(1) All trauma care providers must protect the confidentiality of data in their possession and as it is transferred to the department.
(2) All trauma care providers must correct and resubmit records which fail the department's validity tests described in WAC
246-976-420(7). You must send corrected records to the department within three months of notification.
(3) Licensed prehospital services that transport trauma patients must:
(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 ten days after the trauma patient is delivered, send a complete patient care report to the receiving facility to include the data shown in Table E.
(4) Designated trauma services must:
(a) Have a person identified as responsible for coordination of trauma registry activities.
(b) Report data elements shown in Table F for all patients defined in WAC
246-976-420.
(c) Report patients in a calendar quarter in a department-approved format by the end of the following quarter.
(5) Designated trauma rehabilitation services must: Provide data to the trauma registry upon request.
(a) Data elements shown in Table G; or
(b) If the service submits data to the Centers for Medicare and Medicaid Services (CMS) for medical rehabilitation, provide a copy of the data to the department.
| TABLE E: Prehospital Data Elements for the Washington Trauma Registry |
| | Pre-Hosp Transport | Inter-Facility |
| Data Element | Type of patient |
| Incident Information | | |
| Transporting EMS agency number | X | X |
| Unit en route date/time | X | |
| Patient care report number | X | X |
| First EMS agency on scene identification number | X | |
| Crew member level | X | X |
| Mode of transport | X | X |
| Incident county | X | |
| Incident zip code | X | |
| Incident location type | X | |
| Incident response area type | X | |
| Mass casualty incident declared | | |
| | | |
| Patient Information | | |
| Name | X | X |
| Date of birth, or Age | X | X |
| Sex | X | X |
| Cause of injury | X | |
| Use of safety equipment (occupant) | X | |
| Extrication required | | |
| Extrication > 20 minutes | | |
| | | |
| Transportation | | |
| Facility transported from (code) | | X |
| | | |
| Times | | |
| Unit notified by dispatch date/time | X | X |
| Unit arrived on scene date/time | X | X |
| Unit left scene date/time | X | X |
| | | |
| Vital Signs | | |
| Date/time vital signs taken | X | |
| Systolic blood pressure (first) | X | |
| Respiratory rate (first) | X | |
| Pulse (first) | X | |
| GCS eye, GCS verbal, GCS motor, GCS total, GCS qualifier | X | |
| | | |
| Treatment: Procedure performed | X | |
| Procedure performed prior to this unit's care | | |
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): Record Identification Identification 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;
Was the patient pregnant;
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 ID number;
Transporting agency ID and unit number;
Transporting agency patient care report number;
Cause of injury;
Incident county code;
Incident location type;
Incident response area type;
Work related?;
Use of safety equipment (occupant);
Earliest Available Prehospital Vital Signs Time;
Systolic blood pressure (first);
Respiratory rate (first);
Pulse rate (first);
GCS eye, GCS verbal, GCS motor, GCS qualifier, GCS total;
Intubated at time of scene GCS;
Pharmacologically paralyzed at time of scene GCS;
Vitals from first EMS agency on-scene;
Extrication;
Extrication time over twenty minutes;
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?;
ED or Admitting Information Was patient intubated prior to arrival at hospital?;
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;
Lowest systolic blood pressure;
First hematocrit level;
Controlled rate of respiration;
Glasgow coma scores (eye, verbal, motor);
Intubated at time of ED GCS;
Pharmacologically paralyzed at time of ED GCS;
Disaster plan implemented;
Injury severity scores
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 Date and time of head CT scan;
For patients with diagnosis of brain or facial injury:
Was the patient diagnosed with brain or facial injury before transfer?;
Was the diagnosis of brain or facial injury based on either physician documentation or head CT report?;
Did the patient receive Coumadin or warfarin medication in the four days prior to injury?;
Date/time of first international normalized ratio (INR) performed at your hospital;
Results of first INR done at your hospital;
Source of date and time of CT scan of head;
Was fresh frozen plasma (FFP) or Factor VIIa administered for reversal of anticoagulation?;
What medication was first used to reverse anticoagulation?;
Date and time of first dose of anticoagulation reversal medication;
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;
Surgical 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 patient was transferred to
Rehabilitation facility ID; If patient died in your facility
Date and time of death;
Was an autopsy done?;
Was patient declared brain dead prior to expiring?;
Was life support withdrawn?;
Was organ donation requested?;
Organs donated?;
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
Facility code
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 (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
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
Remitted reimbursement by category
Rehabilitation, Level III Patient Information Facility ID
Patient number
Social Security number
Patient name
Care Information Date of admission
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)
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
Remitted reimbursement by category
[Statutory Authority: RCW 70.168.060 and 70.168.090. 09-23-083, § 246-976-430, filed 11/16/09, effective 12/17/09; 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.]