Ariz. Admin. Code § 9-25-1309

Current through Register Vol. 30, No. 50, December 13, 2024

Section R9-25-1309 - Trauma Registry Data (Authorized by A.R.S.Sections 36-2202(A)(4), 36-2208(A), 36-2209(A)(2), 36-2221, and 36-2225(A)(5) and (6))

A. A trauma registry established according to R9-25-1308(B)(1) includes the following in the record of a patient's episode of care, as defined in A.A.C. R9-11-101, for each patient meeting the criteria in R9-25-1308(C)(1):

1. An identification code specific to the health care institution that had contact with the patient during the episode of care;

2. Demographic information about the patient:

a. The unique number assigned by the health care institution to the patient;

b. A code indicating whether the patient's record will be submitted to the Department as required in R9-25-1308(C)(2);

c. The unique number assigned by the health care institution for the episode of care;

d. The date the patient arrived at the health care institution for the episode of care;

e. For the episode of care, a code indicating whether the patient:

i. Was directly admitted to the health care institution,

ii. Was admitted to the health care institution through the emergency department,

iii. Was seen in the emergency department then transferred to another health care institution by an ambulance service or emergency medical services provider,

iv. Was seen in the emergency department and discharged, or

v. Died in the emergency department or was dead on arrival;

f. The patient's first name, middle initial, and last name;

g. The patient's Social Security Number;

h. The patient's date of birth and age;

i. Codes indicating the patient's gender, race, and ethnicity;

j. The zip code of the patient's residence or, if applicable, an indication of why no zip code was reported; and

k. The city, state, and county of the patient's residence;

3. Information about the occurrence of the patient's injury:

a. The date and time the injury occurred;

b. The ICD-code describing the type of location where the injury occurred;

c. The zip code of the location where the injury occurred;

d. The city, state, and county where the injury occurred;

e. A code indicating whether the patient's injury resulted from blunt force trauma, a penetrating wound, or a burn;

f. The ICD-code indicating the primary mechanism or cause of the patient's injury resulting in the episode of care and the manner or intent through which the injury occurred;

g. A description of the cause and circumstances leading to the patient's injury;

h. Whether the patient was using a protective device or safety equipment at the time of the injury and, if so, the type or types of protective device or safety equipment being used;

i. If the patient was subject to the requirements in A.R.S. § 28-907 at the time of the injury, whether the patient was using a child restraint system, as defined in A.R.S. § 28-907, at the time of the injury and, if so, the type of child restraint system being used; and

j. If the patient's injury resulted from a motor vehicle crash, a code describing the status of airbag deployment;

4. Information about the patient's arrival at the health care institution:

a. A code identifying the mode of transportation by which the patient arrived at the health care institution; and

b. If applicable:

i. The ambulance service or emergency medical services provider that transported the patient to the health care institution;

ii. The unique identifier given by the ambulance service or emergency medical services provider to the incident during which the patient received EMS;

iii. The date the ambulance service or emergency medical services provider transported the patient to the trauma center; and

iv. If the patient was transferred from another health care institution, the name of the other health care institution;

5. Information about the health care institution's assessment or treatment of the patient in the emergency department:

a. A code indicating which of the criteria in R9-25-1308(C)(1) the patient met;

b. A code indicating whether an ambulance service or emergency medical services provider transported the patient to the health care institution and, if so, the criteria used by the transporting ambulance service or emergency medical services provider for transporting the patient to the health care institution;

c. The date and time the patient arrived at the emergency department of the health care institution for the episode of care;

d. The date and time the patient died or left the emergency department of the health care institution for the episode of care;

e. The length of time in hours and in minutes that the patient remained in the emergency department of the health care institution during the episode of care;

f. If trauma team activation occurred, the time when the last trauma team personnel member arrived at their assigned location in the health care institution;

g. Whether the patient showed signs of life when the patient arrived at the health care institution;

h. The values of the following for the patient at the time of their first assessment at the health care institution:

i. Pulse rate;

ii. Respiratory rate;

iii. Oxygen saturation;

iv. Systolic blood pressure; and

v. Temperature, including the units of temperature and the route used to measure the patient's temperature;

i. A code indicating whether the patient was receiving respiratory assistance at the time the patient's respiratory rate was assessed;

j. A code indicating whether the patient was receiving supplemental oxygen at the time the patient's oxygen saturation was assessed;

k. Codes indicating the Glasgow Coma Score for:

i. Eye opening,

ii. Verbal response to stimulus, and

iii. Motor response to stimulus;

l. The patient's total Glasgow Coma Score;

m. Whether the patient was intubated at the time of the patient's assessments in subsections (A)(5)(h)(ii), (k)(ii), and (l);

n. A code indicating whether a paralytic agent or sedative had been administered to the patient at the time the patient's Glasgow Coma Score was measured;

