Version 2016.0

Effective for January 1, 2016 admissions

Acknowledgements

The NORTN TACR Data Dictionary has been developed according to the OH-TACR which is maintained by the Ohio Department of Public Safety and the NTDS with is maintained by the National Trauma Data Bank.

NORTN Trauma Data Purpose

The purpose of the NORTN Trauma Data is to enhance trauma care and system performance in the Northeast region of Ohio through collaboration, data-driven performance improvement and coordinated educational programs.

Analysis of Registry data by NORTN staff, NORTN Data Manager Committee; NORTN Performance Improvement Committee, vendors, and/or consultants.

NORTN employees, members, and affiliates are bound by Confidentiality Agreements and Provider Agreements with contributing hospitals. Discussions regarding database contributors will be limited to official registry business. All individual hospital data is strictly confidential.

INTERFACE WITH THE STATE TRAUMA REGISTRY

NORTN Registry has incorporated all data elements required by the Ohio Trauma Registry which is housed at the Division of EMS Ohio Department of Public Safety (ODPS). A few additional data elements have been added to NORTN Registry in order to gain a more precise picture of trauma specific to Northeast Ohio.

Ohio Hospitals are mandated by Ohio Law to submit trauma data to the State Trauma Registry. The Ohio Revised Code allows hospitals to submit data to the State of Ohio Trauma Acute Care Registry (TACR) via regional registries such as NORTN. The NORTN Registry is not responsible to the State of Ohio for data not provided by the individual hospitals to NORTN. Data submitted to the State of Ohio Trauma Registry will be downloaded through the State’s database by NORTN personnel.

Although the dictionary shows XML references, the files will be sent from NORTN facilities to the regional database through CDM proprietary format and then converted into XML when regional information is uploaded to the TACR.

PROVIDING QUALITY DATA

This Data Dictionary is a tool to assist health information abstractors and trauma registrars in interpreting the Data Elements for NORTN Registry. (The data elements mandated by the State Trauma Registry and the National Trauma Registry are included in NORTN Registry.) Data abstractors may at times interpret certain data fields differently. Quality data is dependent upon accurate and consistent abstracting of data elements by all registry participants. Data abstractors should read this manual in its entirety before beginning data collection.

All abstractors for NORTN Registry should receive an orientation training session before starting data collection. For tutorial/training related to their computerized trauma registry, call Clinical Data Management, Inc. (CDM), the software vendor, at the number listed below. Telephone support is available to answer questions or provide additional clarification as needed.

Northeastern Ohio Regional Trauma Network (NORTN)

Deanah Moore, RHIT – 419-349-3193

Clinical Data Management, Inc. (CDM)

(303) 670-3331

TIMELINE FOR REPORTING: WHEN IS DATA DUE?

The NORTN Registry should have individual hospital data within 60 days after the end of each quarter. Data should be reported quarterly based on the patient’s discharge date. For example, if a patient’s discharge date is February 22, this data should be reported with the 1st quarter data by June 15. Data is needed according to this time frame in order to prepare it for a quarterly export to the State Registry. Data is sent to the State Registry within 90 days of the conclusion of each quarter. NORTN downloads data to the State Registry based on the deadlines.

Collection Period /

Submission Date to NORTN

/

Submission Deadline to State of Ohio

1st Quarter 01/01 – 03/31 / 06/15 / 6/30
2nd Quarter 04/01 – 06/30 / 09/15 / 9/30
3rd Quarter 07/01 – 09/30 / 12/15 / 12/30
4th Quarter 10/01 – 12/31 / 03/15 / 3/30

CONTACTING NORTN REGISTRY

Deanah Moore, RHIT

419-349-3193

Table ofContents

Submission Date to NORTN

Submission Deadline to State of Ohio

Northeastern Ohio Regional Trauma Network - Trauma Acute Care Registry (NORTN-TACR)

