1. Trauma Registry Mazen S. Zenati, M.D. MPH, PH.D. University of Pittsburgh Department of Surgery and Epidemiology

2. What Is a Trauma Registry? A computerized data base that consist of extensive demographic, injury information, and trauma outcome Includes all trauma patient data from scene to hospital discharge Many uses, many users

3. Trauma Registry A trauma registry is a system of timely data collection that aids in the evaluation of trauma care for a set of injured patients who meet specific criteria for inclusion. In addition to hospital-based trauma data, it also includes patient information from other health care providers including pre-hospital care and rehabilitation if utilized. Provides a mechanism for overall patient care and system evaluation.

4. Trauma Registry Relay on Commercial Software: Collector®, TraumaBase®, Trauma 1®, NTRACS®. Used by most trauma centers in U.S. Designed by Tri-Analytics, based on: The ABBREVIATED INJURY SCALE (AIS) which is an anatomical scoring system in which injury are ranked on a scale of 1 to 6, with a being minor, 5 severe, and 6 an un-survivable The INTERNATIONAL CLASSIFICATION of DISEASES (ICD-9) which is used to provide a standard classification of diseases for the purpose of health records and to classify diseases and to track mortality rates based on death certificates and other vital health records.

5. What Does a Trauma Registry Do? Provides for the: Collection Storage Reporting of trauma patient data

6. Trauma Registry Functions Trauma case identification, abstraction Trauma quality improvement Data sets for research and outcome studies Reporting: Standard reports, quarterly reports to State registry Trauma report for projecting and strategic planning: Billing, transfer center, ad hoc reports State trauma designation

7. Trauma Case Abstraction: Collector Trauma patient information from: Power chart notes and other electronic data sources Emergency Department (ED), Operating Room (OR) radiology reports and discharge summary Entered directly into Collector data base

8. Data Collection Certain parts are concurrent and many retrospective in nature Concurrent for front ended data and retrospective for back ended data Identifying patients based on trauma lists, ICD-9 of admission and diagnosis and used to obtain concurrent data Medical records are the main source for retrospective data collection Data collected on concurrent bases can be used in identifying patients for quality assurance projects and clinical trial.

9. Record Manager to add, edit, view and search

10. Data that need to be entered

11. Looking for individual record

12. Trauma Registry Functions: Quality Improvement Quality improvement looks at: Patients Providers Processes Outcomes

13. Collector Registry Software Free to all hospitals Built-In Logic Checks Logger Submission Tool Error Reports Training Data Entry & Submission Report Writing Registry Users Manual AIS Injury Scoring Course Technical Assistance On-site consultation Toll-free support Trauma Registry Quality Improvement Internal Analysis Record linking Comparative Reports Data quality indicators Trauma Registrars Networks Trauma Registry Data Validation during Designation Reviews A Model for Trauma Registry Quality Improvement Outcomes TAC

14. Trauma Registry : Quality Improvement Individual and aggregate cases Many trauma quality indicators reviewed by an interdisciplinary committee Indicators (audit filters) divided into categories by patient age, area of care, complications Trauma Quality Audit Filters-- Pre-hospital: No Emergency Medical Services (EMS) run report in chart Scene time > 20 minutes Cricothyroidotomy in field

15. Trauma Registry : Quality Improvement Trauma Audit Filters-- Emergency Department: Difficult intubation No CAT scan within 2 hours if head injury ED stay > 2 hours with BP <90, admit to OR Admitted, readmitted within 72 hours Trauma Team not activated Delay in attending/service response Length of ED stay > 6 hours ISS > 14 (medium to serious injury) admitted to non- surgical service

16. Trauma Registry : Quality Improvement Trauma Audit filters-- Complications: Decubitus ulcer Deep vein thrombosis Pulmonary Embolus Trauma Audit Filters—Process: Laparotomy needed, not done within 4 hr Non-surgical treatment of: Gunshot wound to abdomen Adult femoral shaft fracture Open long bone fractures, no operative treatment within 8 hours Epidural and subdural hematoma, first craniotomy > 4 hours after arrival Trauma audit filters—Deaths: All trauma deaths Unexpected deaths (ISS < 15) Unexpected survivors (ISS > 50)

17. Trauma Registry: Quality Improvement Trauma audit filters– Pediatric: Transfers to Children’s Hospital for continued care—review length of stay, outcomes (excludes rehab transfers) Diagnostic peritoneal lavage in child < 12 years of age Negative laparotomy; or gastrostomy, jejunostomy tube placement in patients < 15 years of age ALL pediatric deaths

