# COMAR Title 30 — Maryland Institute for Emergency Medical Services Systems (MIEMSS)

## Subtitle 08 — Designation of Trauma and Specialty Referral Centers

### Chapter 05 — Trauma Center Designation and Verification Standards

#### Regulation .04 Medical Staff.

*COMAR 30.08.05.04*

PARC
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            ED
          
        
        
          
            A. Credentialing Process.  Each physician and Advanced Practice Professional (APP) shall be credentialed by the hospital for the appropriate specialty, including trauma care.
            E
            E
            E
            E
            E
          
          
            B. Delineation or Reevaluation of Privileges:
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            E
            E
            E
            NA
          
          
            (1) The trauma physicians and APPs shall be limited to those with demonstrated skills, commitment, experiences, and interest in trauma care.
            E
            E
            E
            E
            NA
          
          
            (2) The trauma medical director shall serve on the medical staff as the trauma chief of service.
            E
            E
            E
            E
            NA
          
          
            (3) Appointment and reappointment to the trauma admitting or consulting staff shall be coordinated by the trauma medical director and based on the following criteria:
            E
            E
            E
            E
            NA
          
          
            (a) Maintenance of good standing in the primary specialty;
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            E
            E
            E
            NA
          
          
            (b) Evidence of the required continuing medical education in trauma, including:
            
            
            
            
            
          
          
            (i) For general surgeons taking trauma calls evidence of 16 hours of trauma-related CME credits a year;
            E
            E
            E
            E
            NA
          
          
            (ii) Over a 2-year period, half of the CME hours shall be obtained outside the hospital and be recognized by a national accrediting body;
            E
            E
            D
            D
            NA
          
          
            (iii) ATLSTM which may be counted in required CME credits; and
            E
            E
            E
            E
            NA
          
          
            (iv) Physician CME credits shall be documented in accordance with hospital policy.
            E
            E
            E
            E
            NA
          
          
            (c) Documented attendance at Trauma QM meetings, as those meetings are institutionally defined, of no less than monthly averaged over 12 months;
            E
            NA
            NA
            NA
            NA
          
          
            (d) Documented attendance at Trauma multidisciplinary meetings, Morbidity and Mortality (MandM)  rounds, or hospital peer-review conference that deal with the care of injured patients; and
            NA
            E
            E
            E
            NA
          
          
            (e) Satisfactory performance in managing trauma patients based on performance assessment and outcome analysis.
            E
            E
            E
            E
            NA