NORTN Inclusion/Exclusion Criteria - ICD-10

COMMON NULL VALUES

HOSPITAL CODE

TRAUMA TRACKING NUMBER

UNIQUE ADMISSION NUMBER

DATE EXPORTED

PATIENT’S HOME CITY

PATIENT’S HOME STATE

PATIENT’S HOME COUNTY

PATIENT’S HOME ZIP CODE

PATIENT’S HOME COUNTRY

ALTERNATE HOME RESIDENCE

DATE OF BIRTH

AGE

AGE UNITS

SEX

RACE

ETHNICITY

*CAUSE CODE (NORTN)

*INJURY DETAILS(NORTN)

*TRAUMA TYPE (NORTN)

PRIMARY ICD-10 EXTERNAL CAUSE CODE4

ADDITIONAL ICD-10 EXTERNAL CAUSE CODE...... ……………….………………………………………………..35

ICD-10 PLACE OF OCCURANCE CODE …………………....……………………………………………..……………………………………………………36

WORK-RELATED...... 37

PATIENT’S OCCUPATIONAL INDUSTRY...... 38

PATIENT’S OCCUPATION...... 39

INJURY INCIDENT DATE

INJURY INCIDENT TIME

*INCIDENT STREET ADDRESS (NORTN)

INCIDENT CITY

INCIDENT STATE

INCIDENT COUNTY

INCIDENT LOCATION ZIP CODE

INCIDENT COUNTRY

*EXTRICATION (NORTN)

PROTECTIVE DEVICES

CHILD SPECIFIC RESTRAINT

AIRBAG DEPLOYMENT

REPORT OF PHYSICAL ABUSE (NTDS)2

INVESTIGATION OF PHYSICAL ABUSE (NTDS)3

CAREGIVER AT DISCHARGE (NTDS)4

TRANSPORT MODE FOR ARRIVAL AT YOUR HOSPITAL...... 55

OTHER TRANSPORT MODES6

TRANSPORT AGENCY (OTR)

*SCENE EMS RUN REPORT PRESENT(NORTN)

*INTER-FACILITY TRANSFER EMS RUN REPORT PRESENT (NORTN)

EMS DISPATCH DATE TO SCENE OR TRANSFERRING FACILITY

EMS DISPATCH TIMETO SCENE OR TRANSFERRING FACILITY

EMS UNIT ARRIVAL DATE AT SCENE OR TRANSFERRING FACILITY2

EMS UNIT ARRIVAL TIME FROM SCENE OR TRANSFERRING FACILITY

EMS UNIT DEPARTURE DATE FROM SCENE OR TRANSFERRING FACILITY

EMS UNIT DEPARTURE TIME FROM SCENE OR TRANSFERRING FACILITY

INITIAL FIELD SYSTOLIC BLOOD PRESSURE

INITIAL FIELD PULSE RATE

INITIAL FIELD RESPIRATORY RATE

INITIAL FIELD OXYGEN SATURATION

INITIAL FIELD GCS - EYE

INITIAL FIELD GCS - VERBAL

INITIAL FIELD GCS - MOTOR2

INITIAL FIELD GCS - TOTAL3

INITIAL FIELD GCS QUALIFIER4

SCENE INTERVENTIONS (OTR)5

INTER-FACILITY TRANSFER6

TRANSFERRING HOSPITAL CODE (OTR)

TRAUMA CENTER CRITERIA (NTDS)...... 7

VEHICULAR, PEDESTRIAN, OTHER RISK INJURY (NTDS)...... 7

PREHOSPITAL CARDIAC ARREST0

ED/HOSPITAL ARRIVAL DATE...... 81

ED/HOSPITAL ARRIVAL TIME2

TRAUMA ACTIVATION LEVEL (OTR)3

*VITAL SIGNS NUMBER (NORTN)4

*VITAL SIGNS LOCATION (NORTN)5

INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE6

INITIAL ED/HOSPITAL PULSE RATE...... 87

INITIAL ED/HOSPITAL RESPIRATORY RATE...... 88

INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE...... 8

INITIAL ED/HOSPITAL OXYGEN SATURATION

INITIAL ED/HOSPITAL SUPPLEMENTAL OXYGEN

INITIAL ED/HOSPITAL TEMPERATURE

INITIAL ED/HOSPITAL GCS - EYE3

INITIAL ED/HOSPITAL GCS - VERBAL4

INITIAL ED/HOSPITAL GCS - MOTOR5

INITIAL ED/HOSPITAL GCS - TOTAL6

INITIAL ED/HOSPITAL GCS ASSESSMENT QUALIFIERS...... 97

HEIGHT...... 98

WEIGHT

ED DISCHARGE ORDER WRITTEN TIME (OTR)...... 100

ED DISCHARGE ORDER WRITTEN DATE (OTR)...... 101

ED DISCHARGE DATE

ED DISCHARGE TIME3

ED DISCHARGE DISPOSITION

ED TRANSFER TO HOSPITAL (OTR)

