1. Previous Report Findings 1.1. Criterion Deficienc...

4/12/2018 Home - Verification

https://ameriburn.sharepoint.com/abaverification/QuestionnairePrint.aspx 1/62

1. Previous Report Findings 1.1. Criterion Deficiencies

1.2. Areas for Improvement 2. General Information

2.1 This American Burn Association/ American College of Surgeons Review has been requested bythe Hospital and Burn Center:

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2.2 What do the burn center and hospital hope to gain from this review?

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3. Infrastructure3.1. Hospital Organization

3.1.1 Is the hospital currently accredited by The Joint Commission (or equivalent)? CD1

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3.1.1.1 If yes, when was the date of the last review?

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3.1.1.2 If no, why not?

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3.1.2 The Hospital is which of the following:To choose more than one option press and hold the "Ctrl" button on your keyboard whilemaking your selections.

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3.1.2.1 Burn center may provide further details (optional):

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3.1.2.2 Hospital Bed Size

Previous CurrentNumber of Hospital beds licensed



Number of Hospital beds in use currentlyAverage hospital daily occupancy %Number of ICU bedsNumber of surgical ICU bedsTotal Number of designated Burn Unit BedsNumber of Burn Unit ICU BedsNumber of Burn Unit intermediate/acute care beds

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3.1.3 The Hospital has Magnet status

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3.1.3.1 The burn center may add further details regarding status:

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3.1.4 Is the burn center hospital a designated verified trauma center? CD12

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3.1.4.1 If yes, what level and by whom

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3.1.4.2 If yes, please provide details about the trauma center and interactions betweenthe two centers.

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3.1.4.3 If “no” is there affiliation with a designated trauma center?

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3.1.4.4 If “no” Please provide details about how are patients with burns and other traumamanaged

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3.1.5 Does the hospital have a surgery residency program?

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3.1.5.1 If yes, it isTo choose more than one option press and hold the "Ctrl" button on your keyboardwhile making your selections. Reviewer Comments:

3.2. Burn Center Organization3.2.1 Burn Center is

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3.2.2 Is there a regional or state burn center designating agency

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3.2.2.1 If yes, what is the name of the agency and how does it obtain its authority?

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3.2.3 Is the administrative commitment to the burn center current? CD2 Please include appendix of Administrative Letter of Commitment. Reviewer Comments:

3.2.4 Within the hospital structure the burn center is a: CD3 Please provide an organizational chart which relates the burn center to the hospital anddescribes the supervisory structure of the individual members of the burn team Reviewer Comments:

3.2.4.1 WithinTo choose more than one option press and hold the "Ctrl" button on your keyboardwhile making your selections. Reviewer Comments:

3.2.4.1.1 It "Other" please explain:

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3.2.5 Geographic catchment. Describe the geographical area served by the burn center

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3.2.6 Configuration



Burn Center may expand here on any details regarding the following questions related toconfiguration.

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3.2.6.1 Is there a specialized unit dedicated to acute burn care? CD4

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3.2.6.2 Are there designated Burn ICU beds? CD5

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3.2.6.3 Is the burn unit used predominantly for patients with burn injuries or thosesuffering from skin disorders or other injuries whose treatment requirements aresimilar to those of burn patients?

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3.2.6.4 Does the burn unit have a conference room?

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3.2.6.5 Does the burn unit have a family waiting room?

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3.2.6.6 Does the burn unit have a patient exercise area?

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3.2.6.7 Is there a special tank/tub/shower room?

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3.2.7 Is there a line item budget for the burn unit?

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3.3. Burn Center InPatient Admissions3.3.1 List the annual number of admissions for the last three years: CD13

CD14 CD15

ADMISSIONS 3 yearsprevious

2 yearsprevious

Last fullyear



Total number of new admissionsAdult ICU patientsChildren (<18y/o)Pediatric ICU patientsICU admissions totalBurn ReconstructionTENS / SJSTotal number of admissions for other skinconditions (Optional)Soft Tissue Skin Infections (Optional)Non-Burn Wounds (Optional)OtherTotal number of admissions to the burn center forthe reporting year.

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3.3.2 What has been the average daily burn patient (total ICU + acute care) census? CD16

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3.3.2.1 3 Years Previous

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3.3.2.3 Last Full Year

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3.3.3 How many patients with a primary diagnosis of a burn injury have been admittedto other medical or surgical services?

CD17

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3.3.4 How many acutely burned patients meeting ABA admission criteria weretransferred from your facility to another acute burn care facility during the pastthree years?

CD89

Please have medical records for each case available at the site visit. Reviewer Comments:


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3.4. Burn Center OutPatient Visits3.4.1 Total number of outpatient visits seen by the burn service CD14

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3.4.2 Total number of non-admitted outpatients with new burns treated:

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3.4.3 Total number of inpatients who had follow up in other facilities CD79 CD89 CD80 CD81 CD82 CD83 CD84 CD85 CD86 CD87 CD88

Please have medical records for each case available at the site visit. Reviewer Comments:


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3.5. Personnel3.5.1 Info

Each burn patient must have an identifiable qualified burn surgeon responsible for allaspects of his/her care. This mandates that the surgeon or designee (surgery resident,alternative burn center intensivist, hospitalist or physician extender directly under thesupervision of the burn surgeon) oversees all daily care including daily notes and orders.



All other surgeons/physicians should be clearly identified as consultants and with fewexceptions (specified in the policy and procedure manual) they should not direct care orindependently write orders. When other care providers help to manage patients, they mustdo so in conjunction with daily interaction with the attending burn surgeon who concurswith the orders. Reviewer Comments:

3.5.2 Burn Director CD27 CD28 CD29 CD30 CD31 CD39 CD40 CD41

CD0 CD32 CD33 CD34 CD35 CD36 CD37 CD38

Please attach job description in Appendix. Reviewer Comments:

3.5.2.1 Who appoints the burn center director?

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3.5.2.2 Burn Director Name:Please attach current curriculum vita in Appendix. Reviewer Comments:

3.5.2.3 Year the burn director was appointed:

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3.5.2.4 Board Certification: CD27

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3.5.2.4.1 American Board of Surgery (or equivalent for international centers)



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3.5.2.4.1.1 Year certified:

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3.5.2.4.1.2 Year recertified:

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3.5.2.4.2 American Board of Plastic Surgery (or equivalent for international centers)

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3.5.2.4.3 Surgical Critical Care

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3.5.2.4.4 Other Boards of Certificates:

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3.5.2.5 Has the director completed a burn fellowship? CD28

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3.5.2.6 Does the Burn Director have experience in managing burn patients for atleast 2 of the previous 5 years?

