Identifying cases&

Quality Assurance:Data Completeness & Accreditation

The Trauma Audit & Research Network (TARN)

Data Collection session

Identifying cases: 2 case studies

System 1: Retrospective Data captureClinical (ICD10) codes

Clinical coding departments use a coding system called ICD10

ICD10: International Classification of Diseases ICD10 codes document: Admission reason (Injury, Medical, Elective, Complication)

ICD10 codes that begin with S or T indicate injury e.g. S82.2: fracture to shaft of tibia S82.21: open shaft of tibia S82.20: closed shaft of tibia T055: Traumatic amputation of both legs

Trust IT dept. can therefore generate weekly spreadsheet showing:

Patients discharged previous week with any S or T ICD10 code Filtering out:

<3 days stay, discharge destination = home 65+ isolated NOF 65+ isolated pubic rami fracture Minor injuries

Full list of all applicable ICD10 codes: www.tarn.ac.uk/resources

Result: List of potential TARN patients

Check imaging reports to ensure inclusion

System 1: Retrospective Data captureClinical (ICD10) codes

System 1: Retrospective Data captureClinical (ICD10) codes

Example ICD10 spreadsheet

Age Admission

DateDischarge

Date Disch. Destination LoS Diag. 1 ICD Diag. 1 TextDiag. 2

ICD Diag. 2 TextDiag. 3

ICDDiag. 4

ICDDiag. 5

ICDDiag. 6

ICD

84 05/06/2010 16/07/2010 NHS NURSING 41 S0650TRAUMATIC SUBDURAL

HAEMATOMA K709 ALCOHOLIC LIVER DAMAGE UNSPECIFIED L031 B181 F102 N179

84 14/12/2010 06/01/2011 USUAL RESIDENCE 23 S825FRACTURE OF MEDIAL

MALLEOLUS S526CLOSED FRACTURE OF RADIUS AND ULNA,

LOWER END V99X

82 26/11/2010 01/12/2010 PATIENT DIED 5 S063CLOSED HINDBRAIN

CONTUSION W199[X]UNSPECIFIED FALL, OCCURRENCE AT

UNSPECIFIED PLACE N390 I48X I120 I258

78 01/06/2010 16/07/2010 USUAL RESIDENCE 45 S323CLOSED FRACTURE OF ILIUM,

UNSPECIFIED N390URINARY TRACT INFECTION, SITE NOT

SPECIFIED NOS I10X F339 F319 E039

78 04/07/2010 09/08/2010 USUAL RESIDENCE 36 S220CLOSED FRACTURE THORACIC

VERTEBRA W190[X]UNSPECIFIED FALL, OCCURRENCE AT

HOME N390 J22X I639 I10X

75 19/09/2010 05/10/2010NON-NHS RUN

RESID. CARE HOME 16 S422CLOSED FRACTURE PROXIMAL

HUMERUS, NECK S721CLOSED FRACTURE OF FEMUR,

INTERTROCHANTERIC W194 N390 D649 E039

75 03/10/2010 03/11/2010NHS NURSING

HOME/ 31 S327MULTIPLE FRACTURES OF

LUMBAR SPINE AND PELVIS S499[X]UNSPECIFIED INJURY OF SHOULDER AND

UPPER ARM W109 N390 R32X I10X

75 03/11/2010 21/12/2010 USUAL RESIDENCE 48 Z501 [X]OTHER PHYSICAL THERAPY S327MULTIPLE FRACTURES OF LUMBAR SPINE

AND PELVIS S499 I350 R32X I10X

Patients potentially have multiple ICD10 (Diagnosis) codes

Ensure your Trust reviews the first 5 diagnosis codes

Reviewing Primary Diagnosis code only – will definitely result in missed cases

System 1: Retrospective Data captureClinical (ICD10) codes: Advantages

Captures patients who bypass ED (transfers in, GP admissions)

TARN can liaise with IT to help set this up: SQL script

Limited staff resource required

Used by most Trauma Units who employ Retrospective data capture

Used as backup to “live” data capture by most Major Trauma Centres

Only admitted patients are assigned an ICD10 code Transfers out from ED Deaths in ED

Separate system required to capture these

Accuracy of Trust ICD10 coding

Use of NOS (not otherwise specified) codes can increase potential cases

Cases admitted for Rehabilitation only – not easily identified

Delay between discharge and clinical coding

System 1: Retrospective Data captureClinical (ICD10) codes: Disadvantages

System 2: Live Data captureEmployed by Royal Stoke University Hospital

Major Trauma CentreNorth West Midlands & North Wales Major Trauma Network

System 2: Live Data captureEmployed by Royal Stoke University Hospital Major Trauma Centre

Diary in Resuscitation completed by ED Consultant.

