Original Notice.

Preproposal statement of inquiry was filed as WSR 01-10-014.

Title of Rule: Trauma registry data collection (WAC 246-976-330, 246-976-420, and 246-976-430).

Purpose: The purpose of the rule change is to gather prehospital data through designated trauma hospitals, to improve the completeness and accuracy of all data collected, and to improve the availability and delivery of prehospital and hospital trauma care services.

Statutory Authority for Adoption: RCW 70.168.060 and 70.168.090.

Statute Being Implemented: RCW 70.168.060 and 70.168.090.

Summary: The statewide trauma registry was established to collect and analyze data on the incidence, severity and causes of trauma, including traumatic brain injury. The registry is used to improve the availability and delivery of prehospital and hospital trauma care services (RCW 70.168.090, 1990). The trauma registry is recognized as an integral part of the trauma system - necessary for quality improvement, research, monitoring of performance standards, and measuring the impact of a coordinated trauma response on patient outcomes.

Reasons Supporting Proposal: The proposed rule change is intended to improve the availability and delivery of prehospital and hospital trauma care services and therefore minimize the human suffering and costs associated with preventable mortality and morbidity. The proposed rule changes will allow for: (1) Better data for injury surveillance, analysis and prevention programs; (2) better monitoring and evaluating of outcomes of care of major trauma patients; (3) better assessment of compliance with state standards for trauma care; (4) increased information for resource planning, system design and management; (5) an enhanced resource for research and education; (6) concentration of training efforts to improve quality and consistency of data, which includes efforts focused on major trauma patients and efforts focused on eighty hospital trauma registries, rather than five hundred eighty registries (eighty hospitals and five hundred prehospital databases); and (7) prehospital and hospital records to be linked, creating a robust source of data on the clinical care of trauma patients. (Attempts to link prehospital and hospital records under the current procedure have shown only limited success.)

Name of Agency Personnel Responsible for Drafting: Tami Schweppe, 2725 Harrison Avenue N.W., Olympia, WA, (360) 705-6748; Implementation and Enforcement: Don Fernandes, 2725 Harrison Avenue N.W., Olympia, WA, (360) 705-6734.

Name of Proponent: Department of Health, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: The statewide trauma registry was established to collect and analyze data on the incidence, severity and causes of trauma, including traumatic brain injury. The registry is used to improve the availability and delivery of prehospital and hospital trauma care services (RCW 70.168.090, 1990). The trauma registry is recognized as an integral part of the trauma system - necessary for quality improvement, research, monitoring of performance standards, and measuring the impact of a coordinated trauma response on patient outcomes. The purpose of the rule change is to gather prehospital data through designated trauma hospitals, to improve the completeness and accuracy of all data collected, and to improve the availability and delivery of prehospital and hospital trauma care services. These requirements will improve the quality, quantity, efficiency and effectiveness of the trauma registry, and improve compliance. As a result the proposed rule change will reduce over all costs to providers.

Proposal Changes the Following Existing Rules: The following changes will be made to the existing rule language:

	Transporting prehospital agencies will no longer be required to submit prehospital trauma data directly to OEMTP. Transporting agencies will continue to leave an initial record of care at the receiving hospital.
	Nontransporting prehospital agencies will no longer be required to submit trauma registry data.
	The hospital inclusion criteria (criteria used to identify those injured patients that must be reported in the trauma registry) will be expanded to include:

&sqbul;	All pediatric patients (ages under fifteen years) admitted to the hospital due to an injury, and
&sqbul;	All patients who meet the requirements of the state of Washington prehospital trauma triage procedures.

Amendments will be made to the list of data elements that must be reported (prehospital and hospital) by designated trauma services in the trauma registry.

A small business economic impact statement has been prepared under chapter 19.85 RCW.

