V trauma centers may be issued
by the department to hospitals with deficiencies identified by the site survey team and
reviewed by the state trauma committee and are partially compliant with the trauma center
standards. Hospitals must submit a plan of correction within one month after notification for
deficiencies that are identified by the site survey team. The plan of correction will be reviewed
by the state trauma committee. If approved, the department may issue a provisional
designation for up to twelve months to the hospital or until another state designation visit is
completed.
7. The health council, in establishing a comprehensive trauma system, may designate an
out-of-state hospital as a trauma center within fifty miles of any border of North Dakota.
History: Effective July 1, 1997; amended effective June 1, 2001; July 1, 2010.
General Authority: NDCC 23-01.2-01
Law Implemented: NDCC 23-01.2-01
### § 33-38-01-07. Trauma center revocation of designation.

The department may revoke designation of a trauma center if evidence exists that the facility does
not meet the required trauma center standards. The department or its designee may inspect any
trauma center or applicant for trauma center designation at any time for compliance with the standards.
Designation must be revoked if a facility denies or refuses inspection.
Failure to follow an approved plan of correction or maintain trauma center designation standards
will result in:

1. Revocation of the trauma center's designation.
2. Notification to the division of health facilities regarding the failure to comply with state law.
3. Placement of a public notice in the newspapers in the area which the hospital is located to
notify the public of the enforcement action to be imposed and the effective dates. The
department shall notify the hospital in writing of the impending notice fifteen days prior to the
publication of the notice.
History: Effective July 1, 1997; amended effective July 1, 2010.
General Authority: NDCC 23-01.2-01
Law Implemented: NDCC 23-01.2-01
### § 33-38-01-08. State trauma registry.

The department shall establish a trauma registry including the minimum data elements. All
hospitals must report the minimum data elements to the department.
Reporting shall occur by a method approved by the department. Information may not be released
from the state trauma registry except as permitted by North Dakota Century Code sections 23-01-15
and 23-01-02.1.
History: Effective July 1, 1997; amended effective June 1, 2001; July 1, 2010.
General Authority: NDCC 23-01.2-01
Law Implemented: NDCC 23-01.2-01
### § 33-38-01-09. Quality improvement process.

A quality improvement process shall be established by the state trauma committee. The process
must include evaluation criteria that will provide guidelines for acceptable standards of care, address
system issues, and monitor patient outcomes.
The regional committees shall evaluate the trauma system within their regions based upon the
evaluation criteria. The regional trauma committee shall make recommendations to emergency medical
services and trauma centers in the development of plans to improve the system.
History: Effective July 1, 1997; amended effective July 1, 2010.
General Authority: NDCC 23-01.2-01
Law Implemented: NDCC 23-01.2-01
### § 33-38-01-10. State trauma committee membership.

The state trauma committee membership must include the following:
1. One member from the North Dakota committee on trauma - American college of surgeons,
appointed by the committee.
2. One member from the American college of emergency physicians - North Dakota chapter,
appointed by the chapter.
3. One member from the North Dakota health care association, appointed by the association.
4. One member from the North Dakota medical association, appointed by the association.
5. One member from the North Dakota EMS association - basic life support, appointed by the
association.

6. One member from the North Dakota EMS association - advanced life support, appointed by
the association.
7. One member from the North Dakota nurses association, appointed by the association.
8. One member on the faculty of the university of North Dakota school of medicine and health
sciences, appointed by the dean of the medical school.
9. One member from the North Dakota emergency nurses association, appointed by the
association.
10. One member from Indian health service, appointed by the Aberdeen area director of the
service.
11. One member from accredited trauma rehabilitation facilities, appointed by the state health
council.
12. One member who is a hospital trauma coordinator, appointed by the trauma coordinators
committee.
13. The medical director of the division of emergency medical services and trauma of the
department.
14. The regional trauma committee chair from each region, if not representing an association.
15. One member representing injury prevention, appointed by the health council.
16. One member representing the public appointed by the health council.
17. One member representing the legislative assembly selected by the health council.
18. One member representing emergency preparedness and response appointed by the
department.
19. One member representing pediatric physicians appointed by the North Dakota American
academy of pediatrics.
20. Four additional ad hoc members, appointed by the health council.
History: Effective July 1, 1997; amended effective June 1, 2001; July 1, 2010.
General Authority: NDCC 23-01.2-01
Law Implemented: NDCC 23-01.2-01
### § 33-38-01-11. Trauma regions - Regional trauma committee.

