Trauma Association of South Carolina
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Table of Contents
Introduction 3
Definition of Trauma Patient 4
Registry Inclusion/Exclusion Criteria 4
Data Elements……………………………………………………………………………………..6
Demographic Information 7
Injury Information 9
Pre Hospital Information 12
Emergency Department Information 20
Hospital Procedure Information 24
Injury Severity 26
Outcome Information 28
Introduction
This Data Dictionary contains inclusion and exclusion registry criteria and structured trauma data element definitions. This manual is to be used as a guide to trauma centers in South Carolina. The Data Dictionary serves to provide “help” to trauma professionals to understand data elements, as well as the data functions and features.
The Data Dictionary is divided into logical sections allowing the user to locate information quickly and easily.
The Data Dictionary provides the following:
• Registry inclusion and exclusion criteria
• Data element definitions and options
South Carolina Department of Health & Environmental Control
Division of Emergency Medical Services & Trauma
2600 Bull Street
Columbia, SC 29201-1708
Phone: (803) 545-4204 Fax: (803) 545-4563
|Definition of Trauma Patient |
| |
|A trauma patient is defined as a patient who sustains a traumatic injury |
| |
|and meets the inclusion/exclusion criteria approved by the Trauma |
| |
|Advisory Council and included in this data dictionary. |
Inclusion Criteria and Data Submit Dates
Include the following injuries:
At least one of the following injury diagnostic codes defined in the International Classification of Diseases, Tenth Revision (ICD-10-CM):
• S00-S99 with 7th character modifiers of A, B, or C ONLY. (Injuries to specific body parts – initial encounter)
• T07 (unspecified multiple injuries)
• T14 (injury of unspecified body region)
• T20-T28 with 7th character modifier of A ONLY (burns by specific body parts- Initial encounter)
• T30-T32 (burn by TBSA percentages)
• T79.A1-T79.A9 with 7th character modifier of A ONLY (Traumatic Compartment Syndrome – initial encounter)
AND MUST INCLUDE ONE OF THE FOLLOWING IN ADDITION TO (ICD -10-CM S00-S99, T07, T14, T20-T28, T30-T32 and T79.A1-T79.A9):
• Hospital admission OR
• Patient transfer via EMS transport (including air ambulance) from one hospital to another hospital OR
• Death resulting from the traumatic injury (independent of hospital admission or hospital transfer status)
Exclusion Criteria
Excluding the following isolated injuries:
ICD-10-CM:
• S00 (Superficial injuries of the head)
• S10 (Superficial injuries of the neck)
• S20 (Superficial injuries of the thorax)
• S30 (Superficial injuries of abdomen, pelvis, lower back, and external genitals)
• S40 (Superficial injuries of shoulder and upper arm)
• S50 (Superficial injuries of elbow and forearm)
• S60 (Superficial injuries of wrist, hand, and fingers
• S70 (Superficial injuries of hip and thigh)
• S80 (Superficial injuries of knee and lower leg)
• S90 (Superficial injuries of ankle, foot, and toes)
Late effect codes, which are represented using the same range of injury diagnosis codes but with the 7th digit modifier code of D through S, are also excluded.
Age > 65 years with same level fall (including but not limited to W18.30-W18.39) and isolated hip fracture (S72.00-S72.26)
Trauma Registry Data Submission Schedule
|ADMISSION PERIOD |DUE DATE |
|January – March |Due July 1 |
|April – June |Due October 1 |
|July – September |Due January 1 |
|October – December |Due April 1 |
**Whether the data point is a “State Element” or “National Element” is delineated in the right-hand column. If the data point is a “National Element” refer to the latest edition of the “ACS NTDB National Trauma Data Standard: Data Dictionary” for further information.
Demographics
TRAUMA NUMBER
Data Format [number] State Element
Definition: Indicates a unique number assigned to each trauma patient per visit at time of admission. This number is unique to the trauma patient.
