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2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick, CPC Trauma Data Analyst

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Page 1: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2020 Collector Update

Lyndsey Diehl, RHIA, CHDA, CSTRDirector of Trauma Data Quality

Stephanie Radzevick, CPCTrauma Data Analyst

Page 2: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Proprietary Rights NoticeProprietary Rights NoticeThe Digital Innovation, Inc. Trauma Registry Software and related materials, including but not limited to this document, and other written material provided by Digital Innovation, Inc. (collectively “Software Products”) constitute confidential and proprietary information of Digital Innovation, Inc. It is the responsibility of the user to comply with all applicable copyright laws. The Software Products are to be maintained in confidence and not to be disclosed, duplicated, or otherwise reproduced, directly or indirectly, whole or in part, or any materials relating thereto, except as specifically authorized by Digital Innovation, Inc. No portions of this presentation may be reproduced, duplicated, or disclosed without the expressed written approval of Digital Innovation, Inc. Reasonable steps are to be taken to ensure that no unauthorized persons have access to the Software Products and that all authorized persons having access to the Software Products refrain from any such disclosure, duplication, or reproduction except as authorized by Digital Innovation, Inc.

Page 3: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Proprietary Rights NoticeProprietary Rights NoticeCopyright © 1998‐2017. Digital Innovation, Inc. All Rights ReservedThe referenced Trauma Registry Software is developed and maintained by Digital Innovation, Inc., PTSF’s Technology Partner.The Trauma Registry Software screenshots included in this presentation are from Digital Innovation, Inc.’s product suite.

Page 4: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Change CycleRequest received (by August 1)

Trauma Registry Committee (March, June, 

August, December)

PTSF Board of Directors (March, July, September, 

December)

PTOS Manual (December)

Collector Software (January)

Page 5: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Breakdown

This Photo by Unknown Author is licensed under CC BY‐ND

Page 6: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Stephanie Radzevick, CPCTrauma Data Analyst

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Page 8: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Initial ED/Hospital Height• Has been an NTDB element, but in 2020 will be added as required PTOS element and match NTDB ‘Initial Height’ element

• Definition ‐ First recorded height within 24 hours or less of ED/hospital arrival.

• Move from NTDB tab to PTOS Clinical Data section, Admission Vitals tab under Weight element

• Allows for auto calculation of BMI• Only for On Admission vitals, not added to Referring Facility vitals

Page 9: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Initial ED/Hospital Oxygen Saturation, Supplemental Oxygen

• The following NTDB elements will also become required PTOS elements in 2020– Initial ED/Hospital Oxygen Saturation 

• 1st recorded oxygen sat within 30 mins or less of ED/hospital arrival, expressed as %

and– Initial ED/Hospital Supplemental Oxygen

• Presence of supplemental oxygen during assessment of initial ED/Hospital oxygen sat level within 30 mins or less of arrival

• Will be moved to the Clinical tab under Admission Vitals 

Page 10: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Audit Filters 16 and 20 ‐ Signs of Life 

• Add Signs of Life = 2 (Arrived with signs of life) to the queries for Audit Filters 16 and 20

• Audit Filter 16 = Nonfixation of femoral shaft fx in adult trauma patient

• Audit Filter 20 = Diagnosis at discharge of c spine fx, subluxation, or neuro deficit not addressed on admission

• Eliminate DOA’s from triggering for these two filters

Page 11: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Audit Filters 16 and 20 ‐ Signs of Life 

• Audit Filter 16 = Nonfixation of femoral shaft fx in adult trauma patient– Trauma Patient; AND– Derived Age (AGE) ≥ 15; AND– Any ICD‐10‐CM diagnosis code (ICD10_01, ICD10_02, ... ICD10_27) that starts with S72.3;

– AND– NO Procedure that starts with (PR_01_I10...PR_84_I10 OQS [6,7,8,9,B,C] [0,3,4][4,5,6,B,C,D]OR starts with OQH [6,7,8,9,B,C]

– Signs of Life = 2 (Arrived with signs of life)

Page 12: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Audit Filters 16 and 20 ‐ Signs of Life 

