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.
There are no guidelines in the PTOS Manual that tell you not to use PACU as a post ed location, it just isn’t in the current menu as an option. I recommend recording 15, other, for Post ED Destination and specifying PACU in the Specify field that opens.
For Procedure Location, you can record 13, PACU.
If there is documentation and/or an order that the patient is a transfer out and is to report to a receiving facility, PTSF recommends this patient be captured as a transfer out. You may have other transfer out by private vehicle patients that do the same, stop somewhere, they just don’t tell you. It isn’t your responsibility to confirm the patient actually arrived at the receiving facility and when. As long as your facility ordered the transfer, you should capture the patient as a transfer out.
If, however, the direction was for the patient to go for follow- up (a scheduled surgery) later, then PTSF would recommend recording a discharge from the ED to home.
If the patient has multiple x-rays performed, there needs to be documentation of portable for all or documentation of the presence of the RN or CRNA, patient vital signs, and/or care rendered must be present for all x-rays that are not performed portable. If this is not the case, you should report 2, no, for this data element.
You are not to use data from the referring facility here. You must record the first height and weight documented within 24 hours of ED or hospital arrival at your facility.
You are correct that these are optional elements that are NOT required to be completed. PTSF will work with ESO to modify or remove this check.
You cannot record both a controlled and an uncontrolled rate in PTOS. The idea is that you are capturing the initial vitals. For respiratory rate, you are capturing the initial respiratory rate, which will be either controlled or uncontrolled.
If you are confident this information documented in the nursing notes is accurate, you can use it. I find it unusual it is not also documented elsewhere. I recommend you use caution and perhaps query the providers to ensure these medications were given to the patient.
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.
You are correct the abuse coding guidelines within the PTOS Manual instruct you to leave the secondary and tertiary fields blank in situations of suspected abuse. PTSF is working with ESO to remove the incorrect check. For the time being, please enter “/” for n/a in the secondary and tertiary fields and validate the check. PTSF will also correct the guidance within the PTOS Manual.
We recommend to always record the mechanism that caused the most severe injuries first. In this situation, we recommend the mechanism code for the strike by train as the primary and the mechanism for the electrocution as secondary based on the information provided.
In order to capture this as a pre-existing, the patient’s advanced directive to limit life-sustaining treatment must have been present on their person on arrival or already on file at your center.
Yes, your example would meet Advanced Directive assuming it was either on the patient’s person on arrival, or already on file with your hospital. It must be a written request (not verbal), limiting life-sustaining therapy, and present on arrival or prior. The NTDB has listed Living Will has one example of an Advanced Directive; other examples include Healthcare Power of Attorney, DNR. With your example being labeled Living Will and noting that they are specifically requesting not to be kept alive by artificial means or “heroic measures”, it would qualify.
That is correct. There must be documentation of the condition itself AND documentation of onset or increasing symptoms within 30 days prior to injury in order to include A.03-CHF as a PEC.
Mechanism of injury plays no role in the Pre-hospital Cardiac Arrest definition. This pre-existing condition should be considered for every PTOS patient regardless of their MOI or diagnoses.
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.
Interpeduncular cistern does code to brain stem. In the AIS clarification document from October 2019 they have
“Interpeduncular fossa (cistern) basal cisterns code as injury involving hemorrhage in the brainstem;”
The ICD-10 code has hemorrhage of brain stem also.
I would note any specifics related to LOC if you have documentation, as it will assume the LOC nfs otherwise.
If you have an AIS code recorded that falls within the defined coding criteria for these fields, you will need to answer the antibiotic elements as if there is an open fracture present for both PTOS and the NTDB. This criteria is provided by the NTDB/TQIP, and we understand sometimes it is not perfect as some non-open fractures do get included simply based on how they are coded in AIS. PTSF can provide the current list of AIS codes that fall within the criteria.
This could be used to code cerebrum brain swelling. Partial effacement would go to moderate; compressed – 140664.4, while complete effacement would go to severe; absent/obliterated/closed – 140666.5. I wouldn’t use edema unless the provider notes as edema.
Correct. You are to code brain injuries based on what is documented closest to or at 24 hours, or at initial confirmed diagnosis if later than 24 hours. If a head bleed is noted after the first 24 hours, that would be considered the initial confirmed diagnosis and you would capture the injury.
The guideline states, “coding of brain injuries should be done at 24 hours or at initial confirmed diagnosis if later than 24 hours.” Since the initial brainstem herniation was not initially diagnosed until after 24 hours, you can code it based on the information you have when the diagnosis was confirmed.
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.
It all comes down to the ICD-10-CM diagnosis code. Lacerations do typically fall within our ICD-10-CM inclusion code range. It is the superficial abrasions and contusions that are excluded.
