Section 246-976-430. Trauma registry—Provider responsibilities.

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

(2) Verified prehospital agencies that transport trauma patients 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 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.

(3) Designated trauma services shall:

(a) Have a person identified as responsible for 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.

(4) All designated trauma care facilities shall correct and resubmit records that fail the department's validity tests described in WAC 246-976-420(7). The trauma care facilities shall send corrected records to the department within three months of notification of errors.

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

Data elements shown in Table G are to be provided to the trauma registry in a format determined by the department.

TABLE F: Hospital-Designated Trauma Services Data Elements for the Washington Trauma Registry

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

Record Identification

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;

Patient Identification

Name;

Date of birth;

Sex;

Race;

Ethnicity;

Last four digits of Social Security number;

Home zip code;

Prehospital Incident Information

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);

Procedures performed;

Earliest Available Prehospital Vital Signs

Time;

Systolic blood pressure (first);

Respiratory rate (first);

Pulse rate (first);

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

Intubated at time of scene GCS;

Pharmacologically paralyzed at time of scene GCS;

Vitals from first EMS agency on-scene;

Extrication;

Transportation Information

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;

Emergency Department (ED) or Admitting Information

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;

Controlled rate of respiration;

Lowest systolic blood pressure (SBP);

Lowest SBP confirmed Y/N?;

First hematocrit level;

GCS (eye, verbal, motor);

Intubated at time of ED GCS;

Pharmacologically paralyzed at time of ED GCS;

MCI disaster plan implemented;

Injury Scores

Injury severity score (ISS);

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);

Diagnostic and Consultative Information

Did the patient receive aspirin in the four days prior to the injury?

Did the patient receive clopidogrel (Plavix) in the four days prior to the injury?

Did the patient receive any oral anticoagulation medication in the four days prior to the injury, such as warfarin (Coumadin), dabigatran (Pradaxa), rivaroxaban (Xarelto) or others?

What was the name of the anticoagulation medication?

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;

Date/time of first partial thrombin time (PTT) performed at the hospital;

Results of first PTT done at the hospital;

Source of date and time of CT scan of head;

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;

Elapsed time from ED arrival;

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;

Procedural Information

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;

Critical Care Unit Information

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;

Other in-house procedures performed (not in OR)

Discharge Status

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;

Discharge Disposition

Hospital discharge disposition;

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

Rehabilitation facility ID;

If patient died in the facility;

Date and time of death;

Location of death;

Was an autopsy done?;

Was patient declared brain dead?;

Was organ donation requested?;

Organs donated;

Did the patient have an end-of-life care document before injury?;

Was there any new end-of-life care decision documented during the inpatient stay in the facility?;

Did the patient receive a consult for comfort care, hospice care, or palliative care during the inpatient stay?;

Did the patient receive any comfort care, in-house hospice care, or palliative care during the inpatient stay (i.e., was acute care withdrawn?);

Financial Information (All Confidential)

For each patient

Total billed charges;

Payer sources (by category);

Reimbursement received (by payer category);

TABLE G: Data Elements for Designated Rehabilitation Services

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

Rehabilitation services, Levels I and II

Patient Information

Facility ID

Patient code

Date of birth

Social Security number

Patient name

Patient sex

Care Information

Date of admission

Admission class

Date of discharge

Impairment group code

ASIA impairment scale

Diagnosis Codes

Etiologic diagnosis

Comorbidities

Complications

Diagnosis for transfer or death

Other Information

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

Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - One set on admission and one on discharge

Self care

Eating

Grooming

Bathing

Dressing - Upper

Dressing - Lower

Toileting

Sphincter control

Bladder

Bowel

Transfers

Bed/chair/wheelchair

Toilet

Tub/shower

Locomotion

Walk/wheelchair

Stairs

Communication

Comprehension

Expression

Social cognition

Social interaction

Problem solving

Memory

Payment Information (all confidential)

Payer source - Primary and secondary

Total charges

Total remitted reimbursement

Rehabilitation, Level III

Patient Information

Facility ID

Patient number

Social Security number

Patient name

Care Information

Date of admission

Impairment Group Code

Diagnosis Codes

Etiologic diagnosis

Comorbidities

Complications

Other Information

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

Payment Information (all confidential)

Payer source - Primary and secondary

Total charges

Total remitted reimbursement

[Statutory Authority: RCW 70.168.060 and 70.168.090. WSR 14-19-012, § 246-976-430, filed 9/4/14, effective 10/5/14; WSR 09-23-083, § 246-976-430, filed 11/16/09, effective 12/17/09; WSR 02-02-077, § 246-976-430, filed 12/31/01, effective 1/31/02. Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. WSR 00-08-102, § 246-976-430, filed 4/5/00, effective 5/6/00. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. WSR 93-01-148 (Order 323), § 246-976-430, filed 12/23/92, effective 1/23/93.]

RCW 70.168.060 and 70.168.090. WSR 14-19-012, § 246-976-430, filed 9/4/14, effective 10/5/14; WSR 09-23-083, § 246-976-430, filed 11/16/09, effective 12/17/09; WSR 02-02-077, § 246-976-430, filed 12/31/01, effective 1/31/02. Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. WSR 00-08-102, § 246-976-430, filed 4/5/00, effective 5/6/00. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. WSR 93-01-148 (Order 323), § 246-976-430, filed 12/23/92, effective 1/23/93.

Rules

246-976-330,246-976-420,246-976-420,246-976-420,246-976-420,