• Audit Filter 20 = Diagnosis at discharge of c spine fx, subluxation, or neuro deficit not addressed on admission

• Trauma Patient; AND• "Did patient have discharge diagnosis of cervical spine fracture, subluxation, or neuro deficit not addressed on admission?" (MISSED_CS) = 1 (Yes)

• Signs of Life = 2 (Arrived with signs of life)

Page 13: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Audit Filter #3a

• In 2019 it was discovered that AF 3a was not applying the 2 hour criteria

• Change made to title of Audit filter in manual for 2019– Patient with admission Glasgow Coma Scale score <13 and no head computerized tomography (CT) scan within 2 hours of arrival at hospital (if CT available in hospital) excluding DOAs

• For 2020, PTSF will work with DI staff to build the 2 hours criteria within the query

Page 14: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Audit Filter #11a

• AF #11a ‐ Patient transferred in after 3 hours at initial hospital– "Is this a transfer patient?"  (TRANSF_PT) = 1 (Yes); – AND Time from Arrival at Referring Hospital (DATE_REF_AR, TIME_REF_AR) to Departure from Referring Hospital > 3 hours (DATE_REF_DP, TIME_REF_DP)

• For 2020 – Add to Filter 11a query to exclude patients with injury time greater than 24 hours prior to arrival at referring hospital

• Applies to patients transferred in to your facility

Page 15: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Audit Filter #11b

• Filter 11b ‐ Patient transferred out after 3 hours from ED arrival

• Should filter #11b also exclude patients who are transferred out > 24 hours after injury time?

• There is a standards requirement to review pts transferred out > 3 hours (regardless of injury date/time)

• No changes will be made to filter #11b

Page 16: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

TRISS EOE Functionality

• TRISS EOE is designed to provide scoring for intubated patients but uses ICD‐9 codes. This is not seen in Collector, as it requires automapping to report out. We are working with DI to update this measure to utilize ICD‐10 codes

Page 17: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Administrative Time in ED (LOS) (Auto‐Calculation)

• For 2020 ‐ Add an Auto Calculation for administrative ED length of stay

• ED Admission Date/Time to Administratively Discharged from ED Date/Time– Administratively Discharged = Time order was written for pt to be d/c’d from ED

• Will be located on Acute Care/Arrival/Admission tab of collector

• HH:MM

Page 18: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Others Called to ED ‐ PGY option

• Currently ‐ PGY field enabled only if a resident specialty is selected

Page 19: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Others Called to ED ‐ PGY field

• Request to make PGY available for all menu choices in ‘Others Called to ED’ list– A Not Applicable (N/A) option will be added – There is currently no check on the PGY fields– No plans to add a check 

Page 20: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Consult Tab ‐ PGY field

• Request to make PGY available for all specialty choices on the Consult tab– A Not Applicable (N/A) option will be added – There is currently no check on the PGY fields– No plans to add a check 

Page 21: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Admit Unit

• Admit Unit ‐ New optional element for 2020– Will allow PA Trauma Centers to record a specific floor or location within their facility for Post ED Destination

• For 2019 admissions, an “other” and specify option was added to the “Post ED Destination” menu– This new “other” option should NOT be used to enter specific floors or ICU’s within your facility, only to capture a Post ED Destination that is not listed as a menu option

• Negatively affects reporting on Post ED Destination

Page 22: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Death/Discharge/Transfer Date and Time

• Currently ‐• Date of Death/Discharge/Transfer

– Record the date (month/day/year) the patient expired, was discharged alive, or was transferred

• Time of Death/Transfer– Record the time patient expired or was transferred to another acute care facility (trauma center, burn center, other)

• For 2020, record Date and Time for ALL hospital deaths, discharges, and transfers– Death/Discharge/Transfer Date – Death/Discharge/Transfer Time

Page 23: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Midline Shift

• Located on the Procedures 2 tab

• Update element to read ‘Midline Shift >5mm imaged within 24 hours?’ in 2020

Page 24: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Date/Time Entered ED

• Currently ‐• Date Entered ED – record date pt entered the emergency department (ED)

• Time Entered ED – record military time pt entered the emergency department (ED)

Page 25: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Date/Time Entered ED/Hospital

• Request to add ‘Hospital’ to title and definition• Date Entered ED/Hospital – Record the date the pt arrived to the Emergency Department (ED)/hospital

• Time Entered ED/Hospital – Record the military time ptentered the Emergency Department (ED)/hospital– Additional Information 

• If the patient was brought to the ED, enter time patient arrived at ED.  If patient was directly admitted to the hospital, enter time patient was admitted to the hospital.

