WAC 246-976-430   Trauma registry -- Provider responsibilities.  (1) Trauma care providers, prehospital and hospital, must place a trauma ID band on trauma patients, if not already in place from another agency.

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

     (3) All trauma care providers must correct and resubmit records which fail the department's validity tests described in WAC 246-976-420(6). You must send corrected records to the department within three months of notification.

     (4) Licensed prehospital services that transport trauma patients must:

     (a) Assure personnel use the trauma ID band.

     (b) Report data as shown in Table E for trauma patients defined in WAC 246-976-420. Data is to be reported to the receiving facility in an approved format within ten days.

     (5) Designated trauma services must:

     (a) Assure personnel use the trauma ID band.

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

     (c) Report patients discharged in a calendar quarter in an approved format by the end of the following quarter. The department encourages more frequent data reporting.

     (6) Designated trauma rehabilitation services must:

     (a) Report data on all patients who were included in the trauma registry for acute care.

     (b) Report either:

     (i) Data elements shown in Table G; or

     (ii) If the service submits data to the uniform data set for medical rehabilitation, provide a copy of the data to the department.

TABLE E: Prehospital Data Elements for the Washington Trauma Registry
Type of patient	Pre-Hosp Transport	Inter-Facility
Data Element
Note: (C) identifies elements that are confidential. See WAC 246-976-420 (2)(c).
Incident Information
Agency identification number (C)	X	X
Date of response (C - day only)	X	X
Run sheet number (C)	X	X
First agency on scene identification number (C)	X
Level of personnel	X	X
Mode of transport	X	X
Incident county code	X
Incident location (type)	X
Incident response area type	X
Patient Information
Patient's trauma identification band number (C)	X	X
Name (C)	X	X
Date of birth (C), or Age	X	X
Sex	X	X
Mechanism of injury	X
Safety restraint or device used	X
Transportation
Transported from (code) (C - if hospital ID)	X	X
Reason for destination decision	X	X
Times
Transporting agency dispatched	X	X
Transporting agency arrived at scene	X	X
Transporting agency departed from scene	X	X
Vital Signs
Time	X	X
Systolic blood pressure	X	X
Respiratory rate	X	X
Pulse	X	X
Glasgow coma score (three components)	X	X
Pupils	X	X
Vitals from 1st agency on scene?	X
Trauma Triage Criteria
Vital signs, consciousness level	X
Anatomy of injury	X
Biomechanics of injury	X
Other risk factors	X
Gut feeling of medic	X
Prehospital trauma system activation?	X
Other Severity Measures
Respiratory quality	X
Consciousness	X
Time (interval) for extrication	X
Treatment: EMS interventions	X	X

TABLE F: Hospital Data Elements for the

Washington Trauma Registry

All licensed hospitals must submit the following data for patients identified in WAC 246-976-420(3):

Note: (C) identifies elements that are confidential. See WAC 246-976-420(2).

Record Identification

     Identification of reporting facility (C);

     Date and time of arrival at reporting facility (C - day only);

     Unique patient identification number assigned to the patient by the reporting facility (C);

     Patient's trauma identification band number (C);

Patient Identification

     Name (C);

     Date of birth (C - day only);

     Sex;

     Race;

     Social Security number (C);

     Home zip code;

Prehospital Incident Information

     Date and time of incident (C - day only);

     Prehospital trauma system activated?;

     First agency on-scene ID number;

     Arrival via EMS system?;

     Transporting (reporting) agency ID number;

     Transporting agency run number (C);

     Mechanism of injury;

     Respiratory quality;

     Consciousness;

     Incident county code;

     Incident location type;

     Response area type;

     Occupational injury?;

     Safety restraint/device used;

Earliest Available Prehospital Vital Signs

     Time;

     Systolic blood pressure;

     Respiratory rate;

     Pulse rate;

     Glasgow coma score (three components);

     Pupils;

     Vitals from 1st on-scene agency?;

Extrication time over twenty minutes?;

Prehospital procedures performed;

Prehospital Triage

     Vital signs/consciousness;

     Anatomy of injury;

     Biomechanics of injury;

     Other risk factors;

     Gut feeling of medic;

Transportation Information

     Time transporting agency dispatched;

     Time transporting agency arrived at scene;

