<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".21" citation="COMAR 30.08.08.21" title_num="30" subtitle_num="08" chapter_num="08" heading="Trauma Registry.">
  <paragraph num="A.">
    <text>The Trauma Center shall maintain a pediatric Trauma Registry with participation in the MSTRB. The Trauma Registry shall include, at a minimum, all of the data elements compliant with the MSTR Data Dictionary for Pediatric Patients, including:</text>
    <paragraph num="(1)">
      <text>Demographic data;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Pre-hospital data;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Process of acute care;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Clinical data;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Outcome data;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Final anatomical diagnoses;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Procedure codes;</text>
    </paragraph>
    <paragraph num="(8)">
      <text>QM data;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Standard report utilization; and</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Case inclusion criteria.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>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.</text>
  </paragraph>
  <paragraph num="C.">
    <text>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.</text>
  </paragraph>
  <paragraph num="D.">
    <text>The Trauma Program Manager shall have the authority, responsibility, accountability, and oversight of the Trauma Registry, inclusive of data submission as required by MIEMSS.</text>
  </paragraph>
  <paragraph num="E.">
    <text>The Trauma Registry shall have:</text>
    <paragraph num="(1)">
      <text>A staffing plan that includes workload analysis that defines personnel needs necessary to comply with the MIEMSS data submission requirements, and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>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.</text>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>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.</text>
  </paragraph>
  <paragraph num="G.">
    <text>All records shall be completed within 60 days of patient discharge.</text>
  </paragraph>
  <paragraph num="H.">
    <text>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.</text>
  </paragraph>
  <paragraph num="I.">
    <text>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.</text>
  </paragraph>
  <paragraph num="J.">
    <text>The Trauma Center shall submit data to the NTDB.</text>
  </paragraph>
  <paragraph num="K.">
    <text>Trauma Registry staff shall have:</text>
    <paragraph num="(1)">
      <text>A job description developed by the hospital to reflect roles and responsibilities;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Core requirements including:</text>
      <paragraph num="(a)">
        <text>Anatomy and physiology;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Medical terminology; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Education to be completed within 1 year of hire includes:</text>
        <paragraph num="(i)">
          <text>American Trauma Society Trauma Registrar Course; and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Association of the Advancement of Automotive Medicine’s Injury Scaling Course; and</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>Job responsibilities to include:</text>
      <paragraph num="(a)">
        <text>Ensuring assigned cases are compliant with Maryland Data Dictionary Inclusion Criteria or other trauma center self-defined criteria;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Compiling abstracted data for MSTR case from various sources; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Appropriately coding injuries, complications, and procedures.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="L.">
    <text>The Trauma Registry staff liaison shall:</text>
    <paragraph num="(1)">
      <text>Attend a minimum of 50 percent all trauma multidisciplinary/peer review meetings that are held; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Actively participate in the Maryland TQIC.</text>
    </paragraph>
  </paragraph>
</regulation>