Page 26: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

GCS Qualifiers – Paralyzing Drug Specify

• GCS Qualifiers do not apply when GCS 40 is used– GCS 40 does not have qualifier elements– GCS 40 contains ‘Not Testable’ options for each component, eliminating the need for Qualifiers

• The Paralyzing Drugs element is triggered by GCS Qualifiers• Paralyzing Drugs will be separated from GCS Qualifier elements for 2020– This is the way it had been setup prior to 2018

• This will apply to Pre‐hospital (Scene and transport), Referring Facility, Inter‐Hospital Transport and On Admission sections

Page 27: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Current Screen

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Page 29: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Lyndsey Diehl, RHIA, CHDA, CSTRDirector of Trauma Data Quality

Page 30: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

ABUSE – WAS PATIENT DISCHARGED TO A DIFFERENT CAREGIVER THAN WHEN THEY WERE ADMITTED? & IF YES…Patient discharged to a different caregiver than when they were admitted to your facility 

Made optional for 2020!

Page 31: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2019 ‐ S.08 – Pre‐hospital Cardiac Arrest with CPR 

A patient who experienced a sudden cessation of cardiac activity. The patient was unresponsive with no normal breathing and no signs of circulation. The event must have occurred outside of the reporting hospital, prior to admission at the center in which the registry is maintained. Pre‐hospital cardiac arrest could occur at a transferring institution. Any component of basic and/or advanced cardiac life support must have been initiated by a health care provider.

Revised for 2020!

Page 32: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2020 ‐ S.08 – Pre‐hospital Cardiac Arrest with CPR Indication of whether patient experienced cardiac arrest prior to ED/Hospital arrival.Additional Information• A patient who experienced a sudden cessation of cardiac activity. The patient was unresponsive with no normal breathing and no signs of circulation.

• The event must have occurred outside of the index hospital. Pre‐hospital cardiac arrest could occur at a transferring institution.

• Any component of basic and/or advanced cardiac life support must have been initiated.

Page 33: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2019 ‐ Post ED DestinationRecord the patient’s final destination from the ED

Additional Information• If patient was a direct admission, record patient 

destination.• The ‘Other’ option should not be used to capture specific 

floors at a facility. If the location is a step down, ICU, or floor unit, the appropriate menu option should be used– A custom element can be used to capture specific units within 

your facility

Definition revised and clarification added for 2020!

Page 34: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2020 ‐ Post ED DestinationThe disposition unit the order was written for the patient to be discharged from the ED.Additional Information• If patient was a direct admission, record patient destination.• The ‘Other’ option should not be used to capture specific floors at a 

facility. If the location is a step down, ICU, or floor unit, the appropriate menu option should be used– A custom element can be used to capture specific units within your 

facility• If multiple orders were written, report the final disposition order.• If the patient was discharged from the ED to the OR, Interventional 

Angiography or Morgue, record the destination even if there is no formal order documented.

Page 35: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2019 ‐ N.02 – Chronic Ongoing Alcohol Abuse Utilize the NTDB definition for Alcohol Use Disorder, (Consistent with American Psychiatric Association (APA) DSM 5, 2013.) which is defined Diagnosis of alcohol use disorder documented in the patient medical record, present prior to injury, consistent with APA DSM 5. Note: Social work, drug and alcohol counselor consults may be used to document this pre‐existing condition. Do not also code N.01 Substance Abuse Disorder. Revised for 2020!

Page 36: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2020 ‐ N.02 – Chronic Ongoing Alcohol Abuse 

Descriptors documented in the medical record consistent with the diagnostic criteria of alcohol use disorder OR a diagnosis of alcohol use disorder documented in the patient’s medical record.Additional Information• Present prior to injury.• Consistent with American Psychiatric Association (APA) DSM 5, 2013.

