In this chapter, the following terms have the meanings indicated. Terms Defined. “Accreditation Council for Graduate Medical Education (ACGME)” means the private, nonprofit council that evaluates and accredits medical residency programs in the United States. “Commission on Accreditation of Rehabilitation Facilities (CARF)” means the international independent, nonprofit accreditor of human service providers in the areas of rehabilitation, employment, child, and family. “Hand and upper extremity physician trauma team” means the physician team required by Regulation .03 of this chapter. “Hand Therapy Certification Commission (HTCC)” means an independent, nonprofit accrediting body for the testing and credentialing of hand therapists. A hand and upper extremity trauma center shall: Be licensed as an acute care hospital by the hospital licensing authority in the jurisdiction in which it is located; Be accredited by [the Joint Commission on Accreditation of Health Care Organizations] 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, with a designated hand surgery service; Have an emergency department which offers comprehensive emergency care 24 hours a day with: At least one physician experienced in emergency care on duty in the emergency care area; and In-hospital physician coverage by members of the medical staff or by senior-level residents who are postgraduate year 3 or higher for the following services: Medical; Surgical; Orthopedic; and Anesthesia; Have a resolution adopted by the Board of Directors of the hospital committing the hospital to: Participate in State and regional emergency medical services; and Maintain the infrastructure necessary to support the hospital's provision of state-of-the-art hand and upper extremity trauma care including the following resources necessary to the provision of such service: Financial; Human; and Physical. The hand and upper extremity trauma center shall have: A medical director; Appropriately educated nurse leaders and clinical staff to provide care for hand and upper extremity trauma patients; A fellowship training program in hand surgery accredited by the ACGME; A comprehensive post-trauma rehabilitation program accredited by CARF; A quality improvement program which participates in State and regional emergency medical services quality management; An educational program for physicians, nurses, and therapists who treat trauma patients with single system upper extremity trauma; A policy committee that oversees the activities of the hand and upper extremity trauma center; An internal morbidity and mortality conference scheduled to meet at least monthly to record and discuss any complications; A maintained hand registry; and Timely submission of data to the MIEMSS State trauma registry. The hospital shall have a hand and upper extremity physician trauma team that shall include at least eight physicians who are Board-eligible or Board-certified in the following specialties: General surgery; Plastic surgery; or Orthopedic surgery. A member of the hand and upper extremity physician trauma team shall be on call 24 hours a day with a response time of 30 minutes or less. As back-up, a second member of the hand and upper extremity physician trauma team shall be on call 24 hours a day with a response time of 30 minutes or less. The physicians who satisfy §A of this regulation shall also hold or be eligible to hold a Certificate of Added Qualifications in Hand Surgery through: The American Board of Orthopedic Surgery; The American Board of Plastic Surgery; or The American Board of Surgery. Each member of the hand and upper extremity trauma physician trauma team shall be competent in: Microsurgery of the upper extremity; Neurovascular surgery of the upper extremity; Emergency skeletal reconstruction; Emergency soft tissue reconstruction; and Upper limb replantation. A call roster for the hand and upper extremity physician trauma team shall be published and available in the emergency department and operating room. The hospital shall staff the hand and upper extremity trauma center with registered nurses competent in the care of patients with hand and upper extremity disorders. The hospital shall provide all nurses who care for patients in the hand and upper extremity trauma center with: Specific orientation to procedures and protocols for hand and upper extremity emergencies; and Education in hand and upper extremity emergencies and trauma care that meets the learning outcomes approved by MIEMSS. Nursing staff caring for hand and upper extremity trauma patients shall at a minimum have 8 hours of continuing medical education in hand trauma related topics every 2 years. Hand and upper extremity trauma facilities shall be able to optimally and comprehensively care for every patient with an isolated upper extremity injury from the time the patient arrives at the hospital through acute treatment, rehabilitation, reconstruction, and re-entry into the work force. Hand and upper extremity trauma area facilities shall have: A suite of rooms identified and specialized for examination and treatment of hand and upper extremity trauma emergencies in the hospital's emergency department with: A medical director or representative on the hospital's emergency services committee that shall oversee the management of the hand and upper extremity trauma center; and Appropriate nurse leaders who shall be responsible for all venues in which hand and upper extremity trauma care is rendered; Organized and specialized equipment and supplies to care for hand and upper extremity trauma including specialized prepackaged sterile surgical sets located in the hand trauma rooms to enable the performance of procedures including, but not limited to: Exploration and debridement of complex hand injuries; Bony debridement and shortening; Thermal injury care; Tendon repair; Full and partial thickness skin grafts; Composite tissue grafts; and Repair of simple