Data Co-ordinators pagers that receive Trauma Calls.

ED system search: Patients who were imaged & admitted.

Daily contact with relevant Wards: Notification of any trauma patients admitted.

Attend morning Orthopaedic/Neurosurgical case discussion meetings.

Liaise with Rehabilitation Co-ordinators re: Trauma patients seen on wards

When eligible cases identified: Early care data collected on forms by TNC & Data coordinators whilst still inpatient.

Later care data (Operation, ICU, Imaging, Ward, Discharge data) taken from online systems.

System 2: Live Data capture: AdvantagesEmployed by Royal Stoke University Hospital Major Trauma Centre

Very little backlog; patients often dispatched to TARN day after discharge.

Case notes only required for “missed” cases identified post discharge.

Regular communication between Coordinators & Clinicians.

Rehabilitation Co-ordinators involved very early on.

Deaths data: Available from Bereavement office quickly, no waiting for inquest.

System 2: Live Data capture: Disadvantages Employed by Royal Stoke University Hospital Major Trauma Centre

Greater staff resource required

Post discharge ICD10 report required to capture “missed” patients.

Collecting the data

Retrospective Data Entry: Post discharge

Access to electronic Imaging and Theatre systems required

Enter data directly from notes or use Pro-forma

CORE PROFORMA IN REPORTS SECTION OF WEBSITE

DO NOT have to start and finish a submission in one session

Quality Assurance

Data Completeness (quantity)

& Data Accreditation (quality)

Data completeness % Measure of Expected v Submitted number of cases

HES Data used to calculate expected no. of cases per Trust

HES = Hospital Episode Statistics database

HES data contains ICD10 codes assigned by Trusts in previous year: 2013

TARN Inclusion criteria applied to HES data

No. of Expected cases then derived

Expected number of cases used as a guide only. Not a 100% target!

All eligible cases should be submitted to TARN

Data completeness %Measure of Expected v Submitted number of cases

% of expected v submitted cases shown on TARN website

Updated every 4 months: End of March July November

Shown as Trust and individual Hospital figures

Should always be viewed alongside Hospital Survival rate

Data Completeness calculation

Data Completeness

76.1%

Submissions: NUMERATOR 238

Expected submissions: DENOMINATOR 313

Data completeness 76.1%

HES dataset/Denominator

TARN submissions/Numerator

1-49%: May not reflect true practice50-79%: May not reflect true practice80%+: View with confidence

Improving Data completeness

HES v TARN 2013 Data comparison exercise

HES v TARN 2013 comparison exercise Comparison spreadsheet produced:

Green: Cases appear in both datasets (Submission ID shown) Black: Cases appear in HES dataset only (not submitted in TARN)

‘Not TARN eligible’ field: Completed by Trust & Fed-back to TARN Missing cases: Issues identified & entered: Increase in Numerator

Ineligible cases: Removed from expected no. of cases: Decrease in Denominator

HES v TARN 2013 comparison exercise results

Commonly missed groups: Aged 65+ Hip fractures with other (non hand or foot) fracture Traumatic SDH admitted to medical wards Aged 65+ Pelvic fractures Spinal fractures Patients whose LOS is exactly 3 days

Common reasons for the variance between the HES and TARN: Inaccuracies in ICD10 coding Old injuries being coded. Use of NOS (Not Specified) codes, which varies from trust to trust Rehabilitation only admissions Elective admissions

45 Trust participated in exercise >3,700 cases removed from Expected no. of cases 18% reduction & comparable Data Collection increase

Data Accreditation % (quality)Measure of frequency of CORE data field completion

CURRENT ACCREDITATION FIELDSGlasgow Coma Score or Intubation/ventilation

(Pre Hospital or ED)

Incident or Call 999 Date/time

Arrival time

Transfer: Reason & Date of Referral

CT time

Operation: Start time, grade & speciality of surgeon & grade of anaesthetist

ED Doctors: Time seen, grade & speciality

Injury detail – proportion of NFS codes

NEW ADDITIONS TO ACCREDITATION FIELDS*Pre-existing conditions

**Pupil reactivity for patients with AIS 3+ (Serious) head injuries

Data Accreditation%: Recent additionsFrom December 2014 onwards

* New Probability of Survival (Ps)14 model‘Other’ and ‘Not Known’ detrimental to Data Accreditation

** Future Probability of Survival model

Data Accreditation

Data Accreditation report available on TARN

Missing fields highlighted

Questions?