18. Trauma Registry: Reporting Standard reports: Run a SQL query against the main data base Convert result to Excel spreadsheet, MS word document Standard reports: Abstract list, status report Activity reports Transfusion Practice Committee report Annual trauma summary Regional Quality Assurance summary State Trauma Registry Quarterly report Requires complex manipulation of data in certain occasions

19. Trauma Registry: Reporting Standard reports—Collector: Billing reports—Uses ISS for state trauma fund reimbursement Transfer Center reports—ISS info to referring facilities Ad hoc reports: As requested, Trauma Registry info to support quality improvement and research programs Data released under HIPPA and IRB (Institutional Review Board) guidelines

20. Query the registry and producing reports

21. Running a report

22. Trauma Registry Who Do We Include? State criteria: All patients with a discharge trauma diagnosis code ICD-9 800-904, 910-959 Drowning, asphyxiation (hanging), electrocution Activated the Trauma Resuscitation Team response Deaths: on arrival, in hospital Transfers: In or out, via EMS or ambulance All pediatric trauma patients, age 0 to 14 All adult patients with length of stay > 48 hours Foreign body diagnosis that causes injury (GSW) ALL admits, even if < 48 hours

23. Trauma Registry: What We Collect Demographics: Name, hospital number, address, age Date of birth, race, sex Social Security number Incident info: Injury date/time Primary, secondary E-codes (etiology, external cause of event) Setting (street vs home) Injury location (address) E-codes: External cause, circumstances of injury Very detailed—Falls: From stairs, or steps, ladders, scaffolding, out of building, other structure, into hole or other opening,

24. Trauma Registry: What We Collect One level, same level, other, unspecified……. Incident info, E-Codes very important for: Research: What really causes injury? Injury prevention: Intentional vs non-intentional trauma and interventions Incident info: (Yes, No, Unknown) Occupant: Driver, passenger, unknown Seat belt: Type (lap, shoulder) Air Bag Protective Device: (helmet, other) Work Related

25. Trauma Registry: What We Collect Incident info: Injury note: Hand written explanation of any unusual factors relating to traumatic event Abuse, pregnant, missed diagnosis Seen within 72 hours Other Hospital: Other facility transfer: Yes, No Transfer from: Other facility: admit date/time, patient number, alcohol level, toxicology screen Pre-hospital/field: Transport mode: Air, ground, multiple methods Times: Dispatch, scene arrival/departure, ED arrival Pre-hospital/field: Field vital signs: pulse, respiratory rate, blood pressure

26. Trauma Registry: What We Collect Glasgow Coma Score: neuro status Procedures: CPR, flutter valve, intubation, MAST pants Emergency Department: Admit date/time, disposition Trauma Team Activation Admit vital signs: pulse, respirations, blood pressure, Glasgow coma score Procedures: multiple! Inpatient: Inpatient admit date/time, service, unit, provider, disposition Discharge: transfer, rehab, psych Patient Outcome: Glasgow coma score, functional level Diagnosis, procedures summary Death: Organ/tissue donor status Brain Death criteria

27. Trauma Registry: Where Does the Data Go? Quarterly submission to State Trauma Registry—300 to 400 data elements per patient

28. Trauma Registry: How Is The Data Used? Injury surveillance, analysis, prevention programs Monitor, evaluate major trauma patient outcomes Compliance with state standards Resource planning, system design and management Research and education State-wide and regional quality assurance, system evaluation

29. Trauma Registry: Impact On Trauma Care Identifies injury cause: What is really hurting people? Provides “counts:” Spike in injury type Intentional vs. unintentional: GSW: suicide, homicide, or “accidental” Identifies cases for research, quality assurance Data drives legislation: Motorcycle helmet, seatbelt laws Design, evaluate injury prevention programs Evidence based trauma care practice Injury severity scores/financial issues —State trauma fund

30. Trauma Registry: Impact On Trauma Care Concurrent review of complications: preventable/non-preventable Case distribution: Facial fractures Facility improvements: More operating rooms, ED CAT scanner Blood usage Answers the questions: Who is getting hurt and how? What really works for treatment, prevention? How much does it all cost? How, where can we improve?

31. Trauma Registry: Summary Lots of data Lots of users Lots of uses Lots of work Increasingly important for evaluating care, systems, and prevention Very useful tool for trauma research Still under-utilized and need to be more readily accessible for research