*DELAY IN TRANSFER (NORTN)

*REASON FOR TRANSFER (NORTN)

COMMENTS

SIGNS OF LIFE

ALCOHOL USE INDICATOR0

ALCOHOL LEVEL RANGE (OTR)

DRUG USE INDICATOR2

*ADMITTING SPECIALTY (NORTN)3

*HOSPITAL PROCEDURE CODE (NORTN)4

PROCEDURE EPISODE (OTR)7

*PROCEDURE LOCATION (NORTN)8

HOSPITAL PROCEDURES ICD-10

HOSPITAL PROCEDURE START DATE0

HOSPITAL PROCEDURE START TIME

CO-MORBID CONDITIONS2

DNR STATUS3

INJURY DIAGNOSES ICD-10

*INJURY DIAGNOSES DESCRIPTION (NORTN)

*ISS BODY REGION (NORTN)6

AIS PRE-DOT CODE27

AIS SEVERITY28

AIS VERSION9

INJURY SEVERITY SCORE0

TOTAL ICU LENGTH OF STAY1

TOTAL VENTILATOR DAYS2

HOSPITAL DISCHARGE ORDER WRITTEN DATE (OTR)...... 135

HOSPITAL DISCHARGE ORDER WRITTEN TIME (OTR)……………………………………………………………………………………………….136

HOSPITAL DISCHARGE DATE7

HOSPITAL DISCHARGE TIME8

HOSPITAL DISCHARGE DISPOSITION

INPATIENT TRANSFER TO HOSPITAL (OTR)0

LENGTH OF STAY (OTR)1

DISCHARGE STATUS (OTR)2

TIME OF DEATH (OTR)3

PRIMARY METHOD OF PAYMENT4

*BILLED HOSPITAL CHARGES (NORTN)5

*ORGANS/TISSUE REQUESTED (NORTN)6

AUTOPSY PERFORMED (OTR)7

COMPLICATIONS...... 148

GLOSSARY OF TERMS – DISCHARGE DISPOSITION49

GLOSSARY OF TERMS - COMORBID CONDITIONS...... 150

GLOSSARY OF TERMS - COMPLICATIONS...... 154

GLOSSARY OF ABBREVIATIONS...... 163

CHANGE LOG4

Northeastern Ohio Regional Trauma Network- Trauma Acute Care Registry (NORTN-TACR)

TRAUMA PATIENT DEFINITION

In order to ensure consistent data collection within the NORTN region, across the State of Ohio and following the National Trauma Data Standard, a trauma patient is defined as a patient sustaining a traumatic injury and meeting the patient inclusion criteria described below.

PATIENT INCLUSION CRITERIA - ICD 10

To be included in the NORTN - Trauma Acute Care Registry (TACR),

  1. The patient must incur at least one of theinjury 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)

  1. The patient MUST ALSO:
  • Be admitted for the first time to a hospital or hospital observation unit as defined by a physician order regardless of the length of stay, with the injury having occurred no more than 30 days prior to arrival; AND/OR
  • Be transferred via EMS transport (including air ambulance) from one hospital, or free standing emergency department to another hospital regardless of the patient’s hospital length of stay; AND/OR
  • Have an outcome of death resulting from the traumatic injury (independent of hospital admission or hospital transfer status).

PATIENT EXCLUSION CRITERIA

Patients with the following isolated ICD-10-CM codes areEXCLUDED from the TACR:

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 the 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.

NORTN TACR Inclusion/Exclusion Decision Tree – ICD-10


Was the patient transferred to (or from) your hospital via another hospital, or Free Standing Emergency Department using EMS or air ambulance?

