Trauma Diagnoses: Acute Surgical Diagnoses · blank. Select diagnosis whether or not surgery was...
Transcript of Trauma Diagnoses: Acute Surgical Diagnoses · blank. Select diagnosis whether or not surgery was...
APPENDIX A: EAST MCT – Outcomes after acute care surgery and trauma care in incarcerated individuals
Trauma Diagnoses: (select all that apply) Neurologic Injuries
Traumatic Brain Injury
Epidural
Subdural
Subarachnoid
Diffuse axonal injury
Concussion
Other______________
Spine injuries
Cervical spine
Thoracic spine
Lumbar spine
Other______________
Paralysis (circle) Yes No Orthopedic injuries
Fracture Location(s)___________
Dislocation Location(s)___________
Other______________ Location(s)___________ Intra-abdominal injuries (check all)
Liver laceration Grade:
Spleen laceration Grade:
Kidney laceration Grade:
Large bowel injury
Small bowel injury
Bladder injury
Other organ injury
Other______________ Thoracic Injuries (check all)
Rib fractures
Hemothorax
Pneumothorax
Sternal fracture
Cardiac injury
Other _________________ Other Injuries (check all)
Vascular injuries Location__________
Laceration Location__________
Facial fracture
Other _________________
Acute Surgical Diagnoses: (select all that apply) General Surgery
Acute appendicitis (circle) Perforated Non-perforated
Cholecystitis (circle) acute chronic
Symptomatic cholelithiasis
Choledocholithiasis
Cholangitis
Gallstone pancreatitis
Alcoholic pancreatitis
Diverticulitis (circle) With abscess With peritonitis
Esophageal Perforation
GI Bleed(circle): Upper Lower
Bowel obstruction(circle): Large Small
Volvulus (circle) Sigmoid Cecal Small bowel
Gastric/duodenal ulcer(circle): Bleeding Perforation
Intestinal perforation (circle): Large Small
Hernia (circle) Ventral Inguinal Femoral Other : (circle) Reducible Incarcerated
Strangulated Unknown
Soft tissue infections
Abscess
Necrotizing infection
Location ______________
Perianal disease
Acute limb ischemia
Aneurysmal disease
Other______________
TITLE: Outcomes after acute care surgery and trauma care in incarcerated individuals: a prospective
observational trial
Data Element Definition / Instructions Demographics: Case Number Assigned number by institution, Ordered chronologically from oldest (1) to newest Age Free text entry of patient’s age, age 16 and older at
time of admission Biological sex Select patient’s biological sex from the following:
• Male
• Female Race Select patient’s race from the following:
• White
• Black
• Hispanic
• Asian
• Other Height Free text entry of patient’s height in cm Weight Free text entry of patient’s weight in kg Payor Primary payor identified for the individual patient.
Usually identified by business manager of surgery department.
Medical History: Comorbidities Recorded (Yes, No, NR = Not Recorded) for all of the
following:
• Obesity
• Hypertension
• Diabetes mellitus (includes type I and type II)
• Drug use disorder, including alcohol use disorder
• Mental health condition
• COPD
• CHF
• Dementia
• Anticoagulant use
• HIV
• Hep C
• History of Tobacco use
• Cancer
o Type (free text)
• Other (free text)
Pre-hospital data: Treatment location prior to presentation Record location of patient prior to presentation to
definitive hospital
• Prison
• Jail
• Outside emergency department
• Outside inpatient hospital
• Other (free text) Duration of symptoms prior Record approximate time elapsed since injury or to arrival symptom onset to presentation to initial health facility
outside correctional facility. Circle <12 hours, 12-24 hours, >24 hours, or unknown.
Similar presentation Was the patient previously evaluated for same injury or
for same problem/symptoms? Yes, No, NR = Not Recorded.
Incarceration Data: State of incarceration Specifies in which state patient is currently incarcerated
in order to classify by structure/model of correctional healthcare. Information on state of incarceration will only be used to classify by model of care. Use two letter abbreviation
Location of incarceration - arrival Record location of incarceration prior to presentation.
• Prison
• Jail
• Unspecified
Location of incarceration - discharge Record location of incarceration at discharge from hospital or ED
• Prison
• Jail
• Unspecified
Injury Data (if applicable): ISS Free text entry of Patient’s calculated ISS (ISS = Injury
severity score, range 1-75) ED GCS Free text entry of patient’s initial or first recorded GCS
(Glasgow Comas Scale; range 3 to 15; composed of three parts: eye, verbal, motor). 3 is the worst.
