1. Registry Inclusion Criteria

Who should be included?
All patients who meet both Diagnosis Criteria AND Status Criteria should be entered into the Kansas Trauma Registry.  Certain patients may be excluded using the Exclusionary Diagnosis Test.

Diagnosis Criteria
To meet the diagnosis criteria, a patient must have at least one of the following ICD-9 diagnosis codes:

• 800-904.9, or
• 925-929.9, or
• 940-959.9, or
• 994.0 (lightning strikes), or
• 994.1 (drowning), or
• 994.7 (hanging), or
• 994.8 (electrocution).

Status Criteria
To meet the status criteria, a patient must be:

• Pronounced dead in the Emergency Department (even if no intervention performed), or
• Dead on arrival, or
• Pronounced dead after receiving any evaluation or treatment during hospital admission, or
• Acutely transferred into the facility, or
• Acutely transferred out to another acute care facility, or
• For adult patients (>14 years): Admitted to the hospital for at least 48 hours, or
• For pediatric patients (0-14 years): Admitted to the hospital for any length of stay.

Exclusionary Diagnosis Test
Exclude patients with isolated hip fractures, acetabular or femoral neck fractures from same level falls. Exclude the patient if they have only one ICD-9 diagnosis code in the following range:

• 820-820.9 (femoral neck fractures), or
• 808.0 (acetabular fracture closed), or
• 808.1 (acetabular fracture open)
 AND an E-code of:

• E885-E885.9 (fall from same level from slipping, tripping, or stumbling), or
• E888-E888.9 (other/unspecified fall on same level).

What counts as an admission?
Patients should be formally admitted to the hospital for acute or critical care to meet inclusion criteria.  Patients admitted directly without evaluation in the emergency department do meet criterion.

If a patient is kept under observation and subsequently admitted to the hospital, include the observation time in determining status criterion.  Patients who are kept under observation but never admitted do not meet inclusion criteria.

What counts as a transfer?
Those transfers between hospitals where the referring hospital initiates contact with the accepting hospital to complete necessary transfer documentation, AND an EMS transport is needed to complete the transfer.

If patients drive themselves to another hospital, do they meet the status criterion as a transfer?
No.  Only transfers using an EMS provider meet status criterion.  These patients will be entered into the state trauma registry by the final destination of care facility if they meet the length of stay requirement.

Are all injuries from same-level falls excluded?
No.  Only isolated hip fractures (ICD-9-CM 820, 808.0 or 808.1) from same-level falls should be excluded.  So, for example, a patient with an ankle dislocation from a same-level fall should be included as long as they meet status criterion.

Are all hip fractures excluded?
No.  Only isolated hip fractures (ICD-9-CM 820, 808.0 or 808.1) from same-level falls should be excluded.  So, for example, a patient with an isolated hip fracture from a car accident should be included as long as they meet status criterion.

Should I include a patient admitted for treatment related to an old injury?
No.  The trauma registry is meant for acute injuries.  This does require that you decide whether the injury is acute.  For example, a patient who sustains a serious dislocation, but does not seek medical treatment for 2 or 3 days should be included in the registry.  However, a patient being treated for pain related to an injury that occurred several weeks before this visit would not be included.

Do burn injuries go in the registry?
Yes, as long as they meet status criteria.  Burn injuries meet the diagnosis criteria (ICD-9-CM 940 to 949).

Do poisoning injuries go in the registry?
No.  While poisoning continues to be an important category of injury, the Kansas Trauma Registry is limited to traumatic injuries.  The diagnosis codes for poisonings to do not meet the diagnosis criteria (ICD-9-CM 960 to 989).

2. Trauma Registry Basics

What is the trauma bracelet number?
For now, this data field can be used for internal purposes or marked unknown.  The field was added as a potential solution for tracking patients through the trauma system.  For example, the first responder could attach an arm band to the patient that is associated with a unique ID.  This unique ID would link patient records between EMS, referral hospitals and final destinations of care.  We have not implemented this plan in Kansas, however, so right now we don’t use the field.

