(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 trauma surveillance, analysis, and prevention programs;

(b) Monitor and evaluate the outcome of care of 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; and

(e) Provide a resource for research and education.

(2) Confidentiality: RCW 70.168.090, 70.41.200, and chapter 42.56 RCW apply to trauma registry data and patient quality assurance proceedings, records, and reports developed pursuant to RCW 70.168.090. Data elements related to the identification of individual patient's, provider's, and facility's care outcomes shall be confidential, shall be exempt from chapter 42.56 RCW, and shall not be subject to discovery by subpoena or admissible as evidence. Patient care quality assurance proceedings, records, and reports developed pursuant to RCW 70.168.090 are confidential, exempt from chapter 42.56 RCW, and are not 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 customized reports, prepared in response to such requests.

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

(d) Subsection (2)(a) through (d) of this section does not limit access to confidential data by approved regional quality assurance and improvement programs established under chapter 70.168 and described in WAC 246-976-910.

(3) Inclusion criteria: The department establishes inclusion criteria to identify those injured patients whom trauma services must report to the trauma registry.

(a) The criteria includes all patients who were discharged with International Classification of Diseases (ICD) diagnosis codes for injuries, drowning, burns, asphyxiation, or electrocution per the department's specifications and one of the following additional criteria:

(i) The trauma service trauma resuscitation team (full or modified) was activated for the patient;

(ii) The patient was dead on arrival at the trauma service;

(iii) The patient was dead at discharge from the trauma service;

(iv) The patient was transferred by ambulance into the trauma service from another facility;

(v) The patient was transferred by ambulance out of the trauma service to another acute care facility;

(vi) The patient was an adult patient (age fifteen or greater) and was admitted to the trauma service and had a length of stay of more than twenty-four hours;

(vii) The patient was a pediatric patient (ages under fifteen years) and was admitted to the trauma service, regardless of length of stay; or

(viii) The patient was an injured patient flown from the scene.

(b) For all licensed rehabilitation services, the criteria includes all patients who received rehabilitative care for acute injury or illness.

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

(5) Data submission: The department establishes procedures and format for trauma services 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.

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

(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.

(7) Trauma registry reports:

(a) Annually, the department reports:

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

(ii) Risk adjusted benchmarking and outcome measures, for system-wide evaluation and regional quality improvement programs;

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

(iv) Aggregate regional data upon request, excluding any confidential or identifying data.

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