Kansas Trauma Registry Data Dictionary

KANSAS TRAUMA REGISTRY DATA DICTIONARY

Kansas Department of Health and Environment Bureau of Community Health Systems

Revised July, 2014

Questions about the Kansas Trauma Registry Data Dictionary 785-296-5459 [email protected]

Questions about the operation of Collector Software 1-800-344-3668 ext. 4 [email protected]

Questions on the Kansas Trauma Program 785-296-1210

Kansas Trauma Registry State-Required Core Data Elements

Demographic Information Facility Number Last 4 digits of SS# Trauma Number Patient’s Residence (City, County, State, Zip-Code) Submit Record to KDHE Date of Birth ED/Arrival Date/Time Age Frist Closed Date Gender Entry Form Number Race Medical Record Number Ethnicity Trauma Bracelet Number

Prehospital Injury Information Incident Date/Time Injury Location City, County, State, Zip-Code Primary Injury Type Protective Devices – Restraint ICD-9-CM E-code (External Cause of Injury) Protective Devices – Airbag Description of Injury Circumstanced Protective Devices - Equipment Place of Injury Category

Other Prehospital Information – Section Repeats for each Transport Provider Mode of Transportation Arrived Hospital Date/Time Linked Record Systolic/Diastolic Blood Pressure EMS Agency Heart Rate Run Sheet Received/Complete Unassisted Respiratory Rate Call Received Date/Time Glasgow Coma Score (Motor, Eye, Verbal, Total) Dispatched Date/Time Glasgow Coma Score Assessment Qualifier En Route Date/Time Revised Trauma Score (unweighted) Arrived Location Date/Time Airway Patient Contact Date/Time CPR Departed Location Date/Time Fluids

Emergency Department Arrived From Base Deficit Transferring Facility ID Temperature Transferring Facility Medical Record Number Glasgow Coma Score (Motor, Eye, Verbal, Total) Activation Glasgow Coma Score Assessment Qualifier Injury Mechanism/Off Road Vehicle Revised Trauma Score (unweighted) Signs of Life ETOH/BAC Test Results ED Disposition/Admit to Drug Screen Results OR Disposition Abdominal CT Results Systolic/Diastolic Blood Pressure Chest CT Results Heart Rate Head CT Results Unassisted Respiratory Rate Airway Oxygen Administered Trauma Team Leader Oxygen Saturation Trauma Team Leader Called/Arrived on Time

Procedures ICD-9-CM Procedure Code Days on Ventilator Procedure Date, Start Time, Stop Time

Diagnoses ICD-9-CM Diagnosis Code-Injury Injury Severity Scores (ISS and TRISS) Abbreviated Injury Score (AIS) ICD-9-MC Diagnosis Code-Comorbid Condition

Outcomes Discharge Date/Time Disabilities at Discharge-Ambulation Score/Qualifier Discharge Status Disabilities at Discharge-Communication Score/Qualifier Discharge to (Facility ID) Primary Payer Source EMS Mode of Transport for discharged patient Secondary Payer Source EMS called and arrived date/time Total Hospital Charges Days in Intensive Care Unit Total Hospital Collection Disabilities at discharge-Feeding Score/Qualifier Autopsy Performed

Quality Assurance/Quality Improvement Non-Injury-Related Occurrences (complications)

Last Updated September, 2014

Kansas Trauma Registry Data Dictionary Table of Contents

Section 1 DEMOGRAPHIC

Section 2 PREHOSPITAL

Section 3 INTERMEDIATE FACILITY

Section 4 EMERGENCY DEPARTMENT

Section 5 PROCEDURES

Section 6 DIAGNOSIS

Section 7 OUTCOME

Section 8 QUALITY ASSURANCE/QUALITY IMPROVEMENT

Appendix: GLOSSARY OF TERMS

KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic

SECTION 1 – DEMOGRAPHIC

Facility Number* ...... 3 Trauma Number* ...... 3 Core/Comprehensive Data ...... 3 Submit Record to KDHE* ...... 4 First Closed Date/Time* ...... 4 First Transfer Date/Time* ...... 4 ED Arrival Date - Month* ...... 5 ED Arrival Date - Day* ...... 5 ED Arrival Date - Year*...... 5 ED Arrival Time - Hour* ...... 6 ED Arrival Time - Minute* ...... 6 Entry Form Number* ...... 7 Medical Record Number* ...... 7 Trauma Bracelet Number* ...... 7 Patient Social Security Number* ...... 8 Visit Number ...... 8 Patient’s Last Name ...... 8 Patient’s First Name ...... 8 Patient’s Middle Name ...... 9 Patient’s Home Zip Code 1* ...... 9 Patient’s Home Zip Code 2 ...... 9 Patient’s Street Address 1 ...... 10 Patient’s Street Address 2 ...... 10 Patient’s Home City* ...... 10 Patient’s Home City – If Other* ...... 11 Patient’s County of Residence* ...... 11 Patient’s State of Residence* ...... 11 Date of Birth - Month* ...... 12 Date of Birth - Day* ...... 12 Date of Birth – Year* ...... 12 Age* ...... 13 Age Units* ...... 13 Patient’s Race* ...... 13 Patient’s Gender* ...... 14 Patient’s Ethnicity* ...... 14 Occupation ...... 15 Demographic Memo ...... 16

*Items are CORE (State Required) Data Elements.

Demographics Page 1 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic Demographic – Demographic Tab

Demographics Page 2 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic Facility Number*

Window Location: Data Field Name: Demographic : Demographic INST_NUM

State Required: Type of Field: Length: Yes Integer 7 DEFINITIONS Facility Number – The number assigned by the program that identifies the facility. This number cannot be changed. INSTRUCTIONS The Facility Number will be provided by the program.

Trauma Number*

Window Location: Data Field Name: Demographic : Demographic TRAUMA_NUM

State Required: Type of Field: Length: Yes Integer 8

DEFINITIONS Trauma Number – The number assigned by the program that identifies the patient record. This number should not be changed once the case is submitted to the state. Please consult with Digital Innovation or KTR Staff before changing this number. INSTRUCTIONS Trauma Number is incremented by 1 automatically. Use direct keyboard entry to change the number if needed.

Core/Comprehensive Data

Window Location: Data Field Name: Demographic : Demographic CORE_COMP

State Required: Type of Field: Length: No Integer 1

DEFINITIONS Core data – State-required data elements and selected demographic information. Comprehensive data – The entire dataset. Data can be entered for core and comprehensive variables. INSTRUCTIONS Use direct keyboard entry. If your hospital only collects the core dataset, this should be set to default to “core”. This is done by selecting Data Entry Defaults from the Setup menu and choosing 1 (Core) for the Core/Comprehensive Data field. To skip the comprehensive elements, select “Core”. If you wish to enter comprehensive data elements you can switch the value back during data entry.

Web Users – the comprehensive dataset is not available for users of the web version of the database. Choose “core- plus” to enter extra data elements for internal record keeping. Core-plus data elements are not included in the state dataset. VALID OPTIONS 1 Core – State required data elements only (skips data elements that are not sent to State) 2 Comprehensive – Full data set

Demographics Page 3 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic Submit Record to KDHE*

Window Location: Data Field Name: Demographic : Demographic SYSTEM_YN

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Submit Record to KDHE – Patient meets inclusion criteria for the state trauma registry

INSTRUCTIONS Enter the appropriate option in the checkbox by clicking with mouse or typing the option or pressing spacebar. If your hospital only collects data on trauma patients that meet the minimum criteria for submission to the state registry, this should be set to default “YES”. This is done by selecting Data Entry Defaults from the Setup menu and choosing 1 (Yes) for Submit Record to KDHE. If this field is not marked “YES”, the data will not be sent to the central site registry. VALID OPTIONS 1/Y Yes – Patient record is selected to be submitted to the State via the transfer process. 2/N No – Patient record will not be submitted to the State.

First Closed Date/Time*

Window Location: Data Field Name: Demographic : Demographic FIRSTCD

State Required: Type of Field: Length: Yes Integer 8 DEFINITIONS First Closed Date/Time – The date/time assigned by the program when the record is checked and closed. This date/time cannot be changed.

INSTRUCTIONS This date/time is assigned by the program.

ADDENDUM: This variable was added to the registry beginning on entry form number 13. For web registry records, this is when the record was first submitted to the state trauma registry (if the variable “submit record to KDHE” is checked Y). For local registry records, this is when the record was first checked and closed.

First Transfer Date/Time*

Window Location: Data Field Name: Demographic : Demographic TRANSFER_EVENT

State Required: Type of Field: Length: Yes Integer 8 DEFINITIONS First Transfer Date/Time – The date/time assigned by the program when a local trauma registry record is first sent to KDHE. This date/time cannot be changed.

INSTRUCTIONS This date/time is assigned by the program.

ADDENDUM: This variable was added to the registry beginning on entry form number 14. Web registry records do not have this variable.

Demographics Page 4 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic ED Arrival Date - Month*

Window Location: Data Field Name: Demographic : Demographic EDA_DM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS ED Arrival Date – Month – The month the patient arrived at ED or was directly admitted to the hospital INSTRUCTIONS If the patient was not a direct admit, enter the month the patient arrived at your ED. This information should be taken from your ED log system or ED documentation. If the patient was a direct admit (i.e., Direct Admit 'Y'), enter the month the patient was admitted to your facility. Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

ED Arrival Date - Day*

Window Location: Data Field Name: Demographic : Demographic EDA_DD

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS ED Arrival Date – Day – The day the patient arrived at ED or was directly admitted to the hospital INSTRUCTIONS If the patient was not a direct admit, enter the day the patient arrived at your ED. This information should be taken from your ED log system or ED documentation.

If the patient was a direct admit (i.e., Direct Admit 'Y'), enter the day the patient was admitted to your facility. Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

ED Arrival Date - Year*

Window Location: Data Field Name: Demographic : Demographic EDA_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS ED Arrival Date – Year – The year the patient arrived at ED or was directly admitted to the hospital INSTRUCTIONS If the patient was not a direct admit, enter the year the patient arrived at your ED. This information should be taken from your ED log system or ED documentation.

If the patient was a direct admit (i.e., Direct Admit 'Y'), enter the year the patient was admitted to your facility. Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Demographics Page 5 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic ED Arrival Time - Hour*

Window Location: Data Field Name: Demographic : Demographic EDA_TH

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS ED Arrival Time – Hour – The hour the patient arrived at ED or was directly admitted to the hospital INSTRUCTIONS If the patient was not a direct admit, enter the hour the patient arrived at your ED. This information should be taken from your ED log system or ED documentation.

If the patient was a direct admit (i.e., Direct Admit 'Y'), enter the hour the patient was admitted to your facility. Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

ED Arrival Time - Minute*

Window Location: Data Field Name: Demographic : Demographic EDA_TM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS ED Arrival Time – Minute – The minute the patient arrived at ED or was directly admitted to the hospital INSTRUCTIONS If the patient was not a direct admit, enter the minute the patient arrived at your ED. This information should be taken from your ED log system or ED documentation.