• The null value “Not Known/Not Recorded” is only reported if no past medical history is available.

Page 37: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2019 ‐ E.00 – Mental/Personality DisorderUtilize the NTDB definition for Mental/Personality Disorder which is defined as ‐ (Consistent with American Psychiatric Association (APA) DSM 5, 2013 Documentation of the presence of pre‐injury depressive disorder, bipolar disorder, schizophrenia, borderline or antisocial personality disorder, and/or adjustment disorder/post‐traumatic stress disorder. A diagnosis of Mental/Personality Disorder must be documented in the patient's medical record.

Revised for 2020!

Page 38: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2020 ‐ E.00 – Mental/Personality DisorderHistory of a diagnosis and/or treatment for the following disorder(s) documented in the patient’s medicalrecord:• Schizophrenia• Bipolar Disorder• Major Depressive Disorder• Social Anxiety Disorder• Posttraumatic Stress Disorder• Antisocial Personality DisorderAdditional Information• Present prior to injury.• Consistent with American Psychiatric Association (APA) DSM 5, 2013.• The null value “Not Known/Not Recorded” is only reported if no past 

medical history is available.

Page 39: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2019 – P.00 – Pregnancy

Patient presenting with current (gravid) pregnancy with obvious physical findings of pregnancy, confirmed by lab work, ultrasound, or as reported by patient and/or family members.

Revised for 2020!

Page 40: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2020 – P.00 ‐ Pregnancy

Pregnancy confirmed by lab, ultrasound, or other diagnostic tool OR diagnosis of pregnancy documented in the patient’s medical record.Additional Information• Present prior to arrival at your center.

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2019 – N.01 – Substance Abuse DisorderUtilize the NTDB definition for Substance Abuse Disorder (Consistent with American Psychiatric Association (APA) DSM 5, 2013. Documentation of Substance Abuse Disorder in the patient medical record, present prior to injury. A diagnosis of Substance Abuse Disorder must be documented in the patient's medical record. EXCLUDE: Tobacco Use Disorder and Alcohol Use Disorder

Revised for 2020!

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2020 – N.01 – Substance Abuse DisorderDescriptors documented in the patient’s medical record consistent with the diagnostic criteria ofsubstance use disorders specifically cannabis, hallucinogens, inhalants, opioids, sedative/hypnotics, andstimulants (e.g. patient has a history of drug use; patient has a history of opioid use) OR diagnosis of anyof the following documented in the patient’s medical record:• Cannabis Use Disorder; Other Cannabis‐Induced Disorder; Unspecified Cannabis‐Related• Disorder• Phencyclidine Use Disorder; Other Hallucinogen Use Disorder; Hallucinogen Persisting Perception 

Disorder; Other Phencyclidine‐Induced Disorder; Other Hallucinogen‐Induced Disorder; Unspecified Phencyclidine‐Related Disorder; Unspecified Hallucinogen‐Related Disorder

• Inhalant Use Disorder; Other Inhalant‐Induced Disorder; Unspecified Inhalant‐Related Disorder• Opioid Use Disorder; Other Opioid‐Induced Disorder; Unspecified Opioid‐Related Disorder• Sedative, Hypnotic, or Anxiolytic Use Disorder; Other Sedative, Hypnotic, or Anxiolytic‐Induced• Disorder; Unspecified Sedative, Hypnotic, or Anxiolytic‐Related Disorder• Stimulant Use Disorder; Other Stimulant‐Induced Disorder; Unspecified Stimulant‐Related Disorder

Additional Information• Present prior to arrival at your center.• Consistent with the American Psychiatric Association (APA) DSM 5, 2013. 

Note: Now referred to as “Substance Use Disorder” in NTDB!

