California
Trauma Data Management Requirements.
22 CCR 100143.01
Source text
33 segments
22 CCR 100143.01
22 CCR 100143.01
§ 100143.01. Trauma Data Management Requirements.
(a)
Data Collection and Reporting Process Requirements.
(1)
LEMSA. The local EMS agency (LEMSA) shall develop and implement a standardized data collection and reporting process for the trauma care system.
(A)
The process shall include the collection of both prehospital trauma patient care data and general acute care hospital (GACH) trauma patient care data. The data shall include the elements specified in subdivision (b) and may include additional elements as specified by the LEMSA.
(B)
The LEMSA, in collaboration with trauma centers, trauma receiving hospitals, and EMS providers, shall develop a process for the sharing of outcome data from the trauma center or trauma receiving hospital to the EMS providers for all transported trauma patients, including patients who were initially identified as potential trauma cases but were not ultimately included in the trauma center's or trauma receiving hospital's trauma registry.
(C)
The LEMSA shall:
(i)
Provide quarterly trauma system data reports to all trauma care system-participating general acute care hospitals (GACHs) that summarize the collected prehospital- and GACH-level trauma patient care data.
(ii)
Share any National Trauma Data Bank® (NTDB) information collected for trauma centers within its local EMS system with the Emergency Medical Services Authority (EMSA).
(2)
GACHs.
(a)
All trauma centers and trauma receiving hospitals that receive patients via EMS shall maintain a LEMSA-approved trauma patient registry (trauma registry) within which the GACH shall collect trauma patient care data. The GACH shall submit trauma registry data either directly to CEMSIS or the LEMSA in a manner that is compliant with the Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191). When trauma registry data is submitted to the LEMSA, the LEMSA shall upload the data to CEMSIS.
(b)
All GACHs within an approved trauma care system that receive trauma patients via EMS shall participate in the LEMSA data collection process in accordance with LEMSA policies and procedures.
(3)
Timing of submission. The prehospital trauma patient care data and GACH trauma patient care data shall be collected and submitted to the Emergency Medical Services Authority (EMSA), either directly or through the LEMSA in accordance with the LEMSA's data policy, on at least a quarterly basis and within ninety (90) days of patient discharge.
(b)
Trauma Patient Care Data Requirements.
(1)
Prehospital Trauma Patient Care Data Elements. The prehospital trauma patient care data elements shall be compliant with the most current version of the CEMSIS and NEMSIS databases.
(2)
GACH Trauma Patient Care Data Elements. GACH trauma patient care data elements shall include, at a minimum:
(A)
Time of arrival in the emergency department (ED);
(B)
Dates of:
(i)
Initial admission;
(ii)
Intensive care unit (ICU) admission; and
(iii)
Discharge.
(C)
Discharge data, including:
(i)
Patient destination;
(ii)
Discharge diagnosis;
(iii)
Gender;
(iv)
Date of Birth;
(v)
Age;
(vi)
ED/hospital arrival date;
(vii)
ED/hospital arrival time;
(viii)
ED disposition;
(ix)
Hospital disposition;
(x)
International Classification of Diseases, 10th Revision, Injury Diagnosis (ICD-10 Injury Dx) codes;
(xi)
Abbreviated Injury Scale (AIS) severity codes;
(xii)
Mode of arrival.
Source outline
32 anchors in this source