CD28



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3.5.2.7 Does the director participate in the care of at least 50 acutely burnedpatients that satisfy the ABA Burn Center Referral Criteria?

CD40

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3.5.2.8 Number of total Director CME credits: CD41 Please have documentation available at the site-visit. Credits may include on-siteconferences if approved for CME Credit, or from regional and national meetingattendance, SESAP, or Web based CME. Reviewer Comments:

3.5.2.8.1 2 years previous:

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3.5.2.8.2 Last full year:

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3.5.2.9 Regional, national, and international burn meetings attended during thepast two years: (list)

CD39

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3.5.2.10 Total number of Burn Director publications during the past 5 years: CD41

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3.5.2.10.1 Number of peer review publications:

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3.5.2.10.2 Number of burn-related peer reviewed publications:

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3.5.2.10.3 Number of other (non-peer-reviewed) publications:

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3.5.2.10.4 Advocacy Efforts:



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3.5.2.11 Number of burn-related oral presentations in the last 3 years: CD41

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3.5.2.11.1 Local (include courses taught, EMS, etc.):

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3.5.2.11.2 Regional:

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3.5.2.11.3 National:

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3.5.2.11.4 International:

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3.5.2.12 The Director has completed the ABLS course: CD29

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3.5.2.13 The Director has completed the ABLS Instructor couse:

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3.5.2.14 The Director has oversight responsibility for the following burn centeractivities:

CD30 CD31 CD32 CD33 CD34 CD35 CD36 CD37

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3.5.2.14.1 Direction of the burn center administrative functions?

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3.5.2.14.2 Approving privileges for physicians participating in the burn service incoordination with medical staff credentialing processes?

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3.5.2.14.3 Creation of policies and procedures within the burn center specifying allaspects of care for burned patients?

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3.5.2.14.4 Coordination with regional EMS authorities regarding triage and transportof burn patients?

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3.5.2.14.5 Ensuring that all burn center providers conform to the burn center's locallyestablished policies and procedures?

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3.5.2.14.6 Communications on a regular basis with referring physicians regardingpatients who have been transferred?

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3.5.2.14.7 Direction and participation in the burn center Quality & ProcessImprovement Programs?

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3.5.2.14.8 Development and participation in internal and external continuing medicaleducation programs in the care and prevention of burn injuries?

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3.5.2.15 The burn center Director demonstrates ongoing involvement in burn-related research, community education, continuing medical education,prevention efforts and/or local, regional, or national burn advocacy.

CD41

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3.5.2.16 Is there least one qualified burn center staff surgeon accessible foradministrative and clinical decision when the director is not available?

CD31

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3.5.2.16.1 List in order the individuals most likely to be designated:

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3.5.3 Burn Center Staff

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3.5.3.1 Burn surgeons are board certified by the American Board of Surgery or theAmerican Board of Plastic Surgery (or equivalent international accreditingorganizations).

CD42

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3.5.3.2 Attending staff burn surgeons have demonstrated expertise in burntreatment as evidenced by completion of a one-year fellowship in burntreatment or by two or more years of mentored experience in themanagement of patients with acute burn injuries.

CD43

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3.5.3.3 Qualifications for all physicians (and physician extenders) who are routinelyresponsible for the care of burned patients conform to criteriadocumenting approporate training, patient care experience, continuingmedical education, and commitment to the care of the burned patient.

CD48

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3.5.3.3.1 If no, please explain in detail:

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3.5.3.4 Privileges for physicians (and physician extenders) participating in the burn serviceare determined by the hospital medical staff credentialing process and areapproved by the burn center director.

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3.5.3.4.1 If yes, please provide documentation at the site visit. - If no, please explainthe role of the burn center director.

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3.5.3.5 List all burn center staff surgeons and any other surgeons who cared for burnpatients in the last year in the following table.



Please upload CV's of all surgeons.

Name Specialty Qualifications# patientswith burns last year

# AcuteBurnOperations last year

# BurnReconstructiveOperations last year

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3.5.3.5.1 Provide as an appendix the last 3 months on-call schedule for residents andmedical staff assigned to the burn unit.

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3.5.3.5.2 In the unusual event that all burn surgeons are unavailable, who covers theburn service?Provide name, speciality, board cretification status, and burn experience foreach individual who would cover for more than three days. Attach CVs in theappendix.

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3.5.3.5.3 For each Staff Surgeon / Physician / Physician Extender overseeingcare of burn patients, please provide the number of CMEs for:

CD44

Please have documentation available at the site-visit. Credit may include on-site conferences if approved for CME credit, or from regional and nationalmeeting attendance, SESAP, or Web based CME. Reviewer Comments:

3.5.3.5.3.1 2 years previous:

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3.5.3.5.3.2 Last full year:

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3.5.3.5.4 Are the other burn center staff physicians and surgeons ABLS (orequivalent) certified?

CD29 CD45

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3.5.4 Physician Coverage for the Burn Unit

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3.5.4.1 Does each patient have an identifiable, qualified attending burn surgeon incharge of all clinical care?

CD47 CD34

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3.5.4.1.1 If no, explain in detail why:

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3.5.4.1.2 When more than one surgeon is involved, please explain how they sharepatients, admissions, night-weekend call, continuity of care, etc. :

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3.5.4.2 Is an attending surgeon who is capable of dealing with burn patientemergencies always available in a timely fashion?

CD47

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3.5.4.2.1 If "No" please explain

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3.5.4.3 Is a physician with appropriate privileges assigned to the burn service andavailable within 30 minutes on a 24-hour basis?

CD50

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3.5.4.3.1 If no, please explain:

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3.5.4.3.2 If this physician is not already 'in house', who provides immediateemergency response?

CD51

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3.5.4.3.2.1 Resident?

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3.5.4.3.2.2 Intensivist?

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3.5.4.3.2.3 Hospitalist?

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3.5.4.3.2.4 Physician Extender?

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3.5.4.3.2.5 Emergency Physician?

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3.5.4.3.3 If not answered above, who provides emergency and night time coverage?

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3.5.4.4 Surgical specialty support: CD51 Are surgical staff on-call and available for consultation? Reviewer Comments:

3.5.4.4.1 General Surgery?

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3.5.4.4.2 Neurologic Surgery?

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3.5.4.4.3 Obstetrics / Gynecology?

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3.5.4.4.4 Ophthalmology?

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3.5.4.4.5 Orthopedic Surgery?

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3.5.4.4.6 Otorhinolaryngology?