Page 43: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2019 – 206 = Cardiac Arrest with CPRUtilize the NTDB Complication definition for Cardiac Arrest with CPR, which states: Cardiac arrest is the sudden cessation of cardiac activity after hospital arrival. The patient becomes unresponsive with no normal breathing and no signs of circulation. If corrective measures are not taken rapidly, this condition progresses to sudden death.INCLUDE patients who have had an episode of cardiac arrest evaluated by hospital personnel and received compressions or defibrillation or cardioversion or cardiac pacing to restore circulation.EXCLUDE patients who are receiving CPR on arrival to your hospital

Revised for 2020!

Page 44: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2020 – 206 = Cardiac Arrest with CPRCardiac arrest is the sudden cessation of cardiac activity after hospital arrival. The patient becomes unresponsive with no normal breathing and no signs of circulation. If corrective measures are not taken rapidly, this condition progresses to sudden death.

Additional Information• Must have occurred during the patient's initial stay at your hospital.• Cardiac arrest must be documented in the patient's medical record.• EXCLUDE patients whose ONLY episode of cardiac arrest with CPR 

was on arrival to your hospital.• INCLUDE patients who, after arrival at your hospital, have had an 

episode of cardiac arrest evaluated by hospital personnel, and received compressions or defibrillation or cardioversion or cardiac pacing to restore circulation.

Page 45: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2020 ‐ DeliriumAdded for 2020 (# TBD)!

Acute onset of behaviors characterized by restlessness, illusions, and incoherence of thought and speech. Delirium can often be traced to one or more contributing factors, such as a severe or chronic medical illness, changes in your metabolic balance (such as low sodium), medication, infection, surgery, or alcohol or drug withdrawal.ORPatient tests positive after using an objective screening tool like the Confusion Assessment Method (CAM or the Intensive Care Delirium Screening Checklist (ICDSC).ORA diagnosis of delirium documented in the patient’s medical record.

Additional Information• Must have occurred during the patient's initial stay at your hospital.• EXCLUDE: Patient’s whose delirium is due to alcohol withdrawal.

Page 46: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2019 – 35 = Myocardial InfarctionUtilize the NTDB Complication definition for Myocardial Infarction, which states: An acute myocardial infarction must be noted with documentation of any of the following:Documentation of ECG changes indicative of acute MI (one or more of the following three):1. ST elevation >1 mm in two or more contiguous leads2. New left bundle branch block3. New q‐wave in two or more contiguous leadsORNew elevation in troponin greater than three times upper level of the reference range in the setting of suspected myocardial ischemiaORPhysician diagnosis of myocardial infarctionMust have occurred during the patient’s initial stay at your hospital.

Revised for 2020!

Page 47: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2020 – 35 = Myocardial InfarctionAn acute myocardial infarction must be noted with documentation of ECG changes indicative of an acuteMIANDNew elevation in troponin greater than three times upper level of the reference range in the setting of suspected myocardial ischemiaANDPhysician diagnosis of an acute myocardial infarction that occurred subsequent to arrival at your center

Page 48: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2019 – 203 = Unplanned Return to the OR

203 = Unplanned return to the OR: Unplanned return to the operating room after initial operation management for a similar or related previous procedure.

Revised for 2020!

Page 49: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2020 – 203 = Unplanned Visit to the Operating Room

Patients with an unplanned operative procedure OR patients returned to the operating room after initial operation management of a related previous procedure.Additional Information• Must have occurred during the patient's initial stay at your 

hospital.• EXCLUDE: Pre‐planned, staged and/or procedures for 

incidental findings.• EXCLUDE: Operative management related to a procedure that 

was initially performed prior to arrival at your center.

Page 50: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2019 – Discharge DestinationThe destination of the patient on formal discharge.

Additional Information• See Appendix 8 for more information on Discharge Destination choices• This element will be skipped if the patient died• If a burn patient is discharged or transferred to a burn center that is also a trauma center the 

“Discharge Destination” should be “6” for burn center• “If the patient is discharged from the acute care unit to a facility rehab• If the patient is discharged to an in‐patient rehabilitation facility or in‐patient psychiatric facility within 

an acute care hospital, record ‘Discharge Destination’ as 4, Rehabilitation Center or 7, Psychiatric Facility. Use the facility number for the acute care hospital to record ‘Discharge to Facility Number.’

