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WAC 246-976-420

Trauma registry—Department responsibilities.

(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 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 must be confidential, must be exempt from RCW 42.17.250 through 42.17.450, and 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 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 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 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 the facility; or
(iii) Who were dead at discharge from the facility; or
(iv) Who were transferred by ambulance into the facility from another facility; or
(v) Who were transferred by ambulance out of the facility to another acute care facility; or
(vi) Adult patients (age fifteen or greater) who were admitted to the facility 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 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 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.
(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.
(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.
[Statutory Authority: RCW 70.168.060 and 70.168.090. WSR 14-19-012, § 246-976-420, filed 9/4/14, effective 10/5/14; WSR 09-23-083, § 246-976-420, filed 11/16/09, effective 12/17/09; WSR 02-02-077, § 246-976-420, filed 12/31/01, effective 1/31/02. Statutory Authority: Chapters 18.71, 18.73, and 70.168 RCW. WSR 00-08-102, § 246-976-420, filed 4/5/00, effective 5/6/00. Statutory Authority: RCW 43.70.040 and chapters 18.71, 18.73 and 70.168 RCW. WSR 93-01-148 (Order 323), § 246-976-420, filed 12/23/92, effective 1/23/93.]
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