WTA Significance of Blush on CT Scan for Splenic Injuries

WTA Significance of Blush on CT Scan for Splenic Injuries

Data Dictionary

Table of Contents

Standard Study Questions 1 – 10

In-Hospital Case Information 11 – 50

Discharge Data 51 – 53

Appendix A 55 – 56

Standard Study Questions

Is this patient ONLY on the Western Trauma Association study?

Definition

The status of the subject regarding the Western Trauma Association Natural History of Pseudoaneurysm Study.

Field Values

Yes
No

Additional Information

· The value of “No” should be used if the patient is on BOTH the AAST SPOT study and the Western Trauma Association Natural History of Pseudoaneurysm Study.

Data Source Hierarchy

1. N/A

ADMIT DATE

Definition

The date the patient arrived to the ED/hospital.

Field Values

· Relevant value for data element.

Additional Information

· If the patient was brought to the ED, enter date patient arrived at ED. If patient was directly admitted to the hospital, enter date patient was admitted to the hospital.

· Collected as MM/DD/YYYY.

· This field is required.

Data Source Hierarchy

1. Triage Form / Trauma Flow Sheet

2. ED Record

3. Billing Sheet / Medical Records Coding Summary Sheet

4. Hospital Discharge Summary

ADMIT TIME

Definition

The time the patient arrived to the ED/hospital.

Field Values

· Relevant value for data element.

Additional Information

· If the patient was brought to the ED, enter time patient arrived at ED. If patient was directly admitted to the hospital, enter time patient was admitted to the hospital.

· Collected as HH:MM.

· HH:MM should be collected as military time.

· This field is required.

Data Source Hierarchy

1. Triage Form / Trauma Flow Sheet

2. ED Record

3. Billing Sheet / Medical Records Coding Summary Sheet

4. Hospital Discharge Summary

AGE

Definition

The patient’s age at the time of injury (best approximation).

Field Values

· Relevant value for data element

Additional Information

· Collected as a whole number.

· This field is required.

Data Source Hierarchy

1. ED Admission Form

2. Billing Sheet / Medical Records Coding Summary Sheet

3. EMS Run Sheet

4. Triage Form / Trauma Flow Sheet

5. ED Nurses’ Notes

GENDER

Definition

The patient’s sex.

Field Values

Male / Female

Additional Information

· Patients who have undergone a surgical and/or hormonal sex reassignment should be coded using the current assignment.

Data Source Hierarchy

1. ED Admission Form

2. Billing Sheet / Medical Records Coding Summary Sheet

3. EMS Run Sheet

4. Triage Form / Trauma Flow Sheet

5. ED Nurses’ Notes

RACE

Definition

The patient’s race.

Field Values

White / Other
African-American
Asian

Additional Information

· Patient race should be based upon self-report or identified by a family member.

· The maximum number of races that may be reported for an individual patient is 1.

Data Source Hierarchy

1. ED Admission Form

2. Billing Sheet / Medical Records Coding Summary Sheet

3. Triage Form / Trauma Flow Sheet

4. EMS Run Sheet

5. ED Nurses’ Notes

ETHNICITY

Definition

The patient’s ethnicity.

Field Values

Hispanic / Non-Hispanic

Additional Information

· Patient ethnicity should be based upon self-report or identified by a family member.

· The maximum number of ethnicities that may be reported for an individual patient is 1.

Data Source Hierarchy

1. ED Admission Form

2. Billing Sheet / Medical Records Coding Summary Sheet

3. Triage Form / Trauma Flow Sheet

4. EMS Run Sheet

5. ED Nurses’ Notes

HEIGHT

Definition

The height of the patient in centimeters.

Field Values

· Relevant value for data element (integer).

Additional Information

· Recorded to the nearest whole number. Do not include characters in the data field.

Data Source Hierarchy

1. Nursing Flow Sheet or admission assessment

2. Admission Form and Discharge Sheet

3. Nursing Progress Notes

4. Physician History and Physical

5. Physician Progress Notes

WEIGHT

Definition

The weight of the patient in kilograms.

Field Values

· Relevant value for data element (integer).

Additional Information

· Recorded to the nearest whole number. Do not include characters in the data field.

Data Source Hierarchy

1. Nursing Flow Sheet or admission assesment

2. Admission Form and Discharge Sheet

3. Nursing Progress Notes

4. Physician History and Physical

5. Physician Progress Notes

CHARLSON COMORBIDITY INDEX

Definition

Calculated Charlson Comorbidity Index based on pre-existing co-morbid factors present before patient arrival at the ED/hospital.

Field Values

· Relevant value for data element (integer).

Additional Information

· The value 0 should be used for patients with no known co-morbid conditions.

· The score ranges from 0 – 37.

