Trauma Center Uniform Reporting Requirements

Section 515 Section 515.2050  Trauma Center Uniform Reporting Requirements a)         Each trauma center shall have available to the Trauma Service use of an IBM compatible personal computer capable of handling the software contracted by the Department and that meets the following general standards: CPU 80586, 200 MHz, RAM 32Mb, hard drive 1Gb, floppy drive 3½" CD-ROM 20x, color VGA, inkjet or laser printer, 57.6 Baud Modem, software to support the trauma registry program, and backup capability.  The Department shall provide Trauma Registry software for use by the trauma center.  This software shall be used for data collection and shall have a provision to prepare electronic media reports to the Department on a quarterly basis. b)         The trauma center shall provide the following information on each reportable trauma patient: 1)         Trauma hospital number 2)         Trauma hospital level of care 3)         Trauma registry number 4)         Crash record number 5)         Pre-hospital record number 6)         Medical record number 7)         Last name 8)         First name 9)         Middle initial 10)       ED arrival date 11)       EMS region 12)       Birth date 13)       Age 14)       Sex 15)       Race 16)       Injury date 17)       Injury time 18)       Home address 19)       Home city 20)       Home state 21)       Home country 22)       Home zip code 23)       Federal Information Processing Standard (FIPS) home 24)       Scene address 25)       Scene city 26)       Scene state 27)       Scene zip code 28)       FIPS scene 29)       International Classification of Diseases (ICD)-9CM codes and effective dates, including E-codes, N-codes, P-codes with location date, time and physician (number code) performing procedure, and V-codes 30)       School related injury 31)       Work related injury 32)       Safety equipment 33)       Vehicle seat position 34)       Date arrived at transferring hospital 35)       Time arrived at transferring hospital 36)       Initial Glasgow Coma Score (GCS) total at transferring hospital 37)       Initial respiration rate at transferring hospital 38)       Initial temperature at transferring hospital 39)       Initial temperature scale at transferring hospital 40)       Initial temperature method at transferring hospital 41)       Admission/surgery at transferring hospital 42)       Transferring hospital number 43)       Transferring vehicle number 44)       Transport vehicle highest level of care 45)       Date discharged from transferring hospital 46)       Time discharged from transferring hospital 47)       Pre-hospital dispatch time 48)       Pre-hospital scene arrival date 49)       Pre-hospital scene arrival time 50)       Pre-hospital patient contact time 51)       Pre-hospital scene depart time 52)       Pre-hospital scene minutes-calculated 53)       Pre-hospital transport minutes-calculated 54)       Pre-hospital vehicle number 55)       Pre-hospital initial GCS total 56)       Pre-hospital systolic pressure 57)       Pre-hospital pulse 58)       Pre-hospital respiratory rate 59)       Pre-hospital revised trauma score 60)       Pre-hospital pediatric trauma score 61)       Pre-hospital triage criteria as referenced in Section 515.Appendix C 62)       Pre-hospital run sheet on chart 63)       ED arrival date 64)       ED arrival time 65)       Minimum trauma field triage criteria-in-house assessment as referenced in Section 515.Appendix C 66)       Category - level of trauma care activation (I, II, other) 67)       Category - location of trauma activation 68)       Category - initial time trauma activation declared 69)       Category - trauma grade change 70)       Category - initial time of trauma category grade change 71)       ED physician, trauma surgeon, assistant surgeon, neurosurgeon and consulting physician code numbers, and notification and ED arrival times 72)       ED blood alcohol 73)       ED drug screen-therapeutic and self-administered 74)       ED initial eye, verbal, motor and total Glasgow Coma Scores 75)       ED initial systolic pressure 76)       ED initial respiratory rate and assessment qualifier 77)       ED initial pulse rate 78)       ED initial temperature 79)       ED initial temperature scale 80)       ED initial temperature method/rate 81)       ED trauma score revised 82)       ED pediatric trauma score 83)       Breakdown score for pediatric trauma score 84)       Pediatric resuscitation tape-height and weight 85)       ED minutes prior to head computerized tomography (CT) 86)       ED cervical clearance 87)       ED discharge date 88)       ED discharge/depart time 89)       ED minutes 90)       ED disposition 91)       ED reason for transfer 92)       ED disposition death 93)       Admitting service 94)       Date of first operation 95)       Time of first operation 96)       Complications 97)       Unanticipated operation 98)       Blood products, including auto-transfusion 99)       Total ICU days 100)     Total monitored bed days 101)     Total ventilator days 102)     In-patient consult 103)     Injury severity score (ISS) 104)     ISS calculation 105)     Abbreviated injury score for each injury with description and AIS revision and effective year 106)     Trauma Score/Injury Severity Score (TRISS) survival probability 107)     Discharge disposition 108)     Transferred to (facility number) 109)     Hospital discharge date 110)     Total hospital days 111)     