Frequently Asked Questions

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.

Fentanyl is recorded under opioids and should not be captured separately.  

This check was generated as a 3-day ED LOS is unusual. As long as you verified your data entry, and it is correct, you can simply verify this check.     

The only time the Others Called to ED section is required to be used is when the record is determined by your center to be an emergent case. And even in these situations, only specific providers are required to be captured based on those that are required to respond to the patient within a certain amount of time per the Standards of Accreditation. Note, Internal Medicine is not included as a required provider to respond. For all other situations, you can really use the Others Called to ED section to capture provider called and arrived times as your trauma program sees fit.
If you wish to capture Internal Medicine as a consult and they are called and see the patient prior to the patient leaving the ED, you would capture the Internal Medicine consult solely on the ED Response tab under Others Called to ED. The ED phase of care for PTOS is defined as from the time of ED hospital arrival through the time they physically leave the ED.

That is for all studies, yes.

I recommend recording unknown as the determination of supplemental oxygen should be made during the assessment of the initial ED/hospital oxygen saturation level. In this situation the initial O2 sat is documented at 14:59 with no documentation of supplemental oxygen.

You are correct that you do not need to capture procedures for coexisting medical conditions. Only procedures related to evaluation and treatment of injury are required to be included in PTOS. However, if the blood products were given within first 4 hours after ED/hospital arrival, you do need to capture those volumes appropriately under the blood product data elements as there is not exclusion for medical conditions unrelated to the trauma for these data elements.

Yes, if an incomplete GCS is documented, record as many of the GCS items as are available. This includes the Total GCS. You may record individual scores with a GCS of 3 [1,1,1] or 15 [4,5,6] recorded in the medical record.

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.

First, I want to remind you that the sequential neurological documentation data element is optional and is no longer submitted to the central site. Centers now have the liberty to abstract this data element as they see fit for their institution, or not at all. In other words, this data element is a facility-specific data element, and is no longer part of the PTOS dataset.

If you would like to abstract this data element based on the definition that was applicable 2021 and prior, it does look like pneumocephalus is coded to the head region in AIS. Therefore, 1 (yes) or 2 (no) should be recorded for the sequential neuro data element. Option 3 for head or spine injury not present would not apply. I don’t see anything in the AIS coding guidelines that states pneumocephalus should not be coded in addition to a Lefort fracture.

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.

In situations where patients fall in place while going up steps, we recommend recording a fall height of 0 = fall on same level. This is only true if their fall did not result in a fall down the stairs. For mechanism in ICD-10, you will use the category for fall from/on stairs.

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 to ICD-10-CM coding guidelines, adult and child abuse, neglect and maltreatment are classified as assault. Any of the assault codes may be used to indicate the external cause of any injury resulting from the confirmed abuse. For cases of confirmed abuse or neglect an external cause code from the assault section (X92-Y09) should be added to identify the cause of any physical injuries. A perpetrator code (Y07) should be added when the perpetrator of the abuse is known. For suspected cases of abuse or neglect, do not report external cause or perpetrator code. Lastly, if the intent (accident, self-harm, assault) of the cause of an injury or other condition is unknown or unspecified, code the intent as accidental intent.

Regardless of an assault or abuse as the presenting injury, you will answer the element “was the patient being evaluated for abuse as “yes” as long as the patient has a workup for physical or sexual abuse at your facility due to the presenting injury event. To code mechanism of injury correctly when abuse is suspected or confirmed, you will need to follow the guidelines in the reference document mentioned above and the current PTOS Manual.

The current definition for Advanced Directive Limited Care states “the patient had a written request limiting life-sustaining therapy, or similar advanced directive, present prior to arrival at your center.” If the refusal for blood products due to religious reasons was documented in the patient’s chart prior to arrival at your center, I recommend capturing this pre-existing. If there was no documentation prior to patient arrival at your center, I recommend not capturing.  “Prior to patient arrival” is defined as present on their person on arrival or already on file at your center.

Note that this definition will be changing significantly for 2022 admissions. Happy to explore this same scenario further if it arises again in the future.

Any previous head injury that caused anything from drowsiness to severe injury. When we say “A TBI must be clearly documented” this means any brain injury, so SDH qualifies. You do not need the actual text of “TBI”. You would often only see that wording if they don’t get a diagnosis.

This definition is very specific. Both the NTDS definition and PTOS definitions are consistent with the American Psychological Association (APA) DSM 5, 2013, and documentation of “depression” is not the same as the diagnosis of a major depressive disorder. The patient must have a diagnosis of a major depressive disorder OR received treatment for major depressive disorder in order to capture this pre-existing condition. The same is true for “anxiety.” Documentation of “anxiety” is not the same as social anxiety disorder. You will only capture this pre-existing if the patient has a diagnosis of social anxiety disorder OR there is documentation of treatment for social anxiety disorder.

In these situations, Height of Fall is recorded with an I for inappropriate. You can record any additional information you wish (excluding patient/provider specific information (PHI)) in the Cause of Injury Specify field.