Required: Yes
Field Values: Auto-calculated with creation of new record
STATE
Data Format [combo] single-choice State Element
Definition: Indicates if the trauma patient’s data is to be sent to the state central site registry.
Required: Yes
Field Values
Yes No
DATE OF BIRTH National Element
AGE National Element
AGE UNITS National Element
SEX National Element
RACE National Element
ETHNICITY National Element
PATIENT’S HOME ZIP CODE National Element
PATIENT’S HOME CITY National Element
PATIENT’S HOME STATE National Element
PATIENT’S HOME COUNTY National Element
ALTERNATE HOME RESIDENCE National Element
PATIENT’S HOME COUNTRY National Element
Injury Information
ICD-9 PLACE OF OCCURRENCE E-CODE National Element
ICD-10 PLACE OF OCCURRENCE E-CODE National Element
INJURY INCIDENT DATE National Element
INJURY INCIDENT TIME National Element
INDICATION LOCATION ZIP CODE National Element
INCIDENT CITY National Element
INCIDENT STATE National Element
INCIDENT COUNTY National Element
INCIDENT COUNTRY National Element
PROTECTIVE DEVICES National Element
CHILD SPECIFIC RESTRAINT National Element
AIRBAG DEPLOYMENT National Element
WORK-RELATED National Element
PATIENT’S OCCUPATION National Element
PATIENT’S OCCUPATIONAL INDUSTRY National Element
REPORT OF PHYSICAL ABUSE National Element
INVESTIGATION OF PHYSICAL ABUSE National Element
ICD-9 PRIMARY E-CODE National Element
ICD-10 PRIMARY E-CODE National Element
ICD-9 SECONDARY E-CODE National Element
ICD-10 SECONDARY E-CODE National Element
INJURY TYPE (Blunt/Penetrating)
Data Format [combo] single-choice State Element
Required: Yes
Definition: Indicates primary mechanism or type of force causing injury to trauma patient.
Field Values:
1. Blunt 2. Penetrating 3. Burn 4. Other
/- Not Applicable U- Unknown
Additional Information
• Blunt- Non penetrating injury, from an external force causing injury.
• Penetrating- Injury resulting from a projectile force, piercing instrument, and entering deeply causing tissue and/or organ injury.
• Burn- Tissue injury from excessive exposure to chemical, thermal, electrical, or radioactive agents.
Injury Mechanism (Cause of Injury)
Data Format [combo] single-choice State Element
Required: Yes
Definition: The event(s) that occurred to cause injury to patient.
Field Values
01. MVC 02. Motor Water Related Injury 03. Pedestrian
04. Bicycle 05. Motorcycle 06. Cut/Piercing
07. Stab 08. Gunshot Wound 09. Assault
10. Industrial 11. Farm 12. Fall
13. Sports 14. Burn 15. Other
16. Snake Bite 17. Asphyxiation 18. Injury by Animal
19. Moped 20. Four Wheel/ATV
U- Unknown
Additional Information
02. Motor Water Related - Includes boating, water skiing, jet skiing, para-sailing, etc.
04. Bicycle - Non-motorized two to four wheeled pedal cycle
10. Industrial - Accidents that occur in industry, plant, or factory facilities
11. Farm - Includes farming equipment or actual farming, whether private or non-private
13. Sports - Includes organized or recreational activity
14. Burn - Includes chemical, electrical, thermal, and radiation
15. Other- Includes Lawnmowers; Golf Cart
17. Asphyxiation - Includes hanging, drowning, and suffocation
18. Injury by Animal Related - Includes marine life, dog bites, etc.
19. Moped- Includes Motorized Scooters
21. Motor Water Related - Includes boating, water skiing, jet skiing, para-sailing, etc.
Pre-hospital Information
TRANSPORT MODE National Element
OTHER TRANSPORT MODE National Element
PREHOSPITAL EMS AGENCY (DHEC Number)
Data Format [combo] single-choice State Element
Definition:
Pre-hospital EMS Agency Name/DHEC Permit Number (including “0’s”) is shown on the ambulance run report and is the same as the providers license number.