The state trauma committee shall establish four trauma regions. The regions must be designated
northwest, northeast, southeast, and southwest. An emergency medical service or trauma center that is
located within fifteen miles [24.14 kilometers] of a regional boundary may request to function within
another region. This request shall be reviewed and is subject to approval by the state trauma
committee.
The state trauma committee shall appoint a regional trauma committee to serve each trauma
region. The regional committees may consist of members representing the following:
1. North Dakota committee on trauma - American college of surgeons.
2. North Dakota chapter of American college of emergency physicians.
3. Physician of a level IV and level V trauma center.

4. Level IV or level V hospital representative.
5. All hospital trauma coordinators within the region.
6. Accredited rehabilitation facility representative.
7. Indian health service or tribal government representative.
8. North Dakota EMS association.
9. Other members, chosen by the state trauma committee.
History: Effective July 1, 1997; amended effective June 1, 2001; July 1, 2010.
General Authority: NDCC 23-01.2-01
Law Implemented: NDCC 23-01.2-01
### § 33-38-01-12. Trauma center name restriction.

No health care facility in North Dakota may use the title "trauma center" or otherwise hold itself out
as a trauma center unless the facility is designated by the department as a trauma center.
History: Effective July 1, 1997.
General Authority: NDCC 23-01.2-01
Law Implemented: NDCC 23-01.2-01
### § 33-38-01-13. Level IV trauma center designation standards.

The following standards must be met to achieve level IV designation:
1. Trauma team activation plan.
2. Trauma team leader must be a physician currently certified in advanced trauma life support
who is on call and available within twenty minutes. If the trauma team leader is not current in
advanced trauma life support, the facility must provide a backup physician that is current in
advanced trauma life support to assess and evaluate the trauma patients meeting step one,
two, or three of the field triage decision scheme, provided by the current edition of the
American college of surgeons Resources for Optimal Care of the Injured Patient when the
noncertified physician is on call. If backup cannot be provided, the facility must go on diversion
and notify the surrounding emergency medical services and the department.
3. The facility must have transfer agreements with facilities capable of caring for major trauma
patients, burn care, pediatric trauma management, acute spinal cord and traumatic brain
injury management, and rehabilitation services for long-term care.
4. Equipment for resuscitation and life support as determined by the department and state
trauma committee.
5. Quality improvement programs, to include:
a. Focused audit of selected criteria.
b. Trauma registry in accordance with section 33-38-01-08.
c. Focused audit for all trauma deaths.
d. Morbidity and mortality review.
e. Medical nursing audit, utilization review, and issue review.

6. Trauma transfer protocol to identify trauma patients whose condition may require care which
exceeds current resources available.
History: Effective June 1, 2001; amended effective July 1, 2010.
General Authority: NDCC 23-01.2-01
Law Implemented: NDCC 23-01.2-01
### § 33-38-01-14. Level V trauma designation standards.

The following standards must be met to achieve level V designation:
1. Trauma team activation plan.
2. Trauma team leader must be on call and available within twenty minutes. The trauma team
leader must be one of the following:
a. A physician who is current in advanced trauma life support.
b. A physician assistant, whose supervising physician has delegated to the physician
assistant the authority to provide care to trauma patients and is current in advanced
trauma life support.
c. A nurse practitioner whose scope of practice entails the care of trauma patients, is
current in advanced trauma life support, and whose scope of practice is approved by the
state board of nursing.
d. If the trauma team leader is not current in advanced trauma life support, the facility must
provide a backup team leader that is current in advanced trauma life support to assess
and evaluate the trauma patients meeting step one, two, or three of the field triage
decision scheme, provided by the current edition of the American college of surgeons
Resources for Optimal Care of the Injured Patient when the noncertified provider is on
call. If backup cannot be provided, the facility must go on diversion and notify the
surrounding emergency medical services and the department.
3. The facility must have transfer agreements with facilities capable of caring for major trauma
patients, burn care, pediatric trauma management, acute spinal cord and traumatic brain
injury management, and rehabilitation services for long-term care.
4. Equipment for resuscitation and life support as determined by the department.
5. Quality improvement programs to include:
a. Focused audit of selected criteria.
b. Trauma registry in accordance with section 33-38-01-08.
c. Focused audit for all trauma deaths.
d. Morbidity and mortality review.
e. Medical nursing audit, utilization review, and issue review.
f. Current advanced trauma life support certified physician review of all trauma codes
managed by a physician assistant or nurse practitioner within seventy-two hours. This
may be either the consulting or transfer receiving physician.
6. Trauma transfer protocols to identify trauma patients whose condition may require care which
exceeds current resources available.

History: Effective June 1, 2001; amended effective July 1, 2010.
General Authority: NDCC 23-01.2-01
Law Implemented: NDCC 23-01.2-01
