* 1. Date:

* 2. Name of Entity:

* 3. Person Completing Report:

* 4. Diversion:
# of diversion occurrences this quarter

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

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

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

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

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

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

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

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

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

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

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

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

* 17. Number of preventable trauma deaths this quarter.

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

* 19. Specific Occurrence Report
Age:

* 21. Chart Identification #:

* 22. Mechanism of Injury:

* 23. Identified injuries and pertinent information:

* 24. Patient Outcome:

* 25. Provider Discussion:

* 26. Contributing Factors

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