• If the patient is discharged from the acute care facility to a Skilled Nursing Facility, record the discharge destination as “5” Skilled Nursing Facility. Comment field may be used to note “Home” if the SNF is patient residence.

• If patient discharge home on hospice services, record discharge destination as ’17 Hospice’. Comment field may be used to note “Home” for patient location.

• If patient instructed to go to another hospital via private vehicle, record ’14 PA Trauma Center’. Comment field may be used to indicate ‘Private Vehicle’.

Clarification added for 2020!

Page 51: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2020 – Discharge DestinationThe destination of the patient on formal discharge.

Additional Information• See Appendix 8 for more information on Discharge Destination choices• This element will be skipped if the patient died• If a burn patient is discharged or transferred to a burn center that is also a trauma center the “Discharge 

Destination” should be “6” for burn center• “If the patient is discharged from the acute care unit to a facility rehab• If the patient is discharged to an in‐patient rehabilitation facility or in‐patient psychiatric facility within an 

acute care hospital, record ‘Discharge Destination’ as 4, Rehabilitation Center or 7, Psychiatric Facility. Use the facility number for the acute care hospital to record ‘Discharge to Facility Number.’

• If the patient is discharged from the acute care facility to a Skilled Nursing Facility, record the discharge destination as “5” Skilled Nursing Facility. Comment field may be used to note “Home” if the SNF is patient residence.

• If patient discharge home on hospice services, record discharge destination as ’17 Hospice’. Comment field may be used to note “Home” for patient location.

• If patient instructed to go to another hospital via private vehicle, record ’14 PA Trauma Center’. Comment field may be used to indicate ‘Private Vehicle’.

• If multiple orders were written, report the final disposition order.

Page 52: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2019 ‐ Blood Products

Retired for 2020! (New Additions for 2020!)

Page 53: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2020 – Blood Products• Packed Red Blood Cells• Whole Blood• Plasma• Platelets• Cryoprecipitate

Additional Definition Changes:• Enter only in CC/mLs within 4 hours• Exclude transfusing product upon patient arrival

Note: PTOS will continue to capture Total Prehospital Units of Blood Hung which will capture the number of units of packed cells or whole blood hung during the pre‐hospital treatment.

Added for 2020!

Page 54: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

2020 – Antibiotic Therapy• Was Intravenous Antibiotic Therapy Administered Within 24 Hours After the First Hospital Encounter? 

• Antibiotic Therapy Date• Antibiotic Therapy Time

Additional Information:Open fractures as defined by the Association for the Advancement of Automotive Medicine AIS Coding Rules and Guidelines.

Page 55: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Tourniquet Use (Draft Only!)New Additions for 2020!

• Tourniquet Use• Tourniquet Placed• Tourniquet Placed By• Date Tourniquet Placed• Time Tourniquet Placed• Date Tourniquet Removed• Time Tourniquet RemovedNote: These elements will be located under “Demographics” on the Injury Tab within Collector.

Page 56: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Tourniquet Use

Definition: Did the patient have a tourniquet placed? Field Values: 1 – Yes 2 – No U – Unknown 

Page 57: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Tourniquet PlacedDefinition: In what setting was the tourniquet placed? Field Values: 1 – Prehospital 2 – Outside Hospital 3 – Interhospital Transport 4 – In house U – Unknown Additional Information: Will skip if Tourniquet Use is answered as 2 – No or U –Unknown 

Page 58: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Tourniquet Placed ByDefinition: Who placed the tourniquet? Field Values: 1 – EMS 2 – Police 3 – Fire 4 – Bystander 5 – Hospital Staff U – Unknown Additional Information: Will skip if Tourniquet Use is answered as 2 – No or U –Unknown 

Page 59: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Others Called to ED & Consults

Interventional Radiology to be added to both Others Called to ED and Consults dropdown menus for 2020. 

Page 60: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

34 = Major DysrhythmiaREMOVED for 2020!

This Photo by Unknown Author is licensed under CC BY

Page 61: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Provider IDNew addition for 2020!

Page 62: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Burn Patients at Burn Centers Only!

