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<regulation prefix="Regulation" num=".03" citation="COMAR 30.08.08.03" title_num="30" subtitle_num="08" chapter_num="08" heading="Medical Staff.">
  <paragraph num="A.">
    <text>The hospital shall have a credentialing process. Each physician and all advance practice professionals (APPs) shall be credentialed by the hospital for the appropriate specialty, including pediatric trauma care.</text>
  </paragraph>
  <paragraph num="B.">
    <text>The hospital shall have a process for delineation and reevaluation of privileges that includes:</text>
    <paragraph num="(1)">
      <text>A pediatric trauma panel, which shall be limited to those with demonstrated skills, commitment, experience, and interest in pediatric trauma care;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Appointment and reappointment to the pediatric trauma admitting or consulting staff that is coordinated by the medical staff office; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>The delineation of privileges for the pediatric trauma admitting or consulting staff approved by the pediatric TMD based on the following criteria:</text>
      <paragraph num="(a)">
        <text>Maintenance of good standing in the primary specialty;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Evidence of the required continuing medical education in trauma;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Documented attendance at multidisciplinary meetings, morbidity and mortality (M&amp;M) rounds, and hospital peer-review conferences that deal with the care of injured patients; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Satisfactory performance in managing pediatric trauma patients based on performance assessment and outcome analysis.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>The hospital shall have continuing medical education (CME) requirements as follows:</text>
    <paragraph num="(1)">
      <text>Pediatric surgeons taking trauma calls shall have evidence of 16 hours of trauma-related CME credits per year;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>ATLS® may be counted toward the required CME credits;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Successful completion of an ATLS® course, at least once, is required for all attending pediatric surgeons providing pediatric trauma care;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>The TMD and APPs providing pediatric trauma care must maintain a current ATLS® certification; and</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Physician CME credits shall be documented in accordance with hospital policy.</text>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Clinical service requirements are as follows:</text>
    <paragraph num="(1)">
      <text>Pediatric surgery:</text>
      <paragraph num="(a)">
        <text>Board-certified or board-eligible pediatric surgeons trained in trauma care;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Either:</text>
        <paragraph num="(i)">
          <text>An in-house PGY3 or higher resident or attending surgeon, who shall be at the bedside within 15 minutes of being called, with compliance demonstrated at least 80 percent of the time; or</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>An attending pediatric trauma surgeon who takes out-of-the-hospital trauma calls shall be immediately available for consultation and at the bedside within 30 minutes of being called, with compliance demonstrated at least 80 percent of the time; and</text>
        </paragraph>
      </paragraph>
      <paragraph num="(c)">
        <text>General surgery APPs taking trauma call who have documentation of an average of 16 hours per year of trauma-related education.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Pediatric neurosurgery:</text>
      <paragraph num="(a)">
        <text>Either:</text>
        <paragraph num="(i)">
          <text>A board-certified or board-eligible, trauma fellowship-trained attending neurosurgeon, or PGY2 or higher resident with an attending neurosurgeon on call, who shall be at the patient’s bedside within 30 minutes after emergent consultation has been requested; or</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>A Neurosurgery APP with an attending neurosurgeon on-call, who shall be at the patient’s bedside within 30 minutes after emergent consultation has been requested;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>Neurosurgery APPs taking trauma call shall have documentation of average of 16 hours a year of trauma-related education; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>A liaison to the trauma QM program with 50 percent attendance.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>Pediatric Orthopedic surgery:</text>
      <paragraph num="(a)">
        <text>Either:</text>
        <paragraph num="(i)">
          <text>A board-certified or board-eligible trauma-fellowship-trained attending orthopedic surgeon or PGY2 or higher resident with an attending orthopedic surgeon on call, who shall be at the patient’s bedside within 30 minutes after emergent consultation has been requested; or</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>A PGY2 or higher orthopedic surgeon in house with an attending orthopedic surgeon on call, who shall be at the patient’s bedside within 30 minutes after emergent consultation has been requested;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>Orthopedic surgery APPs taking trauma call shall have documentation of average of 16 hours a year of trauma-related education; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>A liaison to the trauma QM program with 50 percent attendance.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Pediatric anesthesia:</text>
      <paragraph num="(a)">
        <text>A board-certified or board-eligible in-house attending physician 24 hours a day; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A liaison to the trauma QM program with 50 percent attendance.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(5)">
      <text>Pediatric emergency medicine:</text>
      <paragraph num="(a)">
        <text>A physician director who is board certified in pediatric emergency medicine;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Board-certified or board-eligible pediatricians, emergency medicine physicians, or pediatric emergency medicine physicians in house 24 hours a day;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Physicians who have demonstrated special capabilities through commitment, CME, and experience in the care of injured children; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>A liaison to the trauma QM program with 50 percent attendance.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(6)">
      <text>Pediatric critical care:</text>
      <paragraph num="(a)">
        <text>A board-eligible or board-certified pediatric critical care physician in house 24 hours a day for the ICU;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>A designated liaison from pediatric surgery; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>A liaison to the trauma QM program with 50 percent attendance.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>The hospital shall have the following additional pediatric surgical specialties on call and available 24 hours a day, and shall be at the bedside within 30 minutes after emergent consultation has been requested by the trauma resuscitation team leader based on institution-specific criteria:</text>
    <paragraph num="(1)">
      <text>Plastic surgery;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Urology;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Oral-maxillofacial surgery;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Ophthalmology;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Otolaryngology, head, and neck surgery;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Cardiovascular surgery; and</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Hand surgery.</text>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>The hospital shall have the following additional nonsurgical pediatric specialties on call and available 24 hours a day within 60 minutes after emergent consultation has been requested by the trauma resuscitation team leader based on institution-specific criteria:</text>
    <paragraph num="(1)">
      <text>Radiology;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Neuroradiology;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Interventional radiology;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Physiatry;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Psychiatry;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Infectious disease;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>General pediatrics;</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Neurology;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Gastroenterology;</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Nephrology;</text>
    </paragraph>
    <paragraph num="(11)">
      <text>Cardiology;</text>
    </paragraph>
    <paragraph num="(12)">
      <text>Hematology-oncology;</text>
    </paragraph>
    <paragraph num="(13)">
      <text>Pulmonology;</text>
    </paragraph>
    <paragraph num="(14)">
      <text>Endocrinology;</text>
    </paragraph>
    <paragraph num="(15)">
      <text>Pathology;</text>
    </paragraph>
    <paragraph num="(16)">
      <text>Allergy and immunology; and</text>
    </paragraph>
    <paragraph num="(17)">
      <text>Angiography.</text>
    </paragraph>
  </paragraph>
</regulation>