Required - Yes
Field Values
Relevant code value for EMS agency
Additional Information
• List is provided of all EMS/Air Medical providers in the state.
Data Source Hierarchy
1. EMS Run Sheet
ROLE
Data Format [combo] single-choice State Element
Definition: The role EMS provider played in transport to facility.
Required - Yes
Field Values
1-Transport from scene 2-Transport from rendezvous 3-Non-transport
/- N/A ? - Unknown
Additional Information
None
Data Source Hierarchy
1. EMS Run Sheet
SCENE EMS REPORT:
Data Format [combo] single-choice State Element
Definition: Indicates if the EMS Run Form was available
Required - Yes
Field Values
1- Complete 2- Incomplete 3- Missing 4-Unreadable
/- Not Applicable U- Unknown
Data Source Hierarchy
1. EMS Run Sheet
PATIENT CARE REPORT NUMBER (PCR#)
Data Format –Alpha_Numeric State Element
Definition:
This number is unique per patient per incident. Pre-printed reports have six digits, and letters, however, electronic run reports may have any number of digits.
Required - Yes
Field Values
Relevant from the PCR
Additional Information
• EMS Report Number
Data Source Hierarchy
1. EMS Run Sheet
EMS DISPATCH DATE National Element
EMS DISPATCH TIME National Element
EMS UNIT ARRIVAL DATE AT SCENE OR TRANSFERRING FACILITY
National Element
EMS UNIT ARRIVAL TIME AT SCENE OR TRANSFERRING FACILITY
National Element
EMS UNIT DEPARTURE DATE FROM SCENE OR TRANSFERRING FACILITY National Element
EMS UNIT DEPARTURE TIME FROM SCENE OR TRANSFERRING FACILITY National Element
EMS SCENE TIME ELAPSED
Data Format: numerical State Element
Definition
Total EMS Scene Time (elapsed time from EMS scene arrival to EMS departure from scene)
Required - Yes
Additional Information
• Auto calculated
Data Source Hierarchy
1. EMS Run Sheet
TRAUMA CENTER CRITERIA National Element
**This data element should be “U-Unknown” until NEMSIS 3 is live in the State of South Carolina. As of 11/2014, NEMSIS 3 is not live in South Carolina. After go-live of NEMSIS 3, the pre-hospital provider will choose the corresponding field value as to specific reason the patient was transported to a Trauma Center.
VEHICULAR, PEDESTRIAN, OTHER RISK INJURY National Element
PRE-HOSPITAL CARDIAC ARREST National Element
INTUBATED State Element
Data Format: Single-Choice
Definition
Was the patient intubated by EMS
Required-Yes
Field Values:
Yes No /-Not Applicable ?-Unknown
Data Source Hierarchy
1. EMS Run Sheet
IF YES, METHOD
Data Format: Single-Choice State Element
Definition
If the patient was intubated by EMS, what was the method used for intubation
Required- Yes
Field Values:
1. Combitube 2. Cricothyrotomy
4. Endotracheal Tube-Nasal 5. Endotracheal tube-Oral
6. Endotracheal Tube0 Route NFS 7. Esophageal Obturator Airway
8. Laryngeal Mask Airway 9. LT Blind Insertion Airway Device
10. Tracheostomy ?-Unknown
Data Source Hierarchy
1. EMS Run Sheet
INITIAL FIELD SYSTOLIC BLOOD PRESSURE National Element
INITIAL FIELD PULSE RATE National Element
INITIAL FIELD RESPIRATORY RATE National Element
INITIAL FIELD OXYGEN SATURATION National Element
INITIAL FIELD GCS – EYE National Element
INITIAL FIELD GCS – VERBAL National Element
INITIAL FIELD GCS – MOTOR National Element
INITIAL FIELD GCS – TOTAL National Element
RTS (Revised Trauma Score)
Data Format [number] State Element
Definition
Is based on the values of the Glasgow Coma Scale, systolic blood pressure and respiratory rate. This field is calculated automatically or may be entered manually.