If the patient has an ICD-10-CM diagnosis code that falls within the PTOS inclusion code range AND the patient meets another portion of the criteria (i.e. LOS, transfer, etc.), the patient should be captured as PTOS.
Treatment vs no treatment or medical admissions no longer play a role in determining inclusion.
Note we are discussing this further at registry committee. However, the current guidance should be followed.
Appendix 15 are examples for our solitary hip fracture exclusion. In order for a patient to meet this exclusion the patient must sustain a solitary hip fracture from a fall on the same level. It does not sound like from the information you provided that the patient fell. Therefore, the patient would not meet the exclusion.
Based on the information you provided, the patient should be considered for PTOS. The patient must have an injury diagnosis that falls within the ICD-10 inclusion code range AND meet another portion of the criteria (i.e. LOS, ICU admission, transfer, etc.).
If this second encounter is based on the same injury due to the fall as the first encounter, you will not capture as PTOS. If there is documentation that there was a new injury mechanism (i.e. another fall), the patient would be considered for PTOS as long as there was also a diagnosis that falls within our inclusion code range.
Yes, the code W18.2 is not in the exclusion list and so would meet PTOS criteria.
The patient had a new mechanism of injury (fall), and since he expired rapidly and no workup was completed, he can be captured as PTOS.
When the patient is made CMO prior to meeting PTOS then they are excluded. So with your patient in the ED, assuming they haven’t met the LOS requirement prior to the determination for comfort measures, then they would be excluded.
If your patient was in the ED for extended time and met LOS before they went to CMO, then they would be included.
‘Admission to’ for our purposes can be admission to a hospice unit, service change, or just the status change/order for CMO, palliative care, hospice.
Yes, that is correct based on the current guideline. A fall sustained while a patient at any acute care hospital is considered a complication of medical care and is not picked up.
There is currently no flag for the NTDB/TQIP or a check in PTOS that generates if the injury date/time is unknown regarding the 14-day requirement. Therefore, it is the default that patients with unknown injury dates and times are to be considered for inclusion. If the patient has a documented injury that falls within the ICD-10 inclusion code range and meets another portion of the criteria, they should be captured as PTOS.
No, not necessarily. If they are saying this is osteoporotic, and therefore pathological, then no it wouldn’t be PTOS. That could get coded to M80.08XA, Age-related osteoporosis with current pathological fracture, vertebra OR M80.88XA, Other osteoporosis with current pathological fracture, vertebra. Neither of those two codes are in our inclusion.
In order to qualify for PTOS, it has to be determined as a traumatic fracture, not pathological. Then it would be assigned a traumatic fracture code in the inclusion criteria. You may need to query your surgeon for determination.
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.
With physician documentation of a false positive, and negative test results following, you will enter negative.
With patients now being tested multiple times during their stay, if they test positive at any point, we are directing to record a positive result. If you did not have the physician documentation and negative result confirmation, then you would have reported positive.
You are correct that TRISS will not calculate for every patient. TRISS EOE, which is a Pennsylvania specific estimated TRISS used in these situations, is planned to be included in the next software platform.
You can absolutely use the yellow memo field after the diagnosis tab in Collector! It is the only memo field that transfers information to PTSF. We often suggest using it to describe unusual scenarios (additional prehospital info, for example), not just for diagnoses. However, please do NOT include any patient or provider identifiers in this free-text field. Use of this memo field does result in errors only if copy and/or paste is used. You cannot use copy/paste functionality in Collector. It may look fine, but when processed at the state, or when the interface is run to v5, errors are the result. Simply avoid copy/paste, and all will be well!
The best resource to use for this is the PTOS Element History. In the Comments column it will note if the element is an optional element. Note on the Element History that elements titled in blue are current; elements with no highlight are retired.
Your best practice is to delete the second record entirely, and not reuse the number. If it was already copied over into v5 with the interface, then you want to delete it there as well. If you haven’t submitted to us yet, we will not need to delete here. But before you delete, ensure that you do change it to NPTOS, just in case it would still be in the system when the transfer process is run.
It depends. Some fields have checks that won’t allow blanks, while others you can pass through.
Registrars may use the discharge destination specify field in specific situations listed in the manual (one example is to enter Home when discharge to SNF which is patient’s residence). Otherwise, can be left blank. This field used to be used for reason and mode of transfer out, but we have specific elements for those now.
Yes, the payor specify fields can be left blank (example: Medicare, with no MCO or other name). Some use these fields to track specific payor info that requires transfer, for example.
With no secondary payor, you can now enter “9 None”. This is a new option to report for 2021 admissions instead of n/a or leaving blank.