Why are there multiple spaces to enter Race?
This is a standard format for recording race and allows you to record multiple races for a single individual.  If the individual identifies with only one race, leave the other fields blank.

Should I record BOTH Race and Ethnicity?

Yes.  Race (White, Black or African American, Native Hawaiian or other Pacific Islander, Native American/Alaska Native, Asian, Other) and ethnicity (Hispanic or Latino, Non-Hispanic or Latino) are different fields.  Everyone should be categorized with both a race and an ethnicity if the information is available.

Where do I find pre-hospital data?
If a patient was transferred to your hospital by an EMS service, that service is required to provide their run sheet to the destination hospital.  In the event that the run sheet can’t be provided at the time of transfer, the service is required to provide that report within 24 hours (K.A.R. 109-2-5 subsection U.).  The run sheet is the source for most pre-hospital data elements and should be filled out completely and legibly.

Where do I find the injury time?
Usually, this is documented on the EMS run sheet.  However, if that data are not available on the run sheet but you can estimate the approximate time of the accident based on other information in the medical record, we encourage you to do so.  This is an important but difficult-to-document data element.

What is the E849.X Code?
The E849.X code is the place of injury code.  It is a standard E-code.  However, in the trauma registry we expect that each patient has an E849 code in addition to at least one other E-code.  For this reason, indicate the E849 code in the Place of Injury field and not in the E-code section.  You can find some pointers on entering the E849 code here.

If someone is injured at home, did they arrive from “home” or “scene of injury”?
Even though the home is the scene of injury in this situation, indicate “scene of injury” for the Arrived From field in the ED section.  Record “Home” in the E849.X field in the prehospital section.  If the patient was injured outside of the home but returned home before transport to the ED, indicate “HOME” in the Arrived From field and the appropriate injury location in the E849.X field.

What is GCS?
GCS stands for Glasgow Coma Score, a validated clinical metric for identifying potential brain injuries.  To learn more about GCS visit Trauma.org.

What is MAST?
MAST stands for Medical (or Military) Anti-Shock Trousers.  Another term is PASG or Pneumatic Anti-Shock Garment.  These devices are sometimes used in the prehospital setting for the stabilization of hypotension associated with unstable pelvic fractures.  In Kansas, the use of MAST is relatively limited.

What is Base Deficit?
Base Deficit is one measurement used to guide ongoing resuscitation efforts.  It is a measurement of bicarbonate concentration in the blood and normally ranges between 2 and -2.  A base deficit below -3 indicates metabolic acidosis, frequently associated with hemorrhagic shock. 

If SBP is taken by palpation, what do I record for DBP?
Record “0” for DBP if SBP is taken by palpation.

What counts as a timely response?
At this time there are no statewide standards for trauma surgeon response time.  Response time limits vary by level of trauma designation.  Typically, level 1 trauma centers require a response time of 15 minutes or less.  Level 3 trauma centers require response times of 30 minutes or less for general surgeons.

If your facility doesn’t have a trauma surgeon, record “I” or “/” for inappropriate in the field.

How do I enter ICD9 codes?
ICD-9 diagnosis codes are entered as numbers, one code per line with no punctuation.  You can also enter text descriptions of the diagnosis, but you should be careful to check and make sure that the numeric code was assigned correctly.

Once the codes are entered, click the tricode button.  The database should correctly associate each code with a description, body region and injury severity. 

Do not enter non-injury or comorbidity codes on this screen.

What is “Injury Narrative”?

Injury Narrative is the screen into which you enter your diagnosis codes.  Enter ICD9 codes, one code per line with no punctuation, then press TriCode.  See above.

What are ISS and NISS?
ISS stands for Injury Severity Score.  This score ranges from 0 to 75 and summarizes the overall injury severity for patients who have only one or multiple injuries.  For more information visit Trauma Scoring.

NISS is another version of the ISS.  The following paper provides an empirical comparison of Injury Severity Scores:

Frankema S.P., Steyerberg E.W., Edwards M.J., van Vugt A.B.  (2005).  Comparison of current injury scales for survival chance estimation: an evaluation comparing the predictive performance of the ISS, NISS, and AP scores in a Dutch local trauma registration.  Journal of Trauma 58(3): 596-604.

