The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Bureau of Health Care Safety and Quality
99 Chauncy Street, 2nd Floor, Boston, MA 02111
617-753-8000 

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
JOHN AUERBACH
COMMISSIONER	
CIRCULAR LETTER: DHCQ 08-03-483

TO:		Acute Care Hospital Chief Executive Officers

FROM:	Paul I. Dreyer, Ph.D.
		Bureau Director
 
RE:		Requirement for the Submission of Trauma Data 

DATE:		April 30, 2008

Please note that this circular letter replaces the version dated March 12, 2008; minor revisions made for clarity (see highlighted sections).

The purpose of this memo is to update you on the development of the Trauma Registry for the statewide collection of data on patients who receive medical care for traumatic injuries in Massachusetts hospitals.  On March 12, 2004, the Department of Public Health (the Department) promulgated hospital licensure regulations for the provision of trauma data (105 CMR 130.850 - .854) to the Division of Healthcare Finance and Policy (the Division) by hospitals providing trauma care. 

As required under 105 CMR 130.851 (D): a hospital providing Trauma Services as a Designated Trauma Center must: 

Provide to the Division of Health Care Finance and Policy the designated trauma center data set to be specified in administrative requirements jointly developed by the Department and the Division of Health Care Finance and Policy, and promulgated by the Department,

And as required under 105 CMR 130.852 (A), a hospital that is not a designated trauma center but provides trauma care as part of its emergency service must:

Provide to the Division of Health Care Finance and Policy the trauma service hospital data set to be specified in administrative requirements jointly developed by the Department and the Division of Health Care Finance and Policy.

The Department and the Division have completed the development of the trauma data requirements to be used by hospitals for submission of data to the State Trauma Registry.  The trauma data submission due date is September 13, 2008 for patients who receive trauma care from April 1, 2008 to June 30, 2008.

Trauma data shall be reported for all trauma cases having a principal ICD-9-CM diagnostic code of 
800 - 959.9 or 994.1 or 994.7, 

AND

•	Hospital inpatient admission; OR 
•	Observation stay; OR 
•	Transfer patient via EMS transport (including air ambulance) from one hospital to another hospital (includes inpatient or observation or emergency department); OR 
•	Death (independent of hospital admission source or hospital transfer status) 
 
The following table shows the required data elements for Designated Trauma Centers and the requirement data elements for Non-Trauma Centers. 
Field Name	(R)equired

(C)onditionally
Required	Required by Non-Trauma Centers 	Required by DesignatedTrauma
Centers	
FilingOrgID	R	X	X	
SiteOrgID	R	X	X	
Inter-Facility Transfer	R	X	X	
SiteOrgID of Transferring Hospital	C	X	X	
Discharge Time from Transferring Hospital	C	X	X	
Inpatient or Observation Admission Date	R	X	X	
Inpatient or Observation Admission Time	R	X	X	
Location of Direct Admission 	C	X	X	
Medical Record #	R	X	X	
Social Security #	R	X	X	
Date of Birth	R	X	X	
Gender	R	X	X	
Patient Street Address	R	X	X	
Patient City	R	X	X	
Patient Zip Code	R	X	X	
Injury Incident Date	C	X	X	
Injury Incident Time	C		X	
Work-related	C	X	X	
Incident City	R	X	X	
Incident State	R	X	X	
Transport Mode	R	X	X	
Alcohol Use Indicator	C		X	
Drug Use Indicator	C		X	
Primary ECode	R	X	X	
Location ECode	R	X	X	
Initial Glasgow Eye Component in ED	C		X	
Initial Glasgow Verbal Component in ED	C		X	
Initial Glasgow Motor Component in ED	C		X	
Glasgow Coma Score Total in the ED	C		X	
Glasgow Coma Score Assessment Qualifier in the ED	C		X	
Respiration Rate	R	X	X	
Systolic Blood Pressure	R	X	X	
Pulse Rate	R	X	X	
Diagnosis Code	R	X	X	
AIS	R		X	
AIS Version	R		X	
Protective Devices	R		X	
Child Specific restraint	C		X	
Airbag Deployment	C		X	
Co-Morbid Conditions	R		X	
Complications	R		X	

Hospitals shall submit data in accordance with trauma data submission specifications containing full file layout information file components, edit specifications, and future technical specifications which shall be available shortly at http://www.mass.gov/dph/oems under Trauma.  Please take important note: for Non-Trauma Centers, the pass/fail requirement edits for the systolic blood pressure, respiration rate, and pulse rate data fields will be turned off for the first filing deadline of September 13, 2008, and will be turned on for all subsequent filing deadlines.

Hospitals shall submit trauma data quarterly.  After the first submission deadline on 
September 13, 2008, trauma data submission shall be due according to the following schedule:

Quarter 	Quarter Begin & End Dates	Due Date for Data File:  75 days following the end of the reporting period	
1	10/1 – 12/31	 3/16	
2	 1/1 – 3/31	 6/14	
3	 4/1 – 6/30	 9/13	
4	 7/1 – 9/30	12/14	

The Division may, for good cause, grant an extension in time to a hospital submitting trauma data.

If the Division notifies a hospital that it is required to resubmit a data submission because the submission was rejected or as part of a data verification process, the hospital must submit its data no later than 30 days following the date of the notice to resubmit.

The Division shall institute appropriate administrative procedures and mechanisms to ensure that it is in compliance with the provisions of M.G.L. c. 66A, the Fair Information Practices Act, to the extent that the data collected thereunder are "personal data" within the meaning of that statute.  In addition, the Division shall ensure that any contract entered into with other parties for the purposes of processing and analysis of this data shall contain assurances such other parties shall also comply with the provisions of 
M.G.L.c. 66A.

The Department may revise the specifications or other administrative requirements from time to time by notice of circular letter.
For questions regarding the Trauma registry, please contact at Sylvia Hobbs, at 617-753-7304, or email sylvia.hobbs@state.ma.us.  For other questions about this correspondence please contact Gail Palmeri, Program Manager, at 617-753-8230, or email gail.palmeri@state.ma.us.

REGULATORY AUTHORITY
105 CMR 130: M.G.L. c. 111, §§ 3 and 51 through 56.