Per ICD-10 guidelines, SUV is included in the same category as pick-up truck or van. Although Jeep is not specifically defined in ICD-10, I recommend including Jeeps in the SUV/pick-up truck or van category.

No, PTSF does not recommend capturing Functionally Dependent Health Status with documentation of a prosthetic eye as a prosthetic eye is more aesthetic than functional.

D.08 is not limited to the three listed, those are examples. I could not find the specific reference document on the ASH website either, but we’ve understood that this list is not all inclusive.

The NTDB FAQ’s does tell us to report bleeding disorder for thrombocytopenia. It is for any condition where the blood does not clot properly.

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.

The S73 code has an Excludes 2 note, excluding dislocation of prosthetic. So if all that is dislocated is the prosthetic, it directs to use the T84 code, which does not qualify for inclusion. Excludes 2 means there could also code S73, if there is injury to anything (hip) other than the prosthetic.

Thanks for the question, and sorry for the confusion. For brain injury, AIS does direct to take findings from what is present at 24 hours, unless initially identified later. In October 2019, the AIS clarification document updated the 24 hour rule. It states, “Within the first 24 hours post injury, patients with transient signs and symptoms should be coded even if they are resolved within the 24 hour period.” This language now allows you to pick up a previously identified injury, even if no longer present. Note, AAAM also updated the same rule for spine injury, and allows transient symptoms to code. As far as size, you can continue your current practice. However, ensure the size you are recording is prior to any intervention.

If it is present on arrival, for the purposes of diagnoses, you can enter up to 35 c. You are correct that this is different from the hospital event definition.

Pathologic, chronic, age-indeterminate, stress, and traumatic fractures are all coded differently in ICD-10; only traumatic codes are included within the PTOS inclusion criteria.
AIS has clarified that osteophyte/bone spurs are not to be coded. We default to AIS rules, so osteophyte fractures should not be included.

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.

These are tricky scenarios, and clarification is typically needed from the provider in order to make a determination. We recommend querying the provider for clarification on whether this is a traumatic or pathological fracture.

The current PTOS patient criteria states that patients that are transferred in but discharged home from the ED should be excluded from PTOS. Even if the patient had an admission order, this is based on physical location of the patient. The patient can be captured as PTOS if they meet another portion of the criteria such as length of stay.

Note, for 2022 admissions, the language I mentioned will be removed from the PTOS inclusion criteria and you will capture the transfer in patient as PTOS even if they are discharged home from the ED.

No, this patient won’t be PTOS if the injury happened in your hospital while they were a patient. They do not need to be officially admitted, may be in ED or observation.

: Since this patient is a transfer in, you will include this patient as PTOS. A patient that meets the PTOS inclusion criteria prior to the order for hospice care, or the equivalent, should be captured as PTOS. If the patient would have come directly to your facility, they would have been excluded.

The reason for this inclusion/exclusion guidance is to ensure consistency statewide. It is our hope that this guidance will eliminate hospitals making differing determinations using variables that are not part of the inclusion criteria.

You only need to pick them up if they still have a qualifying injury diagnosis. If the patient has a diagnosis that falls within the inclusion criteria code range (lacerations are included) and meets another portion of the inclusion criteria (i.e. LOS, ICU admit, etc), they should be captured as PTOS. If the lacerations are resolved and not documented as an “active” or “current” diagnosis, you could exclude the patient because they would not have a diagnosis that falls within the inclusion code range. Note, cellulitis does not fall within our inclusion code range. If just cellulitis is documented, the patient would be excluded.

This is a good question. Since the abrasions are not injuries that fall within the accepted PTOS ICD-10-CM code range, this patient should be excluded from PTOS.

Note the following isolated injuries are excluded from PTOS:
S00, S10, S20, S30, S40, S50, S60, S70, S80, S90, *T68, T71.1 and T75.1 are excluded if no other
injuries are present

If the patient would have had hypothermia along with an injury that falls within the ICD-10-CM code range listed in the PTOS inclusion criteria, the patient would be captured as PTOS.

Since this patient is a transfer in, you will include this patient as PTOS. A patient that meets the PTOS inclusion criteria prior to the order for hospice care, or the equivalent, should be captured as PTOS. If the patient would have come directly to your facility, they would have been excluded.

I agree with you capturing this patient as PTOS and recording them as a transfer out since all of your documentation appears to indicate the patient was to go to the OSF via POV. Starting with 2021 admissions, the requirement for patients to go from one acute care facility to another via EMS or air ambulance was removed. Patients transferred in/out via private vehicle are now included in the transfer in/out criteria. Whether the patient makes it to the OSF or not is out of your control.

The patient would be NPTOS for the second encounter. This applies to existing injury and newly identified injury attributed to the same traumatic event.

Yes, these are the challenging cases. The idea is to exclude patients for whom your team has ruled out traumatic injury. If your team is transferring and has not ruled out injury, then include them. For example, you may not do imaging on peds patients that transfer out, the receiving facility will do it and you are trying to limit exposure for the kids. If you are sending them thinking there may be injury, they are PTOS for you. The determination at the other hospital may be different, but that is not a factor in your decision.

