Requirements covering trauma registry management are spread throughout Resources for Optimal Care of the Injured Patient: 2022 Standards. These requirements touch on everything from trauma registry staffing and registrar education to trauma data quality and data utilization.
To help trauma program leaders manage compliance more effectively, this article brings together and summarizes everything that the 2022 standards from the American College of Surgeons (ACS) say about trauma registry.
How the trauma registry team must be staffed
The ACS requires every trauma center to have a team of trauma registrars with sufficient staff to handle a large volume of data-related activities.
According to Standard 4.31, trauma centers must have at least 0.5 full-time employee (FTE) registry staff for every 200 to 300 annual patient entries in the registry.
What counts as a patient entry? The standard defines a patient entry as a patient who meets the inclusion criteria of the National Trauma Data Standard (NTDS) or the inclusion criteria of any hospital, local, state or regional registries in which the center participates.
Is this threshold the only consideration? No, the standard emphasizes that a registry team must be large enough to handle the wide range of tasks that registrars are responsible for, including report writing, data validation, data submission and other activities (see Standard 4.31 for full details).
Standard 4.31 also encourages program leaders to assess the impact of electronic download and automated data integration capabilities in newer trauma registry systems. These automations may create additional work for registrars but may also create registry work efficiencies.
In addition, Standard 4.32 states that at least one member of the trauma registry team must be a current Certified Abbreviated Injury Scale Specialist (CAISS). According to the December 2023 update: “Combined adult and pediatric programs (Level I/II adult trauma center with Level II pediatric trauma center) may share the CAISS certified registrar to meet this requirement.”
The 2022 standards include two other requirements related to trauma registry staffing and roles:
- Standard 2.11 specifies that the trauma program manager’s responsibilities must include oversight of the trauma registry.
- Standard 4.31 notes that a combined adult-pediatric trauma program may share registry staff. (This standard applies to combined programs that include a Level I or II adult trauma center and a Level II pediatric trauma center.) However, one of these staff members “must be identified as the lead pediatric registrar” within the program.
How the trauma registry team must be educated
The ACS requires that trauma registrars receive education in the foundations of trauma registry and continuing education on trauma topics.
Standard 4.33 requires registry staff to take three educational courses: Specifically, registry staff must participate in an Abbreviated Injury Scale (AIS) training course, a trauma registry course and an ICD-10 course.
- The AIS course from the Association for the Advancement of Automotive Medicine must be for the version of AIS in use at the trauma center. (In other words, if a center uses AIS 2008 in its registry, the center’s registrars should take an AIS 2008 course.) Staff must not only participate in but pass the course.
- The trauma registry course must cover abstraction, data management, reports and report analysis, data validation and the Health Insurance Portability and Accountability Act (HIPAA).
- The ICD-10 course can be either an initial training or a refresher course. Staff must participate in an ICD-10 course at least once every five years.
According to the standard, these education requirements apply to all staff members who have any of the following roles in the trauma registry:
- Data abstraction and entry
- Injury coding
- Injury severity score (ISS) calculation
- Data reporting
- Data validation
In addition to the baseline education noted above, Standard 4.34 specifies that every trauma registrar must earn at least 24 hours of trauma-related continuing education (CE) credit during each three-year verification cycle. (For centers undergoing a consultation or an initial review, a minimum of 8 hours of this CE must be earned during the reporting period.)
According to the standard, these CE credits can be earned through the hospital’s own education programs, programs from outside organizations or online educational opportunities.
How trauma registry data must be collected and submitted
The ACS requires that trauma centers collect data in compliance with national standards, complete data collection in a timely manner and submit data on injured patients to the organization’s national trauma database.
Standard 6.3 requires that registry data be collected in compliance with the National Trauma Data Standard (NTDS). This requirement applies to both patient inclusion criteria and data element definitions.
Standard 6.2 states that every trauma center’s registry must be concurrent. A trauma registry is concurrent if at least 80% of patient records are complete within 60 days of the discharge date. The standard defines a completed record as “one where all of the required data have been entered in the registry and the record has been closed”.
Standard 6.3 also requires that trauma registry data be submitted to the TQP Data Center. Eligible data submitted in a call for data “must include at least 12 continuous and complete months of trauma registry data”. In addition, the data must contain no unresolved Level I or Level II edit checks.
In general, registry data must be submitted in the most recent call for data. However, special timing may apply to a trauma center undergoing an ACS site visit. If a call for data occurs within 30 days before the site visit, the center should submit data for the prior call for data. (See Standard 6.3 for precise wording and examples.)
How the quality of trauma registry data must be ensured
The ACS requires every trauma center to have a plan for ensuring the quality of its data on injured patients.
Standard 6.1 requires trauma centers to have a written data quality plan. The plan must:
- Describe “a continuous process that measures, monitors, identifies and corrects data quality issues and ensures the fitness of data for use”.
- Ensure data validity using either internal or external resources. (Examples of external data validation include Validation Summary Reports and Submission Frequency Reports from the TQP Data Center.)
- Require regular review of data quality (at a minimum, quarterly).
Measures of compliance for this requirement include written summaries of data validation efforts, trauma registry data validation reports, and evidence of comprehensive review of applicable TQP reports. (See Standard 6.1 for precise wording.)
In addition, Standard 7.4 requires every trauma center to take part in a risk-adjusted benchmarking program — for example, the Trauma Quality Improvement Program (TQIP). Centers must use the benchmarking results to identify any opportunities for improvement in trauma registry data quality.
How trauma registry data must be used
The ACS requires trauma centers to use their trauma data in two specific ways.
To identify OFIs in patient care. As noted above, Standard 7.4 requires trauma centers to use risk-adjusted benchmarking results to watch for potential problems in data quality. This standard also requires centers to use benchmarking results to identify any opportunities for improvement in patient care.
To prioritize injury prevention activities. Standard 2.12 requires every trauma center to have an injury prevention (IP) program. The program must prioritize IP work “based on trends identified in the trauma registry and local epidemiological data”. The measures of compliance for this standard include “graphs/tables highlighting recent injury mechanism trends from registry”.
In addition, the ACS notes two ways in which the trauma registry can help support compliance with the standards.
First, Standard 2.1 requires trauma centers to participate in a state and/or regional trauma system. According to the standard, taking part in “the development of a state or regional trauma plan or state trauma registry” is one example of system participation.
Second, Standard 7.2 requires every center’s written Performance Improvement and Patient Safety (PIPS) plan to specify “the processes for event identification.” Under the standard, registry surveillance is noted as a possible method for identifying PI events.
Finally, registry data is a key element of calculating required PI staffing levels. Under Standard 4.35, if the annual number of trauma registry patient entries is more than 500, the center must have at least 0.5 FTE dedicated to PI. If the annual patient volume of trauma registry entries exceeds 1,000, the center must have a least 1.0 FTE dedicated to PI.