Wisconsin Trauma Registry

 

Frequently Asked Questions

May, 2007

 

 

NOTE:  This is an evolving document.  As significant questions and issues arise they will be added. 

 

Trauma Registry Website Address:  https://witrauma.han.wisc.edu/wiweb/witrauma.isa

 

1.      Which trauma patients are to be entered into the State Trauma Registry?

 

Answer:  Only those patients listed on the inclusion criteria should be entered into the State Trauma Registry.  Please note the "AND" and "OR" in the inclusion criteria.  If the patient is admitted for "social" observation or potential injuries that could develop they should not be entered.  They would be entered if they are admitted or transferred for their injury.  If you activate your trauma activation procedure you put the patient into the registry.  This will help you track under/over triage.

 

2.      What qualifications should the data entry person have?

 

Answer:  It is recommended that the person submitting the data have anatomy and physiology knowledge, medical terminology and the ability to extract data from the patient's chart.  People who may have a strong background or training in these areas include the following: RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician), RN (Registered Nurse), LPN (Licensed Practical Nurse), or CSTR (Certified Specialist in Trauma Registry).  This list is not inclusive.  Others may be qualified for this position.

 

3.         What is the Trauma Registry Liaison's role?

 

Answer:  The Trauma Registry Liaison is responsible for determining who in his/her trauma care facility has access to the trauma registry and whether the user(s) may:

 

·        View data only

·        View data and access Reports

·        Enter data and access Reports

·        Enter data but not access Reports   

 

To enter a new user or to change a role, the Trauma Registry Liaison should contact Marianne Peck. There is no limit on the number of users a facility may authorize but be aware that maintenance is required for each user authorized to access the trauma registry.  Maintenance tasks include adding new users, resetting forgotten passwords, changing roles and facilities, and deleting users.  Information entered into the trauma registry is confidential health care information; therefore, access must be limited to those who have a direct responsibility for the Trauma Registry and for Performance Improvement (PI).

 

4.         How often am I required to send data to the State?

 

Answer:  According to HFS 118, Wis. Admin. Code, Trauma Care System, data shall be submitted to the department on a quarterly basis. The data submission should be completed on closed records only.  

January, February and March - due the end of April

April, May and June - due the end of July

July, August and September - due the end of October

October, November and December - due the end of January

 

5.         What is a completed, closed record?

 

Answer:  A completed, closed record has all possible data entered and verified.  There is no other data to be added to the record.

 

6.         Where can I find information on the State Trauma Registry?

 

Answer:  At this time, the most efficient way to get information regarding the trauma registry is to contact Marianne Peck, State Trauma Care System Coordinator, at 608-266-0601 or via email at peckme@dhfs.state.wi.us.  There is a plan in the future to have information available on the trauma system website at http://dhfs.wisconsin.gov/ems.

 

7.         When a patient is transferred to our facility from another facility or if we transfer a patient to another facility, who enters the data on the patient?

 

Patients Admitted to your facility: If your trauma care facility (TCF) is admitting the patient to your facility, your facility must put the data in for that patient. 

 

Patients Transferred to another facility out of State:  If your TCF is transferring the patient to another hospital in another state, your TCF must put the data in for that patient.

 

Patients Transferred to an ACS Verified Trauma Center (Level 1 or 2) or a Level III Trauma Care Facility with an In-House Registry:  If you are transferring the patient to an American College of Surgeon (ACS) Verified Trauma Center or a Level III facility with an in-house trauma registry (a list of ACS Trauma Centers and Level III facilities with in-house registries is at the end of this document) your TCF has the option of entering the data yourself or having the Receiving Facility enter the data for you.  However, you must select one option then always submit the data according to the option you selected.  You may not decide to have the receiving facility enter the data one day and your facility enter the data the next. 

 

Patients Admitted to a Level III or IV facility and then Transferred to an ACS Verified Trauma Center (Level 1 or 2) or a Level III with an In-House Registry: If a Level III or IV admits the patient to the trauma care facility and then transfers that patient to a Trauma Center or Level III with an in-house registry another day, the Level III or IV that first admitted the patient must enter the data on the patient.

 

Patients Transferred from a Level III to another Level III or Level IV: If the patient is transferred from a Level IV to a Level III or from a Level III to a Level III, the receiving facility (not the transferring facility) should enter the data on the patient.

