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

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

### Chapter 10 — Neurotrauma Center Standards

**Authority:** Education Article, §13-509, Annotated Code of Maryland

**Administrative History:** Effective date: May 27, 2002 (29:10 Md. R. 827)

**Administrative History:** Regulation .01 amended effective March 7, 2022 (49:5 Md. R. 368)

**Administrative History:** Regulation .01D amended effective July 21, 2025 (52:14 Md R. 714)

**Administrative History:** Regulation .02 amended effective March 7, 2022 (49:5 Md. R. 368)

**Administrative History:** Regulation .03A, C amended effective March 7, 2022 (49:5 Md. R. 368)

**Administrative History:** Regulation .04A amended effective March 7, 2022 (49:5 Md. R. 368)

**Administrative History:** Regulation .05 amended effective March 7, 2022 (49:5 Md. R. 368)

**Administrative History:** Regulation .06 amended effective March 7, 2022 (49:5 Md. R. 368)

**Administrative History:** Regulation .07 amended effective March 7, 2022 (49:5 Md. R. 368)

**Administrative History:** Regulation .08B, C amended effective March 7, 2022 (49:5 Md. R. 368)

**Administrative History:** Regulation .09 amended effective March 7, 2022 (49:5 Md. R. 368)

**Administrative History:** Regulation .10 amended effective March 7, 2022 (49:5 Md. R. 368)

**Administrative History:** Regulation .11 amended effective March 7, 2022 (49:5 Md. R. 368)

**Administrative History:** Regulation .13 amended effective March 7, 2022 (49:5 Md. R. 368)

#### Regulation .01 Organization.

*COMAR 30.08.10.01*

A neurotrauma center hospital shall:

A. Maintain a specialized unit dedicated to traumatic brain injury and spinal cord injury;

B. Be designated as Level 1 trauma center or PARC by MIEMSS;

C. Demonstrate both a medical and administrative commitment to the care of the neurotrauma patient by:

  (1) Having a board of director's resolution stating:

    (a) That the hospital agrees to meet the neurotrauma standards for designation; and

    (b) The hospital's commitment to the infrastructure and the financial, human, and physical resources necessary to support the neurotrauma center;

  (2) Establishing an identifiable organization whose dedication to the care of the neurotrauma patient is shown in:

    (a) Its mission statement;

    (b) The configuration of its medical, administrative, and support staffs; and

    (c) The configuration of its physical plant; and

D. Maintain current hospital accreditation by an organization that has been granted deeming authority by the Centers for Medicare & Medicaid Services and approved by the Maryland Department of Health to accredit hospitals in the State.

#### Regulation .02 Neurotrauma Center.

*COMAR 30.08.10.02*

A. A neurotrauma center shall:

  (1) Participate in the Statewide trauma and specialty care system, including submission of patient care data to the State trauma registry for quality management; and

  (2) Receive a minimum annual volume of 100 traumatic brain injured patients, spinal cord injured patients, or both.

B. Prehospital Care. A neurotrauma center shall:

  (1) Maintain access to an EMS system for the transport of patients with neurotrauma injuries from referral sources within the geographic service area;

  (2) Demonstrate participation and involvement in local, regional, or State trauma EMS systems; and

  (3) Provide education on the current concepts in emergency and inpatient neurotrauma treatment to prehospital and hospital care clinicians within its geographic service area.

#### Regulation .03 Neurotrauma Center Director.

*COMAR 30.08.10.03*

A. A neurotrauma center shall have a director who provides oversight to all care for neurotrauma patients admitted to the center.

B. The neurotrauma center director shall meet the requirements in Regulation .05 of this chapter.

C. Responsibilities of the neurotrauma center director include:

  (1) Creation of policies procedures, and protocols/guidelines for the neurotrauma center that specify the care of neurotrauma patients;

  (2) Participation with the State EMS system in development of policies and protocols for use throughout the EMS system for initial care, triage, and transport of neuro-injured patients;

  (3) Communication on a regular basis with physicians and other authorities regarding patients who have been referred;

  (4) Direction of the neurotrauma center administrative functions in collaboration with Level I/PARC leadership;

  (5) Direction and active participation in the neurotrauma quality management (QM) program; and

  (6) Development of and participation in both internal and external continuing medical education (CME) programs in the care and prevention of neuro injuries.

