37.104.3014    TRAUMA REGISTRIES AND DATA REPORTING

(1) For the purpose of improving the quality of trauma care, all Montana health care facilities, as defined in 50-6-401, MCA, must participate in the state trauma register by collecting and reporting to the department the data listed in (4), on the schedule required by (2).

(2) Within 60 days after the end of each quarter, each health care facility that provides service or care to trauma patients within Montana must submit to the department the information required by (4) concerning any trauma patient that it serves during any month of the quarter and who meets the criteria for inclusion in the trauma register that are set forth in the State Trauma Plan.

(3) The data must be submitted to the department's trauma register in the same format as the state register uses, unless the department allows an alternate means of submission if use of the department's prescribed format would impose a severe hardship on the reporting facility. All health care facilities must submit the data electronically.

(4) The following data fields must be reported to the department:

(a) patient information that includes:

(i) a unique trauma patient identifier;

(ii) date of birth;

(iii) age;

(iv) sex;

(v) race; and

(vi) address;

(b) injury information that includes:

(i) date, time, and location of injury;

(ii) trauma injury diagnostic codes;

(iii) injury cause;

(iv) protective devices used by the patient, if any;

(v) results of alcohol or drug testing, if any; and

(vi) trauma injury diagnoses;

(c) prehospital information that includes:

(i) prehospital transport agencies;

(ii) patient extrication time;

(iii) emergency medical service (EMS) dispatch date;

(iv) EMS notification time;

(v) time of arrival at scene;

(vi) departure time from scene;

(vii) time of arrival at the facility;

(viii) triage criteria, including physiologic and anatomic conditions, injury circumstances, and comorbid factors;

(ix) EMS activation of trauma team;

(x) vital and neurologic signs;

(xi) treatment and procedures provided; and

(xii) whether a prehospital report is included in the facility patient medical record;

(d) interfacility transfer information that includes:

(i) the names of the referring and receiving facilities;

(ii) trauma team activation;

(iii) patient arrival and discharge date and times from the referring facility;

(iv) vital and neurologic signs;

(v) date, time, and results of tests and procedures performed;

(vi) treatment at the referring facility;

(vii) payor source; and

(e) inpatient care information that includes:

(i) the name of the facility;

(ii) emergency department admission and discharge dates and times;

(iii) trauma team activation;

(iv) emergency department vital and neurologic signs;

(v) status of intubation and ventilation;

(vi) date, time, and results of tests and procedures performed;

(vii) post emergency department destination;

(viii) admitting service;

(ix) previous admission for the injury in question, if any;

(x) total days in the intensive care unit;

(xi) total days on ventilator;

(xii) date for rehabilitation consult;

(xiii) date nutrition addressed;

(xiv) substance counseling, if applicable;

(xv) use of blood products, if applicable;

(xvi) facility discharge date and time;

(xvii) discharge disposition;

(xviii) functional ability at discharge;

(xix) payor source;

(xx) hospital charges and payments received;

(xxi) for all deaths, if an autopsy was performed; and

(xxii) for all deaths, whether there was any donation of tissue or organs.

(5) Failure of a designated trauma facility to timely and accurately report to the department all data required by these rules is grounds for revocation of designation status.

History: 50-6-402, MCA; IMP, 50-6-401, 50-6-402, MCA; NEW, 2006 MAR p. 1896, Eff. 7/28/06; AMD, 2016 MAR p. 1461, Eff. 8/20/16.