 

8.         What factors should we consider in determining whether our facility or the Trauma Center should enter the data?

 

Answer:  American College of Surgeons (ACS) Verified Trauma Centers will be entering the data regardless of your decision.  It is a requirement for them to enter data on all trauma patients they receive that meet their criteria.  If you enter the data on the patients you transfer, you will have immediate access to your own data.  If the Trauma Center enters the data, your facility will not have access to that data until the Trauma Center closes that patient's chart and enters all information into their own database.  That may take longer due to the high volume of trauma patients that are seen at Trauma Centers.  If the trauma center enters the data, you will have data on the patient's incident from the time of injury up to the time of transfer to the Trauma Center.  You will not have access to the patient's information during his/her stay at the Trauma Center.  Follow-up on the trauma patient may occur at a performance improvement meeting that may be occurring through the Regional Trauma Advisory Council (RTAC).  Otherwise, you would handle follow-up on those patients the same as you do now.

 

9.         Do we put in all the diagnosis codes for the patient or only the ones that fall into the inclusion criteria?

 

Answer:  You will enter all injuries.  For example, if the patient sustains injuries that fall within the inclusion criteria such as a subdural hematoma or a pneumothorax, but also sustains an ankle fracture, you would include the ankle fracture in your injury narrative (diagnosis code).  The patient that sustains an isolated ankle fracture and no other injuries does not meet the inclusion criteria and would not be entered into the registry. If the patient has injuries that meet the inclusion criteria and other injuries that do not, all injuries should be included in the injury narrative (diagnosis codes).  It will have an impact on the results of the coding and hence on the analysis of injuries in Wisconsin.

 

10.     If a traffic collision occurs on an interstate what do I put in for the Injury Site E-Code?

 

Answer:  It would go in under Street/Highway

 

11.     What is the Secondary E-Code?

 

Answer:  The secondary e-code is the cause of an injury that contributed to the patient’s overall condition but it is not the primary cause of the injury.  For example, a patient is in a motor vehicle collision, hits a bridge then goes into water.  The patient suffers hypothermia from the cold water.  The motor vehicle collision is the primary E-code and the hypothermia is the secondary E-Code.  Another example:  driver has an MVC, striking a telephone pole, while fleeing the police, and sustains a fractured arm.  The patient flees the scene and falls over an embankment suffering a fractured femur. 

 

The secondary E-Code is rarely used. 

 

12.     Under Protective/Safety Devices, do you mark Airbag if it exists in the vehicle or only if it was deployed?

 

Answer:  Enter “airbag” only if it was deployed.  The majority of times, EMS will not chart if there is an airbag unless it was deployed.

 

13.     What is a First Responder?

 

Answer:  According to HFS 113, Wisconsin Administrative Code, a First Responder means, “a person who provides emergency medical care to a sick, disabled or injured individual prior to the arrival of an ambulance as a condition of employment or as a member of a first responder service."  A First Responder Service Provider means, “any organization which provides prehospital emergency medical care, but not patient transportation."

 

A First Responder may include law enforcement and fire.  If a First Responder group is state-certified to provide medical first response, it will be on the list available in the Trauma Registry dropdown list.  If you are unable to locate the group that provided care to the patient, select “other” then type in the name of the First Responder group.

 

14.     Who is the Primary EMS Provider?

 

Answer:  The primary EMS provider is the first ambulance service that is paged to the scene.  Ambulance services are responsible to respond within their own Primary Service Area (PSA).  They may or may not transport the patient to the hospital.

 

15.     Who is the Secondary EMS Provider?

 

Answer:  The secondary EMS provider may be called by dispatch, by the primary EMS provider or by police to respond to the scene to serve as back-up, to provide mutual aid or to provide more advanced care, including air ambulance service.  The secondary EMS provider usually transports the patient but there may be infrequent times when they do not transport.

 

16.     What do we do if we do not have the EMS Run Report?

 

Answer:  This is a statewide issue that will be addressed through education of EMS personnel.  It is up to all healthcare personnel to have discussions in their RTAC and trauma care facility regarding the importance of having a readily available report for the continuous care of the patient.  Wisconsin Administrative Rules governing EMS require documentation of ambulance runs on a report form.  The ambulance run report is part of the patient’s medical record.  A copy of the run report must be given to the receiving facility and the provider must keep a copy.  The rule, however, does not specify a timeframe for when EMS must provide a copy of the run report to the hospital.  The EMS provider may fax or send the report electronically.  You may need to contact the EMS provider if a copy of the run report is not available in the file.