What is TRISS?
TRISS stands for Trauma Injury Severity Score.  This score ranges from 0 to 1 and is interpreted by some physicians as the probability of survival.  The score is derived from a logistic regression model of mortality in the Major Trauma Outcomes Study.  The TRISS methodology was described in the following paper:

Boyd C.R., Tolson M.A., Copes W.S. (1987).  Evaluating trauma care: the TRISS method.  Trauma Score and the Injury Severity Score.  Journal of Trauma 27(4): 370-378.

Why do some injuries have ISS, but not TRISS?
ISS is computed based on ICD-9 codes using the TriCode system.  However, ISS cannot be determined for some injuries because the code does not contain enough information or because that injury was not represented in the original study where the methods were developed. 

If you get an ISS score, but there is no TRISS associated, it is probably because of missing data.  ISS relies only on the diagnosis codes.  TRISS relies on ISS, SBP, respiratory rate, Glasgow Coma Scale, injury type and age.  If any of those elements are missing, TRISS cannot be computed.

What do I do if the ISS seems too low or too high?
This is entirely possible, particularly if you use injury text rather than ICD-9 codes in the Injury Narrative section.  It is always a good idea to double-check the ISS.  If it seems to low or too high, go back and see if another ICD9 code is more appropriate, or look for a typo in the vital signs section.

When do I run checks?
You can run checks during data entry or you can enter all of the data for a record before running the checks.  However, you must run the checks so that they all pass before you can close the record.  Only closed records are transferred to the Kansas Trauma Registry.

What does “Validate” mean in the interactive check screen?
If you run into a check that requires you to enter data, but the data are definitely missing, you can press “Validate” to skip that check.  Please use the validate button only for checks that you can’t do anything about.

How do I transfer data to KDHE?
Just enter the data, perform the checks and close the record. Remember to save early and save often.

If you use the locally installed version, use Collector Command Center (CCC) to Transfer data. 

Login to CCC using the same username and password as for the Collector database.

To transfer data, choose “Submit Transfer Data” from the Data Submission menu.

Choose “KDHE Standard Email Transfer from the Pulldown menu and hit “Send”.

If Collector Command Center gives you an error, call Digital Innovation Technical assistance at (800)344-3668 extension 4.

Can I go back and change the record after I’ve transferred it?
            Yes.  These changes will be recorded by the database an updated in the Kansas Trauma Registry.  We encourage you, especially for values like “Hospital Collection” that are frequently not available immediately, to return to the record once the data are available.

3.  Reports, Queries & Gathers (for users of locally installed version only)

What is a report?
Reports are the primary way to get data out of your database.  If you are using the web version, you cannot create your own reports.  However, you will be able to execute reports that are already available in the system.  If you would like to request that a specific kind of report be developed, contact the Kansas Trauma Registry at 785-296-8627 or email KTR@kdheks.gov 

What is a query?
A query is a way to find subsets of records that all share the same property or set of properties.  For example, if you want to know about only patients with penetrating injuries, you would use a query to pull up only those records so that you don’t have to sift through all of them by hand.  Queries are frequently used together with reports to create documents for patient tracking, research or performance improvement.

What is a gather?
In Collector you use a “gather” to create reports on different subsets of patients.  In many other programs, this is called a cross-tab procedure.  For example, if you want to create a list of patient names, ED Arrival times and discharge times, but you wanted to do this separately for the last 4 quarters, you could run the same report 4 different times.  Alternatively, you could create a gather based on quarter.  Using the gather, all for 4 quarters would be included in one report, but in 4 discrete sections.

What is a “piggy-back” query?
Piggy-back queries or compound queries are queries of the database that call upon yet another query within the query itself.  For example, say you wanted to run a report on patients that were transferred in by either land ambulance of helicopter ambulance, but you also wanted only to look at pediatric cases.  You know you want Transport Provider Mode to be either (1) land ambulance or (2) helicopter ambulance.  This is an example of an either/or query: you check “One or more” in the query screen. 