Required – Yes
Field Values
Between 0 to 12 – Auto calculated if all designated values completed.
Data Source Hierarchy
1. EMS Run Sheet
INTER-FACILITY TRANSFER National Element
REFERRING FACILITY (ID)
Data Format [combo choice] State Element
Definition
The name (or identifying number of the referring facility).
Required- Yes
Field Values
Relevant value for data element.
Additional Information
Data Source Hierarchy
1. Hospital Record
REFERRING FACILITY/HOSPITAL ARRIVAL
Data Format [date] State Element
Definition
The date the patient arrived at the referring hospital.
Required- Yes
Field Values
Relevant value for data element.
Additional Information
• Collected as YYYY-MM-DD.
• Used to auto-generate an additional calculated field: Length of Hospital Stay (elapsed time from arrival to departure)
Data Source Hierarchy
1. Hospital Record
REFERRING FACILITY/HOSPITAL DEPARTED
Data Format [date] State Element
Definition
The date the patient departed from the referring hospital.
Required- Yes
Field Values
Relevant value for data element.
Additional Information
• Collected as YYYY-MM-DD.
• Used to auto-generate an additional calculated field: Length of Hospital Stay (elapsed time from arrival to departure)
Data Source Hierarchy
1. Hospital Record
REFERRING FACILITY LOS
Data Format [numerical] State Element
Definition
The length of time the patient was at the referring facility in hours.
Required- Yes
Field Values
Relevant value for data element.
Additional Information
• Auto-calculated if Referring Facility/Hospital Arrival Data and Time and Departed Date and Time are entered.
Data Source Hierarchy
1. Hospital Record
Emergency Department Information
DIRECT ADMIT State Element
Data Format [combo] single-choice
Definition
Patient admitted directly to the floor or ICU without being resuscitated in the emergency department.
Required- Yes
Field Values
1. Yes 2. No
Data Source Hierarchy
1. History & Physical
2. Nurses Notes
3. Hospital Discharge Summary
4. EMS Sheet
5. Consults
ED/HOSPITAL ARRIVAL DATE National Element
ED/HOSPITAL ARRIVAL TIME National Element
ED DISCHARGE DATE National Element
ED DISCHARGE TIME National Element
TIME IN ED National Element
Data Format [numerical]
Definition
The length of time the patient was in the Emergency Department.
Required- Yes
Field Values
Relevant value for data element.
Additional Information
• Auto-calculated if ED/Hospital Arrival Date/Time and ED Discharge Date and Time entered.
Data Source Hierarchy
1. ED Record
2. Nurses Records
SIGNS OF LIFE National Element
MODE OF ARRIVAL
Data Format [combo] single-choice State Element
Definition
The mode of arrival of the patient at the hospital
Required - Yes
Field Values
1- Ground Ambulance 2-Helicopter Ambulance
3- Fixed-Wing Ambulance 4- Private Vehicle or Walk-In
5-Police 6- Public Safety
7- Water Ambulance 8- Other
?- Unknown
Data Source Hierarchy
1. Triage Form / Trauma Flow Sheet
2. ED Nurses’ Notes
INITIAL ED/HOSPITAL WEIGHT National Element
INITIAL ED/HOSPITAL HEIGHT National Element
INITIAL ED/HOSPITAL TEMPERATURE National Element
INITIAL ED/HOSPITAL GCS ASSESSMENT QUALIFIERS National Element
INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE National Element
INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE National Element
INITIAL ED/HOSPITAL PULSE RATE National Element
INITIAL ED/HOSPITAL RESPIRATORY RATE National Element
INITIAL ED/HOSPITAL OXYGEN SATURATION National Element
INITIAL ED/HOSPITAL SUPPLEMENTAL OXYGEN National Element
INITIAL ED/HOSPITAL GCS – EYE National Element
INITIAL ED/HOSPITAL GCS – VERBAL National Element
INITIAL ED/HOSPITAL GCS – MOTOR National Element
INITIAL ED/HOSPITAL GCS – TOTAL National Element
REVISED TRAUMA SCORE (RTS) State Element
Data Element Name: RTS (Revised Trauma Score)
Definition
Physiologic Injury Severity Score
Required: Yes
Field Values
Relevant value for data element; Range from 0 to 12.
