DEPARTMENT OF HEALTH

(1) Purpose: The department maintains a trauma registry, as required by RCW 70.168.060 and 70.168.090. The purpose of this registry is to:

(a) Provide data for ((injury)) trauma surveillance, analysis, and prevention programs;

(b) Monitor and evaluate the outcome of care of major trauma patients, in support of statewide and regional quality assurance and system evaluation activities;

(c) Assess compliance with state standards for trauma care;

(d) Provide information for resource planning, system design and management;

(e) Provide a resource for research and education.

(2) Confidentiality: It is essential for the department to protect information regarding specific patients and providers. Data elements related to the identification of individual patient's, provider's, and facility's care outcomes ((shall)) must be confidential, ((shall)) must be exempt from RCW 42.17.250 through 42.17.450, and ((shall)) must not be subject to discovery by subpoena or admissible as evidence.

(a) The department may release confidential information from the trauma registry in compliance with applicable laws and regulations. No other person may release confidential information from the trauma registry without express written permission from the department.

(b) The department may approve requests for trauma registry data reports from qualified agencies or individuals, consistent with applicable statutes and rules. The department may charge reasonable costs associated with ((such requests)) customized reports, prepared in response to such requests.

(c) The data elements indicated in Tables E, F and G below are considered confidential.

(d) The department will establish criteria defining situations in which additional trauma registry information is confidential, in order to protect confidentiality for patients, providers, and facilities.

(e) This paragraph does not limit access to confidential data by approved regional quality assurance programs established under chapter 70.168 RCW and described in WAC 246-976-910.

(3) Inclusion criteria:

(a) The department will establish inclusion criteria to identify those injured patients ((that)) whom designated trauma services must report to the trauma registry.

These criteria will include:

All patients who were discharged with International Classification of Diseases (ICD) diagnosis codes ((of 800.0 - 904.99, 910 - 959.9 (injuries), 994.1 (drowning), 994.7 (asphyxiation), or 994.8 (electrocution))) for injuries, drowning, burns, asphyxiation, or electrocution per the department's specifications; and:

(i) For whom the hospital trauma resuscitation team (full or modified) was activated; or

(ii) Who were dead on arrival at ((your)) the facility; or

(iii) Who were dead at discharge from ((your)) the facility; or

(iv) Who were transferred by ambulance into ((your)) the facility from another facility; or

(v) Who were transferred by ambulance out of ((your)) the facility to another acute care facility; or

(vi) Adult patients (age fifteen or greater) who were admitted ((as inpatients)) to ((your)) the facility ((and have a length of stay greater than two days or)) and have a length of stay of more than forty-eight hours; or

(vii) Pediatric patients (ages under fifteen years) who were admitted as inpatients to ((your)) the facility, regardless of length of stay; or

(viii) All injuries flown from the scene((;)).

(b) For all licensed rehabilitation services, these criteria will include all patients who were included in the trauma registry for acute care.

(4) Other data: The department and regional quality assurance programs may request data from medical examiners and coroners in support of the trauma registry.

(5) ((Data linking: To link data from different sources, the department will establish procedures to assign a unique identifying number to each trauma patient. All providers reporting to the trauma registry must include this trauma number.

(6))) Data submission: The department will establish procedures and format for providers to submit data electronically. These will include a mechanism for the reporting agency to check data for validity and completeness before data is sent to the trauma registry.

(((7))) (6) Data quality: The department will establish mechanisms to evaluate the quality of trauma registry data. These mechanisms will include at least:

(a) Detailed protocols for quality control, consistent with the department's most current data quality guidelines.

(b) Validity studies to assess the timeliness, completeness and accuracy of case identification and data collection.

(((8))) (7) Trauma registry reports:

(a) Annually, the department will report:

(i) Summary statistics and trends for demographic and related information about trauma care, for the state and for each EMS/TC region;

(ii) Outcome measures, for system-wide evaluation, and regional quality improvement programs;

(iii) Trends, patient care outcomes, and other data, for each EMS/TC region and for the state, for the purpose of regional evaluation;

(iv) Aggregate regional data to the regional EMS/TC council upon request, excluding any confidential or identifying data.

(b) The department will provide reports to facilities and qualified agencies upon request, according to the confidentiality provisions in subsection (2) of this section.

(1) All trauma care providers must protect the confidentiality of data in their possession and as it is transferred to the department.

(2) ((All trauma care providers must correct and resubmit records which fail the department's validity tests described in WAC 246-976-420(7). You must send corrected records to the department within three months of notification.

(3) Licensed)) Verified prehospital ((services)) agencies that transport trauma patients ((must)) shall:

(a) Provide an initial report of patient care to the receiving facility at the time the trauma patient is delivered as described in WAC 246-976-330.

(b) Within ((ten days)) twenty-four hours after the trauma patient is delivered, send a complete patient care report to the receiving facility to include the data shown in Table E.

(((4))) (3) Designated trauma services ((must)) shall:

(a) Have a person identified as responsible for ((coordination of)) trauma registry activities, and who has completed a department-approved trauma registry training.

(b) Report data elements shown in Table F for all patients defined in WAC 246-976-420.

(c) Report patients with a discharge date in a calendar quarter in a department-approved format by the end of the following quarter.

(5) Designated trauma rehabilitation services ((must:)) shall provide data to the trauma registry upon request.

(((a))) Data elements shown in Table G((; or

(b) If the service submits data to the Centers for Medicare and Medicaid Services (CMS) for medical rehabilitation, provide a copy of the data to the department)) are to be provided to the trauma registry in a format determined by the department.