· See Appendix A for worksheet to calculate Charlson Comorbidity Index

· Use only integers

Data Source Hierarchy

1. History and Physical

2. Nursing Admission Assessment

3. Discharge Sheet

4. Billing Sheet

Has the Patient Had Any of the Following (NEXT 4 QUESTIONS):

AT LEAST ONE DOSE OF COUMADIN WITHIN 7 DAYS

Definition

The patient’s use of warfarin (Coumadin) within 7 days of hospital admission.

Field Values

Yes
No
Unknown

Additional Information

· The value of “Unknown” should only be used when past medication history is truly unobtainable.

· The value of “Yes” should be used if the patient took at least one dose of the medication within 7 days of admission (inclusive of the day of admission).

· If the patient has a history of warfarin (Coumadin) use and the admission INR is above the normal range then the value of “Yes” should be used if precise medication history is unobtainable.

· If the patient has a history of warfarin (Coumadin) use and the admission INR is normal then the value of “No” should be used if precise medication history is unobtainable.

Data Source Hierarchy

1. Medication Reconciliation Form

2. ED Admission Form

3. ED Nurses’ Notes

4. Physician History and Physical

5. Discharge Summary

AT LEAST ONE DOSE OF ASPIRIN WITHIN 7 DAYS OF ADMISSION

Definition

The patient’s use of aspirin within 7 days of hospital admission.

Field Values

Yes
No
Unknown

Additional Information

· The value of “Unknown” should only be used when past medication history is truly unobtainable.

· The value of “Yes” should be used if the patient took at least one dose of the medication within 7 days of admission (inclusive of the day of admission).

Data Source Hierarchy

1. Medication Reconciliation Form

2. ED Admission Form

3. ED Nurses’ Notes

4. Physician History and Physical

5. Discharge Summary

AT LEAST ONE DOSE OF CLOPIDROGREL WITHIN 7 DAYS OF ADMISSION

Definition

The patient’s use of clopidrogrel within 7 days of hospital admission.

Field Values

Yes
No
Unknown

Additional Information

· The value of “Unknown” should only be used when past medication history is truly unobtainable.

· The value of “Yes” should be used if the patient took at least one dose of the medication within 7 days of admission (inclusive of the day of admission).

Data Source Hierarchy

1. Medication Reconciliation Form

2. ED Admission Form

3. ED Nurses’ Notes

4. Physician History and Physical

5. Discharge Summary

AT LEAST ONE DOSE OF ANY OTHER ANTI-PLATELET DRUG WITHIN 7 DAYS OF ADMISSION

Definition

The patient’s use of any anti-platelet drug other than aspirin or clopidrogrel within 7 days of hospital admission.

Field Values

Yes
No
Unknown

Additional Information

· The value of “Unknown” should only be used when past medication history is truly unobtainable.

· The value of “Yes” should be used if the patient took at least one dose of the medication within 7 days of admission (inclusive of the day of admission).

Data Source Hierarchy

1. Medication Reconciliation Form

2. ED Admission Form

3. ED Nurses’ Notes

4. Physician History and Physical

5. Discharge Summary

IS THE PATIENT A SMOKER

Definition

The patient’s use of cigarettes, cigars, or other forms of tobacco smoke.

Field Values

Yes
No
Unknown

Additional Information

· The value of “Unknown” should only be used when past smoking history is truly unobtainable.

· The value of “Yes” should be used if the patient is a current user of tobacco smoking products.

Data Source Hierarchy

1. ED Admission Form

2. ED Nurses’ Notes

3. Physician History and Physical

4. Discharge Summary

HOW MANY PACK-YEARS

Definition

Calculated smoking pack-years based on smoking history.

Field Values

· Relevant value for data element (integer).

Additional Information

· The value 999 should be used for patients with no known or unknown smoking history.

· Pack-Years is calculated as the product of the number of reported packs smoked per day and the number of years the patient has been a smoker.

· This field is required if the patient is has a smoking history.

Data Source Hierarchy

1. ED Admission Form

2. ED Nurses’ Notes

3. Physician History and Physical

4. Discharge Summary

HAS THE PATIENT HAD PREVIOUS ABDOMINAL SURGERY

Definition

The patient’s history of any abdominal surgery prior to admission.

Field Values

Yes
No
Unknown

Additional Information

· The value of “Unknown” should only be used when past surgical history is truly unobtainable.

· The value of “Yes” should be used if the patient has had any type (laparoscopic or open) abdominal surgery prior to admission.

Data Source Hierarchy

1. Physician History and Physical

2. ED Admission Form

3. ED Nurses’ Notes

4. Discharge Summary

IS THE ONLY SURGERY PATIENT HAS HAD LAPAROSCOPIC

Definition

The patient’s history of abdominal surgery prior to admission is ONLY laparoscopic.

