New Mexico Administrative Code
Title 7 - HEALTH
Chapter 27 - EMERGENCY MEDICAL SERVICES
Part 7 - TRAUMA CARE SYSTEM
Section 7.27.7.10 - TRAUMA SYSTEMS DATA COLLECTION
Universal Citation: 7 NM Admin Code 7.27.7.10
Current through Register Vol. 35, No. 18, September 24, 2024
A. Bureau Responsibilities: the bureau shall:
(1) establish a statewide
trauma data registry to collect and analyze data on the incidence, severity,
and causes of trauma, including traumatic brain and spinal cord injury for the
purposes of:
(a) monitoring and providing
information necessary to evaluate qualifying trauma patient care, outcome and
cost,
(b) assessing compliance of
pre-hospital providers, designated trauma centers, and other
hospital/healthcare facilities with the standards of the state trauma system
operation and designation,
(c)
providing information necessary for resource planning and management,
(d) providing data for injury surveillance,
analysis, and prevention programs, and
(e) providing a resource for research and
education.
(2) establish
criteria to identify patients to be included in the State trauma system data
collection from:
(a) all EMS
providers,
(b) hospital/healthcare
facilities, both designated and non-designated,
(c) Office of Medical Investigator
reports,
(d) other sources outside
of the trauma system which may include, but not be limited to:
(i) death certificates,
(ii) Hospital Inpatient Discharge Data
(HIDD), and
(iii) law enforcement
agency records.
(3) establish, publish, and periodically
review the required data elements to be submitted to provide information
regarding injury, trauma care, and system operation, in the following
categories:
(a) demographic,
(b) anatomic,
(c) physiologic,
(d) severity,
(e) epidemiologic,
(f) resource utilization,
(g) Process Improvement,
(h) outcome, and
(i) financial.
(4) require a case specific patient
identifier common to all data sources used in the trauma registry;
(5) provide procedures and specifications for
electronic and hard copy submission of data;
(6) develop a system for, and report
mechanism on process improvement through:
(a)
establishing protocols for quality control, consistent with the Bureau's most
current data quality guidelines,
(b) completing studies to assess the
completeness and accuracy of case identification and data collection,
and
(c) assuring the completeness
and accuracy of data submitted for each provider submitting data to the trauma
registry.
(7) evaluate
requests from appropriate ReTrAC for collection of voluntarily submitted
additional data elements from agencies and facilities in that region.
B. Provider Responsibilities:
(1) all certificated
ambulance services shall:
(a) provide
pre-hospital run reports for inclusion of trauma patient data on:
(i) trauma victims dead at scene,
(ii) all patients meeting local/regional
trauma triage criteria who are transported to a hospital or healthcare facility
and,
(iii) all patients transported
in accordance with inter-facility transfer policies to a higher level of care
or for special resources.
(b) submit data by electronic transfer or, if
authorized in writing, to the EMS database as required, on approved
forms.
(c) the transporting service
shall be responsible for submitting to the receiving hospital/healthcare
facility data, described in Appendix A, sub paragraph B (1), on all trauma
patients.
(2) designated
trauma centers shall use the following patient criteria to identify trauma
patients for submission of data as defined in Appendix D, Table 1 as follows:
(a) discharge diagnosis ICD-0-CM codes of
800.0-904.99, including 940.0 - 949.00 (burns) when associated with major
trauma,
(b) meets local, regional
or state trauma triage criteria,
(c) emergency admissions (less than
twenty-four (24) hours after arrival) for traumatic injuries,
(d) transferred to another hospital for
trauma evaluation and/or definitive care by a trauma service,
(e) trauma patients who are pronounced dead
on arrival at a hospital/healthcare facility,
(f) all trauma patients who are pronounced
dead after admission to a hospital/healthcare facility, and
(g) submit required trauma system trauma
registry data as indicated in Appendix C, via electronic transfer or, if
authorized, in writing by the Bureau on approved paper forms.
(3) the Office of Medical
Investigator (OMI) shall submit data to the Systems Trauma Registry, and
appropriate hospital facility trauma registry, on all patients with injury
listed as an underlying cause or contributing factor to death on the death
certificate.
C. Trauma Registry Reports:
(1) the Bureau
shall report:
(a) annually on all patient data
entered into the System Trauma Registry;
(b) on trends, patient care outcomes, and
other data, for each trauma region and for the state, for the purpose of
regional evaluation as required in the State and Regional PI Plan;
and,
(c) periodically on financial
trends and needs.
(2)
the Bureau shall provide:
(a) periodic reports
to all providers submitting data to the System Trauma Registry;
(b) provider-specific raw data to the
provider that originally submitted the data, upon request;
(c) aggregate regional data semiannually to
the appropriate ReTrAC, excluding any confidential or identifying data;
and,
(d) aggregate state trauma
system data for hospitals, public or private, agencies and other interested
parties for prevention activities, epidemiologic/demographic studies, and
education and research projects.
D. Access and Release of Systems Trauma Registry Information:
(1) data
elements related to the identification of individual patient's, provider's, and
hospital/healthcare facility's outcomes shall be confidential.
(2) persons with access to information
collected under these regulations shall use the information for only those
purposes stipulated.
(3) the Bureau
may approve requests for data and other information from the Trauma Registry
for special studies and analyses, consistent with requirements for
confidentiality of patient and quality management records. The Bureau may
require requestors to pay any or all of the reasonable costs associated with
special preparation of such requests, which may be approved. In accordance with
those provisions, confidential information shall not be disclosed, except:
(a) on request, to an approved regional
process improvement program which is bound by the same confidentiality
guidelines as the Bureau;
(b) on
request, to a scientific research professional associated with a scientific
research organization, providing:
(i) the
research professional's written research proposal has been reviewed and
approved by the Bureau with respect to the scientific merit and confidentiality
safeguards;
(ii) the Bureau has
given administrative approval for the proposal; and,
(c) data does not provide specific
hospital/healthcare facility or patient identification.
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