SIC coded businesses that may be affected by the amendments:

	Ground and air ambulance services, SIC 4522, are classified within SIC 4119 Local Passenger Transportation and Air Transportation (nonscheduled). These classifications have a wide variety of service and employment patterns. However, responsibilities under the existing rule are being reduced for all of the emergency services affected by this rule change. The savings are approximately $138,000.
	Hospitals, SIC 8062, are generally large businesses. Their costs are expected to rise by $13,800.

Background: The statewide trauma registry was established to collect and analyze data on the incidence, severity and causes of trauma, including traumatic brain injury. The registry is used to improve the availability and delivery of prehospital and hospital trauma care services (RCW 70.168.090, 1990). The trauma registry is recognized as an integral part of the trauma system -necessary for quality improvement, research, monitoring of performance standards, and measuring the impact of a coordinated trauma response on patient outcomes.

During the establishment of the trauma registry system, constituents helped to define specific data elements (patient information) to be collected and the software (collector) to be used. Two versions of the registry system were created, a prehospital (EMS) registry for prehospital providers and a hospital registry for designated trauma services. The DOH, Office of Emergency Medical and Trauma Prevention (OEMTP), provides free software and training to prehospital agencies and designated trauma care services. In addition, an interface standard was defined and established for those already using existing software. In 1994 the registry began collecting data. The data is sent directly to the OEMTP from both designated trauma care services and verified prehospital agencies.

By 1997, all designated hospitals were reporting to the trauma registry - a 100% compliance rate. By 1999, only 47% of the transporting agencies were reporting data, and the prehospital data being collected and reported to the statewide trauma registry was of questionable quality. The limitations on the data do not allow the DOH to evaluate the trauma system statewide. In addition, the process of collecting prehospital trauma data is inefficient. Of the 330,000+ prehospital records in the database, about 27,000 (8.2%) are true trauma cases. That is, for each trauma record, we handle more than 12 additional nontrauma records. While this over-triage of data would be desirable for a full EMS reporting system, DOH does not have mandate or resources to support this type of data collection. In addition, the prehospital providers have complained that the load is too high for them.

Other states with organized trauma systems have successfully gathered prehospital data through designated trauma hospitals. In an attempt to improve the completeness and accuracy of the data collected and to improve compliance, the following amendments to the established Washington state trauma registry rules are being proposed.

Proposal: The department is proposing the following rule amendments:

	Transporting prehospital agencies will no longer be required to submit prehospital trauma data directly to OEMTP. Transporting agencies will continue to leave an initial record of care at the receiving hospital. But in addition, for patients meeting the state of Washington prehospital trauma triage (destination) procedures, as described in WAC 246-976-930(3), they will now be required to submit the additional trauma data elements to the receiving facility within ten days.
	Nontransporting prehospital agencies will no longer be required to submit trauma registry data.
	The hospital inclusion criteria (criteria used to identify those injured patients that must be reported in the trauma registry) will be expanded to include:

&sqbul;	All pediatric patients (ages under fifteen years) admitted to the hospital due to an injury, and
&sqbul;	All patients who meet the requirements of the state of Washington prehospital trauma triage procedures.

Amendments will be made to the list of data elements that must be reported (prehospital and hospital) by designated trauma services in the trauma registry.

Cost of Compliance: Prehospital Agencies: Prehospital agency staff time will no longer be needed for registry training, or to record and maintain data and send the records to OEMTP. It takes thirty minutes to record each record. Approximately 9,200 trauma records were reported to the OEMTP in the year 2000. Many EMS agencies are nonprofit companies and rely on volunteer personnel for not only EMS response but also for data submission. Most personnel entering this data are volunteers, but we assume that if paid it would cost approximately $30 per record. This means prehospital agencies are spending approximately $138,000 worth of paid and volunteer time producing records.

Prehospital agencies will give the initial record of care, within ten days, to the receiving facility. The selected trauma elements, which must be submitted, have been reduced by eleven (removing twelve elements and adding one).