COMMON NULL VALUES

Data Format is single-choice.

Definition

Common Null Values are terms to be used with NORTN-TACR Data Elements as described in this document for specifically-defined data fields when an answer cannot be provided.

Field Values

NA= Not Applicable

ND= Not Known/Not Recorded/Not Documented

Additional Information

  • Although not written out on the following pages, these Common Null Values are included in the NORTN-TACR dataset for every allowable data field. To ascertain their allowability by data field, see the “Accepts Null Value” notation on every data field descriptor page.
  • Not Applicable (Field Value NA): This null value code applies if, at any time of patient care documentation, the information requested was “Not Applicable” (NA)to the patient, the hospitalization or the patient care event. For example, variables documenting EMS care would be NA if a patient self-transports to the hospital.
  • Not Known/Not Recorded/Not Documented (Field Value ND): This null value applies if, at the time of patient care documentation, information was “Not Known” (to the patient, family, healthcare provider) or no value for the element was recorded for the patient. This documents that there was an attempt to obtain information, but it was unknown by all parties or the information was missing at the time of documentation. For example, injury date and time may be documented in the hospital patient care report as “Unknown”. Another example, Not Known/Not Recorded/Not Documented should also be coded when documentation was expected, but none was provided (i.e., no EMS run sheet in the hospital record for patient transported by EMS).
  • For any collection of data to be of value and reliably represent what was intended, a strong commitment must be made to ensure the correct documentation of incomplete data. When data elements associated with the TACR are be electronically stored in a database or moved from one database to another, the indicated null values should be applied.

References to Other Databases

  • Compare with NHTSA V.2.10 – E00
  • Compare with NTDS V.1.2.5
  • Compare with OH-TACR

HOSPITAL CODE

Data Format is numeric.

Definition

Hospital Code is a four-digit (4) hospital code assigned by the Ohio Department of Public Safety.

TACRData Type / xs-facility / NORTN-TACR Element/Domain (Simple Type) / Facility
Multiple Entry Configuration / No / Accepts Null Value / No
Required in NORTN-TACR / Yes

Field Values

  • Relevant value for data element

Additional Information

  • Stored as a four digit code (xxxx)

Data Source Hierarchy

  • Ohio department of public safety hospital code list

TRAUMA TRACKING NUMBER

Data Format is numeric.

Definition

Trauma Tracking Number is a sequentially assigned number in the trauma database. This number is individually assigned and never repeated.

NORTN-TACR Data Type / xs-traumatrack / NORTN-TACR Element/Domain (Simple Type) / TraumaTrack
Multiple Entry Configuration / No / Accepts Null Value / No
Required in NORTN-TACR / Yes

Field Values

  • Relevant value for data element

Additional Information

  • This number is individually assigned and never repeated.

Data Source Hierarchy

1 Hospital’s trauma registry tracking number

UNIQUE ADMISSIONNUMBER

Data Format is numeric.

Definition

Unique AdmissionNumber is a number assignedto the trauma patient at your facility. A patient encounternumber or account number can be used.

NORTN-TACR Data Type / xs-idno / NORTN-TACR Element/Domain (Simple Type) / IDNo
Multiple Entry Configuration / No / Accepts Null Value / No
Required in NORTN-TACR / Yes

Field Values

  • Relevant value for data element

Additional Information

  • Use an identifiable number specific to your facility, e.g. patient encounter or account number

Data Source Hierarchy

1 Hospital’s trauma registry tracking number

DATE EXPORTED

Data Format is a date.

Definition

Date Exported is the date the record was submitted to the NORTN-TACR.

NORTN-TACR Data Type / xs-exportdate / NORTN-TACR Element/Domain (Simple Type) / ExportDate
Multiple Entry Configuration / No / Accepts Null Value / No
Required in NORTN-TACR / Yes

Field Values

  • Relevant value for data element

Additional Information

  • Collected as MMDDYYYY

PATIENT’S HOME CITY

Data Format issingle-choice.

Definition

Patient’s Home City is the patient’s city, township, or village of residence.

