Frequently Asked Questions
Our PTSF staff have compiled frequently asked questions for you to reference. Do you have a question about basic trauma assessment? Maybe you're looking to better understand basic trauma training?
Trauma Registry related FAQs will be updated here weekly by PTSF staff. Please take the date of the post into consideration. As you know, changes occur frequently in the PTOS dataset.
This scenario falls under W01.0 (tripping over animal). W01.0 does fall within the accepted code range for our solitary hip fracture exclusion. Therefore, based on the information provided, this patient would meet the exclusion and would NOT be captured as PTOS.
Can you please clarify the pre-existing history of head trauma? The term TBI doesn’t need to be specifically documented, correct? If we have documentation of SAH, SDH, concussion, etc. is that sufficient? What about closed head injury?
You don’t need the term “TBI” if you have a specific diagnosis of brain, skull or scalp injury (can be open or closed) , as long as it caused anything from drowsiness to an intracranial bleed. So just diagnosis of SAH is fine; if you get into milder skull/scalp injury I would want to see that at least drowsiness or concussion symptoms were noted.
Based on the information provided, I believe this patient would meet the isolated hip fracture exclusion and NOT be captured as PTOS. In Appendix 15 of the PTOS Manual there are examples provided. This scenario seems similar to Fall from standing (knocked over/pushed) with an isolated hip fracture, which is non-PTOS. However, if a horse hit the patient causing an injury, that is when you would use W55.1 (contact with horse). If it was the fall that caused the injury, you will want to use the fall code, which does meet the exclusion.
No, I wouldn’t pick up substance abuse. While he does have the abstinence syndrome, it wasn’t his direct use/abuse of substance.
If it is a closed fracture, blunt injury, you can code hematoma in addition to the fracture. If it is an open fracture or a penetrating injury, you wouldn’t code those associated.
From what you wrote, it sounds like it could be sequela, as they say there is no injury to muscle, but I might ask your doc. Blood loss associated with certain injuries does increase the severity. Did they note any vessel injuries?
Hemorrhagic shock itself isn’t codable.
That is correct. As long as the patient is placed on comfort care prior to leaving the ED or meeting another portion of the criteria (LOS, ICU, transfer, etc.) that patient will not be captured as PTOS due to our hospice patient exclusion. The patient in your scenario appears to meet this exclusion.
As an example of a patient that would be captured, if a patient were to be admitted to the ICU and it is later decided to place the patient on comfort care, this patient would be captured as PTOS.
This patient would not qualify as PTOS as the fracture is pathological. There is a separate pathologic and traumatic fracture category in ICD-10. Only traumatic fractures fall within the PTOS ICD-10 inclusion code range.
Being lifted certainly could be a traumatic mechanism; however, in this situation, there was no injury.
In both of your scenarios, since the patient has a diagnosis that falls within our inclusion code range, they should be considered for PTOS. Note, they will need to meet the LOS criteria or another portion of the inclusion criteria before you confirm them as PTOS.
In the documentation provided, it appears to me that the mechanism of injury is cat bite. PTOS inclusion does not consider the mechanism of injury, diagnoses only. There is no specific icd-10 diagnosis code related to the bite itself, such as a laceration code. Since there is no documented diagnosis that falls within the ICD-10 code range for PTOS, the patient should be made nonPTOS.
Yes, if the injury occurs after the patient is in your hospital being treated, then that is not a qualifying injury.
The idea is that those patients are being reviewed through another quality review in your hospital, so are not picked up for PTOS or NTDS.
That’s correct. The patient was discharged home from the ED. She went home and did not meet LOS and so does not qualify as PTOS.
In order for Stepdown or ICU to be qualifying criteria, the patient actually has to go to the unit.
If the patient is in an acute care hospital, and falls, that record won’t meet inclusion criteria. In other locations such as a SNF, residential care, or a psychiatric center that is not an acute care hospital, those do qualify for inclusion.
No, if the injuries are due to the disease then you won’t pick it up. Another example would be osteophytes on a vertebra. You can pick up a fractured vertebra, but not a fractured osteophyte.
If your facility has recorded a positive test on the patient, then record positive. With patients now being tested multiple times during their stay, if they test positive at any point, you will record a positive result.
In order to capture any hospital event, including osteomyelitis, the condition must have occurred during the patient’s initial stay at your hospital. If the patient arrived to your hospital with osteomyelitis, it should not be captured as a hospital event.
For patient intubated for airway protection per MD documentation, you would not pick up unplanned intubation.
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 will still capture this Hospital Event. The PI process can further explore and explain.
Yes, if it does not meet CAUTI and does meet UTI, pick up UTI.
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 under NTDB/ED/Hospital Arrival. PTSF is working with ESO in hopes of providing a better solution.
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.
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.
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.
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.
This would meet ambulance/helicopter rendezvous, as both provided part of the transport from the referring facility to you.
I recommend recording 3 – Ambulance/Helicopter Rendezvous as the Scene Provider and 1 – Ambulance as the Transport Provider. This may look a little strange so I also recommend that you utilize the Memo to include a note regarding this scenario (be sure to exclude any provider or patient identifiers from this free-text section). Life Flight is still your transport provider even though they rode in the ALS ambulance since they are now caring for the patient. The information from the Life Flight’s trip sheet will still be used in the Transport section for vitals and other information.
For PTOS, the scene is the scene of injury. Therefore, it would be the patient’s home.
You may enter 1, yes. It sounds like you have documentation from the non-acute care hospital. If this is the case, you will enter 2, no, for is this a transfer patient element. But you will then enter 1, yes, for documentation available from outside facility on the Referring Facility tab.