o. A code indicating another factor that may have affected the patient's Glasgow Coma Score;

p. A revised trauma score for the patient, auto-calculated based on the patient's systolic blood pressure, respiratory rate, and Glasgow Coma Score;

q. A code indicating the status of alcohol use by the patient and, if applicable, the blood alcohol concentration in the patient's blood;

r. A code indicating the status of drug use by the patient and, if applicable, the code for each drug class detected in the patient's blood;

s. A code indicating the disposition of the patient at the time the patient was discharged from the emergency department; and

t. If the patient was transferred to another health care institution upon discharge from the emergency department:

i. The name of the health care institution to which the patient was transferred;

ii. The name of the ambulance service or emergency medical services provider providing the interfacility transport;

iii. A code indicating the reason for transfer; and

iv. If there was a delay in transferring the patient to another health care institution, a code indicating the reason for the delay;

6. Information about the patient's discharge from the health care institution:

a. The date and time the patient was discharged from the health care institution;

b. The length of time the patient remained as an inpatient, as defined in A.A.C. R9-10-201, in the health care institution;

c. The length of time the patient remained in the health care institution's intensive care unit;

d. A code indicating whether the patient was alive or dead at the time of discharge from the health care institution;

e. The ICD-code for each injury identified in the patient, including an indication of whether the ICD-code is for:

i. The principle diagnosis, the reason believed by the health care institution to be chiefly responsible for the patient's need for the episode of care; or

ii. A secondary diagnosis, another reason believed by the health care institution to have contributed to the patient's need for the episode of care;

f. The patient's Injury Severity Score;

g. A code indicating the disposition of the patient at the time the patient was discharged from the health care institution;

h. Whether a report of suspected physical abuse was reported to law enforcement or as required by A.R.S. § 13-3620 or 46-454, if applicable, and, if so:

i. Whether an investigation into the suspected physical abuse was initiated by an entity to which the suspected physical abuse was reported; and

ii. If the patient is a child, whether the patient was discharged in the care of a person other than the person responsible for the care of the patient at the time the patient arrived at the health care institution; and

i. If the patient was transferred to a hospital upon discharge from the health care institution:

i. The name of the hospital to which the patient was transferred,

ii. The name of the ambulance service or emergency medical services provider providing the interfacility transport, and

iii. A code indicating the reason for transfer; and

7. Financial information about the episode of care:

a. A code for the primary source of payment for the episode of care;

b. A code for a secondary source of payment for the episode of care, if applicable;

c. The total amount of charges for the episode of care; and

d. The total amount collected by the health care institution for the episode of care.

B. In addition to the information required in subsection (A), a trauma registry established according to R9-25-1308(B)(1) by a Level I trauma center, Level I Pediatric trauma center, Level II trauma center, Level II Pediatric trauma center, or Level III trauma center includes the following in the record of a patient's episode of care, as defined in A.A.C. R9-11-101, for each patient meeting the criteria in R9-25-1308(C)(1):

1. Demographic information about the patient:

a. The country of the patient's residence;

b. The country where the patient was found or from which an ambulance service or emergency medical services provider transported the patient; and

c. Any pre-existing medical conditions diagnosed for the patient, unrelated to the reason for the episode of care;

2. Information about the occurrence of the patient's injury:

a. Whether the time specified according to subsection (A)(3)(a) is the actual time of occurrence or an estimate;

b. The street address of the location where the injury occurred or, if the location at which the injury occurred does not have a street address, another indicator of the location at which the injury occurred;

c. Any additional ICD-code describing the mechanism or cause of the patient's injury resulting in the episode of care and the manner or intent through which the injury occurred;

d. The ICD-code indicating the activity the patient was engaged in that resulted in the patient's injury;

e. If the patient's injury resulted from a crash involving a means of transportation, including a motor vehicle, other motorized means of transportation, watercraft, bicycle, or aircraft, a code describing the type of vehicle in use at the time of the injury and the patient's location in the vehicle;

f. A description of any issues related to a protective device or safety equipment in use at the time of the patient's injury; and

g. Whether the patient's injury occurred during the patient's paid employment and, if so, a code indicating:

i. The type of occupation associated with the patient's employment, and

ii. The patient's occupation;

3. A code indicating whether EMS was provided to the patient and, if applicable, the type of transport provided to the patient;

