Outcome Archives - PA Trauma

Some of our psych consults are done teleconference – would you consider this an in person consult or a phone consult?

Currently, in order to capture a consult, the provider must be physically at the patient bedside. I recommend using the phone consult data elements to capture these teleconference visits.

We have a case in which the patient CTB shortly after arrival in the ED. We were not able to obtain any imaging and have limited info on the injuries. The patient did have an autopsy done by the ME, however we are currently unable to get information from the ME in writing as it is a homicide and they will not release the report. My question is this. Our PI Coordinator was able to receive a verbal report of the injuries form the MEs office. If they type this up and provide to the registrar and keep for our files, are we able to abstract those injuries. We would put a note in the comment area regarding where the info came from.

We understand that there are sometimes issues accessing autopsy reports. We do allow you to use information received from the ME office even if you don’t have the actual report. I do recommend as you mention logging this information in the PI notes or somewhere else you deem appropriate within the software. I recommend including …

Continue reading “We have a case in which the patient CTB shortly after arrival in the ED. We were not able to obtain any imaging and have limited info on the injuries. The patient did have an autopsy done by the ME, however we are currently unable to get information from the ME in writing as it is a homicide and they will not release the report. My question is this. Our PI Coordinator was able to receive a verbal report of the injuries form the MEs office. If they type this up and provide to the registrar and keep for our files, are we able to abstract those injuries. We would put a note in the comment area regarding where the info came from.”

My question is regarding whether to pick up Unplanned OR for the following scenario: Patient is admitted 3/9/22 & is scheduled to go to OR 3/11/22 for procedure. Attending meets w patient pre-op and she decides she does not want the procedure. Pain becomes unbearable and patient undergoes initially planned procedure on 3/14/22. Should this be picked up as an Unplanned OR?

In this situation, we recommend you NOT capture the unplanned OR hospital event.

If I have a PTOS patient who has a fall while they are admitted I know we are not picking up the injuries from that fall. I also do not pick up any of the related consults. If that patient gets an injury during that fall- say a broken wrist. Ortho ends up taking them to the OR to fix the wrist. Do you want that OR picked up as an unplanned OR event for the patient? Or NO because it was related to the inpatient fall?

There is no exclusion within the definition for the Hospital Event Unplanned Visit to the Operating Room for these situations. Therefore, I recommend you capture the hospital event in the registry.

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.