NORTN-TACR Data Type / xs-string / NORTN-TACR Element/Domain (Simple Type) / HomeCity
Multiple Entry Configuration / No / Accepts Null Value / Yes, common null values
Required in NORTN-TACR / Yes

Field Values

  • Relevant value for data element

Additional Information

  • Used to calculate FIPS code

Data Source Hierarchy

1ED Admission Form

2Billing Sheet/Medical Records Coding Summary Sheet

3EMS Run Sheet

4Triage Form/Trauma Flow Sheet

5Emergency Department (ED) Documentation

References to Other Databases

  • NHTSA V.2.2 – E06_05
  • NTDS 1.2.5
  • OH-TACR

PATIENT’S HOME STATE

Data Format is single-choice.

Definition

Patient’s Home State is the state, territory, or province (or the District of Columbia)of the patient’s residence.

NORTN-TACR Data Type / xs-string / NORTN-TACR Element/Domain (Simple Type) / HomeState
Multiple Entry Configuration / No / Accepts Null Value / Yes, common null values
Required in NORTN-TACR / Yes

Field Values

  • Relevant value for data element (two digit FIPS code)

Additional Information

  • Used to calculate FIPS code

Data Source Hierarchy

1ED Admission Form

2Billing Sheet/Medical Records Coding Summary Sheet

3EMS Run Sheet

4Triage Form/Trauma Flow Sheet

5ED Documentation

References to Other Databases

  • NHTSA V.2.2 – E06_07
  • NTDS 1.2.5
  • OH-TACR

PATIENT’S HOME COUNTY

Data Format is single-choice.

Definition

Patient’s Home County is the patient’s county (or parish) of residence.

NORTN-TACR Data Type / xs-string / NORTN-TACR Element/Domain (Simple Type) / HomeCounty
Multiple Entry Configuration / No / Accepts Null Value / Yes, common null values
Required inNORTN-TACR / Yes

Field Values

  • Relevant value for data element

Additional Information

  • Used to calculate FIPS code

Data Source Hierarchy

1ED Admission Form

2Billing Sheet/Medical Records Coding Summary Sheet

3EMS Run Sheet

4Triage Form/Trauma Flow Sheet

5 ED Documentation

References to Other Databases

  • NHTSA V.2.2 – E06_06
  • NTDS 1.2.5
  • OH-TACR

PATIENT’S HOME ZIP CODE

Data Format is numeric text.

Definition

Patient’s Home Zip Code is thezip code of the patient’s primary residence.

NORTN-TACR Data Type / xs-zip / NORTN-TACR Element/Domain (Simple Type) / HomeZip
Multiple Entry Configuration / No / Accepts Null Value / Yes, common null values
Required in NORTN-TACR / Yes

Field Values

  • Relevant value for data element

Additional Information

  • Stored as a 5 digit code (XXXXX).
  • May require adherence to HIPAA regulations.

Data Source Hierarchy

1Billing Sheet/Medical Records Coding Summary Sheet

2ED Admission Form

3EMS Run Sheet

4Triage Form/Trauma Flow Sheet

5ED Documentation

References to Other Databases

  • NHTSA V.2.2 – E06_08
  • NTDS 1.2.5
  • OH-TACR

PATIENT’S HOME COUNTRY

Data Format is single-choice.

Definition

Patient’s Home Country is thecountry where the patient resides.

NORTN-TACR Data Type / xs-string / NORTNTACR Element/Domain (Simple Type) / HomeCountry
Multiple Entry Configuration / No / Accepts Null Value / Yes, common null values
Required in NORTN-TACR / Yes

Field Values

  • Relevant value for data element (two digit alpha country code)

Additional Information

  • Values are two character fields representing a country (e.g. U.S.)

Data Source Hierarchy

1Billing Sheet/Medical Records Coding Summary Sheet

2ED Admission Form

3EMS Run Sheet

4Triage Form/Trauma Flow Sheet

5ED Documentation

References to Other Databases

  • NHTSA V.2.2 – E06_09
  • NTDS 1.2.5
  • OH-TACR

ALTERNATE HOME RESIDENCE

Data Format is single-choice.

Definition

Alternate Home Residence is documentation of the residential status of a patient who has no home zip code.