All ((licensed hospitals)) designated trauma services must submit the following data for trauma patients ((identified in)); all other licensed hospitals must submit data upon request per WAC 246-976-420(3):

Identification (ID) of reporting facility;

Date and time of arrival at reporting facility;

Unique patient identification number assigned to the patient by the reporting facility;

Name;

Date of birth;

Sex;

Race;

Ethnicity;

Last four digits of Social Security number;

Home zip code;

Date and time of incident;

Incident zip code;

Mechanism/type of injury;

First EMS agency on-scene identification (ID) number;

Transporting agency ID and unit number;

Transporting agency patient care report number;

Cause of injury;

Incident county code;

Incident location type;

Work related((?));

Use of safety equipment (occupant);

Time;

Systolic blood pressure (first);

Respiratory rate (first);

Pulse rate (first);

Glascow coma score (GCS) eye, ((GCS)) verbal, ((GCS)) motor, ((GCS)) qualifier, ((GCS)) total;

Intubated at time of scene GCS;

Pharmacologically paralyzed at time of scene GCS;

Vitals from first EMS agency on-scene;

Extrication;

Date and time unit dispatched;

Time unit arrived at scene;

Time unit left scene;

Transportation mode;

Crew member level;

Transferred in from another facility;

Transported from (hospital patient transferred from);

Who initiated the transfer((?));

Readmission;

Direct admit;

Time ED physician called;

Time ED physician available for patient care;

Trauma team activated;

Level of trauma team activation;

Time of trauma team activation;

Time trauma surgeon called;

Time trauma surgeon available for patient care;

Vital Signs in ED;

First systolic blood pressure;

First temperature;

First pulse rate;

First spontaneous respiration rate;

Lowest systolic blood pressure (SBP);

First hematocrit level;

Glasgow coma scores)) GCS (eye, verbal, motor);

Intubated at time of ED GCS;

Pharmacologically paralyzed at time of ED GCS;

MCI disaster plan implemented;

Revised trauma score (RTS) on admission;

For pediatric patients:

Pediatric trauma score (PTS) on admission;

TRISS;

ED procedures performed;

ED care issues;

Date and time of ED discharge;

ED discharge disposition, including

If transferred out, ID of receiving hospital;

Was patient admitted to hospital?;

If admitted, the admitting service;

Reason for referral (receiving facility);

Reason for transfer (sending facility);

Date and time of head CT scan;

Date/time of first international normalized ratio (INR) performed at your hospital;

Results of first INR done at your hospital;

Source of date and time of CT scan of head;

((Was fresh frozen plasma (FFP) or Factor VIIa administered for reversal of)) Was an attempt made to reverse anticoagulation?;

What medication (other than Vitamin K) was first used to reverse anticoagulation?;

Date and time of first dose of anticoagulation reversal medication;

Date of physical therapy consult;

Date of rehabilitation consult;

Blood alcohol content;

Toxicology screen results;

Drugs found;

Was a brief substance use intervention done?;

Comorbid factors/preexisting conditions;

For the first operation:

Date and time patient arrived in operating room;

Date and time operation started;

OR procedure codes;

OR disposition;

For later operations:

Date and time of operation;

OR procedure codes;

OR disposition;

Patient admitted to ICU;

Patient readmitted to ICU;

Date and time of admission for primary stay in critical care unit;

Date and time of discharge from primary stay in critical care unit;

Length of readmission stay(s) in critical care unit;

Date and time of facility discharge;

Most recent ICD diagnosis codes/discharge codes, including nontrauma codes;

E-codes, primary and secondary;

Glasgow Score at discharge;

Disability at discharge (feeding/locomotion/expression);

Total ventilator days;

Hospital discharge disposition;

If transferred out, ID of facility the patient was transferred to;

Rehabilitation facility ID;

If patient died in ((your)) the facility;

Date and time of death;

Was an autopsy done?;

Was patient declared brain dead ((prior to expiring?;

Was life support withdrawn))?;

Was organ donation requested?;

Organs donated((?));

For each patient

Total billed charges;

Payer sources (by category);

Reimbursement received (by payer category);

Designated trauma rehabilitation services must provide the following data upon request by the department for patients identified in WAC 246-976-420(3).

Facility ID

Patient code

Date of birth

Social Security number

Patient name

Patient sex

Date of admission

Admission class

Date of discharge

Impairment group code

ASIA impairment scale

Etiologic diagnosis

((Other significant diagnoses)) Comorbidities

Complications((/comorbidities))

Diagnosis for transfer or death

Date of onset

Admit from (type of facility)

Admit from (ID of facility)

Acute trauma care by (ID of facility)

Prehospital living setting

Discharge-to-living setting

Eating

Grooming

Bathing

Dressing - Upper

Dressing - Lower

Toileting

Bladder

Bowel

Bed/chair/wheelchair

Toilet

Tub/shower

Walk/wheelchair

Stairs

Comprehension

Expression

Social interaction

Problem solving

Memory

Payer source - Primary and secondary

Total charges

Total remitted reimbursement ((by category))

Facility ID

Patient number

Social Security number

Patient name

Date of admission

Etiologic diagnosis

((Other significant diagnoses)) Comorbidities

Complications((/comorbidities))

Admit from (type of facility)

Admit from (ID of facility)

Acute trauma care given by (ID of facility)

Inpatient trauma rehabilitation given by (ID of facility)

Discharge-to-living setting

Payer source - Primary and secondary

Total charges

Total remitted reimbursement ((by category))