#### Regulation .04 Medical Staff.

*COMAR 30.08.10.04*

A. A neurotrauma center shall have the following team members:

  (1) A Board-certified or board-eligible, in-house neurosurgery attending or PGY2 or higher, dedicated 24 hours a day to trauma care, with a neurosurgery attending on call who shall be at the patient bedside within 30 minutes after emergent consultation has been requested by the trauma team leader for injured patients based on institution-specific criteria;

  (2) A trauma fellowship-trained general surgeon;

  (3) A board-certified anesthesia attending;

  (4) A board-certified orthopedic or neurosurgery spine attending surgeon or PGY2 or higher orthopedic or neurosurgery resident with an attending on call with a 30-minute response to the patient bedside;

  (5) A board-certified or board-eligible trauma/critical care attending or critical care fellow with a trauma/critical care attending on call with a 30-minute response to the patient bedside; and

  (6) An on-call schedule for residents, fellows, and attendings who are assigned to the neurotrauma center.

B. Appointment and Qualifications of Attending Neurosurgeons.

  (1) The neurotrauma center director shall appoint qualified attending staff surgeons to participate in the care of patients in the center.

  (2) An attending neurosurgeon shall meet the requirements in Regulation .05 of this chapter.

#### Regulation .05 Qualifications for Neurotrauma Surgeons.

*COMAR 30.08.10.05*

Category/Description
            Director
            Staff Surgeons
          
        
        
          
            A. Certification. All neurosurgeons shall be board-certified or board-eligible in neurosurgery. A qualified Neurosurgeon shall be regularly involved in the care of patients with neurologic injuries and shall be credentialed by the hospital with general neurosurgical privileges.
            Required
            Required
          
          
            B. Continuing Medical Education. The CME qualification requires annual participation in at least 16 hours or more of trauma or neurotrauma related CME per year.
            Required
            Required
          
          
            C. Research Participation. The research participation qualification is to demonstrate a commitment to clinical or basic science neurotrauma care which can be met by:
            Required
            Desirable
          
          
            (1) Annual submission of an abstract or publication related to neuro injuries; or
            
          
          
            (2) Research projects in progress.
          
          
            D. Community Education and Neurotrauma Injury Prevention. The community education and neurotrauma injury prevention qualification is to participate in:
            Required
            Desirable
          
          
            (1) The development or revision of community or EMS neurotruama treatment protocols, or representation on a State or local EMS committee; and
            
            
          
          
            (2) At least one of the following:
            
            
          
          
            (a) Annual participation in one or more prehospital training/certification courses in neurotrauma care which can be met by prehospital basic life support or advanced life support courses or equivalent courses;
            
            
          
          
            (b) Annual development or presentation of neurotrauma care courses or lectures which can be met by prehospital basic life support or advance life support courses or equivalent courses; or
            
            
          
          
            (c) Participation in a neurotrauma injury prevention program.

#### Regulation .06 Nursing Personnel.

*COMAR 30.08.10.06*

A. A neurotrauma center shall have:

  (1) A nurse manager who is administratively responsible for the center;

  (2) An organizational chart relating the nurse manager to other members of the neurotrauma center and the hospital; and

  (3) A masters-prepared advanced practice nurse with clinical expertise in neurotrauma care with responsibility for clinical nursing oversight and nursing staff consultation.

B. The nurse manager shall have:

  (1) A registered nurse license;

  (2) A baccalaureate or higher degree in nursing;

  (3) At least 2 or more years of experience in acute neurotrauma care; and

  (4) At least 1 year or more of experience in an intensive care unit (ICU).

C. The neurotrauma center nursing department shall:

  (1) Have a patient classification system/staffing matrix for nurse staffing that meets the care needs for each patient in the neurotrauma center;

  (2) Have a neurotrauma center orientation program that documents nursing competencies specific to the care and treatment of acute neurologic injuries;

  (3) Have appropriately trained nursing staff to manage the complex physical and emotional needs of neurotrauma patients;

  (4) Have a neurotrauma orientation program that each new staff nurse hired shall complete before assuming independent practice in the center;

  (5) After completion of the introductory education mandated in this regulation, have continuing education (CE) that is current, meeting the following requirements:

    (a) 8 hours of neuro/trauma-related CE every year for emergency and neurotrauma critical care or intermediate care nurses caring primarily for neurotrauma patients; or

    (b) 4 hours of neuro/trauma-related CE every year for nurses who care for trauma patients and are from other clinical areas; and

  (6) Promote specialty certification for nurses working in the neurotrauma ICU and units within 3 years of assignment to neurotrauma.

