Outcome Archives | PA Trauma

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.

Patient did not have a urine run on admit (1/07) but there was a positive culture on 1/13. This urine was collected 1/13 14:58 and had >100,000 colonies but this patient was discharged 1/13 16:35. So the results were not available prior to discharge. To meet the hospital even for UTI, the patient need to have a culture with >100,000 organisms and physician institutes appropriate therapy for UTI. I think I would not pick this patient up as a UTI for the fact that therapy was not begun. Is that correct?

You are correct. Unless there is documentation that the provider provided appropriate therapy for a urinary tract infection, you will not capture this as a hospital event.

If you initiate CRRT for other reasons rather than renal failure do you still count is as AKI? We had a patient that had hyperammonemia that required CRRT to clear. They were on it for <48 hours. They did not meet the other definitions for AKI other than CRRT. Was wondering if we have to pick up the occurrence.

Based on the information provided, AKI should not be reported. The patient did not have an abrupt decrease in kidney function that required the CRRT nor were they diagnosed with an AKI.

If you have a patient that tests positive for COVID19 on admission and later in the patient’s stay develops an occurrences such as PNA, DVT, or PE (not present on arrival) but meet the definition in the PTSF guideline. Do you include these as hospital occurrences or exclude due to the patient having a positive COVID on admission?

If they meet the definition of the occurrence, you will pick it up and report for PTOS. There are no exclusions related to COVID, it can be addressed in review.

We have a case that when we are following the instructions for a direct admit under the PTSF guidelines it is creating an error code for TQIP. Scenario: Patient is a direct admit and there for should have the administratively discharged date and time entered as either an “I” or “/”. When entering this, it produces a level 2 TQIP flag.

The NTDB/TQIP added a new check on their ED Discharge Date/Time element for 2021 admissions. The field cannot be n/a. When I’s are entered in PTOS, it does map to n/a in the ITDX module, which is problematic. For the time being, you must manually change the value for Discharge Order within the ITDX module …

Continue reading “We have a case that when we are following the instructions for a direct admit under the PTSF guidelines it is creating an error code for TQIP. Scenario: Patient is a direct admit and there for should have the administratively discharged date and time entered as either an “I” or “/”. When entering this, it produces a level 2 TQIP flag.”

I have a patient that does meet the criteria for a UTI, but does not meet the criteria for a CAUTI but the patient did have a foley catheter in place during the stay. Although, I would not pick up the CAUTI as an Event since it does not meet all of the criteria, would I still pick up the UTI as an Event?

Yes, if it does not meet CAUTI and does meet UTI, pick up UTI.

Can you please help me decide if this scenario would be an Event of Unplanned Visit to the OR? Patient went to the OR for a Head Bleed Evacuation on the Right side on 11/15 but then had to go back to the OR hours later on the same day for a Left side Head Bleed Evacuation that was not diagnosed at the time of the original OR because it didn’t show up on the original Scans. Would this be an Unplanned Visit to the OR?

If this was a missed injury, meaning the injury presented itself but was not identified by the medical team, you would capture the Hospital Event. In the definition, patients with an unplanned operative procedure are captured. Also, even if this bleed didn’t present itself and could not be diagnosed until later in the stay, you …

Continue reading “Can you please help me decide if this scenario would be an Event of Unplanned Visit to the OR? Patient went to the OR for a Head Bleed Evacuation on the Right side on 11/15 but then had to go back to the OR hours later on the same day for a Left side Head Bleed Evacuation that was not diagnosed at the time of the original OR because it didn’t show up on the original Scans. Would this be an Unplanned Visit to the OR?”

Patient with PMH of alcohol abuse x 20+ years presents to ED seizure from alcohol withdrawal (withdrawal on admission). Patient became extremely agitated etc. and was transferred to ICU where he can be adequately monitored and sedated. Patient intubated for airway protection per MD documentation. Are these events considered an Unplanned intubation?

For patient intubated for airway protection per MD documentation, you would not pick up unplanned intubation.