Outcome Archives - PA Trauma

If it is stated in a patient’s chart that they are in remission for either drugs or alcohol and there is no signs that there is still ongoing abuse, would you pick up either as an pre-existing condition?

There is no time limitation in the definition; therefore, if there is documentation the patient had substance use disorder at any time you must report the Hospital Event Substance Use Disorder. This is true even if there is documentation the patient is in remission.

Hi, do procedures in IR qualify for this event? We had a patient who went to the OR for ORIF. In PACU, the patient was hypotensive, CT scanned, and taken to IR for an embolization. Not sure if we should include this as an unplanned visit to the OR.

NTDB has just confirmed to us that operative procedures do not need to occur in the OR, it is not tied to location. Their response was, “Some operative procedures are performed outside the OR. If the patient had an unplanned operative procedure you must report Element Value “1. Yes” to TQIP for the Unplanned Visit …

Continue reading “Hi, do procedures in IR qualify for this event? We had a patient who went to the OR for ORIF. In PACU, the patient was hypotensive, CT scanned, and taken to IR for an embolization. Not sure if we should include this as an unplanned visit to the OR.”

Please help me understand when to pick up the Event of Asp. PNA. If the aspiration happened PTA at the scene of the accident, would we pick that up as an Event, or do we only pick this up as an Event if the aspiration happened during the hospital stay? Also, the part about requiring treatment within 48 hours, does that mean requiring treatment within 48 hours of the radiological findings?

All events must occur after arrival at your hospital. If the aspiration occurred prior to arrival, it would not get picked up. If it occurred at a receiving facility, it would be on the receiving facility hospital events. It would get picked up at your hospital only if it occurred after arrival at your facility. …

Continue reading “Please help me understand when to pick up the Event of Asp. PNA. If the aspiration happened PTA at the scene of the accident, would we pick that up as an Event, or do we only pick this up as an Event if the aspiration happened during the hospital stay? Also, the part about requiring treatment within 48 hours, does that mean requiring treatment within 48 hours of the radiological findings?”

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?”

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.