Assessing readiness to meet ACS trauma registry standards

Authored by:
Theresa Radeker, MHA, BSN, RN, TCRN
Vice President and Managing Partner

The 2022 American College of Surgeons (ACS) trauma verification standards—4.31, 4.32, 4.33, and 6.2—place a stronger emphasis on the trauma registry as a foundational element for trauma centers. These updated standards underscore the registry’s critical role in ensuring accurate data collection and quality monitoring, which directly influence patient care. By focusing on staffing adequacy, registry education, ongoing professional development, and data validation, the ACS has made the trauma registry central to achieving and maintaining verification. Below is a practical guide for trauma centers to assess their ability to meet these standards: 

Standard 4.31: Trauma Registry Staffing Requirements

  1. Assess current trauma volume
    • Conduct an internal audit to determine the number of National Trauma Data Standards (NTDS) reportable cases annually.
    • Ensure that 0.5 Full-Time Equivalent (FTE) registrars are allocated per 200-300 trauma cases.
  2. Increase staffing as needed
    • If the registry workload includes additional responsibilities such as data validation, performance improvement (PI), or research support, consider increasing FTE staffing levels beyond the minimum requirement.
    • Use benchmarks from other ACS-verified trauma centers to justify additional staffing needs.
  3. Optimize workflows and automation
    • Implement automated data abstraction tools to reduce manual workload (e.g. HL7)
    • Utilize Artificial Intelligence (AI)-assisted coding tools for injury severity scoring and ICD-10 coding.
  4. Establish clear job descriptions and performance metrics
    • Clearly define registrar responsibilities, including data abstraction, validation, and submission deadlines.
    • Set key performance indicators (KPIs) to track compliance, such as case completion times (of cases completed per month, average time per case) and data accuracy rates (error rate in abstracted cases, IRR score, missing data rate).

Standard 4.32: Trauma Registry Education Requirements

  1. Enroll trauma registrars in required courses
    • Ensure all registrars complete:
      • Abbreviated Injury Scale (AIS) course (AAAM-certified)
      • Trauma Registry Course (covering NTDS, abstraction, and data management)
      • ICD-10 refresher course (required every five (5) years)
  2. Develop an Internal Trauma Program
    • Offer quarterly workshops on AIS, ISS scoring, and NTDS inclusion criteria.
    • Conduct case-based training sessions to reinforce complex abstraction scenarios.
  3. Provide mentorship and competency evaluations
    • Create a “buddy” system. Pair new registrars with experienced trauma registrars so they have a go-to person for questions, tools, and processes.
    • Implement annual competency evaluations to ensure registrars maintain accuracy in abstraction and AIS coding.
  4. Use national and state resources
    • Leverage ACS, state trauma registries, and hospital associations to find approved training programs.
    • Encourage staff to attend national trauma registry conferences for networking and best practice sharing.

Standard 4.33: Trauma Registrar Continuing Education

  1. Develop an annual continuing education plan
    • Each registrar must complete 24 hours of trauma-related continuing education (CE) per 3-year cycle.
    • Use online platforms like American Trauma Society (ATS) to access registry-specific CE courses.
    • Fund attendance at Trauma Quality Improvement Program (TQIP) or AAAM AIS training events.
  2. Offer monthly internal education sessions
    • Create an internal trauma data journal club where registrars review and discuss the latest trauma research and best practices.
  3. Maintain accurate education logs
    • Require registrars to document CE activities in a centralized location.
    • Submit quarterly reports to management to ensure compliance.

Standard 6.2: Data Quality Monitoring Internal

  1. Implement a data validation program
    • Internal validation
      • Monthly – Re-abstraction of 5-10% of patient records. Trauma registrars responsible for re-abstracting other trauma registrar’s randomly selected data.
      • Quarterly – Inter-rater Reliability (IRR) assessment. Multiple registrars independently abstract data from the same set of patient records, entries are compared to assess consistency and identify variations in data interpretation
      • 100% of all records – Automated Data Validation. All registrars utilize registry built in data check in the trauma registry software.
    • External validation
      • Quarterly – The American College of Surgeons (ACS) Trauma Quality Programs (TQP) provide several tools and reports to assist trauma center in managing and validating their data submissions. These tools are TQP Data Center Validation Summary Report, TQP Data Center Submission Frequency Report, and TQP Vendor Aggregator.
      • Twice a year – Trauma Quality Improvement Program (TQIP) Benchmark Report. The lead registrar/performance improvement coordinator should be responsible for reviewing the report and share findings with trauma program leadership.
  2. Develop corrective action plan
    • Discrepancies, missing data, or inconsistencies found during the validation process should be logged and tracked. Once errors are identified, the trauma registrar or designated staff member should be responsible for correcting the data. The lead registrar, in coordination with the trauma program leadership, should perform a root cause analysis for recurring data issues to develop preventative measures
  3. Conduct routine interdisciplinary reviews
    • Schedule quarterly data validation meetings with the Trauma Medical Director (TMD), Trauma Program Manager (TPM), and Performance Improvement Coordinators (PICs).
    • Review high-risk cases and ensure data accuracy for quality improvement initiatives.
  4. Standardize data entry protocols
    • Develop registry-specific standard operating procedures (SOPs) to maintain uniform data abstraction practices.
    • Create a registry data dictionary with clear inclusion/exclusion criteria for trauma cases.

By aligning with these ACS standards, trauma centers can improve the accuracy and efficiency of their trauma registries. A strong registry supports better patient care, helps meet regulatory expectations, and drives continuous improvement. Focusing on staffing, education, and data quality monitoring will position trauma centers for sustained verification and optimal patient outcomes.