Dear Healthcare Provider,
The Fox Valley Regional Trauma Advisory Council (RTAC) has been
meeting since October, 2002. The goal of the RTAC is to improve the
care of the trauma patient in the Fox Valley and surrounding areas.
An executive council consisting of 14 members has been elected and
includes representation from pre-hospital and hospital personnel as
well as community health personnel. Representatives are equally
divided between rural and urban care providers.
The purpose of the attached survey is to determine the
capabilities of the hospitals that are served by the Fox Valley
RTAC. We would appreciate your assistance in obtaining this
information. In addition, we would like to encourage personnel from
your facility to become involved in the RTAC. The RTAC consists of 4
subcommittees that meet monthly prior to the full RTAC meeting. The
subcommittees are: Injury Prevention & Education, Medical Oversight,
Performance & Improvement, and Specialty Care. Meetings of the
subcommittees are held monthly on the 2nd Wednesday of
the month at 6 pm, the full meeting follows at 7 pm. Locations vary.
For more information please go to: www.thedacare.org/trauma and
select the Regional Trauma Advisory Council link or you may call
Kelly Stanislaus, RTAC Secretary, at 920-729-3347.
Please complete this survey and return by July 15, 2003
to:
Kelly Stanislaus, RN, Trauma Coordinator
Theda Clark Medical Center
130 Second Street, PO Box 2021
Neenah, WI 54957-2021
E-Mail: Kelly.stanislaus@thedacare.org
If you have any questions regarding this survey, please e-mail
jeff.grimm@thedacare.org or call me at 920-729-2114. Thank you in
advance for your assistance.
Sincerely,
Jeff Grimm, RN, EMT-P
Co-chairperson
Fox Valley RTAC, Medical Oversight Committee.
Fox Valley Regional Trauma Advisory Council
Hospital Information Survey
All hospitals must register an RTAC selection with the State.
To do so or if you have questions about the State Trauma
Advisory Council (STAC) or which RTAC would be appropriate for
your agency, please contact:
Marianne Peck, RN, MSN
WI Statewide Trauma System Coordinator
Bureau of EMS & Injury Prevention
Division of Public Health
PO Box 2659
Madison, WI 53701-2659
(608) 266-0601
Fax: (608) 261-6392
E-mail: peckme@dhfs.state.wi.us
Has your facility chosen a primary RTAC? YES / NO
If yes, please circle the primary RTAC that you have chosen.
For your information, you may chose to affiliate with more
than 1 RTAC but you must register your choice of a
primary RTAC with the state
Northeast RTAC Fox Valley RTAC Southeast RTAC
Southcentral RTAC Southwest RTAC North/Northwest RTAC
West Central RTAC Lake Superior RTAC North Central RTAC
Please list a contact person at your facility for the RTAC.
AGENCY: _________________________________________
NAME: ___________________________________________
TITLE: ___________________________________________
ADDRESS: ________________________________________
CITY: ____________________________________________
PHONE: ____________________ FAX: ________________________
E-MAIL:
______________________________________________________
Please refer to the attached draft guidelines
for level III & IV trauma providers. After reviewing the
guidelines, which level of service do you feel that your
hospital currently provides or plans to provide within the next
6 months? If you are an American College of Surgeons (ACS)
verified level I or II trauma center please indicate so.
Current Service Level: ACS Verified Level
I ACS Verified Level II
Please indicate any plans to change the trauma service level
at your facility within the next 2 years.
______________________________________________________________________________________________________________________________________________________________________________________________________
Please circle any American College of
Surgeons (ACS) Verified Level I or II trauma centers in WI that
your facility has transfer agreements with.
Froedert Memorial Hospital, Milwaukee: Level
I
UW Hospital, Madison: Level I
Theda Clark Medical Center, Neenah: Level II
St. Vincent’s Hospital, Green Bay: Level II
Luther Hospital, Eau Claire: Level II
Please list your emergency department medical
director and contact information.
AGENCY: _________________________________________
NAME: ___________________________________________
TITLE: ___________________________________________
ADDRESS: ________________________________________
CITY: ____________________________________________
PHONE: ____________________ FAX: ________________________
E-MAIL:
______________________________________________________
Please list your emergency department nursing
director and contact information.
AGENCY: _________________________________________
NAME: ___________________________________________
TITLE: ___________________________________________
ADDRESS: ________________________________________
CITY: ____________________________________________
PHONE: ____________________ FAX: ________________________
E-MAIL:
______________________________________________________
Please include contact information for
the following persons at your facility (if different than
above).
a. Trauma Coordinator
b. Injury Prevention Coordinator
c. EMS Coordinator
Please enclose a copy of any pediatric care
trauma protocols and burn care protocols that your facility
utilizes.
Does your facility have pediatric trauma transfer agreements?
Yes / No
If yes, please list any institutions with which you have
pediatric trauma transfer agreements.
____________________________________________________________________________________________________________________________________
Does your facility have burn patient transfer agreements?
Yes / No
If yes, please list any institutions with which you have burn
transfer agreements:
____________________________________________________________________________________________________________________________________