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3.5.4.4.7 Plastic Surgery?

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3.5.4.4.8 Urology?

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3.5.4.4.9 Cardiothoracic Surgery?

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3.5.5 Non-Surgical Speciality Support CD51 CD52

Are the following non-surgical specialities available? Reviewer Comments:

3.5.5.1 Anesthesiology?

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3.5.5.2 Radiology?

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3.5.5.3 Psychiatry?

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3.5.5.4 Pulmonary Medicine?

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3.5.5.5 Pediatrics (if applicable)?

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3.5.5.6 Nephrology

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3.5.5.7 Cardiology?

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3.5.5.8 Dermatology?

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3.5.5.9 Hematology?

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3.5.6 Resident CoveragePlease provide details regarding coverage. Reviewer Comments:

3.5.6.1 Number of residents on service at a time:

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3.5.6.2 PGY levels:

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3.5.6.3 Other responsibilities besides burns:

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3.5.6.4 Night / Weekend and vacation coverage:

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3.5.6.5 Are there times when residents are not assigned to the burn unit?

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3.5.6.5.1 If yes, please provide further explanation.

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3.5.7 Physician Extenders CD48 CD49

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3.5.7.1 Physician assistants

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3.5.7.2 Nurse practitioners

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3.5.7.3 Other physician extenders

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3.5.7.4 If yes to any of the above:

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3.5.7.4.1 Describe their credentialing process and include documentation:Please include a CV and job description for each phycsician extender.

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3.5.7.4.2 The physician extenders provide care in the:

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3.5.7.4.2.1 ICU?

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3.5.7.4.2.2 Acute care ward?

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3.5.7.4.2.3 Outpatient Clinic?

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3.5.7.4.2.4 Operating room?

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3.5.7.4.2.5 They report to:

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3.5.7.4.2.5.1 Hospital Administrator?

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3.5.7.4.2.5.2 The Nurse Manager?

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3.5.7.4.2.5.3 The Burn Director?

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3.5.7.4.2.6 Other

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3.5.8 Hospital / Intensivist / Other Coverage CD48 CD49 CD50 CD30

Please provide details regarding the responsibilities and coverage by any physicians otherthan burn surgeons and surgery residents.

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3.5.9 Nursing

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3.5.9.1 Burn Unit Nurse Manager CD53

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3.5.9.1.1 Burn Unit Nurse Manager Name:Please attach CV and the past 3 years CEUs as an appendix. Reviewer Comments:

3.5.9.1.2 Year the Burn Unit Nurse Manager was appointed:

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3.5.9.1.3 Does he/she have other units under his/her purview?

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3.5.9.1.3.1 If yes, what other units?

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3.5.9.1.4 What percent of his/her time is devoted to the burn unit?

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3.5.9.1.5 Who appoints the Nurse Manager?

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3.5.9.1.6 To whom does the Nurse Manager report ?name, title and position in the administrative structure:

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3.5.9.1.7 Is the Nurse Manager administratively responsible for the burn unit?

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3.5.9.1.7.1 If no, who is responsible?

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3.5.9.1.7.2 What role does the Nurse Manager play?

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3.5.9.1.8 The Nurse Manager has the following:

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3.5.9.1.8.1 A baccalaureate degree?

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3.5.9.1.8.2 A master's degree?

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3.5.9.1.8.3 A diploma or assosciates degree with at least 2 years of experience asnurse manager of the burn unit?

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3.5.9.1.9 The Nurse Manager has the following: CD54 CD55



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3.5.9.1.9.1 2 years or more experience in acute burn care?

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3.5.9.1.9.2 6 months managerial experience?

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3.5.9.1.10 Number of total Manager CEUs: CD107 CD108 CD109 CD110 CD111

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3.5.9.1.10.2 Last full year:Please have documentation available at the site-visit. Credits mayinclude on-site conferences if approved for CME credit, or from regionaland national meeting attendance. Reviewer Comments:

3.5.9.1.11 What involvement does the Nurse Manager have in local ornational burn projects, prevention, and outreach efforts, meetings,or organizations?

CD112 CD113 CD114

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3.5.9.1.12 Is the Nurse Manager a member of the ABA?

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3.5.9.2 Nurse Staffing and Acuity CD56 CD57

Please have staffing data, assignments, etc. available at the site visit. Reviewer Comments:

3.5.9.2.1 Does the burn unit have qualified burn nurses available 24 hours per day as



needed during all phases of burn care?

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3.5.9.2.1.1 If no, please explain:

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3.5.9.2.2 Do you utilize float staff, PRN RNs, Agency RNs in the unit?

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3.5.9.2.2.1 If yes, please describe how they qualify to work on the burn unit andhow they are trained to maintain their competency for the care of theburn patient population.

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3.5.9.2.3 Is there a burn patient classification system used to determine nurse staffingfor each patient in the burn unit?

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3.5.9.2.4 Is this system employed to determine daily staffing needs?

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3.5.9.2.5 Describe how your staffing acuity system adjusts for the critically injuredburn patient and the extensive care needs on a daily basis.

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3.5.9.2.5.1 If you have no acuity system, how do you justify staffingrequirements?

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3.5.9.2.6 Indicate the patient/nurse ratio for burn patients:

Patient NurseCritical Burn Admission,Emergent Phase (24-48 hrs. post burn),Acute Phase,Rehabilitation Phase,During critical burn wound care,



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3.5.9.2.7 Is there a burn unit orientation program which documentscompetencies specific to treatment of burn patients including criticalcare, wound care, and rehabilitation?

CD58 CD108

Please be prepared to show course outline, handouts, etc., to the surveyors. Reviewer Comments:

3.5.9.2.7.1 Is each new staff nurse hired for the burn unit required tocomplete the orientation program prior to assumingindepedent practice in the burn unit?

CD108

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3.5.9.2.8 Describe competency training for burn nurses who treat burn patients:Please have compentency requirements available at the site visit.

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3.5.9.2.9 Describe the continuing education program for burn nurses:

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3.5.9.2.10 Are nurses supported to attend regional, national, or internationalburn meetings?

CD107

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3.5.9.2.10.1 How many nurses in the past year attended a conference?

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3.5.9.2.11 Have you experienced quality issues in patient care related to availabilityof qualified nursing staff?

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3.5.9.2.11.1 If yes, please explain:

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3.5.9.2.12 Provide the nursing staff demographics (use whole numbers): Answer forall patient care job categories on the unit.



