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Hospital Needs Assessment
1.
Name of Hospital
2.
Physical Address
3.
Mailing Address
4.
City
5.
Zip Code
6.
Hospital Administrator
7.
Phone #
8.
Fax #
9.
Email Address
10.
Administrator's Emergency Contact Number (24/7)
11.
Trauma Coordinator
12.
Phone #
13.
Fax #
14.
Email
15.
Trauma Coordinator's Emergency Contact Number (24/7)
16.
ED Medical Director:
17.
Phone #
18.
Fax #
19.
Email
20.
ED Medical Directors Emergency Contact Number (24/7)
21.
RAC Representative
22.
Phone #
23.
Phone # that can receive text messages for reminders
24.
Fax #
25.
Email
26.
RAC Representative's Emergency Contact Number (24/7)
27.
RAC Alternate Representative
28.
Phone #
29.
Fax #
30.
Email
31.
RAC Alternate Representative's Emergency Contact Number (24/7)
32.
Tax status of Hospital
33.
Phone Number for on-line Medical Control
34.
Radio Frequency for on-line Medical Control:
35.
Number of Licensed Hospital Beds
36.
Number of Emergency Room Beds:
37.
Number of Intensive Care Beds:
38.
Do you have designated ICU beds for Pediatric patients
Yes
No
39.
If yes, how many beds are designated for Pediatric patients
40.
Are you a designated Trauma Facility
Yes
No
41.
Trauma Designation Level
I
II
III
IV
42.
If you are not a designated facility, are you seeking trauma designation
Yes
No
43.
If yes, what level are you seeking?
I
II
III
IV
44.
Do you have a Trauma Registry
Yes
No
45.
How many trauma patients do you see in your ER in a 12 month period?
46.
How many trauma admissions do you have in a 12 month period
47.
What is your average ISS?
48.
When considering transfer of a trauma patient, what facility are you most likely to transfer to?
49.
Why?
50.
Who provides 24 hour coverage in your ER?
MD
PA
NP
51.
How many physicians are certified in ATLS
52.
How many physicians need certification in ATLS
53.
How many nurses are TNCC certified
54.
How many nurses are seeking TNCC certification
55.
How many nurses are ENPC certified
56.
How many nurses are seeking ENPC certification
57.
Please indicate the types of services your facility can provide for a trauma patient:
General Surgery
Orthopedic Surgery
Facial Reconstruction
Spine
Neurosurgery Surgery
Neurology
58.
Of the services you circled, do they provide coverage 24 hours per day
Yes
No
59.
If no, please explain in detail
60.
Describe in detail any injury prevention programs used in your institution:
61.
Describe in detail, issues your facility has identified that would improve trauma care in your facility:
62.
RAC-D can offer assistance to its members through RAC wide projects to meet common needs. It can also offer advice and assistance in carrying out injury prevention activities. With this in mind:
How can the RAC assist your facility to improve trauma care?
63.
RAC-D can offer assistance to its members through RAC wide projects. It can also offer advice and assistance in carrying out injury prevention activities. With that in mind please list your needs below:
Please list EQUIPMENT needed in order or priority
64.
Do you have a plan to obtain this EQUIPMENT?
65.
Please list EDUCATION needed (include course , training equipment and # of students needing training)
66.
Do you have a plan to obtain his EDUCATION?
67.
Please list PUBLIC INJURY PREVENTION needed (include Program, Equipment needed, supplies needed & target audience)
68.
Use the space below to provide details concerning your needs and how the RAC might assist you:
