Md. Code Regs. 30.08.08.21

Current through Register Vol. 51, No. 24, December 2, 2024

Section 30.08.08.21 - Trauma Registry

A. The Trauma Center shall maintain a pediatric Trauma Registry with participation in the MSTR.

B. The Trauma Registry shall include, at a minimum, all of the data elements compliant with the MSTR Data Dictionary for Pediatric Patients, including:

(1) Demographic data;

(2) Pre-hospital data;

(3) Process of acute care;

(4) Clinical data;

(5) Outcome data;

(6) Final anatomical diagnoses;

(7) Procedure codes;

(8) QM data;

(9) Standard report utilization; and

(10) Case inclusion criteria.

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 injured patients across the continuum from injury prevention to outcomes measurement.

D. The Trauma Registry may be under a separate department that provides support and conducts the registry data abstraction with a reporting structure to the TMD and TPM.

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.

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

(2) 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.

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.

H. All records shall be completed within 60 days of patient discharge.

I. Validation and National Trauma Data Bank (NTDB) checks shall be completed and the records shall be closed except when a medical examiner (ME) autopsy report is not yet available for registry record abstraction.

J. The Trauma Registry shall have a plan to ensure Inter-rater reliability of the data entered. Ongoing review and evaluation shall ensure the quality, reliability and validity of the institution's MSTR data.

K. The Trauma Center shall submit data to the NTDB.

L. Trauma Registry staff shall have:

(1) A job description developed by the hospital to reflect roles and responsibilities;

(2) Core requirements including:

(a) Anatomy and physiology;

(b) Medical terminology; and

(c) Education to be completed within 1 year of hire includes:

(i) American Trauma Society Trauma Registrar Course; and

(ii) Association of the Advancement of Automotive Medicine's Injury Scaling Course; and

(3) Job responsibilities to include:

(a) Ensuring assigned cases are compliant with Maryland Data Dictionary Inclusion Criteria or other trauma center self-defined criteria;

(b) Compiling abstracted data for MSTR case from various sources; and

(c) Appropriately coding injuries, complications, and procedures.

M. The Trauma Registry staff liaison shall:

(1) Attend a minimum of 50 percent all trauma multidisciplinary/peer review meetings that are held; and

(2) Actively participate in the Maryland TQIC.

Md. Code Regs. 30.08.08.21

Regulation .21 adopted effective 50:14 Md. R. 594, eff. 7/24/2023