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3.5.9.2.12.1 Average years of experience:

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3.5.9.2.12.2 Annual rate of turnover:

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3.5.10 Rehabilitation / Therapy

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3.5.10.1 Is there a defined burn rehabilitation program? CD59

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3.5.10.1.1 If yes, describe the goals of your rehabilitation program:

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3.5.10.2 Rehabilitation ManagerThis is the person to whom the therapists on the burn unit report and to whom theBurn Director works for in problem solving. Reviewer Comments:

3.5.10.2.1 Rehabilitation Manager Name:Please attach a CV in the appendix.

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3.5.10.2.2 Year the Rehabilitation Manager was appointed:

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3.5.10.2.3 Does he/she have other units under his/her purview?

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3.5.10.2.3.1 If yes, what other units?

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3.5.10.2.3.2 What percent of his/her time is devoted to the burn unit?

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3.5.10.2.4 Who appoints the Rehabilitation Manager?

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3.5.10.2.5 To whom does the Rehabilitation Manager report?

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3.5.10.2.6 Is the Rehabilitation Manager a trained:

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3.5.10.2.6.1 Physical Therapist?

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3.5.10.2.6.2 Occupational Therapist?

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3.5.10.2.6.3 Speech Therapist?

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3.5.10.2.6.4 Other - Please specify:

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3.5.10.2.7 The Rehabilitation Manager has the following:

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3.5.10.2.7.1 A baccalaureate degree?

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3.5.10.2.7.2 A master's degree?

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3.5.10.2.8 The Rehabilitation Manager has the following:

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3.5.10.2.8.1 12 months experience in acute burn care?

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3.5.10.2.8.2 6 months managerial experience?

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3.5.10.2.9 Number of total Rehabilitation Manager CEUs: CD107 CD108 CD109 CD110 CD111

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3.5.10.2.9.2 Last full year:Please have documentation available at the site visit. Credits mayinclude on-site conferences if approved for CME credit, or regional andnational meeting attendance. Reviewer Comments:

3.5.10.2.10 What involvement does the Rehabilitation Manager have in localor national burn projects, preventaion, and outreach efforts,meetings, or organizations?

CD112 CD113 CD114

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3.5.10.2.11 Is the Rehabilitation Manager a member of ABA?

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3.5.10.3 Rehabilitation Personnel CD60 CD61 CD62 CD63 CD65



CD66 CD59

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3.5.10.3.1 Describe the assignment of therapists and the supervision of the therapistson the burn unit:Note: This is not an appendix. Please include the duration of assignments ifthey are on a rotational basis and the qualifications of the individuals whosupervise the burn unit therapists.

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3.5.10.3.2 Are the physical and occupational therapists in the burn centerlicensed or registered in their specific disciplines?

CD60

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3.5.10.3.3 Describe Inpatient and Outpatient Staffing:

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3.5.10.3.3.1 Is staffing based upon both Inpatient and Outpatient activity with atleast one FTE therapist for every 6 patients on the burn unit?

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3.5.10.3.4 Is a licensed therapist (OT / PT) available 7 days per week? CD63

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3.5.10.3.5 Number of Occupational Therapists assigned to your burn unit:

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3.5.10.3.5.1 Do they have inpatient responsibility?

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3.5.10.3.5.2 Do they have outpatient responsibility?

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3.5.10.3.5.3 Do they have responsibilities outside the burn unit?



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3.5.10.3.5.4 What are coverage arrangements for weekends / vacation / illness?

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3.5.10.3.6 Number of Physical Therapists assigned to your burn unit:

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3.5.10.3.6.1 Do they have inpatient responsility?

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3.5.10.3.6.2 Do they have outpatient responsility?

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3.5.10.3.6.3 Do they have responsibilities outside the burn unit?

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3.5.10.3.6.4 What are the coverage arrangements for weekends / vacation /illness?

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3.5.10.3.7 Is there a burn unit orientation program for all new therapistsassiedn to the burn unit?

CD65 CD108

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3.5.10.3.8 Describe competency training for therapists who treat burn patients: CD65 CD66

Please have competency requirements available at the site visit.

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3.5.10.3.9 Are therapists supported to attend regional, national, orinternational burn meetings?

CD107

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3.5.10.3.9.1 How many therapists in the past year attended a conference?



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3.5.11 Ancillary Services CD67 CD68 CD69 CD70 CD71

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3.5.11.1 Social Services

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3.5.11.1.1 Is social service consultation for the burn service available 24 hours 7 daysper week?

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3.5.11.1.2 How many Social Workers are assigned to the burn center?

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3.5.11.1.3 Describe the responsibilities of the Social Worker on the burn center:

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3.5.11.1.4 Are there Patient Care Coordinators?

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3.5.11.1.5 Are there Discharge Facilitators?

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3.5.11.2 Nutrition Support

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3.5.11.2.1 Does the Nutritionist make rounds with the burn team? Or see the burnteam on a daily basis?

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3.5.11.3 Pharmacy Support



Reviewer Comments:

3.5.11.3.1 Is a Pharmacist availabe to the burn unit on a 24 hour basis?

Reviewer Comments:

3.5.11.3.2 Is the Pharmacist able to write orders?

Reviewer Comments:

3.5.11.3.3 Does the Pharmacist have 6 months experience in critical care and in thepharmacokinetics of patients with acute burn injuries?

Reviewer Comments:

3.5.11.3.4 Does the Pharmacist make rounds with the burn team? Or see the burnteam on a daily basis?

Reviewer Comments:

3.5.11.4 Respiratory Therapy

Reviewer Comments:

3.5.11.4.1 Are Respiratory Therapists available for the assessment and managementof burn patients on the burn service?

Reviewer Comments:

3.5.11.4.2 Do they have:

Reviewer Comments:

3.5.11.4.2.1 Ventilator weaning protocols?

Reviewer Comments:

3.5.11.4.2.2 Tracheostomy management protocols?

Reviewer Comments:

3.5.11.5 Clinical Psychology / Psychiatry

Reviewer Comments:



3.5.11.5.1 Is a Psychiartist or Clinical Psychiartist available for consultation?

Reviewer Comments:

3.5.11.6 Vocational Rehabilitation

Reviewer Comments:

3.5.11.6.1 Please describe resources for assisting patients to return to work for:

Reviewer Comments:

3.5.11.6.1.1 Work related injuries (on the job)

Reviewer Comments:

3.5.11.6.1.2 Other injuries

Reviewer Comments:

3.5.11.7 Child-Life CD71 Note: this is mandatory for Verified Pediatric Burn Centers Reviewer Comments:

3.5.11.7.1 Is a Child-Life specialist available for:

Reviewer Comments:

3.5.11.7.1.1 School re-entry?

Reviewer Comments:

3.5.11.7.1.2 Pre-operative teaching?

Reviewer Comments:

3.5.11.7.1.3 Wound Care distraction?

Reviewer Comments:

3.5.11.7.2 Is there a play (recreation) therapist?

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3.5.11.7.2.1 If yes, what resources are available, and what percent of time isdevoted to the burn unit?

