Sec. 30.08.06.21. State Burn Registry

A. The burn center shall maintain the State Burn Registry (BR).

B. The State Burn Registry shall include, at a minimum, all of the data elements compliant with the Maryland Trauma Registry Data Dictionary for Burn Registry and American Burn Association National Burn Repository (NBR), including:

(1) Demographic data;

(2) Injury data;

(3) Hospital data;

(4) Description of injury;

(5) Diagnosis;

(6) Comorbidities;

(7) Procedure codes;

(8) Complications;

(9) Outcome; and

(10) Outpatient module, which includes outpatient information, Lund and Browder, treatment, complications, and comorbidities.

C. The BR shall support the burn center with evidence of active interface with the institution and State QA/QI process to improve the care of the injured patient across the continuum from injury prevention to outcomes measurement.

D. The BR content staff shall be under the direct supervision of the BPM/BMD.

E. The BPM shall have the authority, responsibility, accountability, and oversight of the BR, inclusive of data submission (i.e., ED treat and release, admission, clinic and outpatient) as required by MIEMSS.

F. The BR shall have one burn registrar (1.0 FTE) dedicated to the burn center for every 500—750 MIEMSS defined encounters per year.

G. All discharged burn patient records, with the minimum quarterly and annual data elements with the number of patients, shall be verified no later than 6 weeks after the end of the quarter, as required by MIEMSS.

H. Within 60 days of patient discharge, all records shall be completed, validation and NBR checks shall be done, and the records shall be closed. An exception to the completeness of the BR record is with Medical Examiner (ME) cases where an autopsy is unavailable for registry record abstraction.

I. There shall be a plan to ensure inter-rater reliability of the data entered into the BR at the individual burn centers. Ongoing review and evaluation shall ensure the quality, reliability, and validity of the institution’s BR data.

J. Burn center data shall be submitted to the National Burn Registry Repository per the annual call for data.

K. The BR staff shall have a core set of skill requirements including:

(1) Anatomy and physiology; and

(2) Medical terminology.

L. Education to be completed within 1 year of hire includes the American Trauma Society Trauma Registrar Course.

M. Education to be completed within 1 year of hire includes an International Classification of Diseases Coding Course (most recent version).

N. Job responsibilities include:

(1) Ensuring assigned cases are compliant with MD Data Dictionary Inclusion Criteria or other burn center self-defined criteria;

(2) Compiling abstracted data for BR case from various sources; and

(3) Appropriately coding injuries, complications, and procedures.

O. A job description developed by the hospital to reflect the role and responsibilities as defined by COMAR.