4. If EMS was provided to the patient, whether a prehospital incident history report was provided to the trauma center and, if so:

a. The date on the prehospital incident history report;

b. The identifying number on the prehospital incident history report assigned by the ambulance service or emergency medical services provider;

c. The date and time the ambulance service or emergency medical services provider was dispatched, as defined in R9-25-901, to the scene;

d. The date and time the ambulance service or emergency medical services provider responded to the dispatch;

e. The date and time the ambulance service or emergency medical services provider arrived at the scene;

f. The date and time the ambulance service or emergency medical services provider established contact with the patient;

g. The date and time the ambulance service or emergency medical services provider left the scene;

h. The date and time the ambulance service or emergency medical services provider arrived at the health care institution that was the transport destination;

i. The date and time the patient's pulse, respiration, oxygen saturation, and systolic blood pressure were first measured;

j. At the date and time the patient's pulse, respiration, oxygen saturation, and systolic blood pressure were first measured, the patient's:

i. Pulse rate,

ii. Respiratory rate,

iii. Oxygen saturation, and

iv. Systolic blood pressure;

k. Whether the patient was intubated at the date and time the patient's pulse, respiration, and oxygen saturation were first measured;

l. Codes indicating the Glasgow Coma Score for:

i. Eye opening,

ii. Verbal response to stimulus, and

iii. Motor response to stimulus;

m. The patient's total Glasgow Coma Score;

n. A code indicating whether a paralytic agent or sedative had been administered to the patient at the date and time the patient's Glasgow Coma Score was meas

o. A revised trauma score for the patient, a ured; alculated based on the patient's systolic blood pressure, respiratory rate, and Glasgow Coma Score;

p. Codes indicating all airway management procedures performed on the patient by an ambulance service or emergency medical services provider before the patient's arrival at the first health care institution; and

q. Whether the patient experienced cardiac arrest subsequent to the injury before the patient's arrival at the first health care institution;

5. The amount of time that elapsed from the date and time the ambulance service or emergency medical services provider:

a. Was dispatched and the date and time the ambulance service or emergency medical services provider arrived at the scene,

b. Arrived at the scene and the date and time the ambulance service or emergency medical services provider left the scene,

c. Left the scene and the date and time the ambulance service or emergency medical services provider arrived at the transport destination, and

d. Was dispatched and the date and time the ambulance service or emergency medical services provider arrived at the transport destination;

6. Whether the patient arrived at the trauma center for treatment of the injury resulting in the episode of care through an interfacility transport;

7. If the patient arrived at the trauma center through an interfacility transport, the following information about the health care institution at which the patient was seen immediately before arriving at the trauma center:

a. The name of the health care institution;

b. The date and time the patient arrived at the health care institution in subsection (B)(7)(a); and

c. The date and time the patient left the health care institution in subs ection (B)(7)(a);

8. If the patient arrived at the health care institution in subsection (B)(7)(a) through an interfacility transport, the information in subsections (B)(7)(a) through (c) about each health care institution at which the patient was seen for the injury resulting in the episode of care before arriving at the health care institution in subsection (B)(7)(a);

9. If the patient arrived at the trauma center through an interfacility transport, for each health care institution at which the patient was seen for the injury resulting in the episode of care before arriving at the trauma center, information for the first instance of assessing the patient's:

a. Respiratory rate,

b. Systolic blood pressure,

c. The patient's total Glasgow Coma Score, and

d. Revised trauma score; and

10. Information about the patient's episode of care at the trauma center and the patients discharge from the trauma center:

a. The patient's height and weight when the patient arrived at the trauma center '

b. The number of days the patient spent on a mechanical ventilator;

c. If applicable, the identification number assigned by a medical examiner or alternate medical examiner, as defined in A.R.S. § 11-591, to the documentation of the patient's autopsy;

d. The total length of time the patient remained at the trauma center before discharge;

e. For each ICD-code identified according to subsection (A)(6)(e), a code that reflects the severity of the injury to which the ICD-code refers;

f. For each ICD-code identified according to subsection (A)(6)(e) that does not include an indication of the part of the. patient's body that was injured, a code supplementing the ICD-code that indicates the part of the body that was injured;

g. For each procedure performed on the patient:

i. The ICD-code for the procedure,

ii. The health care institution at which the procedure was performed,

iii. A code indicating the organized service unit within the health care institution in which the procedure was performed, and

iv. The date and time the procedure was begun;

h. Any complications experienced by the patient while the patient remained at the trauma center;

i. The Abbreviated Injury Scale code indicating the severity of each of the patient's injuries;

j. The Abbreviated Injury Scale code indicating the body region affected by each of the patient's injuries;

k. If the trauma center is designated as a Level I trauma center or Level I Pediatric trauma center, the six-digit Abbreviated Injury Scale code and the software version used to calculate the six-digit Abbreviated Injury Scale code; and

l. The patient's probability of survival.

Ariz. Admin. Code § R9-25-1309

New Section made by final rulemaking 11 A.A.R. 4363, effective October 6, 2005 (Supp. 05-4). Amended by final rulemaking at 23 A.A.R. 2656, effective 1/1/2018.