The rule change drops these data elements:

	Agency incident number.
	Transporting agency identification.
	Incident zip code.
	If patient died at scene: Patient home zip code.
	Illness/injury type code.
	Transported to (code).
	If rendezvous, assisting agency ID number.
	Time call received.
	Code response to scene?
	Code response to destination?
	Time arrival at destination.
	Blunt/penetrating injury.

The rule change adds this data element:

Pupil dilation.

This will reduce costs for ambulance services that provide immediate response and transport victims to emergency care facilities. These services, ground and air ambulance services, SIC 4522, are classified within SIC 4119 Local Passenger Transportation and Air Transportation (nonscheduled).

Designated Trauma Facilities: Hospitals, in SIC 8062, are generally large businesses. These companies may experience a 10% increase in costs to fill out the information regarding the initial response.

	Based on the proposed rules, hospital registrars will now be required to enter thirty additional data elements. These are the twenty-eight prehospital data elements that the prehospital agencies used to fill in and two new hospital data elements. Currently there are approximately three hundred data elements per record that must be filled in, and it is estimated to take approximately sixty minutes to complete a record, including abstracting the record and entering the information. The thirty additional data elements represent a 10% increase. The new elements are listed below.
	If these data elements take the same amount of time that the other data elements took, it will take approximately six additional minutes to enter each record.
	Based on year 2000 information approximately 9,200 hospital records were submitted to the statewide trauma registry that met the state inclusion criteria, excluding those transported to designated trauma facilities by private vehicle. This equates to an additional 920 hours of time spread statewide over eighty designated trauma facilities.
	It is estimated that hospital registrars average $30 per hour (inclusive of benefits). If none of the hospitals were generating this data already, this would mean a $27,600 increase in operating expenditures for designated trauma facilities collectively.
	Approximately one half of the current volume of records submitted to the trauma registry already include the prehospital data. This is a result of facilities tracking this information for their own benefit.

Therefore the real world cost increase is $13,800.

There may however be some hospitals which will need to spend an added six minutes to fill out the forms, for a 10% increase in costs. There are one hundred three hospitals that report to Employment Security meeting the classification of a large business, in that they have fifty or more employees. There are forty-three hospitals that have fifty or fewer employees. However, most of these do not meet the definition of a small business. The Regulatory Fairness Act defines a small business as "any business entity, including a sole proprietorship, corporation, partnership, or other legal entity, that is owned and operated independently from all other businesses, that has the purpose of making a profit, and that has fifty or fewer employees. There are no trauma services designated with the DOH that have both fifty or fewer employees and are a profit making business entity, and are required to submit data to the trauma registry. In addition, hospital registrars will now be required to enter all patients into the hospital registry who meet the prehospital trauma triage (destination) procedures. The current registry inclusion criteria captures virtually all of these cases, and as such, less than fifty additional records must be entered into the trauma registry. Any additional time will be insignificant.

These data elements are moved from prehospital to hospital reporting:

	Date and time of incident.
	Prehospital trauma system activated?
	First agency on-scene ID number.
	Respiratory quality.
	Consciousness.
	Incident county code.
	Incident location type.
	Response area type.
	Earliest available prehospital vital signs:

&sqbul;	Time.
&sqbul;	Systolic blood pressure.
&sqbul;	Respiratory rate.
&sqbul;	Pulse rate.
&sqbul;	Glasgow coma score (three components).
&sqbul;	Pupils.
&sqbul;	Vitals from 1st on-scene agency?

	Extrication time over 20 minutes?
	Prehospital procedures performed.
	Prehospital triage:

&sqbul;	Vital signs/consciousness.
&sqbul;	Anatomy of injury.
&sqbul;	Biomechanics of injury.
&sqbul;	Other risk factors.
&sqbul;	Gut feeling of medic.