If the patient was a direct admit (i.e., Direct Admit 'Y'), enter the minute the patient was admitted to your facility. Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search EDA_EVENT – the Date and Time combined that the patient arrived at the ED or was directly admitted to the hospital.

 In Report Writer; search EDA_TIME – the Hour and the Minute combined that the patient arrived at the ED or was directly admitted to the hospital.

 In Report Writer; search EDA_DATE – the Month, Day and Year combined that the patient arrived at the ED or was directly admitted to the hospital.

Demographics Page 6 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic Entry Form Number*

Window Location: Data Field Name: Demographic : Demographic ENTRY_FORM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Entry Form Number – The version of Collector used when the patient record was started. INSTRUCTIONS The Entry Form Number will be provided by the program. This number is incremented by 1 each time the software is updated.

ADDENDUM: This variable was added to the registry beginning on entry form number 9.

Medical Record Number*

Window Location: Data Field Name: Demographic : Demographic MR_NUM

State Required: Type of Field: Length: Yes Alphanumeric 25 DEFINITIONS Medical Record Number – Medical record number or any number used by the hospital or institution to uniquely identify the patient. Found on the transcript of the medical information about a patient. INSTRUCTIONS This field must be completed with a patient identifier, such as medical record number or other identifying character string. This field may contain any alphanumeric data that will help identify the patient. For example, a medical record number consisting of up to 25 digits could be used, but if this number is unknown, a temporary number can be assigned. This temporary number can include letters or other characters and may be specific to your facility. Use direct keyboard entry. VALID OPTIONS Patient Medical Record Number ? Unknown

ADDENDUM: This field was made a core data element on entry form number 9.

Trauma Bracelet Number*

Window Location: Data Field Name: Demographic : Demographic MATCH_ID

State Required: Type of Field: Length: Yes Alphanumeric 10

DEFINITIONS Trauma Bracelet Number – This alpha-numerical value is to be taken from the patient’s trauma bracelet INSTRUCTIONS This field is active even though trauma bracelets have not been implemented in Kansas. KTR staff will alert all users when a system for collecting a unique identifying trauma number is established. Use direct keyboard entry.

Demographics Page 7 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic Patient Social Security Number*

Window Location: Data Field Name: Demographic : Demographic SSN_1, SSN_2, SSN_3

State Required: Type of Field: Length: Yes* Numeric 3,2,4 DEFINITIONS Patient Social Security Number – 9-digit code issued by the Social Security Administration.

*The last 4 digits of the SSN is now a CORE data element, the first 5 digits will not be sent to the State. The last 4 digits of the SSN were made a CORE data element with the Jan. 2011 update. INSTRUCTIONS This field cannot be partially filled. Use direct keyboard entry. You may enter the entire social security number, but only the last 4 digits are sent as a core variable to the central site. Enter leading zeros, e.g., 000-00-xxxx, when entering only the last four digits of the social security number. For unknown social security numbers, please enter 999-99-9999.

Visit Number

Window Location: Data Field Name: Demographic : Demographic ACCT_NUM

State Required: Type of Field: Length: No Alphanumeric 15 DEFINITIONS Visit Number – A sequential number representing how many times this patient has been entered into the trauma registry at this facility INSTRUCTIONS Review trauma registry record log for duplication of patients by social security number, medical record number, birth date, etc. Based on previous records, enter the visit number. Use direct keyboard entry.

Patient’s Last Name

Window Location: Data Field Name: Demographic : Demographic P_NAM_L

State Required: Type of Field: Length: No Text 50 DEFINITIONS Patient's Last Name – Patient’s last name in the patient’s medical record. Given name as on birth certificate or change-of-name affidavit INSTRUCTIONS Enter the patient's last name. Use direct keyboard entry.

Patient’s First Name

Window Location: Data Field Name: Demographic : Demographic P_NAM_F

State Required: Type of Field: Length: No Text 50 DEFINITIONS Patient's First Name – First name found on the patient’s medical record. Given name as on birth certificate or change-of-name affidavit INSTRUCTIONS Enter the patient's first name. Use direct keyboard entry.

Demographics Page 8 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic Patient’s Middle Name

Window Location: Data Field Name: Demographic : Demographic P_NAM_M

State Required: Type of Field: Length: No Text 15 DEFINITIONS Patient's Middle Name – Middle name found in the patient’s medical record. Given name as on birth certificate or change of name affidavit INSTRUCTIONS Enter the patient's middle name. Use direct keyboard entry.

Patient’s Home Zip Code 1*

Window Location: Data Field Name: Demographic : Demographic P_ADR_Z1

State Required: Type of Field: Length: Yes Integer 5 DEFINITIONS Zip Code 1 – The 5-digit numeric code of the locale in which the patient most often resides INSTRUCTIONS Use direct keyboard entry or enter appropriate option. VALID OPTIONS / Not Applicable ? Unknown

Patient’s Home Zip Code 2

Window Location: Data Field Name: Demographic : Demographic P_ADR_Z2

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Zip Code 2 – The 4-digit identifying numeric suffix of the locale in which the patient most often resides INSTRUCTIONS Use direct keyboard entry or enter appropriate option. VALID OPTIONS / Not Applicable ? Unknown

Demographics Page 9 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic Patient’s Street Address 1

Window Location: Data Field Name: Demographic : Demographic P_ADR_S1

State Required: Type of Field: Length: No Text 50 DEFINITIONS Street Address 1 – The number and street name where the patient most often resides INSTRUCTIONS Enter the number and street name where the patient most often resides. If the patient is homeless, enter "homeless" in this field. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Street Address 1

Patient’s Street Address 2

Window Location: Data Field Name: Demographic : Demographic P_ADR_S2

State Required: Type of Field: Length: No Text 50 DEFINITIONS Street Address 2 – The number and street name where the patient most often resides INSTRUCTIONS Enter the number and street name where the patient most often resides. If the patient is homeless, enter "homeless" in this field. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Street Address 2

Patient’s Home City*

Window Location: Data Field Name: Demographic : Demographic P_ADR_CI

State Required: Type of Field: Length: Yes Integer 7

DEFINITIONS Home City – The name of the city in which the patient most often resides. INSTRUCTIONS Enter the appropriate option. If the city is not available, select “other” and detail city name in the following field (Incident Location – City – If Other). If zip code is entered first, this code will populate automatically. VALID OPTIONS City FIPS CODE / Not Applicable ? Unknown

Demographics Page 10 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic Patient’s Home City – If Other*

Window Location: Data Field Name: Demographic : Demographic P_ADR_CI_O

State Required: Type of Field: Length: Yes Text 50

DEFINITIONS Home City – If Other – Any other identifying city not found in the available list of options in which the patient most often resides INSTRUCTIONS Use direct keyboard entry.

Patient’s County of Residence*

Window Location: Data Field Name: Demographic : Demographic P_ADR_CO

State Required: Type of Field: Length: Yes Integer 5

DEFINITIONS County of Residence – The County in which the patient most often resides INSTRUCTIONS Enter the appropriate option. If zip code is entered first, this code will populate automatically. VALID OPTIONS County / Not Applicable ? Unknown

Patient’s State of Residence*

Window Location: Data Field Name: Demographic : Demographic P_ADR_ST

State Required: Type of Field: Length: Yes Alphanumeric 2 DEFINITIONS State of Residence – The state in which the patient most often resides INSTRUCTIONS Enter the appropriate option. If zip code is entered first, this code will populate automatically. VALID OPTIONS State / Not Applicable 29 Missouri ? Unknown 31 Nebraska 20 Kansas 40 Oklahoma 08 Colorado

Demographics Page 11 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic Date of Birth - Month*

Window Location: Data Field Name: Demographic : Demographic DOB_DM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Date of Birth – Month – The month of the patient's birth INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Date of Birth - Day*

Window Location: Data Field Name: Demographic : Demographic DOB_DD

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Date of Birth – Day – The day of the patient's birth INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Date of Birth – Year*

Window Location: Data Field Name: Demographic : Demographic DOB_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS Date of Birth – Year – The year of the patient’s birth INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1800 through 2099 [yyyy] ? Unknown

 In Report Writer; search DOB_DATE – the Month, Day and Year combined that makes up the patients date of birth.

Demographics Page 12 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic Age*

Window Location: Data Field Name: Demographic : Demographic RAW_AGE

State Required: Type of Field: Length: Yes Integer 3 DEFINITIONS Age – If not automatically calculated from birth date and ED arrival date. INSTRUCTIONS This field is only used in cases where a patient's birth date or ED arrival date is unknown, but the patient's age is known. Use direct keyboard entry.

Age Units*

Window Location: Data Field Name: Demographic : Demographic AGE_TYPE

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Age Units – Units of time for age (RAW_AGE) if not automatically calculated. INSTRUCTIONS This field is only used in cases where a patient's birth date or ED arrival date is unknown, but the patient's age is known. Use direct keyboard entry.

VALID OPTIONS 1 Years 3 Days 2 Months 4 Estimated in Years ? Unknown

Patient’s Race*

Window Location: Data Field Name: Demographic : Demographic RACE, RACE_2, RACE_3, RACE_4, RACE_5

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Race – Race group categorized according to the Office of Management and Budget Race and Ethnicity Standards for Federal Statistics and Administrative Reporting, Directive 15. Race should be based on self-report or identified by a family member. INSTRUCTIONS Enter the appropriate option in the first race field. If there is only one race reported for the patient, enter “/” N/A to close out the remaining fields. VALID OPTIONS 1 White 4 American Indian or Alaska ? Unknown Native 2 Black or African American 5 Asian / Not Applicable 3 Native Hawaiian or other Pacific 6 Other Islander

Demographics Page 13 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic Patient’s Gender*

Window Location: Data Field Name: Demographic : Demographic SEX

State Required: Type of Field: Length: Yes Text 1 DEFINITIONS Gender – Patient's gender at time of admit. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Male ? Unknown 2 Female

Patient’s Ethnicity*

Window Location: Data Field Name: Demographic : Demographic ETHNIC

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Ethnicity – Ethnic group categorized according to the Office of Management and Budget Race and Ethnicity Standards for Federal Statistics and Administrative Reporting, Directive 15. Hispanic ethnicity should be based on self-report or identified by a family member. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Hispanic or Latino ? Unknown 2 Not-Hispanic or Latino

Demographics Page 14 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic Occupation

Window Location: Data Field Name: Demographic : Demographic OCC

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Occupation – Occupational industry associated with the patient’s work environment INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 01 Executive, Administrative, and Managerial 15 Fabricators, Assemblers, and Handworking Occupations Occupations 02 Professional Specialty Occupations 16 Production Inspectors, Testers, Samplers and Weighers 03 Technicians and Related Support Occupations 17 Transportation and Material Moving Occupations 04 Sales Occupations 18 Handlers, Equipment Cleaners, Helpers, and Laborers 05 Administrative Support Occupations, Including 19 Military Occupations Clerical 06 Private Household Occupations 20 Unemployed 07 Protective Serv. Occupations 21 Retired 08 Serv. Occupations, Except Protective and Household 22 Homemaker 09 Farming, Forestry, and Fishing Occupations 23 Other 10 Mechanics and Repairers 24 Not Documented 11 Construction Trades 25 Minor/Student 12 Extractive Occupations 26 Disabled 13 Precision Production Occupations / Not Applicable 14 Machine Operations and Tenders, Except Precision ? Unknown

Demographics Page 15 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic

DEMOGRAPHICS-MEMO TAB

Demographic Memo

Window Location: Data Field Name: Demographic : Memo MEMO_DEMO

State Required: Type of Field: Length: No Text 5000 DEFINITIONS Demographic Memo – Text field in which to record additional demographic information if needed INSTRUCTIONS Use direct keyboard entry.

Demographics Page 16 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital SECTION 2 – PREHOSPITAL

Incident Date - Month* ...... 5 Incident Date - Day* ...... 5 Incident Date - Year* ...... 5 Incident Time - Hour* ...... 6 Primary Injury Type* ...... 7 Work Related Injury ...... 7 Cause of Injury – Primary E-Code* ...... 8 Cause of Injury – Secondary E-Code* ...... 8 Cause of Injury – Tertiary E-Code* ...... 9 Specify - Cause of Injury* ...... 9 Off – Road Vehicle* ...... 9 Place of Injury – Primary 849.x Code* ...... 10 Place of Injury – Secondary 849.x Code* ...... 10 Place of Injury – Tertiary 849.x Code* ...... 11 Place of Injury - Specify ...... 11 Zip Code Part 1* ...... 13 Zip Code Part 2 ...... 13 Street Address 1 ...... 13 Street Address 2 ...... 14 City* ...... 14 City – If Other* ...... 14 County*...... 15 State*...... 15 Police Report Number ...... 15 Position in Vehicle ...... 16 Position in Vehicle - Other ...... 16 On Lap...... 16 Protective Devices - Restraint* ...... 17 Protective Device - Airbag* ...... 17 Protective Device - Equipment* ...... 18 Protective Device - Other* ...... 18 Mode of Transport Provider* ...... 20 Transport Provider Agency* ...... 20 Linked with KEMSIS ...... 21 Transport Provider Level ...... 21 EMS Report Available* ...... 22 EMS Report Number ...... 22 EMS PCR Number ...... 23 Triaged by EMS ...... 23 Reason for Choosing Destination ...... 24 Type of Destination ...... 24 Call Received Date - Month* ...... 25 Call Received Date -Day* ...... 25 Call Received Date - Year* ...... 25 Call Received Date - Hour* ...... 26 Call Received Date - Minute* ...... 26 Dispatched Date – Month* ...... 27 Dispatched Date - Day* ...... 27

Prehospital Page 1 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Dispatched Date - Year* ...... 27 Dispatched Time - Hour* ...... 28 Dispatched Time - Minute* ...... 28 EnRoute Date - Month* ...... 29 EnRoute Date - Day* ...... 29 EnRoute Date - Year* ...... 29 EnRoute Time - Hour* ...... 30 EnRoute Time - Minute* ...... 30 Arrived Location Date - Month* ...... 31 Arrived Location Date - Day* ...... 31 Arrived Location Date - Year* ...... 32 Arrived Location Time - Hour* ...... 32 Arrived Location Time - Minute* ...... 33 Patient Contact Date - Month* ...... 33 Patient Contact Date - Day* ...... 34 Patient Contact Date - Year* ...... 34 Patient Contact Time - Hour* ...... 34 Patient Contact Time - Minute* ...... 35 Departed Location Date - Month* ...... 35 Departed Location Date - Day* ...... 36 Departed Location Date - Year* ...... 36 Departed Location Time - Hour* ...... 36 Departed Location Time - Minute* ...... 37 Arrived Facility Date - Month* ...... 37 Arrived Facility Date - Day* ...... 38 Arrived Facility Date - Year* ...... 38 Arrived Facility Time - Hour* ...... 38 Arrived Facility Time - Minute* ...... 39 Assessment Date - Month ...... 41 Assessment Date - Day ...... 41 Assessment Date - Year...... 41 Assessment Time - Hour ...... 42 Assessment Time - Minute ...... 42 Paralytic Agents in Effect ...... 43 Sedated ...... 43 Bagging or Ventilator ...... 44 Intubated – Transport Provider ...... 44 Systolic Blood Pressure – Transport Provider* ...... 45 Diastolic Blood Pressure – Transport Provider * ...... 45 Heart Rate – Transport Provider* ...... 46 Unassisted Respiratory Rate – Transport Provider * ...... 46 O2 Administered – Tranport Provider ...... 47 O2 Saturation – Transport Provider ...... 47 GCS – Eye Opening – Transport Provider * ...... 48 GCS – Verbal Response – Transport Provider * ...... 48 GCS – Motor Response – Transport Provider * ...... 49 GCS Total – Transport Provider * ...... 50 RTS (Unweighted) – Transport Provider * ...... 51 GCS Qualifer – Transport Provider * ...... 52 Airway – Transport Provider * ...... 52

Prehospital Page 2 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital CPR – Transport Provider * ...... 53 Fluids – Transport Provider * ...... 53 MAST – Retired Jan. 2011 ...... 53 Condition of Patient at the Scene –Transport Provider ...... 54 Tube Thoracostomy – Transport Provider ...... 54 Thoracentesis / Needle Thoracostomy – Transport Provider ...... 55 Medication Indicated on PCS ...... 57 Medications Indicated on PCS ...... 58 Procedures Performed on PCR ...... 58 EMS Narrative ...... 58 Prehospital Memo ...... 59

* Items are CORE (State Required) Data Elements.

NOTE: Yellow fields in the registry are autopopulated by the EMS Linkage Module (see Linkage button on Transport Provider Tab, p.19 of this section). They are not core variables and do not need to be entered.

Prehospital Page 3 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital

Prehospital – Incident

Prehospital Page 4 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Incident Date - Month*

Window Location: Data Field Name: Prehospital : Incident INJ_DM

State Required: Type of Field: Length: Yes Integer 2

DEFINITIONS Incident Date – The month in which the injury occurred. INSTRUCTIONS Enter the appropriate option using the [mm] format. If the exact date/time is unknown, the entry of an approximate value is acceptable in this field. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Incident Date - Day*

Window Location: Data Field Name: Prehospital : Incident INJ_DD

State Required: Type of Field: Length: Yes Integer 2

DEFINITIONS Incident Date – Day – The day on which the injury occurred. INSTRUCTIONS Enter the appropriate option using the [dd] format. If the exact date/time is unknown, the entry of an approximate value is acceptable in this field. VALID OPTIONS 01 through 31 [dd] ? Unknown

Incident Date - Year*

Window Location: Data Field Name: Prehospital : Incident INJ_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS Incident Date – Year – The year in which the injury occurred. INSTRUCTIONS Enter the appropriate option using the [yyyy] format. If the exact date/time is unknown, the entry of an approximate value is acceptable in this field. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Prehospital Page 5 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Incident Time - Hour*

Window Location: Data Field Name: Prehospital : Incident INJ_TH

State Required: Type of Field: Length: Yes Integer 2

DEFINITIONS Incident Time – Hour – The hour in which the injury occurred. INSTRUCTIONS Enter the appropriate option using the [hh] format. If the exact date/time is unknown, the entry of an approximate value is acceptable in this field. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Incident Time – Minute*

Window Location: Data Field Name: Prehospital : Incident INJ_TM

State Required: Type of Field: Length: Yes Integer 2

DEFINITIONS Incident Time – Minute – The minute in which the injury occurred. INSTRUCTIONS Enter the appropriate option using the [mm] format. If the exact date/time is unknown, the entry of an approximate value is acceptable in this field. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search INJ_EVENT – the Date and Time combined when the injury occurred.

 In Report Writer; search INJ_TIME – the Hour and the Minute combined when the injury occurred.

 In Report Writer; search INJ_DATE – the Month, Day and Year combined when the injury occurred.

Prehospital Page 6 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Primary Injury Type*

Window Location: Data Field Name: Prehospital : Incident INJ_TYPE

State Required: Type of Field: Length: Yes Integer 1

DEFINITIONS Injury Type – Type of injury the patient sustained. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Blunt – Non-penetrating injury 2 Penetrating – Piercing, entering deeply 3 Burn – Tissue injury from excessive exposure to chemical, thermal, electrical, or radioactive agents 4 Drowning – Asphyxiation due to immersion in liquid ? Unknown

Work Related Injury

Window Location: Data Field Name: Prehospital : Incident WORK_YN

State Required: Type of Field: Length: No Integer 1

DEFINITIONS Work Related – Was this an occupational injury? INSTRUCTIONS Answer the following question: Was injury related to employment? Enter the appropriate option. VALID OPTIONS 1 or Y Yes 2 or N No ? Unknown / Not Applicable

Prehospital Page 7 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Cause of Injury – Primary E-Code*

Window Location: Data Field Name: Prehospital : Incident E_CODE1

State Required: Type of Field: Length: Yes Fixed 1-5

DEFINITIONS E-Code – Index to external causes of injury and poisoning organized by the main terms which describe the accident, circumstance, event, or specific agent which caused the injury or other adverse effect. INSTRUCTIONS This field is for designating the E-Code that caused the patient's most severe injury. If the cause is unknown, use the default of 928.9. DO NOT enter E before the number and use decimal point for last digit.

NOTE: If the E-Code selected falls within the range of 850-869.9 or 880-928.9, a place of occurrence code (site of injury) must also be entered. Use direct keyboard entry. VALID OPTIONS E-Code / Not Applicable ? Unknown

Cause of Injury – Secondary E-Code*

Window Location: Data Field Name: Prehospital : Incident E_CODE2

State Required: Type of Field: Length: Yes Fixed 1-5

Do not repeat previously entered E-Code. If only Primary E-Code is relevant, code this field as N/A. INSTRUCTIONS This field is for designating the E-Code most relevant to the patient's injury after the primary E-code. If the cause is unknown, use the default of 928.9. DO NOT enter E before the number and use decimal point for last digit.

Do not repeat previously entered E-Code.

NOTE: If the E-Code selected falls within the range of 850-869.9 or 880-928.9, a place of occurrence code (site of injury) must also be entered. Use direct keyboard entry. Never leave this field blank. If patient’s record does not indicate a secondary E-code, enter ‘/’ Not Applicable. VALID OPTIONS E-Code / Not Applicable ? Unknown

Prehospital Page 8 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Cause of Injury – Tertiary E-Code*

Window Location: Data Field Name: Prehospital : Incident E_CODE3

State Required: Type of Field: Length: Yes Fixed 1-5

DEFINITIONS E-Code – Index to external causes of injury and poisoning organized by the main terms which describe the accident, circumstance, event, or specific agent which caused the injury or other adverse effect. Do not repeat previously entered E-Code. If only Primary & Secondary E-Codes are relevant, code this field as N/A. INSTRUCTIONS This field is for designating the E-Code most relevant to the patient's injury after the secondary E-code. If the cause is unknown, use the default of 928.9. DO NOT enter E before the number and use decimal point for last digit. Do not repeat previously entered E-Code.

NOTE: If the E-Code selected falls within the range of 850-869.9 or 880-928.9, a place of occurrence code (site of injury) must also be entered. Use direct keyboard entry. If secondary E-code is entered as ‘/’ Not Applicable, this field can be left blank, otherwise, an entry must be made. VALID OPTIONS E-Code / Not Applicable ? Unknown

Specify - Cause of Injury*

Window Location: Data Field Name: Prehospital : Incident CAUSE_INJ

State Required: Type of Field: Length: Yes Text 200

DEFINITIONS Text field for describing the external causes (circumstances) that lead to the injury. INSTRUCTIONS Use direct keyboard entry to record a detailed description of how the injury occurred.

Off – Road Vehicle*

THIS VARIABLE MOVED TO ED Tab on entry form number 14 (July, 2013). See Section 4 – ED for details about this variable.

Prehospital Page 9 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Place of Injury – Primary 849.x Code*

Window Location: Data Field Name: Prehospital : Incident E849_X1

State Required: Type of Field: Length: Yes Integer 1

DEFINITIONS 849.x Code – For use with categories 850-869.9 and 880-928.9 to denote place where the injury occurred. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 0 Home 6 Public Building 1 Farm 7 Residential Institution 2 Mine 8 Other 3 Industry 9 Unspecified 4 Recreation / Not Applicable 5 Street ? Unknown

Place of Injury – Secondary 849.x Code*

Window Location: Data Field Name: Prehospital : Incident E849_X2

State Required: Type of Field: Length: Yes Integer 1

DEFINITIONS Secondary 849.x Code – For use with categories 850-869.9 and 880-928.9 to denote any secondary place where the injury occurred, if applicable. INSTRUCTIONS Enter the appropriate option. Do not leave blank. If there is no secondary E849.x Code, enter “Not Applicable”. Entering “Not Applicable” enables Collector to skip over Tertiary 849.x Code. VALID OPTIONS 0 Home 6 Public Building 1 Farm 7 Residential Institution 2 Mine 8 Other 3 Industry 9 Unspecified 4 Recreation / Not Applicable 5 Street ? Unknown

Prehospital Page 10 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Place of Injury – Tertiary 849.x Code*

Window Location: Data Field Name: Prehospital : Incident E849_X3

State Required: Type of Field: Length: Yes Integer 1

DEFINITIONS Tertiary E849.x Code – For use with categories 850-869.9 and 880-928.9 to denote any tertiary place where the accident or poisoning occurred, if applicable. INSTRUCTIONS Enter the appropriate option. If you entered a Secondary 849.x Code and there is no Tertiary 849.x Code, enter “Not Applicable”. You may leave blank if “Not Applicable” is entered in Secondary 849.x Code. VALID OPTIONS 0 Home 6 Public Building 1 Farm 7 Residential Institution 2 Mine 8 Other 3 Industry 9 Unspecified 4 Recreation / Not Applicable 5 Street ? Unknown

Place of Injury - Specify

Window Location: Data Field Name: Prehospital : Location/Device PLACE_INJ

State Required: Type of Field: Length: No Text 200

DEFINITIONS Text field in which to record additional place of Injury information if needed. INSTRUCTIONS Use direct keyboard entry.

Prehospital Page 11 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital

Prehospital – Location/Devices

Prehospital Page 12 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Zip Code Part 1*

Window Location: Data Field Name: Prehospital : Location/Device I_ADR_Z1

State Required: Type of Field: Length: Yes Integer 5

DEFINITIONS Incident Location – Zip Code 1 – The 5-digit numeric code of the locale where the injury occurred. INSTRUCTIONS Use direct keyboard entry or enter the appropriate option. VALID OPTIONS 5 Digit Zip Code / Not applicable ? Unknown

Zip Code Part 2

Window Location: Data Field Name: Prehospital : Location/Device I_ADR_Z2

State Required: Type of Field: Length: No Integer 4

DEFINITIONS Incident Location – Zip Code 2 – The 4-digit suffix numeric code of the locale where the injury occurred. INSTRUCTIONS Use direct keyboard entry or enter the appropriate option. VALID OPTIONS 4 Digit Zip Code Suffix ? Unknown

Street Address 1

Window Location: Data Field Name: Prehospital : Location/Device I_ADR_S1

State Required: Type of Field: Length: No Text 50

DEFINITIONS Incident Location – Street Address 1 – The street address where the injury occurred. INSTRUCTIONS Use direct keyboard entry. VALID OPTIONS Street Address / Not Applicable ? Unknown

Prehospital Page 13 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Street Address 2

Window Location: Data Field Name: Prehospital : Location/Device I_ADR_S2

State Required: Type of Field: Length: No Text 50

DEFINITIONS Incident Location – Street Address 2 – The street address where the injury occurred. INSTRUCTIONS Use direct keyboard entry. VALID OPTIONS Street Address / Not Applicable ? Unknown

City*

Window Location: Data Field Name: Prehospital : Location/Device I_ADR_CI

State Required: Type of Field: Length: Yes Integer 7

DEFINITIONS Incident Location – City – The city where the injury occurred. INSTRUCTIONS Enter the appropriate option. If the city is not available, select “other” and detail city name in the following field (Incident Location – City – If Other). If injury occurred outside city limits, select “Not Applicable”.

If zip code is entered first, this code will populate automatically. NOTE: Check to make sure the city is correctly autopopulated from the zip code since some zip codes contain multiple cities. VALID OPTIONS City Code / Not Applicable ? Unknown

City – If Other*

Window Location: Data Field Name: Prehospital : Location/Device I_ADR_CI_O

State Required: Type of Field: Length: Yes Text 50

DEFINITIONS Incident Location – City – If Other – Any other identifying city not found in the available list of options in which the incident occurred. INSTRUCTIONS Use direct keyboard entry.

Prehospital Page 14 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital County*

Window Location: Data Field Name: Prehospital : Location/Device I_ADR_CO

State Required: Type of Field: Length: Yes Integer 5

DEFINITIONS Incident Location – County – The County where the injury occurred. NOTE: Check to make sure the county is correctly autopopulated from the zip code since some zip codes contain multiple counties.

INSTRUCTIONS Enter the appropriate option from the popup menu. If zip code is entered first, this code will populate automatically. VALID OPTIONS County code ? Unknown / Not Applicable

State*

Window Location: Data Field Name: Prehospital : Location/Device I_ADR_ST

State Required: Type of Field: Length: Yes Integer 2

DEFINITIONS Incident Location – State – The state where the injury occurred. INSTRUCTIONS Enter the appropriate option from the popup menu. If zip code is entered first, this code will populate automatically. VALID OPTIONS State code ? Unknown 29 Missouri / Not Applicable 31 Nebraska 20 Kansas 40 Oklahoma 08 Colorado

Police Report Number

Window Location: Data Field Name: Prehospital : Location/Device ACC_NUM

State Required: Type of Field: Length: No Alphanumeric 12

DEFINITIONS Police Report Number – The preprinted number on the police report. INSTRUCTIONS Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Police Report Number ? Unknown

Prehospital Page 15 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Position in Vehicle

Window Location: Data Field Name: Prehospital : Location/Device POS_VEH1

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Position in Vehicle – Position of the patient within the vehicle at the time of the injury. INSTRUCTIONS This information is gathered from the description of the scene by EMS personnel. Enter the appropriate option. VALID OPTIONS 01 Driver 10 Bicyclist 02 Passenger-Front-Middle 11 Pedestrian 03 Passenger-Front-Right 12 Riding an Animal 04 Passenger-Rear-Left 13 Occupant of a Street Car 05 Passenger-Rear-Middle 14 Unspecified 06 Passenger-Rear-Right 15 Other 07 Passenger-Open Bed 16 Occupant in Vehicle – Unknown Position 08 Motorcyclist / Not Applicable 09 Motor Cycle Passenger ? Unknown

ADDENDUM: Option 16 “Occupant in Vehicle – Unknown Position” added on Entry Form 15, June 27, 2014. Position in Vehicle - Other

Window Location: Data Field Name: Prehospital : Location/Device POS_VEH0

State Required: Type of Field: Length: No Text 50

DEFINITIONS Position in Vehicle – Other – Text field to record additional Position in Vehicle information if needed Position – Position of the patient within the vehicle at the time of the injury. INSTRUCTIONS This information is gathered from the EMS report. Use the description of the scene documented by EMS personnel. Use direct keyboard entry.

On Lap

Window Location: Data Field Name: Prehospital : Location/Device POS_LAP_YN

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS On Lap – Position of the patient within the vehicle was on the lap of another individual. INSTRUCTIONS Answer the following question: Was the position of the patient in the vehicle on the lap of another individual? Enter the appropriate option. VALID OPTIONS 1 Yes 2 No / Not Applicable ? Unknown

Prehospital Page 16 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Protective Devices - Restraint*

Window Location: Data Field Name: Prehospital : Location/Device PDEVR (PDEV_R_01, PDEV_R_02)

State Required: Type of Field: Length: Yes Yes/No 1 DEFINITIONS Protective Device – Restraint – The primary safety restraint device in use or worn by the patient at the time of the injury. If the injury event would not normally be associated with a restraint; e.g. a fall, enter “Not Applicable”. INSTRUCTIONS Enter the appropriate option. Do not leave blank. If only one restraint type was in use, mark the second as “Not Applicable” (“/”). VALID OPTIONS 00 None 05 Child Booster Seat 01 Lap Belt 06 Child Seat, unspecified type 02 Shoulder Belt 07 Uninstalled Child Car Seat 03 Infant Car Seat / Not Applicable 04 Child Car Seat ? Unknown

Protective Device - Airbag*

Window Location: Data Field Name: Prehospital : Location/Device PDEVA (PDEV_A_01, PDEV_A_02)

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Protective Device – Airbag – Any airbag present at the time of the injury. INSTRUCTIONS Enter the appropriate option. Do not leave blank. If only one airbag type was in use, mark the second as “Not Applicable” (“/”).If the injury event would not normally be associated with an airbag; e.g. a fall, enter “Not Applicable”. VALID OPTIONS 0 No Airbag in Vehicle 4 Airbag deployed other (knee, airbelt, curtain, etc.…) 1 Airbag equipped vehicle, not deployed 5 Airbag deployed unspecified 2 Airbag deployed front / Not Applicable 3 Airbag deployed side ? Unknown

Prehospital Page 17 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Protective Device - Equipment*

Window Location: Data Field Name: Prehospital : Location/Device PDEVE (PDEV_E_01, PDEV_E_02, PDEV_E_03, PDEV_E_04)

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Protective Device – Equipment – Any additional safety equipment in use or worn by the patient at the time of the injury. INSTRUCTIONS Enter the appropriate option. If no additional safety equipment is in use, enter “Not Applicable” (“/”).If the injury event would not normally be associated with protective equipment; e.g. tripped and fell at home, enter “Not Applicable”. VALID OPTIONS 0 None 5 Protective floatation device 1 Helmet (e.g., bicycle, football, motorcycle) 9 Other 2 Protective clothing (e.g., padded leather pants) / Not Applicable 3 Protective non-clothing gear (e.g., shin guard) ? Unknown 4 Eye protection

Protective Device - Other*

Window Location: Data Field Name: Prehospital : Location/Device PDEV_O

State Required: Type of Field: Length: Yes Text 50

DEFINITIONS Protective Device – Other – Text field in which to record additional Protective Device information if needed. INSTRUCTIONS Use direct keyboard entry.

Prehospital Page 18 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital

Prehospital – Transport Provider (1-3)

Prehospital Page 19 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Mode of Transport Provider* Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_MODE, P2_MODE, P3_MODE

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Mode – Type of transportation provided by the prehospital transport provider Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option. If there was only one prehospital transport provider, enter Not Applicable (“/”) for the second provider mode. VALID OPTIONS 01 Land Ambulance 07 Police 02 Helicopter Ambulance 08 Commercial Flight 03 Fixed-wing Ambulance 09 Other 04 Charter Fixed-Wing ? Unknown 05 Charter Helicopter / Not Applicable(2nd, 3rd provider only) 06 Private Vehicle/Walk-In

Transport Provider Agency*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_AGEN, P2_AGEN, P3_AGEN

State Required: Type of Field: Length: Yes Integer 6 DEFINITIONS Agency – The name of the transport provider Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option from the Provider Pick-list. VALID OPTIONS Agency ? Unknown

Addendum: Added to core data set on Entry Form #9

Prehospital Page 20 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Linked with KEMSIS

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_EMSLINK, P2_EMSLINK, P3_EMSLINK

State Required: Type of Field: Length: No Integer 1

DEFINITIONS This field is automatically populated when a user links a record using the EMS Linkage. Transport Provider 1 = P1_EMSLINK Transport Provider 2 – P2_EMSLINK Transport Provider 3 – P3_EMSLINK INSTRUCTIONS The value for Linked is assigned by the program VALID OPTIONS 1 Yes 2 No

ADDENDUM: The EMS Linkage Module, which enables registrars to link records with KEMSIS, was added in 2011, however the ability to record this linkage in the registry (variable EMSLINK) was added in 2012.

Transport Provider Level

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_LEVEL, P2_LEVEL, P3_LEVEL

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Provider Level – The level of service provided by the prehospital transport provider Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 1st Responder 4 ALS 2 BLS 5 Other 3 ILS ? Unknown Notes Though this field is designated as a CORE element in that the data will be sent to the State, it is not required that the Registrar complete this field. This element will be primarily populated through the use of the EMS Linkage.

Prehospital Page 21 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital EMS Report Available*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_R_AV, P2_R_AV, P3_R_AV

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Report Available – Availability of the ambulance report from the prehospital transport provider Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Answer the following question: Was the ambulance report from the prehospital transport provider available? Enter the appropriate option. VALID OPTIONS 1 Received, Complete and Legible, in a Timely Manner 4 Received, Illegible 2 Received, Complete, and Legible, not in a Timely Manner 5 Never Received 3 Received, Incomplete ? Unknown / Not Applicable EMS Report Number

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_R_NUM, P2_R_NUM, P3_R_NUM

State Required: Type of Field: Length: No Alphanumeric 12 DEFINITIONS Report Number – The preprinted number on the transport provider report Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Report Number / Not Applicable ? Unknown Notes Though this field is designated as a CORE element in that the data will be sent to the State, it is not required that the Registrar complete this field. This element will be primarily populated through the use of the EMS Linkage.

Prehospital Page 22 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital EMS PCR Number

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_PCR_N, P2_PCR_N, P3_PCR_N

State Required: Type of Field: Length: No Alphanumeric 25 DEFINITIONS PCR Number – Provided by the EMS Data Linkage Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Report Number / Not Applicable ? Unknown Notes Though this field is designated as a CORE element in that the data will be sent to the State, it is not required that the Registrar complete this field. This element will be primarily populated through the use of the EMS Linkage.

Triaged by EMS

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_EMS_YN, P2_EMS_YN, P3_EMS_YN

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Triaged by EMS – Screening and assessment of patient by EMS for treatment priority Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Answer the following question: Was the patient triaged for appropriate care by the emergency medical service personnel? Enter the appropriate option. VALID OPTIONS 1 Yes 2 No ? Unknown

Prehospital Page 23 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Reason for Choosing Destination

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_DEST, P2_DEST, P3_DEST,

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Reason for Choosing Destination – The reason the unit chose to deliver or transfer the patient to the destination Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Closest Facility (none below) 8 Patient Choice 2 Diversion 9 Patient’s Physician’s Choice 3 Family Choice 10 Protocol 4 Insurance Status 11 Specialty Resource Center 5 Law Enforcement Choice ? Unknown 6 On-Line Medical Direction / Not Applicable 7 Other Notes Though this field is designated as a CORE element in that the data will be sent to the State, it is not required that the Registrar complete this field. This element will be primarily populated through the use of the EMS Linkage.

Type of Destination

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_TYP_D, P2_TYP_D, P3_TYP_D,

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Destination Type – The type of destination the patient was delivered or transferred to Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Home 7 Other EMS Responder (Air) 2 Hospital 8 Other EMS Responder (Ground) 3 Medical Office/Clinic 9 Police/Jail 4 Morgue ? Unknown 5 Nursing Home / Not Applicable 6 Other Notes Though this field is designated as a CORE element in that the data will be sent to the State, it is not required that the Registrar complete this field. This element will be primarily populated through the use of the EMS Linkage.

Prehospital Page 24 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Call Received Date - Month*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_R_DM, P2_R_DM, P3_R_DM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Call Received Date – Month – The month the call was received by transport provider dispatch to respond to injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Call Received Date -Day*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_R_DD, P2_R_DD, P3_R_DD

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Call Received Date – Day – The day the call was received by transport provider dispatch to respond to injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Call Received Date - Year*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_R_DY, P2_R_DY, P3_R_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS Call Received Date – Year – The year the call was received by transport provider dispatch to respond to injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Prehospital Page 25 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Call Received Date - Hour*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_R_TH, P2_R_TH, P3_R_TH

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Call Received Time – Hour – The hour the call was received by transport provider dispatch to respond to injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Call Received Date - Minute*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_R_TM, P2_R_TM, P3_R_TM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Call Received Time – Minute – The minute the call was received by transport provider dispatch to respond to injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown  In Report Writer; search P1_R_EVENT, P2_R_EVENT, P3_R_EVENT – the Date and Time combined that the call was received by transport provider dispatch to respond to the injury.

 In Report Writer; search P1_R_TIME, P2_R_TIME, P3_R_TIME – the Hour and the Minute combined that the call was received by transport provider dispatch to respond to the injury.

 In Report Writer; search P1_R_DATE, P2_R_DATE, P3_R_DATE – the Month, Day and Year combined that the call was received by transport provider dispatch to respond to injury.

Prehospital Page 26 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Dispatched Date – Month*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_D_DM, P2_D_DM, P3_D_DM

State Required: Type of Field: Length: Yes Integer 2

DEFINITIONS Dispatched Date – Month – The month the transport provider was dispatched to the scene of the injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Dispatched Date - Day*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_D_DD, P2_D_DD, P3_D_DD

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Dispatched Date – Day – The day the transport provider was dispatched to the scene of the injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Dispatched Date - Year*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_D_DY, P2_D_DY, P3_D_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS Dispatched Date – Year – The year the transport provider was dispatched to the scene of the injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Prehospital Page 27 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Dispatched Time - Hour*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_D_TH, P2_D_TH, P3_D_TH

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Dispatched Time – Hour – The hour the transport provider was dispatched to the scene of the injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Dispatched Time - Minute*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_D_TM, P2_D_TM, P3_D_TM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Dispatched Time – Minute – The minute the transport provider was dispatched to the scene of the injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown  In Report Writer; search P1_D_EVENT, P2_D_EVENT, P3_D_EVENT – the Date and Time combined that the transport provider was dispatched to the scene of the injury.

 In Report Writer; search P1_D_TIME, P2_D_TIME, P3_D_TIME – the Hour and the Minute combined that the transport provider was dispatched to the scene of the injury.

 In Report Writer; search P1_D_DATE, P2_D_DATE, P3_D_DATE – the Month, Day and Year combined that the transport provider was dispatched to the scene of the injury.

Prehospital Page 28 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Enroute Date - Month*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_I_DM, P2_I_DM, P3_I_DM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Enroute Date – Month – The month the transport provider became mobile to responding to the injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Enroute Date - Day*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_I_DD, P2_I_DD, P3_I_DD

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Enroute Date – Day – The day the transport provider became mobile to responding to the injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Enroute Date - Year*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_I_DY, P2_I_DY, P3_I_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS Enroute Date – Year – The year the transport provider became mobile to responding to the injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Prehospital Page 29 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Enroute Time - Hour*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_I_TH, P2_I_TH, P3_I_TH

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Enroute Time – Hour – The hour the transport provider became mobile to responding to the injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Enroute Time - Minute*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_I_TM, P2_I_TM, P3_I_TM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Enroute Time – Minute – The minute the transport provider became mobile to responding to the injury Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown  In Report Writer; search P1_I_EVENT, P2_I_EVENT, P3_I_EVENT – the Date and Time combined that the transport provider became mobile to responding to the injury.

 In Report Writer; search P1_I_TIME, P2_I_TIME, P3_I_TIME – the Hour and the Minute combined that the transport provider became mobile to responding to the injury.

 In Report Writer; search P1_I_DATE, P2_I_DATE, P3_I_DATE – the Month, Day and Year combined that the transport provider became mobile to responding to the injury.

Prehospital Page 30 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Arrived Location Date - Month*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_A_DM, P2_A_DM, P3_A_DM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Arrived Location Date – Month – The month the transport provider arrived at the location to which they had been dispatched Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Arrived Location Date - Day*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_A_DD, P2_A_DD, P3_A_DD

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Arrived Location Date – Day – The day the transport provider arrived at the location to which they had been dispatched Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Prehospital Page 31 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Arrived Location Date - Year*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_A_DY, P2_A_DY, P3_A_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS Arrived Location Date – Year – The year the transport provider arrived at the location to which they had been dispatched Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Arrived Location Time - Hour*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_A_TH, P2_A_TH, P3_A_TH

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Arrived Location Time – Hour – The hour the transport provider arrived at the location to which they had been dispatched Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Prehospital Page 32 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Arrived Location Time - Minute*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_A_TM, P2_A_TM, P3_A_TM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Arrived Location Time – Minute – The minute the transport provider arrived at the location to which they had been dispatched Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown  In Report Writer; search P1_A_EVENT, P2_A_EVENT, P3_A_EVENT – the Date and Time combined that the transport provider arrived at the location to which they had been dispatched.

 In Report Writer; search P1_A_TIME, P2_A_TIME, P3_A_TIME – the Hour and the Minute combined that the transport provider arrived at the location to which they had been dispatched.

 In Report Writer; search P1_A_DATE, P2_A_DATE, P3_A_DATE – the Month, Day and Year combined that the transport provider arrived at the location to which they had been dispatched.

Patient Contact Date - Month*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_P_DM, P2_P_DM, P3_P_DM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Patient Contact Date – Month – The month the transport provider made first contact with the patient Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Prehospital Page 33 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Patient Contact Date - Day*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_P_DD, P2_P_DD, P3_P_DD

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Patient Contact Date – Day – The day the transport provider made first contact with the patient Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Patient Contact Date - Year*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_P_DY, P2_P_DY, P3_P_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS Patient Contact Date – Year– The year the transport provider made first contact with the patient Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Patient Contact Time - Hour*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_P_TH, P2_P_TH, P3_P_TH

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Patient Contact Time – Hour – The hour the transport provider made first contact with the patient Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Prehospital Page 34 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Patient Contact Time - Minute*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_P_TM, P2_P_TM, P3_P_TM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Patient Contact Time – Minute – The minute the transport provider made first contact with the patient Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search P1_P_EVENT, P2_P_EVENT, P3_P_EVENT – the Date and Time combined that the transport provider made first contact with the patient.

 In Report Writer; search P1_P_TIME, P2_P_TIME, P3_P_TIME, – the Hour and the Minute combined that the transport provider made first contact with the patient.

 In Report Writer; search P1_P_DATE, P2_P_DATE, P3_P_DATE – the Month, Day and Year combined that the transport provider made first contact with the patient.

Departed Location Date - Month*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_L_DM, P2_L_DM, P3_L_DM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Departed Location Date – Month – The month the transport provider departed the location to which they had been dispatched Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Prehospital Page 35 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Departed Location Date - Day*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_L_DD, P2_L_DD, P3_L_DD

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Departed Location Date – Day – The day the transport provider departed the location to which they had been dispatched Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Departed Location Date - Year*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_L_DY, P2_L_DY, P3_L_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS Departed Location Date – Year – The year the transport provider departed the location to which they had been dispatched Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Departed Location Time - Hour*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_L_TH, P2_L_TH, P3_L_TH

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Departed Location Time – Hour –The hour the transport provider departed the location to which they had been dispatched Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Prehospital Page 36 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Departed Location Time - Minute*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_L_TM, P2_L_TM, P3_L_TM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Departed Location Time – Minute – The minute the transport provider departed the location to which they had been dispatched Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] / Not Applicable ? Unknown  In Report Writer; search P1_L_EVENT, P2_L_EVENT, P3_L_EVENT – the Date and Time combined that the transport provider departed the location to which they had been dispatched.

 In Report Writer; search P1_L_TIME, P2_L_TIME, P3_L_TIME – the Hour and the Minute combined that the transport provider departed the location to which they had been dispatched.

 In Report Writer; search P1_L_DATE, P2_L_DATE, P3_L_DATE – the Month, Day and Year combined that the transport provider departed the location to which they had been dispatched.

Arrived Facility Date - Month*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_H_DM, P2_H_DM, P3_H_DM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Arrived Facility Date – Month – The month the transport provider arrived at the facility Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Prehospital Page 37 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Arrived Facility Date - Day*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_H_DD, P2_H_DD, P3_H_DD

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Arrived Facility Date – Day – The day the transport provider arrived at the facility Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Arrived Facility Date - Year*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_H_DY, P2_H_DY, P3_H_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS Arrived Facility Date – Year – The year the transport provider arrived at the facility Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Arrived Facility Time - Hour*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_H_TH, P2_H_TH, P3_H_TH

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Arrived Facility Time – Hour – The hour the transport provider arrived at the facility Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Prehospital Page 38 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Arrived Facility Time - Minute*

Window Location: Data Field Name: Prehospital : Transport Provider 1,2,3 P1_H_TM, P2_H_TM, P3_H_TM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Arrived Facility Time – Minute – The minute the transport provider arrived at the facility Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search P1_H_EVENT, P2_H_EVENT, P3_H_EVENT – the Date and Time combined that the transport provider arrived at the facility.

 In Report Writer; search P1_H_TIME, P2_H_TIME, P3_H_TIME – the Hour and the Minute combined that the transport provider arrived at the facility.

 In Report Writer; search P1_H_DATE, P2_H_DATE, P3_H_DATE – the Month, Day and Year combined that the transport provider arrived at the facility.

Prehospital Page 39 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital

Prehospital- Vitals

Prehospital Page 40 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Assessment Date - Month

Window Location: Data Field Name: Prehospital : Provider 1,2,3- Vitals P1_DM, P2_DM, P3_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Date – Month – The month transport provider personnel conducted a medical assessment of the patient Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Assessment Date - Day

Window Location: Data Field Name: Prehospital : Provider 1,2,3- Vitals P1_DD, P2_DD, P3_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Date – Day – The day transport provider personnel conducted a medical assessment of the patient Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Assessment Date - Year

Window Location: Data Field Name: Prehospital : Provider 1,2,3- Vitals P1_DY, P2_DY, P3_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Assessment Date – Year – The year transport provider personnel conducted a medical assessment of the patient Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Prehospital Page 41 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Assessment Time - Hour

Window Location: Data Field Name: Prehospital : Provider 1,2,3- Vitals P1_TH, P2_TH, P3_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Time – Hour – The hour transport provider personnel conducted a medical assessment of the patient Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Assessment Time - Minute

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 - Vitals P1_TM, P2_TM, P3_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Time – Minute – The minute transport provider personnel conducted a medical assessment of the patient Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search P1_EVENT, P2_EVENT, P3_EVENT – the Date and Time combined that the transport provider personnel conducted a medical assessment of the patient.

 In Report Writer; search P1_TIME, P2_TIME, P3_TIME – the Hour and the Minute combined that the transport provider personnel conducted a medical assessment of the patient.

 In Report Writer; search P1_DATE, P2_DATE, P3_DATE – the Month, Day and Year combined that the transport provider personnel conducted a medical assessment of the patient.

Prehospital Page 42 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Paralytic Agents in Effect

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 – Vitals P1_PAR, P2_PAR, P3_PAR

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Paralytic Agents in Effect – Administration of paralytic agents to patient Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Answer the following question: Have paralytic agents been administered by the transport provider to the patient? Enter the appropriate option. VALID OPTIONS 1 or Y Yes 2 or N No ? Unknown

Sedated

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 – Vitals P1_SED, P2_SED, P3_SED

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Sedated – Administration of drugs to the patient for the purpose of sedation Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility. Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Answer the following question: Have drugs been administered by the transport provider to the patient for sedation? Enter the appropriate option. VALID OPTIONS 1 or Y Yes 2 or N No ? Unknown

Prehospital Page 43 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Bagging or Ventilator

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 - Vitals P1_BAG, P2_BAG, P3_BAG

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Bagging or Ventilator – Bagging of patient or placement of patient on a ventilator in order to provide respiratory assistance Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Answer the following question: Has the patient been bagged or placed on a ventilator to provide respiratory assistance? Enter the appropriate option. VALID OPTIONS 1 or Y Yes 2 or N No ? Unknown

Intubated – Transport Provider

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 - Vitals P1_INT, P2_INT, P3_INT

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Intubated – Intubation of patient to provide a patent and protected airway Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Answer the following question: Has the patient been intubated by the transport provider to provide an airway? Enter the appropriate option. OPTIONS 1 or Y Yes 2 or N No ? Unknown

Prehospital Page 44 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Systolic Blood Pressure – Transport Provider*

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 – Vitals P1_SBP, P2_SBP, P3_SBP

State Required: Type of Field: Length: Yes Integer 3 DEFINITIONS Systolic Blood Pressure – Pressure recorded as occurring during contraction of ventricles Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the patient’s first systolic blood pressure at the scene. Use direct keyboard entry. VALID OPTIONS 0-300 / Not Applicable ? Unknown

Diastolic Blood Pressure – Transport Provider *

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 – Vitals P1_DBP, P2_DBP, P3_DBP

State Required: Type of Field: Length: Yes Integer 3 DEFINITIONS Diastolic Blood Pressure – Pressure recorded during the period of least resistance in the arterial vascular system Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility. Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the patient’s first diastolic blood pressure at the scene. Use direct keyboard entry. VALID OPTIONS 0-200 / Not Applicable ? Unknown

Prehospital Page 45 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Heart Rate – Transport Provider*

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 - Vitals P1_HR, P2_HR, P3_HR

State Required: Type of Field: Length: Yes Integer 3 DEFINITIONS Heart Rate – Rate of the pulse palpated in beats per minute Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the patient’s initial radial or apical pulse at the scene. Do not use the cardiac monitor rate. Use direct keyboard entry. VALID OPTIONS 0-250 / Not Applicable ? Unknown

Unassisted Respiratory Rate – Transport Provider *

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 - Vitals P1_RR, P2_RR, P3_RR

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Respiratory Rate – The act of breathing measured in spontaneous unassisted breaths per minute without the use of mechanical devices Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the patient’s initial respiratory rate. Use direct keyboard entry. VALID OPTIONS 0-99 / Not Applicable ? Unknown

Prehospital Page 46 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital O2 Administered – Transport Provider

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 – Vitals P1_O2_YN, P2_02_YN, P3_O2_YN

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS

O2 Administered – Administration of oxygen to the patient Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Answer the following question: Has supplemental oxygen been administered by the transport provider to the patient to improve oxygenation? Enter the appropriate option. VALID OPTIONS 1 Yes 2 No ? Unknown

O2 Saturation – Transport Provider

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 – Vitals P1_SAO2, P2_SAO2, P3_SAO2

State Required: Type of Field: Length: No Integer 3 DEFINITIONS

O2 Saturation – First recorded oxygen saturation measured at the scene (expressed as a percentage). Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS

Enter the transport provider’s documented O2 saturation level. Use direct keyboard entry. VALID OPTIONS 0-100 / Not Applicable ? Unknown

Prehospital Page 47 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital GCS – Eye Opening – Transport Provider *

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 - Vitals P1_GCS_EO, P2_GCS_EO, P3_GCS_EO

Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the initial best eye opening score for the patient at the scene of the injury. Enter the appropriate option. VALID OPTIONS 1 None 4 Spontaneous 2 To Pain ? Unknown 3 To Voice

GCS – Verbal Response – Transport Provider *

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 - Vitals P1_GCS_VR, P2_GCS_VR, P3_GCS_VR

Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility. Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the initial best verbal score for the patient at the scene of the injury. Enter the appropriate option. VALID OPTIONS 1 None 4 Confused 2 Incomprehensible Sounds 5 Oriented 3 Inappropriate Words ? Unknown

Prehospital Page 48 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital GCS – Motor Response – Transport Provider *

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 – Vitals P1_GCS_MR, P2_GCS_MR, P3_GCS_MR

Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the initial best motor response score for this patient at the scene of the injury. Enter the appropriate option. VALID OPTIONS 1 None 5 Localizes Pain 2 Abnormal Extension 6 Obeys Commands 3 Abnormal Flexion ? Unknown 4 Withdraws to Pain

Prehospital Page 49 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital GCS Total – Transport Provider *

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 - Vitals P1_GCS_TT, P2_GCS_TT, P3_GCS_TT

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS GCS (Glasgow Coma Scale) – Total – The total of the patient’s Eye opening, Verbal response, and Motor response scores

ADULT CHILD 2-5 years INFANT 0-23 months SCORE Eye Opening: None None None 1 To pain To pain To pain 2 To voice To voice To voice 3 Spontaneous Spontaneous Spontaneous 4

Verbal Response: None None None 1 Incomprehensible sounds Incomprehensible words Moans to pain 2 Inappropriate words Inappropriate cries Cries to pain 3 Confused Confused Irritable cries 4 Oriented Oriented Coos, babbles 5

Motor Response: None None None 1 Abnormal extension Extension in response to Decorticate posturing in pain response to pain 2 Abnormal flexion Flexion in response to Decorticate posturing in pain response to pain 3 Withdraws to pain Withdraws in response to pain Withdraws in response to pain 4 Localizes pain Localizes painful stimulus Withdraws to touch 5 Obeys commands Obeys commands Moves spontaneously 6

Total GCS = Eye Opening Score + Verbal Response Score + Motor Response Score (Ranges between 3 and 15)

Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS The total GCS Score for the patient recorded upon arrival at the scene will be computed by the program after all the GCS components are entered.