 

Currently, First Responders are not required to create written reports but they should share information verbally with ambulance services.  The Department of Health and Family Services (DHFS) and the EMS Advisory Board are working on this issue.

 

If you gain access to the Wisconsin Ambulance Run Data System (WARDS) through Brian Litza, the EMS Section Chief (litzaBD@dhfs.state.wi.us), you will be able to see the run report on any patients that come to your facility in the future.  This is a work-in-progress and is dependent on the EMS Services getting into WARDS.  The mandated date for all services to access and report to WARDS is January, 2008.  You should not depend only on WARDS, however, as some services may not have "closed" their record before you enter the data.

 

17.  What is meant by the Referring Facility?

 

Answer:  The Referring Facility is the trauma care facility that receives the patient first if the patient is later transported to another trauma care facility for further acute care.  The facility that the patient is transferred to secondarily will fill out the referring facility screen on the facility that first received the patient.

 

18.  What do we do if the facility is not on the facility list?

 

Answer:  Please enter the name of the facility under "Other."

 

19.  How do we enter data on patients that may have had a seizure, myocardial infarction or diabetic reaction etc., that caused the injury?

 

Answer:  This information should be entered under External Cause Code (E-Code) in the free text for "Cause of Injury."  Example: "Patient suffered a tonic-clonic seizure during which the patient's car struck a tree."

 

20.  What is meant by intubation?

 

Answer:  The patient is intubated if they have an endotracheal tube, or a non-visualized airway in place, such as a Combitube, King LT or LMA. Intubation does not include nasal or oropharyngeal airway.

 

21.     Whom do we contact for which issues?

 

Answer:  For program issues on data, coding and using the data in your hospital, you may contact the trauma center registrars who have agreed to serve as resources in your region.  (See attached list)

 

For upload questions or if you cannot login into the Web application, or page cannot be displayed, contact the Digital Innovation HelpDesk at:

 

(800) 344-3668 - Option 4

Email:  support@dicorp.com

 

For in-house registry questions or if you cannot get into the Internet, contact your local HelpDesk or IT support.

 

For questions on when or how to enter a particular trauma registry patient, contact the Wisconsin Help Desk at: 

(608) 261-4400

(866) 335-2180 (toll free)
(888) 845-4160 (TTY only)
Email: helpdesk@wi.gov

 

22.     How can our trauma care facility staff view the video recorded at the June trauma registry training?

 

Answer:  Go to the following website, http://media1.wi.gov/dhfs/viewer/.  Then   search by the date of June 20, 2006, or by the topic of “Trauma Registry Training.” 

 

23.     What is needed to calculate RTS, ISS, AIS and TRISS?

 

Answer:  RTS (Revised Trauma Score) requires Respirations, Systolic Blood Pressure, and the total Glasgow Coma Score (GCS).  ISS (Injury Severity Scale) requires none of the above information, although sometimes GCS is useful in assigning an Abbreviated Injury Scale (AIS) to a head injury. ISS is auto-calculated in the trauma registry.  It is the sum of the squares of the highest AIS injury value in each of the three most severely injured ISS body regions.  The Trauma Injury Severity Score (TRISS) requires patient age, whether the injury was blunt or penetrating and the RTS score.  The RTS is auto-calculated in the ED/Admission section.  Unfortunately, for severely injured patients who are intubated where an unassisted respiratory rate is unknown, the RTS, and therefore the TRISS, cannot be calculated.  An ISS is also required to obtain the TRISS.

 

24.     Are there any interface capabilities with hospital information systems?

 

Answer:  The State Trauma Registry is a web-based system.  Information may be submitted electronically through individual uploads by facilities that have in-house registries (i.e., Collector, NTRACS, Lancet) or be entered directly to the web-based application by facilities that do not have in-house registries.  It is a self-contained system and there are no additional interface capabilities seen in the near future.

 

25.     Are any fields mandatory or can I proceed with incomplete records?  If I forget the “check” feature will it still accept the record?

 

Answer:  The “Check” feature within the State Trauma Registry software is a convenience to verify the accuracy and completeness of a record before closing it.  Please remember that this function, if it exists in your in-house registry may work differently than it does in the State Trauma Registry.  The “check” is required to close a record; however, it is not necessary to fix all the checks before closing the record.

 

26.     What is the process for confirming consistent data?

 

Answer:  The process for identifying consistent data will evolve over time.  Some of the steps to ensure consistent data entry include your attendance at RTAC meetings and Trauma Registry workshops, through the work being done by the Ad Hoc Sub-Committee and through the report process.  It is your responsibility as part of performance improvement to attend any meetings offered that will allow opportunities to participate in the data consistency process, such as the Trauma Registry Workshops and the RTAC meetings.

 

27.     Can we enter a tracking number?  If so, where and how?  (i.e.:  triage tags)

 

Answer:  No, not at this time.

 

28.     Do we enter a patient who was DOA that is transferred to our hospital?

 

Answer:  If the patient was registered and meets the inclusion criteria, information should be entered into the registry.  If the patient is taken directly to the morgue and no information is collected, there is no information to enter into the registry.

 

29.     What is the process for suggesting enhancements?

 

Answer:  We welcome suggestions for enhancements; however, please be aware that the State does not determine what enhancements should be made without consulting the Ad Hoc Sub-Committee and other data experts.  This reduces the risk that an enhancement that works well for one or several facilities is not having unintentional effects on other facilities.

 

30.     How long are the records retained on the Show All screen?

 

Answer:  At this time, records will be retained indefinitely. 

 

31.     How will we be informed about updates?

 

Answer:  The following communication tools are in place:  the announcement section on the State Trauma Registry homepage, e-mail updates from Marianne Peck, RTAC meetings, STAC meetings and Trauma Registry workshops.

 

32.     Where do we find general system information such as abbreviations and passwords?

 

Answer:  A list of abbreviations will be available under the Contact Support which is on the Welcome page on the website.   Other system information is already available under this section, including password information.

 

33.     Is there a pop-up calendar to enter the date throughout the module vs. typing it in?

 

Answer:  Not at this time.  The vendor is investigating if this is possible in the web-based application.

34.     Is it possible to flag multiple patients from the same incident?

Answer:  Not at this time.

35.     Under the EMS section is the service number the EMS provider number?  If so, can we just enter the EMS provider number?

Answer:  The EMS provider list is not an open text field.  You must select the “^” button to bring up the list.  You cannot enter a number or name so you must scroll through the list.

36.     Can we retrieve a deleted record?

Answer:  Not at this time.

 

37.     Can you click on a message when checking results and go directly to the screen that needs correcting?

Answer:  Not at this time. 

 

38.     How will the State Trauma Registry avoid duplicating trauma numbers of organizations with Collector?

 

Answer:  The State Trauma Registry uses the facility number and the trauma number together to identify a patient record.

 

39.     Can counties designate their own order for drop-downs so their county is on top similar to Wisconsin for state?

 

Answer:  Not at this time.

 

40.     Will trauma care facilities and EMS Providers be able to access other facilities’ data to make changes, view outcomes, or gather information for PI?

 

Answer:  The goal of the State Trauma Registry Program is to improve quality of patient care.  The State Trauma Registry collects data from state facilities but the software is not intended to allow sharing of data without the same restrictions and protections currently in place by individual hospitals.  The sharing of information to evaluate quality, as well as performance improvement, must be initiated by partners and not dictated by the state.  Aggregate reports generated from the State Trauma Registry may guide performance improvement (PI) and quality assurance work.  Trauma care facilities will be working through their performance improvement process in their RTACs to obtain information for PI purposes.

 

41.     Can scene/meeting location and time be calculated from GPS?

 

Answer:  Not at this time.

 

42.     What about readmits?

 

Answer:  If a person meets the inclusion criteria, the patient should be entered into the Trauma Registry.

 

43.     We don’t record the blood alcohol level.  We only indicate if the patient was tested.  Is this a problem?

 

Answer:  Every facility has procedures that work for them.  The State Trauma Registry accepts any data that is submitted by a facility.  However, as everyone involved with the Trauma Registry examines reports and quality assurance is done on the data, discrepancies between how information is reported will be identified. 

 

44.     What is the impact of closed vs. active cases on DHFS reporting?  Should we wait until we have all necessary information before we enter it into the Trauma Registry?

 

Answer:  Facilities using the web-based application may have open records at various levels of completeness unless there is a local decision not to enter any data until all information is collected.  When reports are run, only closed records will be included.  Facilities with in-house registries select records to be electronically submitted so they likely will not have open records in the registry.

 

The timing and amount of information to be gathered before entering data is made by the facility based on its operations, workload and procedures.

 

45.     Do you code any pre-existing conditions which might affect outcomes for example, diabetes or history of transplant?

 

Answer:  There is no place to enter pre-existing conditions at this time; however, it will be considered as an enhancement in the future.

 

46.     Is military time used?

 

Answer:  Yes.

 

47.     If a record is entered by one user and edited by another user, does the system keep track of who made changes?

 

Answer:  No, there is no tracking for changes to individual records within the State Trauma Registry.  Tracking may be part of an in-house registry.

 

48.     Can multiple terminals at the same facility have a short-cut to Collector?

 

Answer:  A short-cut to the web-based State Trauma Registry may be put on any terminal if there is access to the internet.  Facility policies likely dictate how short-cuts should be applied for in-house registries.

 

49.     Can a T be used to enter today’s date rather than entering all the numbers?

 

Answer:  No.

 

50.     Can data be printed for hard copy for future reference?

 

Answer:  There are two ways to print data from the State Trauma Registry.  First, you may print each screen.  Secondly, you may run the facsimile report.  The facsimile report is available only to facilities and contains all data entered on a trauma patient.

 

51.     On the demographics screen – when the age is automatically calculated – if I open that record a year later, will the age change, or does it remain fixed at the age at date of injury?

 

Answer:  The age will not change as long as the Date of Birth or Arrival Date is not changed.  These are the dates from which age is automatically calculated.

 

52.     Trauma Registry Number – is it unique to the patient or to the encounter?  For example, if a patient has an injury that meets the inclusion criteria in 2006 in Milwaukee then has another injury in 2007 in Madison – will that patient have two numbers, one for each encounter?

 

Answer:  The Trauma Registry Number is unique to the encounter.  It is a combination of the submitting facility’s number plus a unique trauma registry number.  In the above scenario, the person would have two different trauma registry numbers.  If those two trauma facilities decide to share data to identify this person, they would need to use other identifying information, such as name and date of birth.

 

53.     How often should the password be changed?

 

Answer:  The system will not force a password change; however, it is recommended your password for the Trauma Registry be changed on the same schedule as your other system passwords.

54.     Are temps in F or C?

Answer:  Both temperature measurements are available.

55.     If initial facility enters data and transferring hospital enters different conflicting data – what will this affect?

Answer:  The records will be kept separate and a decision must be made when producing aggregate reports.  Discrepancies in the data may be discovered through data analysis and may lead to contact with one or both facilities.  The State Trauma Registry will not alter any facility’s data.  It is not the intent of the State Trauma Registry to replace current PI procedures.

56.     Will the data be saved when a “time out” occurs during entry of a record?  (Incomplete records)

Answer:  The Trauma Registry auto-saves data every 15 minutes as well as when the user moves from screen to screen. 

57.     What if the IDC-9 is a combination code, i.e., fracture of the ulna and radius?

Answer:  Enter each injury on separate lines.

58.     How are we suppose to enter a Swing Bed Unit upon discharge from the facility?

Answer:  Swing Bed Units operate under the Nursing Home regulations so I would enter Nursing Home unless it is strictly Rehabilitation and your judgement is under Rehab.

 

Tri-Code

 

59.     Can Tri-Code be revised if a Registrar knows a different AIS is more accurate?

 

Answer:  No.

 

60.     On Tri-code, are there indicators for procedures performed or for a diagnosis?

 

Answer:  The diagnosis is included, i.e., fractured femur, but no procedures are coded.

 

61.     Does Tri-code prompt if information is unclear or if there might be more than one meaning?

 

Answer:  The Tri-code conversion function is very forgiving and unless the injuries entered are too vague or if unrelated language is used, it will usually produce a result.

 

62.     Is it necessary to cross-check ICD-9 codes with actual injuries to confirm accuracy?  Is there a quick way to generate a list of ICD-9 diagnoses based on the text entered in Tri-code?