Discharge expression, feeding and locomotion capabilities as determined by the functional independence measure (FIM) 112)     Organ donor status 113)     Hospital charges 114)     Hospital payment source 115)     Clean/complete record 116)     DNR status c)         Reportable trauma patients 1)         A reportable trauma patient is one who was involved in a traumatic event and: A)        was transferred to the trauma center from another hospital; B)        was transferred from the trauma center to another hospital; C)        was admitted to the trauma center as an inpatient; D)        was assigned an observation status and had a length of stay greater than 12 hours from time of arrival in the ED; E)        was dead on arrival (DOA); F)         died in the emergency department (DIE); or G)        signed out against medical advice after refusing admission (AMA). 2)         A traumatic event is one in which there was a transfer of energy resulting in injury, involving any of the following: A)        aircraft; B)        watercraft; C)        motor vehicles; D)        railway; E)        recreational vehicles; F)         farm machinery; G)        animals, including bites; H)        explosion; I)         falls; J)         thermal (including smoke inhalation)/chemical/radiation injuries; K)        lightning; L)        weather related (tornado, flood, blizzard) injuries; M)       struck by falling object; N)        sports related; O)        caught between objects; P)         cutting or piercing instruments or objects; Q)        firearms; R)        electric current; S)         suicide or self-inflicted injury; T)         homicide; U)        injury inflicted by others; V)        hanging; or W)       strangulation. d)         Illinois trauma registry reporting schedule Patients Discharged Report Date January - March June 30 April - June September 30 July - September December 31 October - December March 31 e)         The trauma center shall have a policy to back up and archive data on a regular basis. f)         Data collected from individual trauma centers shall be cross-referenced with Vital Records Death Certificates to confirm accuracy. g)         Annual reports shall be prepared by the Department presenting summary data to allow trauma centers to evaluate performance.  This data shall have all hospital and patient identifiers removed. h)         All data received by the Department shall be kept confidential.  Patient identifiers shall be kept in such a way to assure that confidentiality is maintained and is not available to the public. 1) All reports and records made pursuant to the Head and Spinal Cord Injury Act [410 ILCS 515] and maintained by the Department and other appropriate persons, officials and institutions pursuant to the Head and Spinal Cord Injury Act shall be confidential.  Information shall not be made available to any individual or institution except to: A) Appropriate staff of the Department; B) Any person engaged in a bona fide research project, with the permission of the Director of Public Health, except that no information identifying the subjects of the reports or the reporters shall be made available to researchers unless the Department requests and receives consent for such release pursuant to the provisions of this Section; and C) The Advisory Council on Spinal Cord and Head Injuries, except that no information identifying the subjects of the reports or the reporters shall be made available to the Council unless consent for release is requested and received pursuant to the provisions of this Section.  Only information pertaining to head and spinal cord injuries as defined in Section 1 of the Head and Spinal Cord Injury Act shall be released to the Council. (Section 3 of the Head and Spinal Cord Injury Act) 2) The Department shall not reveal the identity of a patient, physician or hospital, except that the identity of the patient may be released upon written consent of the patient, parent or guardian, the identity of the physician may be released upon written consent of the physician, and the identity of the hospital may be released upon written consent of the hospital. (Section 3 of the Head and Spinal Cord Injury Act) 3) The Department shall request consent for release from a patient, a physician or hospital only upon a showing by the applicant for such release that obtaining the identities of certain patients, physicians or hospitals is necessary for his bona fide research directly related to the objectives of the Head and Spinal Cord Injury Act. (Section 3 of the Head and Spinal Cord Injury Act) i)          Availability of Registry Information 1)         All requests by medical or epidemiologic researchers for confidential registry data must be submitted in writing to the registry.  The request must include a study protocol that contains:  objectives of the research; rationale for the research, including scientific literature justifying current proposal; overall study methods, including copies of forms, questionnaires, and consent forms used to contact facilities, physicians or study subjects, including methods for documenting compliance with 42 CFR 2A, pars. 4 ambulance, 6 a-b, 7 a-b1; methods for the processing of data; storage and security measures taken to ensure confidentiality of patient identifying information; time frame of the study; a description of the funding source of the study (e.g., federal contract); the curriculum vitae of the principal investigator; and a list of collaborators.  