There is not a specific black and white rule to follow. These types of cases will need to be determined on a case by case basis.

That’s correct, any time in ICU (plus a qualifying diagnosis) is PTOS. Assuming your patient has a diagnosis, they would be picked up as PTOS.

These exact scenarios are why PTOS previously excluded transfers via private vehicle as transfer patients. However, per the current guidelines, yes, this patient would be considered a transfer in as long as the documentation supports that the patient was to go via private vehicle from the OSH to your institution.

That is correct! The patient meets the criteria because they were injured within 14 days of the initial hospital encounter.

Fall in (into) shower or empty bathtub is coded to W18.2XXA. This code does not fall within the solitary hip fracture exclusion; therefore, the patient should be considered for PTOS.

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.

The intent is not that this code be excluded. Part E essentially means a procedure code of 5A19_5Z is captured in the record.

For the PTOS, we recommend you record NO. While we do accept test results from prior to admission, a negative test on arrival at your hospital should be recorded with a NO response for the COVID-19 data element. We also recommend you do reach out to the NTDB for clarification regarding their specific COVID-19 data collection requirements.

Unfortunately, we do not have that information. We recommend you check with your financial, HIM, or billing department as insurance can vary regionally. These would be the best sources.

The following should be included:
• PTOS Patient = Y
• Did the Patient have a craniotomy for trauma = Yes
• Craniotomy procedure ICD10 is detected:
o Any Operative procedure (PR_01_I10…PR_84_I10) = that starts with 0N [8,9,B,R,T,U] [0,1,2,3,4,5,6,7,8,C,D,F,G,]0 OR
00[8,9,B,C,Q] [0,1,2,3,4,5,6,7,8,9,A,B,C,D]0
• AIS Codes between 140630 and 140636 OR AIS codes between 140650 and 140656

Note that there are differences between PTOS (PA) and the NTDS/TQIP in how COVID is captured. For PTOS, I recommend recording 3=not tested. This is because PTOS’ COVID element is specifically related to PCR testing. For the NTDS, you can capture COVID within the diagnoses since you do have physician documentation.

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.

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 to ICD-10-CM coding guidelines, adult and child abuse, neglect and maltreatment are classified as assault. Any of the assault codes may be used to indicate the external cause of any injury resulting from the confirmed abuse. For cases of confirmed abuse or neglect an external cause code from the assault section (X92-Y09) should be added to identify the cause of any physical injuries. A perpetrator code (Y07) should be added when the perpetrator of the abuse is known. For suspected cases of abuse or neglect, do not report external cause or perpetrator code. Lastly, if the intent (accident, self-harm, assault) of the cause of an injury or other condition is unknown or unspecified, code the intent as accidental intent.

Regardless of an assault or abuse as the presenting injury, you will answer the element “was the patient being evaluated for abuse as “yes” as long as the patient has a workup for physical or sexual abuse at your facility due to the presenting injury event. To code mechanism of injury correctly when abuse is suspected or confirmed, you will need to follow the guidelines in the reference document mentioned above and the current PTOS Manual.

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. Lastly, treatment must be within 48 hours of the aspiration.

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 to the OR data element, regardless of the location.”

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.

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.

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

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 the date of the call, the source at the ME office, the staff member at your facility who communicated with the ME office, and a summary of the conversation.

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.

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.

You are to record the first assessment of each vital sign after the patient leaves the facility.   

It sounds like you have two separate encounters here. The first, I’m assuming, is nonPTOS as the patient most likely left AMA prior to meeting a portion of the inclusion criteria (i.e. LOS).

The second encounter should be captured as a separate trauma record that will be PTOS. Information about the injury itself will remain the same; however, arrival information and care information should only be recorded in Collector based on the second encounter. For PTOS, you will enter the scene information based on the EMS provider who took him from his home to your center. I would encourage you to enter some information regarding the first encounter with this patient in your notes/memo sections of Collector. If you complete information in the yellow memo section, please remember to exclude any patient or provider identifying information as that information is sent to us at the central site.

The PTOS Manual provides examples of common paralyzing drugs under the Paralyzing Drugs data element. Rocuronium is included within these examples. Under GCS qualifiers, I recommend Rocuronium be recorded as a paralyzing drug and Ketamine be recorded under sedation. Note that each of these agents has a slightly different duration of action (as you mention), so their effect on the GCS depends on when they were given. You will only record Chemically Sedated or Chemically Paralyzed as a “yes” for the GCS Qualifiers data element if the drug was affecting the patient at the time the GCS score recorded was assessed. You will need to work with your trauma program to make that determination.

There is no specific timeframe. While intent is to document if there is a delay, there does not need to be a delay to report extrication.

We recommend using walk-in as the scene provider and recording the time of injury as the admission date/time. This allows for abstraction to really begin with the injury/fall and not with their initial admission at the referring facility.

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.

You will report “1 Yes” if the procedure was done at either the referring facility or your facility within 24 hours of injury.

This is a great question, and PTSF staff can’t find a specific code. We recommend root operation extraction, and then skin, or subcutaneous (whichever appropriate).