Field Values

Yes
No
Unknown

Additional Information

· The value of “Unknown” should only be used when past surgical history is truly unobtainable.

· The value of “Yes” should be used only if the answer to HAS THE PATIENT HAD PREVIOUS ABDOMINAL SURGERY is YES and if the all the abdominal surgery the patient has had was laparoscopic. Otherwise the answer value should be “NO”.

· This field is required if the patient has had previous surgery.

Data Source Hierarchy

1. Physician History and Physical

2. ED Admission Form

3. ED Nurses’ Notes

4. Discharge Summary

In-Hospital Case Information

MECHANISM OF INJURY

Definition

The mechanism (or external factor) that caused the injury event.

Field Values

Blunt

MVC (Motor Vehicle Cras) / MCC (Motor Cycle Crash)
Auto vs. Peds / Machinery
Fall / Other
Assault

Additional Information

· The value should describe the main reason a patient is admitted to the hospital.

· The values used (Blunt) should correspond with those in the CDC injury matrix.

· The value “Other” should only be used if the injury does not fit into one of the listed categories.

· If the patient suffered more than one injury mechanism, chose the mechanism most closely associated with the reason for the splenic injury.

Data Source Hierarchy

1. EMS Run Sheet

2. Triage Form / Trauma Flow Sheet

3. Billing Sheet / Medical Records Coding Summary Sheet

4. ED Nurses’ Notes

DATE OF INJURY

Definition

The date the injury occurred.

Field Values

• Relevant value for data element.

Additional Information

· Collected as MM/DD/YYYY.

· Estimates of date of injury should be based upon report by patient, witness, family, or health care provider. Other proxy measures (e.g., 911 call time) should not be used.

Data Source Hierarchy

1. EMS Run Sheet

2. Triage Form / Trauma Flow Sheet

3. ED Nurses’ Notes

AIS HEAD

Definition

The Abbreviated Injury Scale (AIS) severity codes that reflect the patient’s injuries to the head and neck.

Field Values

1 Minor Injury / 5 Critical Injury
2 Moderate Injury / 6 Maximum Injury, Virtually Unsurvivable
3 Serious Injury / 9 Not Possible to Assign
4 Severe Injury

Additional Information

· The AIS for the body region should be recorded as an integer (1 – 6, or 9)

· The field value (9) “Not Possible to Assign” would be chosen if it is not possible to assign a severity to an injury.

· Head or neck injuries include injury to the brain or cervical spine, skull or cervical spine fractures.

Data Source Hierarchy

1. Hospital Discharge Summary

2. Billing Sheet / Medical Records Coding Summary Sheet

3. Trauma Flow Sheet

4. Physician History and Physical

5. Radiology Reports

6. ER and ICU Records

AIS CHEST

Definition

The Abbreviated Injury Scale (AIS) severity codes that reflect the patient’s injuries to the chest.

Field Values

1 Minor Injury / 5 Critical Injury
2 Moderate Injury / 6 Maximum Injury, Virtually Unsurvivable
3 Serious Injury / 9 Not Possible to Assign
4 Severe Injury

Additional Information

· The AIS for the body region should be recorded as an integer (1 – 6, or 9).

· The field value (9) “Not Possible to Assign” would be chosen if it is not possible to assign a severity to an injury.

· Chest injuries include all lesions tointernal organs. Chest injuries also include those to the diaphragm, rib cage, and thoracic spine.

Data Source Hierarchy

1. Hospital Discharge Summary

2. Billing Sheet / Medical Records Coding Summary Sheet

3. Trauma Flow Sheet

4. Physician History and Physical

5. Radiology Reports

6. ER and ICU Records

AIS ABDOMEN

Definition

The Abbreviated Injury Scale (AIS) severity codes that reflect the patient’s injuries to the abdomen.

Field Values

1 Minor Injury / 5 Critical Injury
2 Moderate Injury / 6 Maximum Injury, Virtually Unsurvivable
3 Serious Injury / 9 Not Possible to Assign
4 Severe Injury

Additional Information

· The AIS for the body region should be recorded as an integer (1 – 6, or 9).

· The field value (9) “Not Possible to Assign” would be chosen if it is not possible to assign a severity to an injury.

· Abdominal or pelvic contents injuries include all lesions to internal organs. Lumbar spine lesions are included in the abdominal or pelvic region.

Data Source Hierarchy

1. Hospital Discharge Summary

2. Billing Sheet / Medical Records Coding Summary Sheet

3. Trauma Flow Sheet

4. Physician History and Physical

5. Radiology Reports

6. ER and ICU Records

AIS EXTREMITY

Definition