D. Nurses in the ICU shall spend 50 percent of their clinical practice caring for patients with neurologic injury.

E. Neurotrauma nursing staff shall be involved with the centers injury prevention and outreach education programs.

#### Regulation .07 Facility and Equipment.

*COMAR 30.08.10.07*

A neurotrauma center shall have:

A. For emergency resuscitation:

  (1) Immediate access to a computed tomography (CT) scanner; and

  (2) Intracranial Pressure (ICP) monitoring equipment;

B. In its operating room (OR):

  (1) Neurotrauma-specific instrumentation/trays;

  (2) Intraoperative ultrasound; and

  (3) Evoked potential monitoring;

C. A post-anesthesia care unit (PACU) with the necessary equipment and medications to manage the traumatic brain or spinal cord injured patient resuscitation and monitoring;

D. In the ICU:

  (1) ICP monitoring equipment; and

  (2) Advanced Neuro-monitoring equipment;

E. Radiological specialty capabilities, including:

  (1) In-house trauma-dedicated technicians 24 hours a day;

  (2) CT scan available 24 hours a day; and

  (3) Access to magnetic resonance imaging (MRI) capability 24 hours a day; and

F. Clinical laboratory service that meets the standards for PARC and Level I trauma center standard as specified in COMAR 30.08.05.15.

#### Regulation .08 Inpatient Acute Care Rehabilitation Program.

*COMAR 30.08.10.08*

A neurotrauma center shall:

A. Have a rehabilitation program that is designed for neurotrauma patients and directed by a board-certified physiatrist;

B. Meet rehabilitation requirements as follows:

  (1) Rehabilitation services staffed by personnel trained in rehabilitative care and properly equipped for acute care of the traumatic brain injured or spinal cord injured patient; and

  (2) Rehabilitation consultation services, appropriately licensed or registered in their specific disciplines (that is, occupational therapy, speech therapy, physical therapy, and social services), available in the critical care phase as needed;

C. Provide therapists with regular supervision from individuals with at least 1 year of experience with the neuro injury for which the patient is being treated (that is, brain injury or spinal cord injury);

D. Have an orientation program that documents therapists competencies specific to the treatment of acute neurologic injuries and require that each newly hired therapist complete the orientation program before assuming independent practice in the center; and

E. Promote specialty certification for therapists working in the neurotrauma rehabilitation program.

#### Regulation .09 Neurotrauma Rehabilitation.

*COMAR 30.08.10.09*

A neurotrauma center shall have:

A. Transfer agreements to rehabilitation hospitals, for the primary three rehabilitation hospitals the trauma center utilizes, which may be joint transfer agreements if the trauma center is a part of a health system that utilizes a particular rehabilitation center with appropriate services tailored to the needs of traumatic brain and spinal cord injured patients;

B. A referral process/case management plan for timely assessment for, and placement in, an appropriate rehabilitation program;

C. Full in-house service or transfer process in place to a rehabilitation service for acute care or sub-acute care; and

D. Ongoing continuity of care for patients with traumatic brain and spinal cord injuries provided in affiliated rehabilitation acute or sub-acute facilities, by attending neurotrauma center specialists and sub-specialists.

#### Regulation .10 Quality Management Program.

*COMAR 30.08.10.10*

A. A neurotrauma center shall have an ongoing QM program that is multidisciplinary and coordinated with the trauma QM program.

B. The neurotrauma center director is responsible for the QM program for neurotrauma patients.

#### Regulation .11 Research.

*COMAR 30.08.10.11*

A neurotrauma center shall:

A. An organized neurotrauma research program and a documented research plan;

B. Evidence of productivity through peer-reviewed publications;

C. Proposals reviewed by an institutional review board;

D. Presentations at local, regional, or national meetings;

E. Publications in peer-reviewed journals on an average of six per year; and

F. Clinical research trials designed to enhance the trauma system's ability to resuscitate, stabilize, and treat neurotrauma patients in the most cost-effective manner.

#### Regulation .12 Education.

*COMAR 30.08.10.12*

A neurotrauma center shall:

A. Provide outreach education to health care providers throughout the State related to current standards of care for neurotrauma patients;

B. Participate in an ACGME-approved program for neurosurgical residency training;

C. Serve as a clinical site for education for health care providers; and

D. Participate in professional continuing education programs and professional meetings.

#### Regulation .13 Policies, Protocols, and Agreements.

*COMAR 30.08.10.13*

The hospital shall have patient treatment and care documents as specified in COMAR 30.08.05.19 with the addition of:

A. Resuscitation and treatment protocols/guidelines for traumatic brain injury; and

B. Resuscitation and treatment protocols/guidelines for spinal cord injury.