In addition, the research request must specify what patient or facility identifying information is needed and how the information will be used. 2)         All requests to conduct research and modifications to approved research proposals involving the use of data that includes patient or facility identifying information shall be subject to a review to determine compliance with the following conditions: A)        The request for patient or facility identifying information contains stated goals or objectives; B)        The request documents the feasibility of the study design in achieving the stated goals and objectives; C)        The request documents the need for the requested data to achieve the stated goals and objectives; D)        The requested data can be provided within the time frame set forth in the request; E)        The request documents that the researcher has qualifications relevant to the type of research being conducted; F)         The research will not duplicate other research already underway using the same registry data when both require the contact of a patient, reporting facility or physician about an individual patient involved in the previously approved concurrent research; and G)        Other such conditions relevant to the need for the patient or facility identifying information and the patient's confidentiality rights, because the Department will only release the name of the patient, physician (in accordance with the provisions of this Section) or facility identifying information that is necessary for the research. 3)         Research Agreements A)        The Department will enter into research contracts for all approved research requests.  These contracts shall specify exactly what information is being released and how it can be used in accordance with the standards in subsection (c) of this Section.  In addition, the researcher shall include an assurance that: i)          Use of data is restricted to the specifications of the protocol; ii)         Any and all data that may lead to the identity of any patient, research subject, physician, other person, or hospital is strictly privileged and confidential and that such data will be kept strictly confidential at all times; iii)        All officers, agents and employees will keep all such data strictly confidential; will communicate the requirements of this subsection to all officers, agents, and employees; will discipline all persons who may violate the requirements of this Section; and will notify the Department in writing within 48 hours after any violation of this subsection, including full details of the violation and corrective actions to be taken; iv)        All data provided by the Department pursuant to the contract may only be used for the purposes named in the contract and that any other or additional use of the data may result in immediate termination of the contract by the Department; and v)         All data provided by the Department pursuant to the contract is the sole property of the Department and may not be copied or reproduced in any form or manner and that all data and all copies and reproduction of the data will be returned to the Department upon termination of the contract. B)        Any departures from the approved protocol must be submitted in writing and approved by the Director in accordance with subsection (c)(2) of this Section prior to initiation.  No patient or facility identifying information may be released by a researcher to a third party. 4)         The Department shall disclose individual patient or facility information to the reporting facility that originally supplied that information to the Department, upon written request of the facility. j)          The patient identifying information submitted to the Department by those entities required to submit information under the Act and this Part is to be used in the course of medical study under Part 21 of Article 8 of the Code of Civil Procedure [735 ILCS 5].  Therefore, this information is privileged from disclosure by Part 21 of Article 8 of the Code of Civil Procedure. k)         The identity of any facility, or any group of facts that tends to lead to the identity of any person whose condition or treatment is submitted to the Department, shall not be open to public inspection or dissemination.  Such information shall not be available for disclosure, inspection or copying under the Freedom of Information Act or the State Records Act.  All information for specific research purposes may be released in accordance with procedures established by the Department in this Section. l)          Every hospital shall provide representatives of the Department with access to information from all medical, pathological, and other pertinent records and logs related to reportable registry information.  The mode of access and the time during which this access will be provided shall be by mutual agreement between the hospital and the Department.  The Department shall not require hospitals to provide information on cases that are dated more than two years before the Department's request for further information. m)        Every hospital shall provide access to information regarding specified patients or other patients specified for research studies, related to reportable registry information, conducted by the Department.  Any disputes as to access shall be resolved by the hospital and the Department within 30 days after requests for access have been denied.