Additional Information
• This field is calculated automatically or you can enter manually
• Based on the values of the Glasgow Coma Scale, Systolic Blood Pressure and Respiratory Rate
Data Source Hierarchy
1. Triage Form / Trauma Flow Sheet
2. ED Nurses’ Notes
ALCOHOL USE INDICATOR National Element
DRUG USE INDICATOR National Element
ED DISCHARGE DISPOSITION National Element
Hospital Procedure Information
ICD-9 HOSPITAL PROCEDURES National Element
ICD-10 HOSPITAL PROCEDURES National Element
HOSPITAL PROCEDURE START DATE National Element
HOSPITAL PROCEDURE START TIME National Element
Injury Severity Information
AIS VERSION National Element
LOCALLY CALCULATED ISS National Element
TRISS
Data Format Numeric State Element
Definition
Trauma Score Injury Severity Score determines the probability of survival (Ps) of a patient using the ISS and RTS.
Required: Yes
Field Values
Relevant value for data element.
Additional Information
• Patients must have an ISS score and a RTS in the Acute Care section for Collector to calculate.
This field is automatically calculated.
• You must have data in the following fields for a score to calculate:
▪ the patient’s age
▪ blunt or penetrating
▪ WRTS
▪ ISS
If any of these fields are blank or have unknown entered, the TRISS will not calculate.
ICD-9 INJURY DIAGNOSES National Element
ICD-10 INJURY DIAGNOSES National Element
AIS PREDOT CODE National Element
AIS SEVERITY National Element
ISS BODY REGION National Element
CO-MORBID CONDITIONS National Element
Outcome Information
HOSPITAL DISCHARGE DATE National Element
HOSPITAL DISCHARGE TIME National Element
TOTAL ICU LENGTH OF STAY National Element
TOTAL VENTILATOR DAYS National Element
TOTAL LENGTH OF STAY (Total LOS) State Element
Data Formant [number]
Definition
The cumulative amount of time spent at your hospital. Each partial or full day is measure as one day.
Required-Yes
Field Values
Relevant value for data element.
Additional Information
• Recorded in full day increments with any partial calendar day counted as a full calendar day.
• If any dates are missing then a LOS cannot be calculated.
Data Source Hierarchy
1. Nursing Flow Sheet//Progress Notes
2. Calculated Based on Admission Form and Discharge Sheet
HOSPITAL DISCHARGE DISPOSITION National Element
IF TRANSFRRED, FACILITY
Data Format [combo] single-choice State Element
Definition: Indicates the facility code to which the patient was transferred after admission to your hospital
Required: Yes
Field Values
Relevant value for data element
Additional Information
• Please select the appropriate hospital from the menu. All facilities in SC are listed, as well as common facilities in NC and GA. If a hospital is not on the list, choose, Other.
Data Source Hierarchy
1. EMTALA Form
2. Discharge Summary
3. Doctor’s Orders
4. Nurses’ Notes
5. Case Manager’s Notes
WAS AUTOPSY PERFORMED
Data Format [combo] single-choice State Element
O_05
Definition
Indicates if an autopsy was performed on deceased trauma patient
Required - Yes
Field Values
1. Yes 2. No /- Not Appropriate U- Unknown
Data Source Hierarchy
1. Death Form
2. Hospital Discharge Summary
3. Nurses’ Notes
PRIMARY METHOD OF PAYMENT National Element
COMPLICATIONS National Element
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Revised: January 2016
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