     Time transporting agency left scene;

     Transportation mode;

     Personnel level;

     Transported from;

     Reason for destination;

ED or Admitting Information

     Time ED physician called;

     ED physician called "code"?;

     Time ED physician available for patient care;

     Time trauma team activated;

     Level of trauma team activation;

     Time trauma surgeon called;

     Time trauma surgeon available for patient care;

     Vital Signs in ED

          Patient dead on arrival at your facility?;

          First and last systolic blood pressure;

          First and last temperature;

          First and last pulse rate;

          First and last spontaneous respiration rate;

          Lowest systolic blood pressure;

          Glasgow coma scores (eye, verbal, motor);

     Injury Severity scores

          Prehospital Index (PHI) score;

          Revised Trauma Score (RTS) on admission;

          For pediatric patients:

               Pediatric Trauma Score (PTS) on admission;

               Pediatric Risk of Mortality (PRISM) score on      admission;

               Pediatric Risk of Mortality - Probability of      Survival (PRISM P(s));

               Pediatric Overall Performance Category (POPC);

               Pediatric Cerebral Performance Category (PCPC):

     ED procedures performed;

     ED complications;

     Time of ED discharge;

     ED discharge disposition, including

          If admitted, the admitting service;

          If transferred out, ID of receiving hospital

Diagnostic and Consultative Information

     Date and time of head CT scan;

     Date of physical therapy consult;

     Date of rehabilitation consult;

     Blood alcohol content;

     Toxicology screen results;

     Drugs found;

     Co-morbid factors/Preexisting conditions;

Surgical Information

     For the first operation:

          Date and time patient arrived in operating room;

          Date and time operation started;

          OR procedure codes;

     For later operations:

          Date of operation

          OR Procedure Codes

Critical Care Unit Information

     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 procedures performed (not in OR)

Discharge Status

     Date and time of facility discharge (C - day only);

     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)

Discharge disposition

     If transferred out, ID of facility patient was transferred to (C)

     If patient died in your facility

          Date and time of death (C - day only);

          Was an autopsy done?;

          Was case referred to coroner or medical examiner?

          Did coroner or medical examiner accept jurisdiction?

          Was patient evaluated for organ donation?

Financial Information (All Confidential)

     For each patient

          Total billed charges;

          Payer sources (by category);

          Reimbursement received (by payer category);

     Annually, submit ratio-of-costs-to-charges, by department.


TABLE G: Data Elements for Designated Rehabilitation Services

Designated trauma rehabilitation services must submit the following data for patients identified in WAC 246-976-420(3).

Note: (C) identifies elements that are confidential. WAC 246-976-420(2)


Rehabilitation services, Levels I and II

Patient Information

     Facility ID (C)

     Facility Code

     Patient Code

     Trauma tag/identification Number (C)

     Date of Birth (C - day only)

     Social Security Number (C)

     Patient Name (C)

     Patient Sex

Care Information

     Date of Admission (C - day only)

     Admission Class

     Date of Discharge (C - day only)

     Impairment Group Code

     ASIA Impairment Scale

Diagnosis (ICD-9) Codes

     Etiologic Diagnosis

     Other significant diagnoses

     Complications/comorbidities

     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

     Prehospital vocational category

     Discharge-to-living setting

Functional Independence Measure (FIM) - 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

     Remitted reimbursement by category


Rehabilitation, Level III

Patient Information

     Facility ID (C)

     Patient number (C)

     Trauma tag/identification Number (C)

     Social Security Number (C)

     Patient Name (C)

Care Information

     Date of Admission (C - day only)

Impairment Group Code

Diagnosis (ICD-9) Codes

     Etiologic Diagnosis

     Other significant diagnoses

     Complications/comorbidities

Other Information

     Admit from (Type of facility)

     Admit from (ID of facility) (C)

     Acute trauma care given by (ID of facility) (C)

     Inpatient trauma rehabilitation given by (ID of facility) (C)

     Discharge-to-living setting

Payment Information (all confidential)

     Payer source - primary and secondary

     Total Charges

     Remitted reimbursement by category



[Statutory Authority: RCW 70.168.060 and 70.168.090. 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. 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. 93-01-148 (Order 323), § 246-976-430, filed 12/23/92, effective 1/23/93.]