Once you have the first query done, you can save the query:

Now, you want to look at cases where this is true (land or helicopter ambulance) and the patients are 14 or younger.  This is an example of an AND query.  Just start another query and use the one you just created within the new query:

What is the difference between a Data Table report, a Statistics report and an RDL report?
Data table reports are for creating lists.  For example, the following report will list each and every patient within your query by Name, ED arrival date and Discharge date.

A statistics report won’t give you a list of patients, but some statistical description of all the patients in your query.  For example, the following query will report the Minimum, Average and Maximum age for patients that arrived by land ambulance or helicopter ambulance and also the Minimum, Average and Maximum age overall (leave the subset column blank):

4.  Web-Version

How is the web version different from the version I’ve been using?
The web version does not require that you install Collector on you machine.  Instead, you run the database on a computer at KDHE using your web browser.  The web version only allows for data in the core dataset and does not allow you to write your own queries, gathers and reports.  All of the data elements will be the same between the locally installed version and the web version.

Why use the web version?
There are many benefits for using the web version.  This version is ideal for small facilities with limited IT support.  The primary benefit is that upgrades and patches are accomplished automatically.  The only technical requirement for the hospital is to have a functional web-browser and functional web-browser and internet connection. The application will work better on a fast connection, but dial-up connections should still work.

Why NOT use the web version?
Since the web version is limited to the core dataset, comprehensive dataset users should not consider implementing the web version.  Also, facilities that require querying and reporting capabilities should use the locally installed version.  Finally, some facilities with certain network infrastructures may not be able to implement the web version for technical reasons (although we haven’t found any problems like this yet).

I lost my password, what should I do?

No problem, call Laurie at 785-296-8627.  We will get a new password to you within a day or two.

Why do I have to log in twice?

The web-version of Collector works by actually running the database application from a computer at KDHE.  This is known as a “thin-client” setup.  Your first password gets you into the secure KDHE internet environment.  Then, the second password actually starts the application.  You can use different passwords for the two logins, although we suggest you use the same password for the sake of simplicity.

Is this information safe?
We believe that information transferred through KDHE’s secure internet website is safe.  The Trauma Registry is just one of many secure databases administrated by KDHE’s IT department.

How do I transfer data to KDHE with the web version?
Just enter the data, perform the checks and close the record. Remember to save early and save often.

5.  Data Report

How frequently are these reports generated?
These reports will be generated quarterly and sent to the primary trauma registry contact via email.  We will try to send the reports as soon as possible after the deadline for the subsequent quarter.  For example, the 2^nd quarter reports will be distributed after the deadline for the 3^rd quarter.  This is necessary to ensure that as many facilities have time to submit data to be included in the report as possible.

Can I request a report for a larger time period?
Yes.  If you want to see a report with the last 4 or the last 8 quarters-worth of data, just email KTR@kdheks.gov and we can run the report for you.

Who has access to these reports?
We will only send a facilities report to the primary contact for the registry.  We may also provide reports to other personnel from your facility upon request or at a regional meeting.  These reports will not be made available to anyone from outside your facility.

What am I supposed to do with this report?
We want this report to be useful.  If your facility already performs performance improvement using standard audit filters, this report is primarily useful for benchmarking your facility against the region and the state. 

If your facility does not already have a performance improvement process, we hope this report can aid you in establishing one.  In addition to comparing your numbers against the region and state, you can use the list of trauma numbers attached to the report to review records that have been flagged as outliers.

If your patient volume is low and no records are included in the report or none are flagged as outliers, we hope you will still find the report useful for preparing for future patients and for monitoring trauma in your region and in Kansas.