Reviewer Comments:

3.5.11.8 Spiritual Care

Reviewer Comments:

3.5.11.8.1 Please describe available chaplain services:

Reviewer Comments:

3.5.11.9 Translator Services

Reviewer Comments:

3.5.11.9.1 Please describe available services for non-English speaking patients:

Reviewer Comments:

3.5.11.10 Palliative Care Services

Reviewer Comments:

3.5.11.10.1 Please describe any program for end of life goals:If there are established protocols, please attach them in the appendix.

Reviewer Comments:

4. Process4.1. Policy and Procedure

4.1.1 Policy and Procedure ManualPlease have the policy and procedure manual available at the site visit with markers foreach of the following items: Reviewer Comments:

4.1.2 The medical care for patients admitted to the burn service conforms to writtenburn center patient care policies and procedures.

CD6

Reviewer Comments:

4.1.3 Does the policy and procedure manual contain items that address:



Reviewer Comments:

4.1.3.1 Administration of the burn center

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4.1.3.2 Role and responsibilities of medical director

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4.1.3.3 Role and responsibilities of nurse manager

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4.1.3.4 Nursing Staff

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4.1.3.5 Nurse deployment with high/low census

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4.1.3.6 Charges based on service utilization (acuity)

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4.1.3.7 Admission criteria to the burn unit

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4.1.3.8 Admission to burn unit by other services

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4.1.3.9 Criteria for discharge and follow-up care

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4.1.3.10 Transfer of burn patients to other Med / Surg units

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4.1.3.11 Admission of burns to other hospital areas

Reviewer Comments:



4.1.3.12 Identification of primary surgeon, and the role of consultants

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4.1.3.13 Mandatory vs. elective consultations

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4.1.3.14 Ability of consultant physicians to write orders

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4.1.4 Does the medical director and nurse manager review the manual at least annually?

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4.2. Pre-Hospital4.2.1 Brief description of the local/regional/state triage plan CD18

CD19 CD20 CD21

Reviewer Comments:

4.2.2 Please describe the pre-hospital EMS system for your hospital:

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4.2.3 Who owns/controls ambulance, helicopter, and fixed wing aircraft?

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4.2.4 What QI process exists for regional EMS programs? CD20

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4.2.5 What educational opportunities does the Burn Center provide for firstresponders and referring providers ?

CD109

Reviewer Comments:

4.2.5.1 Hospital Organization

Reviewer Comments:



4.2.6 Does the burn center have written guidelines for the triage, treatment, andtransfer of burn patients from other facilities ?

CD18

Please include as an appendix. Reviewer Comments:

4.2.7 Are there formal transfer agreements with outlying non-burn hospitals in the catchmentarea ?Please have them available at the time of the site review. Reviewer Comments:

4.2.8 Burn center collaboration / coordination of regional burn care delivery

Reviewer Comments:

4.3. Disaster Planning4.3.1 Please briefly outline in the text box below the Burn Center/ hospital regional

mass casualty burn disaster plan including burn center plans for patientmanagement once they have arrived at the burn center hospital:

CD22 CD23 CD24 CD25 CD26

Please upload detailed documents as appendices.

Reviewer Comments:

4.3.2 Does the Burn Center maintain current contact information on the American BurnAssociation website

CD26

Reviewer Comments:

4.3.3 In a mass casualty burn disaster how many burn patients could be accommodated atthe burn center hospital?

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4.3.4 Are there current (within the past 3 years) written Memoranda of Understanding withother burn centers regarding secondary triagePlease have them available for review at the site visit. Reviewer Comments:

4.3.5 If there are more patients than surge capability allows, where would they go?



Reviewer Comments:

4.3.6 Are the regional burn mass casualty plans reviewed and updated as necessary on anannual basis by EMS and burn center physicians?Please provide copies at the site-visit Reviewer Comments:

4.3.7 Has a Burn Center surgeon been trained in Disaster Management?

Reviewer Comments:

4.4. Emergency Services4.4.1 Medical Director of the Emergency Department CD21

Reviewer Comments:

4.4.2 ER staffing for surgery/burn patients.

Reviewer Comments:

4.4.3 Who manages burn patients in the emergency department

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4.4.4 Who makes the triage decisions?

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4.4.5 Who performs

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4.4.5.1 wound care

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4.4.5.2 therapy

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4.4.5.3 patient education



Reviewer Comments:

4.4.6 What is the process for Burn QI the Emergency Department

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4.5. InPatient Care4.5.1 Burn diagrams

Please attach in the Appendix the burn diagram you employ to estimate the burn size ofyour patients. Reviewer Comments:

4.5.1.1 Is a Burn Diagram completed on admission?

Reviewer Comments:

4.5.1.2 Who is responsible for completing the burn diagram?

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4.5.1.3 How is it incorporated into the Patient Medical Record

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4.5.1.4 Are additional diagrams completed as patient care progresses?

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4.5.1.4.1 How Often

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4.5.2 Patient Photo documentation

Reviewer Comments:

4.5.2.1 Are photos documenting the burn taken on admission?

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4.5.2.2 Who is responsible for photo documentation?



Reviewer Comments:

4.5.2.3 Are they incorporated into the Patient Medical Record?

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4.5.2.4 Are additional photos taken as patient care progresses?

Reviewer Comments:

4.5.2.4.1 How Often?

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4.5.3 Ancillary Services - Are the following services available on a 24-hour basis? CD8

Reviewer Comments:

4.5.3.1 Renal Dialysis

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4.5.3.2 Plain radiographs

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4.5.3.3 Angiography

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4.5.3.4 Ultrasonography

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4.5.3.5 Nuclear medicine

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4.5.3.6 In house X-ray technician

Reviewer Comments:

4.5.3.7 CT technician available on call

Reviewer Comments:



4.5.3.8 Laboratory services including microbiology

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4.5.3.9 Blood Bank

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4.6. Operating Room4.6.1 Operating Room CD9

CD10

Reviewer Comments:

4.6.2 Are there dedicated operating rooms for the care of the burn patient?

Reviewer Comments:

4.6.3 Operating room location:

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4.6.4 When are elective burns operated?

