Outcome Archives | PA Trauma

I have a question regarding whether a patient meets criteria for hospital event (212) Unplanned Visit to the OR. The patient has had multiple planned Orthopaedic operations. The patient has also had several failed extubations and I have already documented Event (202) Unplanned intubation. ENT is consulted and states that a trach is necessary to establish a definitive airway, patient has vocal cord immobility & airway obstruction. Would the operative event for the tracheostomy tube placement be considered an Unplanned Visit to the Operating Room?

Based on the information provided, it sounds like the patient’s tracheostomy procedure was not initially planned. Therefore, I do recommend capturing Hospital Event 212 for Unplanned Visit to the OR.

This is a great question. Yes, I recommend that you do also capture 212 – Unplanned Visit to the OR based on the information provided. I am making this recommendation because although the unplanned procedure is performed in IR and not the OR, the patient does have documentation of an unplanned operative procedure which is included in the definition.

Yes, I recommend that you do also capture 212 – Unplanned Visit to the OR based on the information provided. I am making this recommendation because although the unplanned procedure is performed in IR and not the OR, the patient does have documentation of an unplanned operative procedure which is included in the definition.

We have a patient that had an orthopedic consult and an orthopedic spine consult, the same orthopedic advanced practitioner saw the patient in the emergency department and did two separate consults for two separate physicians. Would we list them both as orthopedic consults or list the orthopedic consult and “other: specifying orthopedic spine?

PTSF recommends you capture both separately. That means spine would need to be recorded under the “other” option. Note that only Speech Therapy, Occupational Therapy, Physical Therapy, and Physiatry consults are required to be recorded for non-burn patients at a burn center and all patients at non-burn centers.

I’m wondering if I’m not understanding the definition for Unplanned admission to ICU part about PACU. I read the bullet regarding PACU separate statement/criteria from the first bullet about planned transfer to ICU for a planned surgery. Is this correct? Basically, I understand any transfer to ICU post-op UNLESS decided prior to that incision, is an unplanned admission to ICU. Everything I read, has to be decided PRIOR to surgery start, no matter the reason? In PACU, pt needs a higher level of care, no matter the reason, is unplanned ICU, if not decided prior to surgery starting?

Yes, if they went to ICU post op, but it was not decided until after surgery started, then it is unplanned ICU. The NTDB has a couple questions on their FAQ that are similar. They are under “Unplanned Admission to ICU” if you scroll down the 2021 FAQ. The link is https://www.facs.org/quality-programs/trauma/tqp/center-programs/ntdb/ntds/faq/2021.

I have listed a scenario below. This is being questioned because the goal is always conservative treatment for a hospital and the patient and is it an unplanned event if the patient is taken to the OR? For example, if the patient is placed in a TLSO and the patient xray was done showing improper alignment and on 4/20 N/S states will take the patient to the OR for fixation on 4/21 and the patient is made NPO. Based off the most recent TQIP quiz, registry would determine this to be unplanned OR event due to failed conservative treatment.

PTOS aligns with the NTDB/TQIP for the Unplanned Visit to Operating Room Hospital Event. If the initial plan for the patient included conservative management, and no surgery, but the patient declines and ends up needing more aggressive treatment and is taken to the OR, you would capture the Hospital Event Unplanned Visit to the Operating …

Continue reading “I have listed a scenario below. This is being questioned because the goal is always conservative treatment for a hospital and the patient and is it an unplanned event if the patient is taken to the OR? For example, if the patient is placed in a TLSO and the patient xray was done showing improper alignment and on 4/20 N/S states will take the patient to the OR for fixation on 4/21 and the patient is made NPO. Based off the most recent TQIP quiz, registry would determine this to be unplanned OR event due to failed conservative treatment.”

If a patient did not have a prior head surgery and while in the hospital fell and struck his head resulting in an unplanned or visit for evacuation do you pick this event up as an unplanned visit to the OR?

In this situation you would enter unplanned visit to OR. PTOS aligns with the NTDB/TQIP for this Hospital Event. The NTDB has addressed within their FAQ’s that iatrogenic injuries are not excluded within this definition.

If a patient was taken to the OR for organ donation and both kidneys were transplanted do you capture kidney twice?

In these situations, you are to enter kidney one time. Even if multiple sections of skin were taken, for example, or long bone, you would enter only once. It is understood that while multiple donations may be made, they are not necessarily going to the same recipient.

A patient on hospice coming from SNF is admitted to our facility. Discussion with family occurs and it is decided to return the patient to the SNF on hospice. How should the discharge destination be coded, 5 (SNF) or 17 (Hospice)?

For PTOS you should report 17 (Hospice) for discharge destination. We want to capture the level/type of care. You can note “home” in the specify field. Note, the NTDB follows different guidelines in these situations.

Looking at the definition for us to pick up a DVT there is no timeframe as to when it would be considered present on admit or does someone specifically have to say “present on admit”. The scenario I have a patient was admitted on 3/10 and at that time considered a high risk for DVT. She was ordered heparin but refused. Patient came back in 3/16 at 1150 but no mention of DVT was documented. For some reason an ultrasound was ordered and done on 3/16 at 2230 and a DVT was found. So because this patient had no documentation of DVT on admit, this is a hospital event?

Unless you have documentation that suggests the DVT was present on admission, you will capture DVT as a hospital event as long as the definition is met. Note, the patient must also be treated with anticoagulation therapy and/or placement of a vena cava filter or clipping of the vena cava in order to capture the …

Continue reading “Looking at the definition for us to pick up a DVT there is no timeframe as to when it would be considered present on admit or does someone specifically have to say “present on admit”. The scenario I have a patient was admitted on 3/10 and at that time considered a high risk for DVT. She was ordered heparin but refused. Patient came back in 3/16 at 1150 but no mention of DVT was documented. For some reason an ultrasound was ordered and done on 3/16 at 2230 and a DVT was found. So because this patient had no documentation of DVT on admit, this is a hospital event?”

I have a question about the definition of aspiration PN. It reads “documented inhalation of gastric contents or other materials.” Does this mean that we have to see actual documentation somewhere in the record that the patient actually vomited or was noted to aspirate? I feel the definition is not specific as to the mode of aspiration and would like some clarification before I give my patient the event of aspiration PN.

There must be documentation of inhalation of gastric contents or other materials and then also documentation of clinical and new radiological findings of pneumonitis which requires treatment within 48 hours.