Prehospital Page 50 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital RTS (Unweighted) – Transport Provider *

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 – Vitals P1_RTS_U, P2_RTS_U, P3_RTS_U

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS RTS (Unweighted) – Based on the values of the Glasgow Coma Scale, systolic blood pressure and respiratory rate. Raw values are used for triage. Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility

Coded values are summed for outcome evaluation. Raw values (displayed):

Glasgow Coma Scale total points: 13-15 = 4 9-12 = 3 6-8 = 2 4-5 = 1 3 = 0 Respiratory Rate > 29 = 4 10-29 = 3 6-9 = 2 1-5 = 1 0 = 0 Systolic Blood Pressure –

> 89 = 4 76-89 = 3 50-75 = 2 1-49 = 1 0 = 0

Unweighted RTS = Glasgow Coma value + Systolic BP value + Respiratory Rate value INSTRUCTIONS The Unweighted RTS is automatically calculated by the program after the GCS score, respiratory rate, and systolic blood pressure are entered. If one of these parameters is unknown, the RTS cannot be calculated.

Prehospital Page 51 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital GCS Qualifier – Transport Provider *

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 - Vitals P1_GCSQ_1, P1_GCSQ_2, P1_GCSQ_3 P2_GCSQ_1, P2_GCSQ_2, P2_GCSQ_3 P3_GCSQ_1, P3_GCSQ_2, P3_GCSQ_3

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS GCS Qualifier – Factors potentially affecting the assessment of the initial GCS taken at the scene of injury. Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter all qualifiers that could affect the initial assessment of GCS for this patient at the scene of the injury. Enter the appropriate option. VALID OPTIONS 1 Valid GCS 4 Patient Intubated 2 Patient Chemically Sedated or 9 Not documented Paralyzed 3 Obstruction to patient’s eye ? Unknown

ADDENDUM: Options 1. formerly “No Qualifier” and 2. “Chemically altered mental status” was amended on Form 15, June 27, 2014. Airway – Transport Provider *

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 - Vitals P1_AIR, P2_AIR, P3_AIR

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Airway – A device or procedure used to prevent or correct obstructed respiratory passage Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the most invasive airway adjunct used to assist the patient either at the scene or during transport by any transport provider. Enter the appropriate option. VALID OPTIONS 00 No Intervention 10 Nasal Pharyngeal Airway 01 Assisted by Bag and Mask 11 Blow By 02 Cricothyrotomy 12 Non-Rebreather Mask Oxygen 04 Nasal Endotracheal Tube 13 Nasal Cannula Oxygen 05 Oral Airway 14 Tracheostomy 06 Oral Endotracheal Tube 15 Unspecified 07 Oxygen Mask 16 Unsuccessful 08 LMA ? Unknown 09 King/Combi-Tube

ADDENDUM: Option 9 formerly “Combi Tube” amended on Entry Form 15, June 27, 2014.

RETIRED: Option 3 “Esophageal Obturator Airway” retired on Entry Form 15, June 27,2014.

Prehospital Page 52 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital CPR – Transport Provider *

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 – Vitals P1_CPR, P2_CPR, P3_CPR

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS CPR (Cardiopulmonary Resuscitation) – Procedure for revival after lack of heart beat or respirations Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility. Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Answer the following question: Was CPR performed on the patient either at the scene or enroute to the facility? Enter the appropriate option. VALID OPTIONS 0 No Intervention 2 CPR done at the scene ? Unknown 1 CPR done enroute 3 CPR done at scene and enroute

Fluids – Transport Provider *

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 – Vitals P1_FLUIDS, P2_FLUIDS, P3_FLUIDS

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Fluids – Crystalloid only, do not include blood or blood products Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the amount of IV fluid administered at the scene of the injury and enroute to the facility to which the patient was transported. Enter the appropriate option. VALID OPTIONS 1 Less than 500 mL administered 5 Unsuccessful 2 500 to 2000 mL administered 7 Venous access – no fluids given 3 Greater than 2000 mL 8 No venous access administered 4 IV Fluids unknown amount 9 Patient Refused IV Fluids ? Unknown

MAST – Retired Jan. 2011

RETIRED: This data element was retired as part of the Jan. 2011 Collector update.

Prehospital Page 53 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Condition of Patient at the Scene –Transport Provider

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 - Vitals P1_COND, P2_COND, P3_COND

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Condition of Patient at the Scene – AVPU – Neurologic evaluation from ATLS to establish the patient's level of consciousness (ATLS Course Manual) A = Alert, V = Responds to Verbal Stimuli, P = Responds to Painful Stimuli, U = Unresponsive Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility. Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter the patient’s condition at the scene as assessed using the AVPU system. Enter the appropriate option, or if using the EMS Linkage Module, this data element is populated by the EMS Linkage data. VALID OPTIONS 1 Alert 6 Unspecified 2 Responsive to Verbal 7 Combative Stimuli 3 Responsive to Painful / Not Applicable Stimuli 4 Unresponsive/Sedated ? Unknown 5 Unresponsive

Tube Thoracostomy – Transport Provider

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 - Vitals P1_THOR, P2_THOR, P3_THOR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Thoracentesis/Tube Thoracostomy – Surgical entry into the thoracic cavity to remove fluids, or resection of the chest wall to allow drainage of the chest cavity Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Answer the following question: Have transport provider personnel performed a thoracentesis/tube thoracostomy on the patient? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown 3 Unsuccessful

Prehospital Page 54 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Thoracentesis / Needle Thoracostomy – Transport Provider

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 – Vitals P1_NEED, P2_NEED, P3_NEED

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Needle Thoracostomy – Use of needle during resuscitation to relieve pressure and/or allow drainage of the chest cavity Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Answer the following question: Have transport provider personnel performed a needle thoracostomy on the patient? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown 3 Unsuccessful

Prehospital Page 55 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital

Prehospital – Provider Med/Procs (New Tab Jan. 2011)

Prehospital Page 56 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Medication Indicated on PCS

RETIRED: Retired September, 2011

Window Location: Data Field Name: Prehospital : Provider 1, 2, 3 – Med/Procs P1_MEDS_1, P2_MEDS_1, P3_MEDS_1 P1_MEDS_2, P2_MEDS_2, P3_MEDS_2 P1_MEDS_3, P2_MEDS_3, P3_MEDS_3 P1_MEDS_4, P2_MEDS_4, P3_MEDS_4 P1_MEDS_5, P2_MEDS_5, P3_MEDS_5

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Medications - Any Medication given to the patient by the transport provider personnel Transport Provider 1 – First transport provider to care for the patient between the scene and initial facility Transport Provider 2 – Second transport provider to care for the patient between the scene and initial facility Transport Provider 3 – Third transport provider to care for the patient between the scene and initial facility INSTRUCTIONS Enter up to 5 different medications given to the patient at the scene and enroute. VALID OPTIONS 00 None 25 Corticosteroids (Prednisone) 01 ACE inhibitor (Enalapril, Captopril, Lisinopril) 26 Corticosteroids, Inhaled (Beclomethasone) 02 Acetaminophen 27 Diuretic (Hydrochlorothiazide, Furosemide) 03 Antiarrhythmics (Amiodarone, Procainamide, 28 Estrogen replacement (Conjugated Estrogen) Sotalol) 04 Antibacterials (Cefazolin, Augmentin) 29 Gout (Allopurinol, Colchicine, Probenecid) 05 Anticoagulants (Coumadin, Heparin, Enoxaparin) 30 H2 antagonist (Ranitidine, Famotidine) 06 Anticonvulsant (Phenytoin, Carbamazepine) 31 Hypoglycemic (Glyburide, Metformin) 07 Antidepressant (Fluoxetine, Sertraline, 32 Insulin Amitriptyline)) 08 Antifungal (Fluconazole) 33 Laxatives (Bisacodyl, Docusate) 09 Antihistamine (Astemizole, Loratidine) 34 Lithium 10 Antihyperlipedemic (Atorvastatin, Simvastatin) 35 Metoclopramide 11 Antiparkinsonian (Levodopa, Benztropine, 36 Muscle relaxants (Baclofen, Cyclobenzaprine) Amantadine) 12 Anti-platelet agent (Ticlopidine, Clopidogrel) 37 Narcotics (Morphine, Oxycodone, Codeine) 13 Antipsychotic (Haloperidol, Chlorpromazine, 38 Nitroglycerine Fluphenazine) 14 Antispasmodic (Oxybutynin) 39 Non-steroidal anti-inflammatory (Ibuprofen, Rofecoxib) 15 Antithyroid (Propylthiouracil, Methimazole) 40 Oral contraceptives 16 Antituberculosis (Isoniazid, Ethambutol) 41 Progesterone 17 Antiviral (Interferon, Azathioprine, 3TC, Indinavir) 42 Protein pump inhibitor (Omeprazole, Pantoprazole) 18 ASA 43 Sucralfate 19 Barbiturates (Phenobarbital, Secobarbital) 44 Thyroid replacement (Eltroxin) 20 Benzodiazepines (Lorazepam, Diazepam) 45 Vasodilators (Hydralazine, Clonidine, Alpha Methyldopa) 21 Beta blocker (Metroprolol, Atenolol) 46 Other 22 Bronchodilators (Inhaled, e.g. Albuterol, 50 Neuromuscular Blocker Ipratropium Bromide) 23 Calcium channel blocker (Diltiazem, Verapamil, / Not Applicable Lisinopril) 24 Cardiac glycoside (Digoxin) ? Unknown

Prehospital Page 57 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital Medications Indicated on PCS Note: This data element is populated when a record is linked with KEMSIS using the EMS linkage module.

Procedures Performed on PCR Note: This data element is populated when a record is linked with KEMSIS using the EMS linkage module.

EMS Narrative Note This data element is populated when a record is linked with KEMSIS using the EMS linkage module.

Prehospital Page 58 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Prehospital

Prehospital – Memo

Prehospital Memo

Window Location: Data Field Name: Prehospital : Memo MEMO_PRE

State Required: Type of Field: Length: No Memo 5000

DEFINITIONS Prehospital Memo – Text field in which to record additional prehospital information if needed INSTRUCTIONS Use direct keyboard entry.