Reviewer Comments:

4.6.4.1 On specific days of the week

Reviewer Comments:

4.6.4.1.1 If so what days?

Reviewer Comments:

4.6.4.2 Burns are scheduled after other elective OR cases

Reviewer Comments:

4.6.5 Do all burn operating rooms have individual temperature control?

Reviewer Comments:

4.6.6 Is an operating room available to the burn service on a 24-hour basis?



Reviewer Comments:

4.6.7 Is there a team of nurses/techs who regularly do burns?

Reviewer Comments:

4.6.8 Is there dedicated burn anesthesia CD52

Reviewer Comments:

4.6.9 Is an anesthesiologist available in the hospital 24 hrs. per day

Reviewer Comments:

4.6.10 Describe the transport to the OR for a critically ill, ventilated burn patient.(Horizontal and vertical distance, who accompanies, etc.)

Reviewer Comments:

4.6.11 Does the burn center use allograft skin in the care of burn patients

Reviewer Comments:

4.6.11.1 If yes:

Reviewer Comments:

4.6.11.2 Does a skin bank exist within the burn center?

Reviewer Comments:

4.6.11.3 Does the burn center have a policy indicating that it’s provider of allograft skin isin compliance with current U.S. Food and Drug Administration (FDA) regulationsregarding human tissues for transplantation?

Reviewer Comments:

4.6.11.4 Does the burn center hospital have a policy for the receipt, handling and storageof human skin allograft that is compliant with current Joint Commissionstandards?

Reviewer Comments:

4.6.11.5 Does the burn center hospital have a policy and documentation of thenotification of the recipients and the tissue bank in the event of an adverse eventarising from the use of allograft?



Reviewer Comments:

4.7. Infection Control4.7.1 Infection Control CD104

Reviewer Comments:

4.7.2 Please describe the hospital infection control program.Include details regarding the audits and analysis of nosocomial infection data

Reviewer Comments:

4.7.3 Who is responsible for monitoring and enforcing infection control?

Reviewer Comments:

4.7.4 Please describe infection control programs specific to the burn center.

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4.7.5 Describe your isolation policy, if any:

Reviewer Comments:

4.7.6 Do you exclusively use single rooms?

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4.7.7 Do you have a formal hand washing policy?

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4.7.8 Do you require visitors to gown and glove?

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4.7.8.1 If Yes, under what conditions?

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4.7.9 What microbial surveillance is used, if any?

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4.7.10 Are routine cultures done on patients?

Reviewer Comments:

4.7.10.1 If yes, what body sites are cultured and how often?

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4.7.10.2 What organisms are routinely screened?

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4.7.11 What plans are in place if a multi-resistant nosocomial organism infects three or morepatients?

Reviewer Comments:

4.8. Continuity of Care4.8.1 Discharge Planning

Reviewer Comments:

4.8.1.1 Who is responsible for coordinating discharge planning?

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4.8.1.2 What team members participate in this effort?

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4.8.1.3 Do you have a written discharge planning form?If yes, please attach as an appendix Reviewer Comments:

4.8.1.3.1 If “no” please describe how you ensure transition of care to outpatientstatus?

Reviewer Comments:

4.8.2 Do you provide the following for patients CD80 CD81 CD82 CD84




Reviewer Comments:

4.8.2.1 Coordinated transition of care to the outpatient status

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4.8.2.2 Access to appropriate rehabilitation

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4.8.2.3 Support for family members or other significant persons

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4.8.2.4 Follow-up after hospital discharge

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4.8.2.5 Access to social service, pharmacist and dietary consultations

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4.8.2.6 Brief psychological screening / intervention

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4.8.2.7 Evaluation of the patient developmental status

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4.8.2.8 Access to vocational counseling

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4.8.2.9 Access to reconstructive surgery

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4.8.3 Is there an organized aftercare program for burn survivors CD80 CD81



CD82 CD83 CD84 CD85 CD86 CD87 CD88

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4.8.4 Does the burn center participate in a peer support program (such as the SurvivorsOffering Assistance in Recovery program through the Phoenix Society)?

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4.8.5 Does the burn center organize regular or ad hoc meetings of a peer support group forin-patients and their families?

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4.8.6 If the center cares for children, does it offer a school re-entry program?

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4.9. OutPatient Care4.9.1 Outpatient Care CD72

CD73 CD74 CD75 CD76 CD77 CD78

Reviewer Comments:

4.9.2 Is there an organized out patient burn clinic

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4.9.2.1 Where is it located?

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4.9.2.2 How often does it meet?



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4.9.2.3 Who is in attendance at the clinic?

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4.9.2.3.1 General Surgeons

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4.9.2.3.2 Plastic Surgeon

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4.9.2.3.3 Physician extenders

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4.9.2.3.4 Nurses

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4.9.2.3.5 Therapist

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4.9.2.3.6 Social Worker

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4.9.2.3.7 Psychologist

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4.9.2.3.8 Vocational Counselor

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4.10. Rehabilitation4.10.1 Rehabilitation CD90




CD83 CD84 CD85 CD86 CD87 CD88

Reviewer Comments:

4.10.2 Physiatry consultation is available CD90

Reviewer Comments:

4.10.3 What arrangements are made regarding funding, timely admission to rehab, and burnfollow-up during rehab?

Reviewer Comments:

4.10.4 Where do adult patients go?

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4.10.5 Where do children go, if applicable?

Reviewer Comments:

4.11. Education4.11.1 Education CD107

CD108 CD109 CD110 CD111

Reviewer Comments:

4.11.2 Number of Courses Provided

Reviewer Comments:


Reviewer Comments:




Reviewer Comments:


Reviewer Comments:

4.11.3 Professional

Reviewer Comments:

4.11.3.1 Describe the continuing educational program for the medical staff, nursing staff,rehabilitation staff, and other personnel.

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4.11.3.2 How is clinical competency assessed and maintained for

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4.11.3.2.1 Medical staff

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4.11.3.2.2 Nursing

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4.11.3.2.3 Therapy

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4.11.3.2.4 Other

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4.11.3.3 Is there is a residency program with surgical residents on the burnservice

CD110

Reviewer Comments:

4.11.3.3.1 Describe the orientation program for new residents

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4.11.3.4 If there is a burn fellowship:



Reviewer Comments:

4.11.3.4.1 Is it an ACGME Critical Care Fellowship

Reviewer Comments:

4.11.3.4.2 How many Fellows per year?

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4.11.3.4.3 Describe the Fellowship

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4.11.4 Community outreach CD112 CD113 CD114

Reviewer Comments:

4.11.4.1 Describe the center's community education programList all community-related educational activities during the last calendar year in anappendix

Reviewer Comments:

4.11.4.2 Does the Burn Center sponsor ABLS courses (or equivalent?)

Reviewer Comments:

4.11.5 Burn prevention program CD112

Reviewer Comments:

4.11.5.1 Who is responsible?

Reviewer Comments:

4.11.5.2 Describe the burn center’s prevention efforts(List all displays, presentations, PSAs, etc., presented during the past year.)