Where did these indicators come from?
These indicators were developed by the Kansas Trauma Program with guidance from the Trauma Registry Subcommittee of the Advisory Committee on Trauma and assistance from Digital Innovation, Inc., our database vendor.  We tried to identify a handful of filters derived from those suggested by the American College of Surgeon’s Committee on Trauma (ACSCOT).  Evaluation of these standard quality indicators is ongoing.  For excellent discussion of these issues, please consult the following publications:

• American College of Surgeons, Committee on Trauma, Subcommittee on Performance Improvement:  Trauma Performance Improvement Reference Manual.  Chicago, American College of Surgeons, 2002.
• American College of Surgeons, Committee on Trauma: Resources for Optimal Care of the Injured Patient: 1999.  Chicago, American College of Surgeons, 1999.
• Copes W.S., Staz C.F., Konvolinka C.W., Sacco W.J.  (1995).  American College of Surgeons audit filters: Assocations with patient outcome and resource utilization.  Journal of Trauma 38(3): 432-438.
• Cryer H.G., Hiatt J.R., Fleming A.W., Guren J.P., Sterling J.  (1996).  Continuous use of standard process audit filters has limited value in an established trauma system.  Journal of Trauma 41(3): 389-395.
• Nayduch, D., Moylan, J., Long Snyder B., Andrews L., Rutledge R., Cunningham P.  (1994).  American College of Surgeons Trauma Quality Indicators: An analysis of outcome in a statewide trauma registry.  Journal of Trauma 37(4): 565-573.
• O’Keefe G.E., Jurkovich G.J., Maier R.V. (1999).  Defining excess resource utilization and identifying associated factors for trauma victims.  Journal of Trauma 46(3): 473-478.
• Schwartz M.L., Sharkey P.W., Andersen J.A.  (1991). Quality assurance for patients with head injuries admitted to a regional trauma unit.  Journal of Trauma 31(7): 962-967.

Where are the other ACS audit filters?
There are a number of other audit filters suggested by the ACSCOT.  Those that are included in this report were supported by the limited data submitted to the state in the Core Dataset.  Facilities that use the comprehensive dataset can use their database to perform all of the suggested audit filters.

Will I get a report if we didn’t have any traumas to report for the quarter?
Yes.  We hope that your facility will find the report useful even if you have no cases to report for a given quarter.  It is important to be aware of patient volume, case mix and performance issues in your region and in the state even if your’s is a low volume facility.

How does a patient record qualify for evaluation?
Please see the Query Documentation for specific details on how each indicator is evaluated.  In general, each indicator is composed of three database queries: qualifying, outlier and missing. 

The qualifying query retrieves records from the database that are eligible to be tested for the indicator.  For example, this query will identify all transfers that have valid ED arrival and discharge times in order to evaluate the indicator “For all transferred patients, elapsed time between emergency department arrival and discharge to another acute care facility does not exceed 6 hours.”

What is an outlier?
Please see the Query Documentation for specific details on how each indicator is evaluated.  In general, each indicator is composed of three database queries: qualifying, outlier and missing. 

The outlier query retrieves records from the database that did not meet the indicator out of the ones that qualified.  For example, this query will identify all transfers with elapsed times between arrival and discharge over 6 hours to evaluate the indicator “For all transferred patients, elapsed time between emergency department arrival and discharge to another acute care facility does not exceed 6 hours.”

How do you determine if there isn’t enough data to evaluate?
Please see the Query Documentation for specific details on how each indicator is evaluated.  In general, each indicator is composed of three database queries: qualifying, outlier and missing. 

The missing query is usually more complicated than the other two queries.  Here we identify records in the database that might have qualified for an indicator, but because some data were missing, the record couldn’t be evaluated.  For example, this query would identify a record where a transfer was indicted and ED arrival time was given, but discharge time wasn’t provided, so the record couldn’t be evaluated.

If we have an outlier, what do we do?
Assuming enough patient volume, we expect to find outliers.  These do not necessarily indicate less-than-standard of care.  However, they can identify cases were that might be worth reviewing.  Use the list of trauma numbers that comes with the data report.  Each column represents the results of the outlier queries.  The numbers in each column are trauma numbers for records that were evaluated as outliers.  Use the trauma numbers to identify the medical records, pull them, and review them for data entry errors, incomplete documentation, preventable problems or other potential issues that may arise upon review.