and complex skin lacerations; Pneumatic tourniquets; High intensity light; Surgical loupes; Power equipment for skeletal fixation; Figure traps for fracture reduction; Casting material in a variety of sizes and compositions; Metallic malleable splints; Plastic or prefabricated splits; Specialized dressings for hand injuries including burns; Local anesthetics; and Doppler unit for vascular assessment. The hospital shall have appropriate staffing and equipment readily available to offer the following services to patients in the hand and upper extremity trauma area: Standard stationary radiography; Portable C-Arm fluoroscopy; Diagnostic vascular imaging; Interventional vascular procedures; CT and MRI scans; MR angiography; Radionuclide scanning; and Ultrasonography. The hospital shall have a direct communication link to the State communication network including: SYSCOM; Prehospital providers; and Referring hospitals. The hospital shall have pharmacy support to provide all needed medications 24 hours a day. The hand and upper extremity trauma center operating room shall have: Equipment for the treatment of all hand and upper extremity injuries reconstructive procedures; A specially trained and dedicated operating room team for hand surgery, musculoskeletal care, or both; Continuous availability of the operating suite with an in-house operating room scrub team 24 hours a day; and Specialized equipment readily available to enable: Microvascular tissue replantation; Microvascular free tissue transfer; Microsurgical nerve repair; Internal and external fixation of all bones of the upper extremity; Intraoperative vascular evaluation; Upper extremity endoscopy; and Upper extremity arthroscopy. The hand and upper extremity trauma center inpatient unit shall have a nursing unit for the care of the patient with upper extremity injuries that provides nursing staff who are: Specially educated and demonstrate competencies in the postoperative evaluation of limb replantation and revascularization; Able to independently monitor the tissue perfusion of replanted limbs; and Specially educated in the care and postoperative monitoring of free tissue transfers. The hand and upper extremity trauma center hand therapy unit shall have: A specialized area for inpatient and outpatient care utilizing individualized occupational and physical therapy techniques directed specifically towards the rehabilitation of the upper extremity; Certified and licensed occupational and physical therapists; Staff designated or qualified to be designated as certified hand therapist by the “Hand Therapy Certification Commission”; Regular educational programs presented by the therapy staff; A facility for the fabrication of custom individualized splints; and The ability to care for the following types of clinical problems: Flexor tendon repair and reconstruction; Extensor tendon repair and reconstruction; Nerve repair or reconstruction; Tendon transfers; Thermal injuries; Repetitive stress and cumulative trauma disorders; Training in the use of prosthetic devices; and Upper extremity replantation. The hand and upper extremity trauma center work rehabilitation services shall have: A CARF-accredited area dedicated to facilitating the transition of the injured worker back into the workforce; Equipment to stimulate and practice the activities required at the majority of work sites; Computerized analysis of multiple physical parameters required for performance in the workplace; The ability to evaluate ergonomic factors in the scenario of the workers' stations; and Social services to aid in the transition of the injured worker back into the workplace. The hand and upper extremity trauma center outpatient clinical area shall have: A dedicated adaptation hand clinic area for the evaluation and treatment of hand and upper extremity trauma patients on a nonemergent basis; and A hand and upper extremity medical staff physician responsible for the overall clinical coordination and care delivery. The hand and upper extremity trauma center microvascular laboratory shall have: A facility to practice the microsurgical techniques needed in the acute treatment and reconstruction of upper extremity trauma victims; Animal surgery available to simulate the human situation; and Individualized instruction in microsurgery. The hand and upper extremity trauma center anatomy laboratory shall: Have a facility for the dissection of human and animal specimens; and Facilitate instruction in pertinent anatomy implicit in the treatment of hand and upper extremity trauma victims. The hand and upper extremity trauma center information support services shall: Provide educational support services including: Preparation and dissemination of hand and upper extremity trauma educational information for: Patients; Providers; and The public; An Internet server for disseminating information regarding patient education and public safety; Audiovisual facilities to produce materials for presentations and patient education; and A robust conference schedule with rotating didactic lectureships covering the germinal information in the field of hand and upper extremity surgery; Provide psychosocial support, including a certified psychologist and a licensed social worker with special expertise in the evaluation and treatment of hand and upper extremity trauma victims; and Provide an amputee-prosthetic clinic as a regional resource for amputee prosthetics using a team approach for management of post trauma patients with hand or upper extremity amputations, which team shall include one or more of each of the following: Prosthetist; Social worker; Hand therapist; Hand resident; Hand fellow; and Attending hand surgeon. The hand and upper extremity trauma center shall have an ongoing quality management program integrated with the hospital's overall quality management system. Quality management for the hand and upper extremity trauma center shall include: Maintaining the hand physician representative on the following hospital committees to discuss quality management issues during monthly meetings: The hospital operating room committee; and The hospital emergency room committee; Attendance by the hand and upper extremity trauma center representative responsible for quality management and quality improvement activities at: The hand policy committee meetings; and The monthly hospital quality management meetings; Participation in State emergency medical services quality management activities; Maintenance of a hand and upper extremity trauma registry on patients admitted to the hand and upper extremity trauma center; Monthly review of hand and upper extremity trauma registry data and reports; Maintenance of a patient care database on patients treated through the hand and upper extremity trauma rehabilitation unit and evaluation of the various outcomes, measures, and protocols; Monthly review of morbidity and mortality data from the hand and upper extremity trauma center weekly patient sessions for trainees in which cases and complications can be discussed; Making available to MIEMSS documentation of quality management including: Problem identification; Analysis; Action plan; Implementation; and Reevaluation; and A monthly ethics in medicine forum to discuss ethical considerations that confront today's physician. The hand and upper extremity trauma center shall provide leadership and coordination for the development and implementation of prevention and public education programs for hand and upper extremity injuries, by, among other activities: Participation in MIEMSS outcome studies when requested; Training and teaching emergency medical services personnel; Serving as a public resource for the prevention and safety of hand and upper extremity injuries; Participation in media public service announcements for seasonal hand and upper extremity injuries; and Monitoring the progress of prevention programs in cooperation with State monitoring programs. The hand and upper extremity trauma center shall participate in an organized clinical research program which shall include: A research committee; and A research director who shall: Coordinate ongoing research projects; Meet monthly with hand and upper extremity trauma injury center staff to discuss the progress of research projects; Assist in the preparation of projects for presentation and publication; and Prepare documentation of ongoing research grants. Education of the hand and upper extremity trauma center medical staff shall include: Formal didactic lectures available weekly to all hand and upper extremity trauma center staff; At least every other week, cadaver prosections and dissections at the Maryland State Anatomy Board performed on various areas of the upper extremity performed by: Residents; Fellows; and Attending physicians; An annual course for free tissue transfer and brachial plexus dissections at the Maryland State Anatomy Board; The availability of cadaver specimens to evaluate and practice new surgical techniques and procedures for upcoming clinical cases; and An ACGME accredited fellowship program. Internal Continuing Education. Medical staff internal continuing education shall consist of: Participation in weekly case management conferences; Participation in weekly lecture series; Attendance at monthly specialized conferences that include the following subject areas: Amputee; Microsurgery; Plastic surgery; Congenital deformities; and Anatomy; Participation in monthly hand surgery journal club; Attendance at yearly visiting professor lecture and anatomy laboratory; Access to electronic educational materials in the specialty; Access to video library including: Hand surgery; and Microsurgery topics; and Completion of microsurgery laboratory refresher course. Operating room and inpatient nursing staff internal continuing education shall consist of: Participation in nurse specialty education opportunities and American Society for Surgery of the Hand meetings; Attendance at lectures by attending hand surgeons; Access to hand and upper extremity trauma center lecture series; Access to hand surgery and hospital library services; and Participation in case presentations and discussions as appropriate; Hand therapist internal continuing education shall consist of: Access to full schedule of hand center lecture series; Access to monthly congenital conference; Access to monthly hand surgery journal club; and Attendance at National Hand Therapy and American Society for Surgery of the Hand meetings. Special Training in Trauma Protocols. Training in trauma protocols shall include: Review of the new attending and house staff manual; Completion of an orientation/training session for new: Physicians; Nurses; and Therapists; and Review of trauma registry data including: Inclusion criteria; Definitions; and Reports. External Continuing Education. External continuing education programs concerning the care and treatment of hand and upper extremity trauma injury including attendance at external symposia and lectures are required. A hand and upper extremity trauma center shall maintain written policies and protocols for: Emergency triage and protocol for massive upper extremity injuries and replantation; Preoperative and postoperative orders for replantations and free flaps; Care and treatment of a upper extremity injuries; The physician on-call schedule for the hand and upper extremity trauma center; The interhospital transfer protocol; House staff privileges for: Educational activities; Responsibilities; and Grievances; The scope of care for the hand and upper extremity trauma center; and Extramural hospital house staff program agreements for rotation in the hand and upper extremity trauma center. Education Article, §13-509, Annotated Code of Maryland Effective date: August 13, 2007 (34:16 Md. R. 1433) Regulation .02A amended effective July 21, 2025 (52:14 Md. R. 714)