Reviewer Comments:

4.11.6 Does the burn center offer education on the current concepts in emergency and



impatient burn care treatment to pre-hospital and hospital care providers within it'sservice area?If yes, generally describe your program in this section and attach a complete listing ofthem for the past three years and an upload. Reviewer Comments:

4.12. Research4.12.1 Research CD114

Reviewer Comments:

4.12.2 Do you have a Research Program?

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4.12.3 If Yes, how many Research nurses / coordinators?

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4.12.4 Have you participated in ABA Multi-Center Trials?

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4.12.5 List the research activities/projects of your burn center for the past three years

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4.12.6 Publications

Reviewer Comments:

4.12.6.1 List any publications (manuscripts and chapters) from your burn center from thepast three years(Please have reprints available at the site visit).

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5. Outcomes5.1. Mortality Data

5.1.1 Mortality TablePlease complete the following table with burn size across the top and patient agevertically. Place the number of deaths over total admissions for each box. For example in



box age 31-40 and % burn 31-40 if there were 3 deaths and 30 admissions the box wouldcontain 3/30. Statistics should be the sum of deaths for the past three years.

BurnSize

%TBSA(Across)

********* Age

(Down)

0-9%

10-19%

20-29%

30-39%

40-49%

50-59%

60-66%

70-79%

80-89%

90-100% Total

0-1011-2021-3031-4041-5051-6061-7071-8081-90

91-100Total

Reviewer Comments:

5.2. Review Process5.2.1 Info CD93

CD94 CD95

CD101 CD102 CD103 CD104 CD105 CD106

CD96 CD97 CD98 CD99

The Burn Service must conduct internal Quality Improvement meetings to identifyproblems and improvement opportunities related to the delivery of burn care, thecorrective actions taken, and the evaluation of these actions. Please do not send quality assurance documents or mintues! All QI documents should beavilable at the site-visit. Reviewer Comments:



5.2.2 Multi-disciplinary patient care conferences CD7

Reviewer Comments:

5.2.2.1 How often do they meet?

Reviewer Comments:

5.2.2.2 Who attends these meetings?

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5.2.2.2.1 Surgeons?

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5.2.2.2.2 Intensivists?

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5.2.2.2.3 Nursing Leaders?

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5.2.2.2.4 Administration?

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5.2.2.2.5 OT/PT?

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5.2.2.2.6 Social Work?

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5.2.2.2.7 Physician Extenders?

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5.2.2.2.8 Others (list)

Reviewer Comments:

5.2.2.3 Are patient care plans and discharge plans documented?



Please provide examples at the site visit Reviewer Comments:

5.2.3 Morbidity and Mortality ConferencesIn addition to burn team complication conferences, surgical complications and deathsmust be reviewed at regularly scheduled, peer-reviewed mortality and morbidityconferences. Attendees at this conference must include specialist staff members other than thosepracticing in the burn center. All significant burn complications and all deaths must bediscussed. High points of the discussion must be documented and assessment of the deathor complication made in terms of the cause: patient disease, potential preventable, possiblypreventable, etc. (or the equivalent thereof). Recommended actions and loop closure mustbe documented. Note: Records of this conference must be available for review by the surveying team.Failure to do this will be considered a criterion deficiency. The surveryors will review chartsand QI documentation (including M&M notes and loop closure documentation) for alldeaths, complications and transfers to other acute care hospitals during the past year.Deaths and complications should be sorted according to the outcome criteria (disease,possibly preventable, preventable). Reviewer Comments:

5.2.3.1 How often do M&M meetings meet?

Reviewer Comments:


Reviewer Comments:

5.2.3.2.1 General Surgeons?

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5.2.3.2.2 Plastic Surgeons?

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5.2.3.2.3 Intensivists?

Reviewer Comments:

5.2.3.2.4 Hospitalists?



Reviewer Comments:

5.2.3.2.5 Pediatricians?

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5.2.3.2.6 Anesthesiologists?

Reviewer Comments:

5.2.3.2.7 Pulmonologists?

Reviewer Comments:

5.2.3.2.8 Emergency Physicians?

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5.2.3.2.9 Residents?

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5.2.3.2.10 Students?

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5.2.3.2.11 Others

Reviewer Comments:

5.2.4 Burn Quality or Process Improvement meetings CD101 CD102

Reviewer Comments:

5.2.4.1 How often do they meet?

Reviewer Comments:


Reviewer Comments:

5.2.4.2.1 Physicians?



Reviewer Comments:

5.2.4.2.2 Nursing Leaders?

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5.2.4.2.3 Administration?

Reviewer Comments:

5.2.4.2.4 OT/PT?

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5.2.4.2.5 Social Work?

Reviewer Comments:

5.2.4.2.6 Physician Extenders?

Reviewer Comments:

5.2.4.2.7 Others (list)

Reviewer Comments:

5.2.5 Other Burn Center QI meetings:Please describe in brief and provide documentation at site visit.

Reviewer Comments:

5.2.6 Burn Center Intensive Review and Root Cause Analysis CD101 Please outline the process for review and loop closure for a sentinel event.

Reviewer Comments:

5.2.7 How does the burn center QI process integrate with hospital wide performanceimprovement?

Reviewer Comments:

5.3. Burn Registry5.3.1 Info CD105

Submission of Minimal Data Set to the American Burn Association National Burn



Repository is mandatory for verification. Reviewer Comments:

5.3.2 Do you have regional, state, or national affiliation of burn registry?

Reviewer Comments:

5.3.3 Who maintains the burn registry?

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5.3.4 How do you maintain the burn center registry?If not using NTRACS, please provide a data sheet showing collected fields as an appendix. Reviewer Comments:

5.3.4.1 NTRACS 5

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5.3.4.2 Alternative data collection system

Reviewer Comments:

5.3.4.2.1 Do you submit:

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5.3.4.2.1.1 Minimal Data Set

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5.3.4.2.1.2 Hospital Charges?

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5.3.4.2.1.3 Complications?

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5.3.4.2.1.4 Outcomes Data?