Transportation information:

&sqbul;	Time transporting agency dispatched.
&sqbul;	Time transporting agency arrived at scene.
&sqbul;	Time transporting agency left scene.
&sqbul;	Transportation mode.
&sqbul;	Personnel level.
&sqbul;	Transported from.
&sqbul;	Reason for destination.

These two data elements are new and are added to the hospital reporting:

	ED complications.
	Drugs found.

The department is spending $16,000 to upgrade Collector, the statewide trauma registry software, of which approximately $2000 is related to changes required by the proposed rule change. There will be no cost to designated trauma services for software upgrades. In addition, the OEMTP will provide free installation of the upgraded software and free training to those who request it.

Net reduction in costs to business: The estimated net reduction in costs to business from the rule changes is $124,200. Given the magnitude of the cost reduction and the fact that the rule amendment reduces large costs to small business while increasing trauma reporting costs to a few hospitals by 10%, DOH believes this rule amendment constitutes mitigation in and of itself.

A copy of the statement may be obtained by writing to Tami Schweppe, Department of Health, EMS and Trauma, P.O. Box 47853, Olympia, WA 98504-7853, phone (360) 705-6748, fax (360) 705-6706.

RCW 34.05.328 applies to this rule adoption. The proposed rule is a significant legislative rule because it establishes, alters, or revokes any qualification or standard for the issuance, suspension, or revocation of a license or permit. In this instance being recognized as a designated trauma facility, or licensed as a prehospital EMS service.

Hearing Location: 1101 Eastside Street, Olympia, WA, on December 11, 2001, at 9:00 a.m.

Assistance for Persons with Disabilities: Contact Tami Schweppe by December 4, 2001, TDD (800) 833-6388, or (360) 705-6748.

Submit Written Comments to: Kathy Schmitt, Trauma Designation, Registry and QA Manager, Department of Health, Office of Emergency Medical and Trauma Prevention, P.O. Box 47853, Olympia, WA 98504-7853, fax (360) 705-6708, by December 4, 2001.

Date of Intended Adoption: December 14, 2001.

Mary C. Selecky

Secretary

OTS-5232.2

AMENDATORY SECTION(Amending WSR 00-08-102, filed 4/5/00, effective 5/6/00)

WAC 246-976-330   Ambulance and aid services -- Record requirements.   (1) Each ambulance and aid service must maintain a record of:

(a) Current certification levels of all personnel;

(b) Make, model, and license number of all vehicles; and

(c) Each patient contact with at least the following information:

(i) Names and certification levels of all personnel;

(ii) Date and time of medical emergency;

(iii) Age of patient;

(iv) Applicable components of system response time as defined in this chapter;

(v) Patient vital signs;

(vi) Procedures performed on the patient;

(vii) Mechanism of injury or type of illness;

(viii) Patient destination;

(ix) For trauma patients, other data points identified in WAC 246-976-430 for the trauma registry.

(2) Transporting agencies must provide an initial written report of patient care to the receiving facility at the time the patient is delivered. For patients meeting the state of Washington prehospital trauma triage (destination) procedures, as described in WAC 246-976-930(3), the transporting agency must provide additional trauma data elements described in WAC 246-976-430 to the receiving facility within ten days.

(3) Licensed services must make all records available for inspection and duplication upon request of the department.

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, 246-976-330, 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), 246-976-330, filed 12/23/92, effective 1/23/93.]

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

(b) Monitor and evaluate the outcome of care of major trauma patients, in support of state-wide 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 be confidential, shall be exempt from RCW 42.17.250 through 42.17.450, and shall 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 from qualified agencies or individuals, consistent with applicable statutes and rules. The department may charge reasonable costs associated with such requests.

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

(d) The department will establish criteria defining situations in which additional 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 ((providers)) designated trauma services must report to the trauma registry.

(((a) For all licensed prehospital providers these criteria will include injured patients:

(i) Who were dead at the scene;

(ii) Who died enroute; or

(iii) Who met the criteria of the prehospital trauma triage (destination) procedures.

