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* 1. Date:

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* 2. Name of Entity:

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* 3. Person Completing Report:

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* 4. Diversion:
# of diversion occurrences this quarter

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* 5. Total # of hours on diversion this quarter.

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* 6. Number of patients that met the RAC-D definition of “Major Trauma” that were transferred to hospitals outside of RAC-D this quarter.

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* 7. Trauma patient transferred for higher level of care > 2 hours after arrival this quarter.

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* 8. Performance Improvement Criteria / Indicators
Number of trauma related pediatric resuscitations.

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* 9. Number of trauma transfer denials this quarter from lead facility. (Transfers out)

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* 10. If transfer wasn't denied but delayed acceptance how long was the delay for each patient (for each patient list time)

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* 11. If transfer was denied above, why? (List out denial reason for each)

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* 12. Number of trauma admits (> 24 hours) to your facility this quarter.

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* 13. Number of trauma admissions with ISS > 9 this quarter.

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* 14. Number of trauma related deaths at your facility this quarter.

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* 15. Number of non-preventable trauma deaths this quarter.

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* 16. Number of potentially preventable trauma deaths this quarter.

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* 17. Number of preventable trauma deaths this quarter.

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* 18. Number of trauma patients admitted to your ICU this quarter.

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* 19. Specific Occurrence Report
Age:

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* 21. Chart Identification #:

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* 22. Mechanism of Injury:

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* 23. Identified injuries and pertinent information:

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* 24. Patient Outcome:

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* 25. Provider Discussion:

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* 26. Contributing Factors

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