Current through Register Vol. 48, No. 12, March 22, 2024
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.
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 2 A, 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.