PTSF cannot speak to what you are allowed to access or what the appropriate use is for Care Everywhere in your facility. Proper access and use of an outside facility chart in a shared database in Epic is something you will need to discuss within your facility.
Specific to elements that you might abstract from the previous encounter, you can use pre-existing conditions that are documented if you do have access to outside facility charts. You could also capture referring facility information. Note that these fields are specific to facilities that send the patient directly to you. This can be an acute care hospital or a non-acute care facility, for example, an urgent care or residential facility. For these non-acute care facilities, you must answer NO as a transfer. You also do not want to include information from all facilities and providers. You must only record information regarding the care provided just prior to coming to your facility. EMS information is also something you may have access to within this system. Be sure to record the scene, transport, and/or interhospital transport information appropriately by following the definitions provided in the PTOS Manual.
If a physician confirms a positive or negative test result within 30 days, we would accept that documentation, and you can record a yes or no value for the COVID data element. We would not accept hearsay from a patient or family member etc. without physician confirmation.
DI was acquired by ESO in December 2019. There is no longer an annual DI conference you can attend. ESO does hold an annual conference called “Wave.” For 2021, this conference is in the form of a webinar series; however, it is typically held in person. ESO will not be presenting education at the 2021 PTSF Fall Conference. Training opportunities offered by ESO can be found at https://www.eso.com/hospital/di-by-eso-training/.
You are required to have a plan for IRR, but PTSF does not have any specific required process or number of records for IRR. It can include full record reabstraction or focused review. Reabstraction can be done by one or all registrars. Some ideas include:
• Full reabstraction of record by one registrar
• Full reabstraction of a record by all registrars (allows comparison)
• Focused reabstraction on identified areas (procedures, times, etc.)
• A registrar leader/supervisor reabstract from each registrar (allows a consistent ‘grading’).
If using a focused approach, full abstraction recommended at least periodically; especially following:
• Changes/upgrades to your hospital EMR
• Changes to PTOS data dictionary or the Collector software
• Staff turnover
The orange book (ACS) recommends review of 5-10 % of records as an approach. You can choose to do less than 5%, but you’ll want to be able to show your detailed process on survey day so they can see your IRR efforts are sufficient.
Educational visits by PTSF staff require an accuracy rate greater than or equal to 96%. We review every PTOS data element, and each is counted as 1 point. For 2021, each record has 412 possible points/data elements that are reviewed.
Lastly, we recommend you focus on PTOS patients when performing IRR. NonPTOS collection is for internal review and may include a very limited data set abstracted. If your center fully abstracts nonPTOS patients, you may want to include them in your IRR process to ensure your internal reporting is consistent and meaningful, but we recommend you focus on PTOS records.
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.
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 DVT hospital event.
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.
In these situations, you are to enter kidney one time. Even if multiple sections of skin were taken, for example, or long bone, you would enter only once. It is understood that while multiple donations may be made, they are not necessarily going to the same recipient.
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.
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 Room for PTOS as well as the NTDB/TQIP.
The only exclusion is for “pre-planned, staged and/or procedures for incidental findings.” Really, unless the OR is part of the patient’s initial plan, or the procedure is planned to explore further potential injuries for example, you will capture this hospital event. If you remember, the definition used to only capture re-admissions to the OR. Capturing all “unplanned” operative procedures is relatively new.
If you have concerns about the definition and would like to recommend that an exclusion be added to the definition, I recommend you submit a request through the NTDS Revision Site at https://web5.facs.org/ntdsrevisions.
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.
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.
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.
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 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.
If the x-ray is for the hip specifically, I recommend using the BQ0 code. If it is a diagnostic x-ray that is of the entire pelvis that happened to identify a hip injury, that is when I would use the BW01ZZZ code.
If you would like to send over the documentation you have, we can take a look and offer a better recommendation.
We recommend 0QS2XZZ (Reposition Right Pelvic Bone, External Approach) and 0QS3XZZ (Reposition Left Pelvic Bone, External Approach). Way back during ICD-10 implementation we submitted this same question to coding clinic, but we never heard back. However, we feel this is consistent with what others are using.
In ICD-10-PCS, the insertion of an endotracheal tube with subsequent mechanical ventilation requires only one procedure code. Per the Centers for Medicare and Medicaid Services’ ICD-10-PCS Reference Manual, the insertion of an endotracheal tube associated with the mechanical ventilation procedure is considered a component of the equipment used in performing the procedure and is not coded separately.
However, if a center wants to include intubation with the ventilation code, PTSF allows it. Since we don’t use the trauma registry coding for billing purposes, we do have the ability to be more lenient with the coding guidelines in some instances. If your facility would benefit from capturing both codes, you may do so.