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5.3.4.2.2 Describe the criteria for patient entry into the burn registry CD106

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5.3.4.2.2.1 Are outpatients included?

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5.3.4.2.2.2 Are observation status patients included?

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5.3.4.3 Who reviews the NBR Benchmark Report?

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5.3.4.4 Does the burn service conduct audits at least annually?

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5.3.4.4.1 Burn severity?

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5.3.4.4.2 Burn mortality?

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5.3.4.4.3 Incidence of complications?

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5.3.4.4.4 Length of hosiptalization?

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5.3.4.4.5 Hospital charges for care?

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5.4. Current Process Improvement Projects5.4.1 Info CD103

Please indicate the clinical activities currently monitored by the quality assurance/CQIprogram



Reviewer Comments:

5.5. Other Burn Center Programs5.5.1 Please enter any pertinent information

Reviewer Comments:

6. Case Summaries6.1. Death and Complications6.2. Transfers

7. PRQ Onsite Materials7.1 Outpatient Visit

Number of Inpatient followup in other facilities. Provide details for each case and have medicalrecords available for review Reviewer Comments:

7.2 Burn DirectorTotal BCD CME credits. Documentation available of CME credits (may include onsite conferences,if approved for CME credit, or from regional and national meeting attendance, SESAP, or web-based CME). Reviewer Comments:

7.3 Burn Center Staff/Staff SurgeonsPrivileges for physicians (and physician extenders), approved by BCD-Provide documentation. Reviewer Comments:

7.4 Burn Center Staff/Staff SurgeonsNumber of CMEs for each Staff Surgeon/Physician/Physician Extender. Documentation availableof CME credits (may include onsite conferences, if approved for CME credit, or from regional andnational meeting attendance, SESAP, or web-based CME). Reviewer Comments:

7.5 Hospital/Intensivist/Other CoverageProvide details regarding the responsibilities and coverage by any physicians other than burnsurgeons and surgery residents Reviewer Comments:

7.6 Nurse Manager CEU's



Number of total Manager CEUs. Documentation available of credits (may include onsiteconferences, if approved for CME credit, or regional and national meeting attendance). Reviewer Comments:

7.7 Nurse Staffing and AcuityProvide staffing data, assignments, etc Reviewer Comments:

7.8 Burn Center Orientation Program Documenting CompetenciesBe prepared to show course outline, handouts, etc. to site reviewers. Reviewer Comments:

7.9 Burn Nurse Competency TrainingProvide Burn Nurse Competency Requirements, and have available during site visit. Reviewer Comments:

7.10 Rehabilitation Therapist CEUsDocumentation available on site. Credits may include onsite conferences, if approved for CMEcredit, or regional and national meeting attendance. Reviewer Comments:

7.11 Rehabilitation Therapists CompetencyProvide competency requirements for Therapists during the site visit. Reviewer Comments:

7.12 Policy and Procedure Manual-Provide to site reviewers with markers for each of the items in the PRQ. Reviewer Comments:

7.13 Formal Transfer AgreementsProvide formal transfer agreements with outlying non-burn hospitals in catchment area. Reviewer Comments:

7.14 Disaster Planning Memoranda of Understanding with other Burn CentersProvide and have available on site. Reviewer Comments:



7.15 Regional Mass Casualty PlansProvide copies of the Regional Mass Casualty Plans (reviewed and updated on an annual basisby EMS and Burn Center Physicians). Reviewer Comments:

7.16 Research/PublicationsProvide reprints of publications (manuscripts & chapters) from your Burn Center from the past(3) years Reviewer Comments:

7.17 QI DocumentsProvide ALL QI documents on site. Reviewer Comments:

7.18 Patient Care Plans and Discharge PlansProvide examples at the site visit Reviewer Comments:

7.19 Morbidity & Mortality ConferencesRecords/minutes of these conferences must be available for review by the site visit team,including documenetation of the conference attendees. Failure to do this will be considered acriterion deficiency. All documents must contain recommended actions and loop closure. Reviewer Comments:

7.20 Other Burn Center QI MeetingsDescribe in brief and provide documentation at visit Reviewer Comments:

7.21 Burn Center Intensive Review & Root Cause AnalysesOutline the process for review and loop closure for a sentinel event and provide to sitereviewers Reviewer Comments:

8. Clinical Rounds9. Appendix

Document LinkAdministrative Letter of SupportAdministrative Letter of Support



Document LinkBurn Center Director CVBurn Center Director CVBurn Center Director Job DescriptionBurn Center Job DescriptionBurn Center Mass Casualty Plans (may be 2 or 3 documents)Burn Center Mass Casualty Plans (may be 2 or 3 documents)Burn Center Mass Casualty Plans (may be 2 or 3 documents)Burn DiagramsBurn DiagramsCV of Burn Nurse ManagerCV of Burn Nurse ManagerCV of Physical ExtendersCV of Physical ExtendersCV of Physical ExtendersCV of Physical ExtendersCV of Physical ExtendersCV of Physical ExtendersCV of Rehabilitation ManagerCV of Rehabilitation ManagerCV's of all SurgeonsCV's of All SurgeonsCV's of All SurgeonsCV's of All SurgeonsCV's of All SurgeonsCV's of All SurgeonsCV's of individuals who cover burn service aside from burn surgeonsCV's of individuals who cover burn service aside from burn surgeonsCV's of individuals who cover burn service aside from burn surgeonsLine Item BudgetLine Item BudgetListing of Community related Educational Activities (During last calendar year)Listing of Community related Educational Activities (During last calendar year)Listing of Community related Educational Activities (During last calendar year)Listing of Emergency and Inpatient Burn Care Education Program (For past 3 years)Listing of Emergency and Inpatient Burn Care Education Program (For past 3 years)Listing of Emergency and Inpatient Burn Care Education Program (For past 3 years)Listing of Emergency and Inpatient Burn Care Education Program (For past 3 years)Organizational ChartOrganizational Chart



Document LinkProtocols for End of Life GoalsRegistry Data SheetResident On-Call Schedule for last 3 monthsResident On-Call Schedule for last 3 monthsResident On-Call Schedule for last 3 monthsWritten Discharge PlanWritten Discharge PlanWritten Discharge PlanWritten Guidelines of Triage, Treatment, and TransferWritten Guidelines of Triage, Treatment, and TransferWritten Guidelines of Triage, Treatment, and TransferResearch Activities Appendix (Optional)Isolation Policy Appendix (Optional)Orientation Program for Residents (Optional)Prevention Efforts (Optional)Publications

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