AIS by body region Free text entry for head, spine, chest, abdomen,
extremity upon presentation (0=no injury, 1=minor, 2=moderate, 3=serious, 4=severe, 5=critical, 6=unsurvivable)
Mechanism of Injury (MOI) Select mechanism of injury from the following:
• Fall
• MVC (Motor Vehicle Collision)
• Pedestrian
• Gunshot wound
• Machine
• Assault
o Weapon - Choose:
▪ hand/foot
▪ blunt object
▪ free text
• Other (free text)
Intent of Injury Record intent of injury, if known
• Intentional (yes/no)
o Self-harm
o Not self-harm
• Unintentional (yes/no)
o Occupational injury
o Not occupational injury
• Unspecified Admission Data (if applicable): Admitting Service Select admitting service:
• Trauma
• Orthopedic Surgery
• Neurosurgery
• Cardiothoracic surgery
• Medicine
• ENT
• Plastic surgery
• General surgery (non-trauma)
• Other (free text) Post ED Disposition Select patient’s hospital destination following
emergency department consultation:
• Floor
• Intensive Care Unit (ICU)
• Operating Room
• Step-down Unit
• Discharge
• Other (free text) Consulting Service(s) Record if any of the following were consulted during the
patient’s primary admission (Yes, No, NR = Not Recorded.
• Trauma surgery
• Orthopedic surgery
• Neurosurgery
• Cardiothoracic surgery
• Medicine
• ENT
• Plastic surgery
• General surgery (non-trauma)
• Psychiatry Diagnoses: Trauma Diagnoses Appendix I - Select all that apply. If unknown, leave
blank. Specify grade of solid organ injury if known. Spine injuries include compression, herniation, spinal cord injury, or fracture of any part of the vertebrae including spinous, transverse, or articular process(es). Paralysis defined as loss of motor function of any limb due to spinal injury, may be temporary or permanent.
Acute Surgical Diagnoses Appendix I - Select all that apply. If unknown, leave
blank. Select diagnosis whether or not surgery was performed.
Procedures (if applicable): Need for Operation (Need OR) Record if patient sent to operating room for any
procedure. Yes, No, NR = Not Recorded. Time to first operation from admission Free text number of hours from the time of
presentation to the ED to entry into an operating room suite. Round to the nearest whole hour.
Number of Operations (NumOps) Number of operations during length of stay. Free text
entry of number up to 12 patient procedures. CPT of Procedure 1 CPT code of initial procedure performed (if applicable) CPT of Procedure 2 CPT code of 2nd procedure performed (if applicable) CPT of Procedure 3 CPT code of 3rd procedure performed (if applicable) CPT of Procedure 4 CPT code of 4th procedure performed (if applicable) Time to fixation If patient sustained orthopedic fracture requiring
surgical intervention, record free text number of hours from the time of presentation to the ED to entry into an operating room suite for fixation (either definitive or temporary). Report the first procedure only. Round to the nearest whole hour.
Other interventions Recorded (Yes, No, NR = Not Recorded) for the
following:
• Chest tube insertion – Check indication(s)
• Central line insertion
• Tracheostomy
• Traction (orthopedic injury)
• Casting (orthopedic injury)
• Laceration repair – record only if sutured/stapled
• Nasogastric decompression – record if within initial 24 hours of presentation
• Other (free text) Admission Data: Hospital length of stay Free text entry for number of consecutive days patient
hospitalized at index admission (Day of admission = hospital day #0. Include any portion of a day that patient was in the hospital) LOS = Length of Stay. Recorded in days.
ICU length of stay Free text entry of number of days patient required ICU
admission (ICU = Intensive Care Unit, LOS = Length of Stay). Day of admission = hospital day #0. Include any portion of a day that patient was in the ICU. Recorded in days.
Transfusion Number of separate units of packed red blood cells
transfused in the first 24 hours after presentation
Ventilator Days Free text entry of the number of days the patient was
on mechanical ventilation. Include any portion of a day that patient was ventilated. Recorded in days.