• 10 = Burn Graft Loss (of any percentage)– 2020 – 10 = Burn Graft Loss (of any percentage) requiring repeat procedure

• 15 = Hypovolemia – REMOVED for 2020!

Page 63: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

PTOS Patient

Page 64: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Appendix 7: Prehospital Examples

Additions, changes and clarification in 2020 PTOS Manual!

Page 65: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Some Potential Last Minute Changes• Is there sequential neurological documentation on ED record of trauma patient with diagnosis of skull fx, intracranial injury, or spinal cord injury? – Required for 2020!

• Is there hourly documentation beginning with ED arrival?– Required for 2020!

• Drug Screen ‐ Clinician Administered– Clarification regarding the use of medical marijuana

• E‐cigarette and Vaping Use– Added as a pre‐existing condition for 2020

Page 66: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

For Your Information!!!

Page 67: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

NTDB Inclusion Criteria Changes• “…within 14 days of initial hospital encounter…”• “Patient transfer from one acute care hospital* to another acute care hospital”

• “Patients directly admitted to your hospital (exclude patients with isolated injuries admitted for elective and/or planned surgical intervention)”

• “Patients who were an in‐patient admission and/or observed”

• Patients who were a trauma consult or any level of trauma activation”

• REMOVED: “Hospital admission as defined by your trauma registry inclusion criteria;”

Page 68: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Continued…The PTSF Board of Directors discussed the new NTDB inclusion criteria that was recently communicated by the American College of Surgeons as being effective January 1, 2020.  Our PTSF Board Chairman Dr. Patrick Reilly reached out to ACS leadership to communicate the impact this change will have on Pennsylvania trauma centers.  At this time, the PTSF Board asks that you make no changes until further notice related to the patients your hospital is submitting to the NTDB.  The ACS communicated that they are going to further discuss these changes among their leadership and offer further advice in the future.

Meanwhile, we will be asking various Pennsylvania Professional Trauma groups to formally convey the impact of this change with ACS leadership.  Those groups include the PaCOT, PATNAC, and PTSF.  Formal letters from hospitals would also be helpful.   Letters should be sent to: 

American of Surgeons Committee on TraumaAttention:  NTDB Staff633 N. Saint Clair Street

Chicago, Illinois60611‐4111

Page 69: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

DI Projects

• Collector Transition to PA V5 Trauma Registry– Minimal to no changes will be made to PTOS for 2021 admissions!

• PTOS Driller• Registry Educational Software

Page 70: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Trauma Registry Tab

• Resources• Education• FAQ’s

This Photo by Unknown Author is licensed under CC BY‐ND

Page 71: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

FYI

http://www.memegen.com/meme/en82sg

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KnowledgeConnex

https://www.elearningconnex.com/ptsf/

This Photo by Unknown Author is licensed under CC BY

Page 73: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

AIS 2015

https://goo.gl/images/7vLn8F

Page 74: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

PTOS Manual Updates

Look for the 2020 PTOS Manual to be released Mid‐December 2019! 

Throughout 2020 be on the look for…• Minor corrections• Clarification• Possible changes

Page 75: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Additional Resources

• Change Document• PTOS vs NTDB Comparison• Element History• RW Dictionary• Facility Lists• PA EMS Affiliates

Page 76: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

Baby DiehlComing January 2020 (hopefully)!

Page 77: 2020 Collector Updateptsf.org/upload/2020_Collector_Changes_Final_Handout.pdf · 2020 Collector Update Lyndsey Diehl, RHIA, CHDA, CSTR Director of Trauma Data Quality Stephanie Radzevick,

https://goo.gl/images/2TW1Ap

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Lyndsey Diehl, RHIA, CHDA, CSTRTrauma Data Quality Specialist

AHIMA Approved ICD‐10‐CM/PCS Trainer717‐697‐5512 ext. 105

[email protected]

Stephanie Radzevick, CPCTrauma Data Analyst

AHIMA Approved ICD‐10‐CM/PCS Trainer717‐697‐5512 ext. [email protected]

www.ptsf.org

Gabrielle Wenger, RHIT, CPC, CAISSTrauma Registry Auditor717‐697‐5512 ext. [email protected]

www.ptsf.org