Code of Maryland Regulations › Title 30 - MARYLAND INSTITUTE FOR EMERGENCY MEDICAL SERVICES SYSTEMS (MIEMSS) › Subtitle 08 - DESIGNATION OF TRAUMA AND SPECIALTY REFERRAL CENTERS › Chapter 30.08.05 - Trauma Center Designation and Verification Standards › Section 30.08.05.21 - Trauma Registry

Current through Register Vol. 51, No. 14, July 12, 2024
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A. The Trauma Center shall maintain a Trauma Registry.
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B. The Trauma Registry shall include at a minimum, all of the data elements compliant with the Maryland Trauma Registry Data Dictionary for Adult Patients, including:
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(1) Demographic Data;
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(2) Pre-hospital Data;
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(3) Process of acute Care;
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(4) Clinical Data;
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(5) Outcome Data;
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(6) Final Anatomical Diagnosis;
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(7) Procedure Codes;
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(8) Quality Management Data;
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(9) Standard Report Utilization; and
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(10) Case Inclusion Criteria.
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C. The Trauma Registry shall support the Trauma Center with evidence of active interface with the institution and State QM process to improve the care of the injured patient across the continuum from injury prevention to outcomes measurement.
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D. The Trauma Registry may be under a separate department that provides support and conducts the registry data abstraction and ensures that:
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(1) There is a reporting structure from the Trauma Registry to the TPM; and
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(2) The trauma registry content staff will be under the direct supervision of the TPM/TMD.
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E. The Trauma Program Manager shall have the authority, responsibility, accountability and oversight of the Trauma Registry inclusive of data submission as required by MIEMSS.
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F. The Trauma Registry shall have:
(1) A staffing plan that includes workload analysis that defines personnel needs necessary to comply with the MIEMSS data submission requirements; and
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(2) Either:
(a) One Trauma Registrar (1.0 FTE) dedicated to the trauma program for every 500-750 patients, subject to meeting performance standards and MIEMSS defined submissions per year; or
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(b) An electronic interfaced data-content mechanism.
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G. All discharged trauma patient records, with the minimum quarterly and annual data elements with the number of patients shall be verified no later than 6 weeks after the end of each quarter.
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H. All records shall be completed within 60 days of patient discharge; validation and NTDB checks shall be completed and the records shall be closed. An exception to the completeness of the MTR record is with Medical Examiner (ME) where autopsies are unavailable for registry record abstraction.
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I. The Trauma Registry shall have a plan to ensure Inter-rater reliability of the data entered into the MTR at the individual trauma centers. Ongoing review and evaluation shall ensure the quality, reliability and validity of the institution's MTR registry data.
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J. The Trauma Center shall submit data to the National Trauma Data Bank.
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K. Trauma Registry Staff shall have:
(1) A job description developed by the hospital to reflect the role and responsibilities as defined by COMAR;
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(2) A core set of skill requirements including:
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(a) Anatomy and Physiology;
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(b) Medical Terminology; and
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(c) Education to be completed within 1 year of hire includes:
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(i). American Trauma Society Trauma Registrar Course; and
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(ii) Association of the Advancement of Automotive Medicine's Injury Scaling Course; and
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(3) Job responsibilities to include:
(a) Ensuring assigned cases are compliant with MD Data Dictionary Inclusion Criteria or other Trauma Center self-defined criteria;
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(b) Compiling abstracted data for MTR case from various sources; and
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(c) Appropriately coding injuries, complications and procedures.
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L. The Trauma Registry staff liaison shall:
(1) Attend a minimum of 50 percent all trauma multidisciplinary/peer review meetings that are held; and
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(2) Actively participate in the MD Trauma Quality Improvement Committee (TQIC) via attendance in person or phone as defined by the individual institution.
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