DAL 11-13: Maintaining Comprehensive Trauma Registry

December 5, 2013

DAL 11-13: Maintaining Comprehensive Trauma Registry

Dear Hospital Administrator:

As your facility works towards successful trauma center verification through the American College of Surgeons Committee on Trauma, significant emphasis is placed on maintaining a comprehensive trauma registry. The trauma registry not only provides information necessary for managing a trauma center, it is also essential to performance improvement activities, not only at the facility level but also the State level.

In order to ensure that each facility has reported all trauma cases deemed reportable to the State trauma registry, the Department compares SPARCS records that indicate possible trauma admissions or trauma deaths in the ED (utilizing reportable ICD-9 codes) to those cases reported to the State registry. A listing of all cases not in the State registry which may be reportable are sent to each facility for either inclusion in the registry or exclusion.

This matching process will use the patient specific Unique Personal Identifier for each patient which is used on the SPARCS discharge data records. The SPARCS Unique Personal Identifier is made up of characters from the patient's last name, first name and last four digits of the patient's social security number. The ability to create this Unique Personal Identifier using registry data to match with SPARCS data is essential to correctly match trauma registry reports with the associated SPARCS record. In the future, as the Department begins matching the trauma registry data to other data sets available across the Department and other State agencies (in order to provide a more comprehensive assessment of injury in the State), this Unique Identifier will also improve the matching with these other datasets.

In order to create this Unique Identifier, as is already done for SPARCS data, we ask that the Trauma Program Manager and/or Trauma Registrar(s) be given access to the trauma patient's social security number. Since unmatched SPARCS trauma registry data are sent to each trauma registry for reconciliation, improving the matching with the SPARCS Unique Identifier will decrease the workload in this follow back process.

Thank you for your consideration.


Karen Westervelt
Deputy Commissioner
Offices of Primary Care and
Health Systems Management