Discharge data: Discharge to Select patient’s discharge destination:
• Home Self Care
• Home with Services
• Rehab
• Skilled Nursing Facility
• Long-term Care
• Psychiatric facility
• Hospice
• Morgue
• Correctional Facility
• Other
AMA Did the patient leave the hospital against medical advice? Yes/No
Complications: Hospital Mortality Death during index hospitalization (yes or no) Complications during admission Recorded for all of the following:
• Sepsis
• Septic shock
• Acute renal injury
• Deep vein thrombosis
• Stroke
• Pulmonary embolism
• Myocardial infarction
• Cardiac arrest
• Central line-associated blood stream infection (CLABSI)
• Acute respiratory distress syndrome
• Post-operative hemorrhage
• Mechanical wound failure
• Ileus or other post-operative gastrointestinal complication
• Wound infection
o Superficial
o Deep
• Pneumonia (includes ventilator associated)
• Urinary tract infection
• Unplanned ICU admission
• Unplanned re-operation
• Unplanned intubation
• Other Readmission and Follow-up: Follow-up appointment completed Was this patient seen in follow-up in an outpatient clinic
setting with surgical team/primary care provider or documented follow-up (phone call, letter, etc) within 90 days of discharge date? (Yes, No, NR = Not Recorded)
Readmit Patient readmitted for similar problem or complication
from index hospitalization within 90 days of discharge. (Yes, No, NR = Not Recorded)
Readmitdays Record number of days since discharge to first
readmission. Round to nearest whole day. _________________________________________________________________________________ Site Information (only record once per site): Level of Trauma Center Record Level 1-4. If not designated as a trauma center,
enter N/A. ACS admissions Record the number of acute care surgery admissions in
the calendar year preceding the current year of the study
EAST Multi-Center Study Data Collection Tool
Outcomes after acute care surgery and trauma care in incarcerated individuals: a prospective
observational trial
Enrolling Center: ___________________________ Case Number: ________ Demographics: Age _____ Sex: ______ Race: _____________ Height (cm): _________ Weight (kg): _________ Primary payor: ____________________________ Comorbidities (check all that apply):
Obesity
Hypertension
Diabetes mellitus
Drug use disorder (including alcoholism)
Mental health condition
COPD
CHF
Dementia
Anticoagulant use
HIV
Hepatitis C
History of tobacco use
Cancer: Type: ___________
Other: _________________ Pre-hospital Information: Location prior to presentation (circle): Prison Jail Outside ED Outside inpatient hospital Other:____________ Duration of symptoms prior to arrival (circle): <12 hours 12-24 hours >24 hours Unknown Has patient presented for evaluation for same injury or same problem:
Yes No NR Incarceration Information: State of incarceration: ___________ Location of incarceration Prior to Arrival (circle): Prison Jail Unspecified Location of incarceration at Discharge (circle): Prison Jail Unspecified Diagnoses Was the patient admitted for trauma? (circle) Yes No Unknown Injury Information (if applicable):
ISS ______ ED GCS: ______ AIS: Head ______ Spine______ Chest______ Abdomen______ Extremity______ Mechanism of Injury (check one):
Fall
MVC
Pedestrian vs _________
GSW
Machine injury
Assault
Weapon: Hand/foot Blunt object
Other _________
Other: _____________
Intent of Injury (check if applicable):
Intentional If yes: Self-harm Not self-harm
Unintentional If yes: Occupational injury Not occupational injury
Unspecified Admission: Admitting Service (check one):
Trauma
Orthopedic Surgery
Neurosurgery
Cardiothoracic Surgery
General Surgery (non-trauma)
Medicine
ENT
Plastic Surgery
Other _______________
Post ED Disposition (check one):
Floor
ICU
Other ____________-
Step-down unit
Discharge
Consulting Service(s) (check all consulted):
Trauma
Orthopedic Surgery
Neurosurgery
Cardiothoracic Surgery
General Surgery (non-trauma)
Medicine
ENT
Plastic Surgery
Psychiatry
Other _________________ Trauma Diagnoses (see appendix): Acute Surgical Diagnoses(see appendix):
Procedures: Need for operation (circle): Yes No NR Time to first operation: _____________ hours (Use decimals if needed) Number of Operations: ___________________ CPT Procedure 1: ___________ CPT Procedure 2: ___________ CPT Procedure 3: ___________ CPT Procedure 4: ___________ Time to fixation (ortho injuries only): ______________ hours Other interventions (check all performed):
Chest tube insertion Indication: Pneumothorax Hemothorax Other:__________
Central line insertion
Tracheostomy
Traction
Casting
Laceration repair (with suture or staples only)
Nasogastric decompression (in first 24 hours)
Other: ________________ Admission Information: Hospital LOS: _______ days ICU LOS: ___________ days
Ventilator days: ___________ days Transfusion: _______/units pRBCs in first 24 hours of admission
Discharge Information: Discharged to:
Home self-care
Home with services
Rehab
Skilled Nursing Facility
Long-term care
Psychiatric facility
Hospice
Morgue
Correctional Facility
Other: _____________ Did the patient leave AMA (circle): Yes No Complications:
Did patient die during hospital stay: Yes No Complications during admission (check all that apply):
Sepsis
Septic shock
Acute renal injury
Deep vein thrombosis
Stroke
Pulmonary embolism
Myocardial infarction
Cardiac arrest
Central line-associated blood stream infection
Acute respiratory distress syndrome
Post-operative hemorrhage
Mechanical wound failure
Ileus or other GI complication
Wound infection
superficial
deep
Pneumonia (including ventilator associated)
Urinary tract infection
Unplanned ICU admission
Unplanned reoperation
Unplanned intubation
Other: _______________
Other:________________
Other:________________
Readmission and Follow-up: Readmit within 90 days: Yes No NR Number of days from discharge to readmission: ________ days Follow-up appointment completed within 90 days: Yes No NR With (circle): Primary care Surgical Team