(b) For designated trauma services)) These criteria will include:

(i) All patients who were discharged with ICD diagnosis codes of 800.0 - 904.99, 910 - 959.9 (injuries), 994.1 (drowning), 994.7 (asphyxiation), or 994.8 (electrocution) and:

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

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

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

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

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

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

(c))); or

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

(ii) All patients who meet the requirements of the state of Washington prehospital trauma triage procedures described in WAC 246-976-930(3);

(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 registry.

(5) Data linking: To link data from different sources, the department will establish procedures to assign a unique identifying number (trauma band 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 registry.

(7) 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. The department will report quarterly on the timeliness, accuracy and completeness of data.

(8) 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 evaluation of clinical care and system-wide quality assurance and quality improvement programs.

(b) Semiannually, the department will report:

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

(ii) On all patient data entered into the trauma registry during the reporting period;

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

(c) The department will provide:

(i) Provider-specific raw data to the provider that originally submitted it;

(ii) Periodic reports on financial data;

(iii) Registry reports to all providers that have submitted data;

(iv) For the generation of quarterly reports to all providers submitting data to the registry, for the purpose of planning, management, and quality assurance.

[Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. 00-08-102, 246-976-420, 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), 246-976-420, filed 12/23/92, effective 1/23/93.]

(2) ((All trauma care services must submit required data to the trauma registry in an approved format.

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

(((4))) (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.

(((5))) (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.

(((c) Report incidents occurring in a calendar quarter by the end of the following quarter. The department encourages more frequent data reporting.

(6))) (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.

(((7))) (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 No-Trans))	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	X
Date of response (C - day only)	((X))	X	X
Run sheet number (C)	((X))	X	X
((Agency incident number (C)	X	X	X))
First agency on scene identification number (C)	((X))	X
((Transporting agency identification	X	X))
Level of ((transporting agency)) personnel	((X))	X	X
Mode of transport	((X))	X	X
Incident county code	((X))	X
((Incident Zip Code	X	X))
Incident location (type)	((X))	X
Incident response area type	((X))	X
Patient Information
Patient's trauma identification band number (C)	((X))	X	X
Name (C)	((X))	X	X
Date of birth (C), or Age	((X))	X	X
Sex	((X))	X	X
((If patient died at scene: Patient home Zip Code	X	X))
Mechanism of injury	((X))	X
((Illness/Injury type code	X	X))
Safety restraint or device used	((X))	X
Transportation
Transported from (code) (C - if hospital ID)		X	X
((Transported to (code) (C - if hospital ID)		X	X
If rendezvous, assisting agency ID number		X	X))
Reason for destination decision		X	X
Times
((Call received	X	X	X))
Transporting agency dispatched	((X))	X	X
((Code Response to scene?	X	X	X))
Transporting agency arrived at scene	((X))	X	X
Transporting agency departed from scene		X	X
((Code response to destination?		X	X
Arrival at destination		X	X))
First)) Vital Signs
Time	((X))	X	X
Systolic blood pressure	((X))	X	X
Respiratory rate	((X))	X	X
Pulse	((X))	X	X
Glasgow coma score (three components)	((X))	X	X
Pupils		X	X
Vitals from 1st agency on scene?
Trauma Triage Criteria
Vital signs, consciousness level	((X))	X
Anatomy of injury	((X))	X
Biomechanics of injury	((X))	X
Other risk factors	((X))	X
Gut feeling of medic	((X))	X
Prehospital trauma system activation?	((X))	X
Other Severity Measures
((Blunt/Penetrating injury	X	X))
Respiratory ((effort)) quality	((X))	X
Consciousness	((X))	X
Time (interval) for extrication	((X))	X
Treatment: EMS interventions	((X))	X	X

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;

((City and county of incident;

If transfer in, facility patient was transferred from (C);))

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.

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

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: 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.]

Washington State Code Reviser's Office