trauma room

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.

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 […]

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 […]