trauma room

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We are looking for clarification regarding what is considered abuse. I understand, for example, a parent assaulting a child, a spouse/significant other assaulting a spouse, an adult child assaulting an elderly parent is abuse,, but is any physical assault considered abuse for the first registry question “was patient being evaluated for abuse?” or are there specific criteria that constitutes abuse? For example, an acquaintance or neighbor as a one-time event assaulting the patient, how would we answer that first registry question? Or a guy is sitting at a bar and someone comes up and hits him?

Please refer to the Best Practices Guidelines for abuse. If you cannot locate this resource, please contact PTSF staff, and we can provide it for you. I hope this document helps clarify abuse for you. This resource provides great information, and best practices for abstraction as well. Any physical assault is not abuse. However, according …

Continue reading “We are looking for clarification regarding what is considered abuse. I understand, for example, a parent assaulting a child, a spouse/significant other assaulting a spouse, an adult child assaulting an elderly parent is abuse,, but is any physical assault considered abuse for the first registry question “was patient being evaluated for abuse?” or are there specific criteria that constitutes abuse? For example, an acquaintance or neighbor as a one-time event assaulting the patient, how would we answer that first registry question? Or a guy is sitting at a bar and someone comes up and hits him?”

If a patient fall going UP three steps, would they get a fall height? Would their mechanism be fall on steps?

In situations where patients fall in place while going up steps, we recommend recording a fall height of 0 = fall on same level. This is only true if their fall did not result in a fall down the stairs. For mechanism in ICD-10, you will use the category for fall from/on stairs.

Can you please clarify if the MOI plays role in including or excluding pts from pre-hospital CPR w cardiac arrest criteria?

Mechanism of injury plays no role in the Pre-hospital Cardiac Arrest definition. This pre-existing condition should be considered for every PTOS patient regardless of their MOI or diagnoses.

Does an advance directive need to be in the patient’s chart or is it ok if the family says, yes, we have an advance directive, they want nothing done and that is documented?

In order to capture this as a pre-existing, the patient’s advanced directive to limit life-sustaining treatment must have been present on their person on arrival or already on file at your center.

A patient fell from a train platform and was struck by a slow moving train and was then electrocuted. He was worked up at another Level One trauma center and transferred to us for treatment of 3rd and 4th degree burns (but only 5%). His traumatic injuries gave him an ISS of 14 (spleen lac, Tspine fx, HTX, rib fx’s). His burn injury is an ISS of 4. He was transferred here for burn BUT admitted to trauma with a burn consult and a few days later transferred to burn service only. There were no other interventions by the trauma service other than managing a chest tube and ordering consulting services. I understand our manual states to use the highest ISS when the there is more than one mechanism but would you deviate in the case of a transfer in from another trauma center? Burn mech and admit first? Or Trauma mech and admit first?

We recommend to always record the mechanism that caused the most severe injuries first. In this situation, we recommend the mechanism code for the strike by train as the primary and the mechanism for the electrocution as secondary based on the information provided.

Can you please clarify the pre-existing history of head trauma? The term TBI doesn’t need to be specifically documented, correct? If we have documentation of SAH, SDH, concussion, etc. is that sufficient? What about closed head injury?

You don’t need the term “TBI” if you have a specific diagnosis of brain, skull or scalp injury (can be open or closed) , as long as it caused anything from drowsiness to an intracranial bleed. So just diagnosis of SAH is fine; if you get into milder skull/scalp injury I would want to see …

Continue reading “Can you please clarify the pre-existing history of head trauma? The term TBI doesn’t need to be specifically documented, correct? If we have documentation of SAH, SDH, concussion, etc. is that sufficient? What about closed head injury?”

We were having a discussion about an isolated hip fracture and are unsure if she should be included as we feel she falls in a sort of grey area. She was attempting to take her dog out for a walk and in his excitement he tripped by going under her feet and she fell from standing. Not sure is she should be PTOS or not. Should her mechanism be FFS or contact with dog? Please let us know what you think.

This scenario falls under W01.0 (tripping over animal). W01.0 does fall within the accepted code range for our solitary hip fracture exclusion. Therefore, based on the information provided, this patient would meet the exclusion and would NOT be captured as PTOS.