Prehospital Page 59 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility SECTION 3 - INTERMEDIATE FACILITY

Facility ID Number – (Intermediate Facility) ...... 5 Facility ID Number - If Other – (Intermediate Facility) ...... 5 Arrival Date – Month – (Intermediate Facility) ...... 5 Arrival Date – Day – (Intermediate Facility) ...... 6 Arrival Date – Year – (Intermediate Facility) ...... 6 Arrival Time – Hour – (Intermediate Facility) ...... 6 Arrival Time – Minute – (Intermediate Facility) ...... 7 Departure Date – Month – (Intermediate Facility) ...... 7 Departure Date – Day – (Intermediate Facility) ...... 8 Departure Date – Year – (Intermediate Facility) ...... 8 Departure Time – Hour – (Intermediate Facility) ...... 8 Departure Time – Minute – (Intermediate Facility) ...... 9 Referring Physician – (Intermediate Facility) ...... 9 Reason for Discharge – (Intermediate Facility) ...... 10 Discharge By – (Intermediate Facility) ...... 10 Assessment Date – Month – (Intermediate Facility) ...... 11 Assessment Date – Day – (Intermediate Facility) ...... 11 Assessment Date – Year – (Intermediate Facility) ...... 11 Assessment Time – Hour – (Intermediate Facility) ...... 12 Assessment Time – Minute – (Intermediate Facility) ...... 12 Paralytic Agents in Effect – (Intermediate Facility) ...... 13 Sedated – (Intermediate Facility) ...... 13 Bagging or Ventilator – (Intermediate Facility) ...... 13 Intubated – (Intermediate Facility) ...... 14 Systolic Blood Pressure – (Intermediate Facility) ...... 14 Diastolic Blood Pressure – (Intermediate Facility) ...... 14 Heart Rate – (Intermediate Facility) ...... 15 Unassisted Respiratory Rate – (Intermediate Facility) ...... 15 O2 Administered – (Intermediate Facility) ...... 15 O2 Saturation – (Intermediate Facility)...... 16 GCS – Eye Opening – (Intermediate Facility) ...... 16 GCS – Verbal Response – (Intermediate Facility) ...... 17 GCS – Motor Response – (Intermediate Facility) ...... 17 GCS – Total – (Intermediate Facility) ...... 18 RTS (Weighted) – (Intermediate Facility) ...... 19 GCS Qualifier – (Intermediate Facility) ...... 20 Abdominal CT Results – (Intermediate Facility) ...... 22 Abdominal Ultrasound Results – (Intermediate Facility) ...... 22 Aortogram / Anteriogram / Angiogram Results – (Intermediate Facility) ...... 23 Chest CT Results – (Intermediate Facility) ...... 23 Head CT Results – (Intermediate Facility) ...... 24 Peritoneal Lavage – (Intermediate Facility) ...... 24 ICU – (Intermediate Facility) ...... 25 Airway – (Intermediate Facility) ...... 25 OR – (Intermediate Facility) ...... 26 CPR – (Intermediate Facility) ...... 26 Medications – (Intermediate Facility) -- RETIRED ...... 27

Intermediate Facility Page 1 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Transfer Provider Mode – (Intermediate Facility) ...... 29 Transfer Provider Agency – (Intermediate Facility) ...... 29 Transfer Provider Level – (Intermediate Facility) ...... 30 Report Available – Transfer Provider – (Intermediate Facility) ...... 30 Report Number – Transfer Provider – (Intermediate Facility) ...... 31 PCR Number – (Intermediate Facility) ...... 31 Call Received Date – Month – (Intermediate Facility) ...... 31 Call Received Date – Day – (Intermediate Facility) ...... 32 Call Received Date – Year – (Intermediate Facility) ...... 32 Call Received Time – Hour – (Intermediate Facility) ...... 32 Call Received Time – Minute – (Intermediate Facility) ...... 33 Dispatched Date – Month – (Intermediate Facility) ...... 33 Dispatched Date – Day – (Intermediate Facility) ...... 34 Dispatched Date – Year – (Intermediate Facility) ...... 34 Dispatched Time – Hour – (Intermediate Facility) ...... 34 Dispatched Time – Minute – (Intermediate Facility) ...... 35 EnRoute Date – Month – (Intermediate Facility) ...... 35 EnRoute Date – Day – (Intermediate Facility) ...... 36 EnRoute Date – Year – (Intermediate Facility) ...... 36 EnRoute Time – Hour – (Intermediate Facility) ...... 36 EnRoute Time – Minute – (Intermediate Facility) ...... 37 Arrived Location Date – Month – (Intermediate Facility) ...... 37 Arrived Location Date – Day – (Intermediate Facility) ...... 38 Arrived Location Date – Year – (Intermediate Facility) ...... 38 Arrived Location Time – Hour – (Intermediate Facility) ...... 38 Arrived Location Time – Minute – (Intermediate Facility) ...... 39 Patient Contact Date – Month – (Intermediate Facility) ...... 39 Patient Contact Date – Day – (Intermediate Facility) ...... 40 Patient Contact Date – Year – (Intermediate Facility) ...... 40 Patient Contact Time – Hour – (Intermediate Facility) ...... 40 Patient Contact Time – Minute – (Intermediate Facility) ...... 41 Departed Location Date – Month – (Intermediate Facility) ...... 41 Departed Location Date – Day – (Intermediate Facility) ...... 42 Departed Location Date – Year – (Intermediate Facility) ...... 42 Departed Location Time – Hour – (Intermediate Facility) ...... 42 Departed Location Time – Minute – (Intermediate Facility) ...... 43 Cardiac Arrest – Transfer Provider – (Intermediate Facility) ...... 43 Cardiac Arrest Date – Month – (Intermediate Facility) ...... 44 Cardiac Arrest Date – Day – (Intermediate Facility) ...... 44 Cardiac Arrest Date – Year – (Intermediate Facility) ...... 44 Cardiac Arrest Time – Hour – (Intermediate Facility) ...... 45 Cardiac Arrest Time – Minute – (Intermediate Facility) ...... 45 Assessment Date – Month – Transfer Provider – (Intermediate Facility) ...... 47 Assessment Date – Day – Transfer Provider – (Intermediate Facility) ...... 47 Assessment Date – Year – Transfer Provider – (Intermediate Facility) ...... 47 Assessment Time – Hour – Transfer Provider – (Intermediate Facility) ...... 48 Assessment Time – Minute – Transfer Provider – (Intermediate Facility) ...... 48 Paralytic Agents in Effect – Transfer Provider – (Intermediate Facility) ...... 49 Sedated – Transfer Provider – (Intermediate Facility) ...... 49 Bagging or Ventilator – Transfer Provider – (Intermediate Facility) ...... 49

Intermediate Facility Page 2 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Intubated – Transfer Provider – (Intermediate Facility) ...... 50 Systolic Blood Pressure – Transfer Provider – (Intermediate Facility) ...... 50 Diastolic Blood Pressure – Transfer Provider – (Intermediate Facility) ...... 50 Heart Rate – Transfer Provider – (Intermediate Facility) ...... 51 Unassisted Respiratory Rate – Transfer Provider – (Intermediate Facility) ...... 51 O2 Administered – Transfer Provider – (Intermediate Facility) ...... 51 O2 Saturation – Transfer Provider – (Intermediate Facility) ...... 52 GCS – Eye Opening -Transfer Provider – (Intermediate Facility) ...... 52 GCS – Verbal Response – Transfer Provider – (Intermediate Facility) ...... 53 GCS – Motor Response – Transfer Provider – (Intermediate Facility) ...... 53 GCS – Total - Transfer Provider – (Intermediate Facility)...... 54 RTS (Unweighted) –Transfer Provider – (Intermediate Facility) ...... 55 GCS Qualifier – Transfer Provider – (Intermediate Facility) ...... 56 Airway – Transfer Provider – (Intermediate Facility) ...... 56 CPR – Transfer Provider – (Intermediate Facility) ...... 57 Fluids – Transfer Provider – (Intermediate Facility) ...... 57 Transfer Vitals Mast – RETIRED Jan. 2011 – (Intermediate Facility) ...... 57 Condition of Patient During Transfer – (Intermediate Facility) ...... 58 Tube Thoracostomy – Transfer Provider – (Intermediate Facility) ...... 58 Thoracentesis / Needle Thoracostomy – (Intermediate Facility) ...... 59 Medication – RETIRED Jan. 2012 – (Intermediate Facility) ...... 60 Intermediate Facility 1 Memo ...... 61 Intermediate Facility 2 Memo ...... 61

* Items are CORE (state required) data elements

Intermediate Facility Page 3 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility

Intermediate Facility – Facility (1-2)

Intermediate Facility Page 4 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Facility ID Number – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_ID, F2_ID

State Required: Type of Field: Length: No Alphanumeric 6 DEFINITIONS Facility ID Number – The numeric identifier for the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS Facility ID Number / Not Applicable ? Unknown Facility ID Number - If Other – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_ID_O, F2_ID_O

State Required: Type of Field: Length: No Text 50 DEFINITIONS Facility ID Number – If Other –Text field in which to record additional information regarding intermediate facility name Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Use direct keyboard entry. Arrival Date – Month – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_ARR_DM, F2_ARR_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Arrival Date – Month – The month the patient arrived at the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Intermediate Facility Page 5 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Arrival Date – Day – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_ARR_DD, F2_ARR_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Arrived Date – Day – The day the patient arrived at the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Arrival Date – Year – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_ARR_DY, F2_ARR_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Arrived Date – Year – The year the patient arrived at the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Arrival Time – Hour – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_ARR_TH, F2_ARR_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Arrival Time – Hour – The hour the patient arrived at the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Intermediate Facility Page 6 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Arrival Time – Minute – (Intermediate Facility) Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_ARR_TM, F2_ARR_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Arrival Time – Minute – The minute the patient arrived at the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search F1_ARR_EVENT, F2_AAR_EVENT, F3_AAR_EVENT – the Date and Time combined that the patient arrived at the intermediate facility.

 In Report Writer; search F1_ARR_TIME, F2_ARR_TIME, F3_ARR_TIME – the Hour and the Minute combined that the patient arrived at the intermediate facility.

 In Report Writer; search F1_ARR_DATE, F2_ARR_DATE, F3_ARR_DATE – the Month, Day and Year combined that the patient arrived at the intermediate facility.

Departure Date – Month – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_DIS_DM, F2_DIS_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Departure Date – Month – The month the patient departed from the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Intermediate Facility Page 7 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Departure Date – Day – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_DIS_DD, F2_DIS_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Departure Date – Day – The day the patient departed from the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Departure Date – Year – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_DIS_DY, F2_DIS_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Departure Date – Year – The year the patient departed from the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Departure Time – Hour – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_DIS_TH, F2_DIS_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Departure Time – Hour – The hour the patient departed from the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Intermediate Facility Page 8 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Departure Time – Minute – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_DIS_TM, F2_DIS_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Departure Time – Minute – The minute the patient departed from the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search F1_DIS_EVENT, F2_DIS_EVENT, F3_DIS_EVENT – the Date and Time combined that the patient departed from the intermediate facility.

 In Report Writer; search F1_DIS_TIME, F2_DIS_TIME, F3_DIS_TIME – the Hour and the Minute combined that the patient departed from the intermediate facility.

 In Report Writer; search F1_DIS_DATE, F2_DIS_DATE, F3_DIS_DATE – the Month, Day and Year combined that the patient departed from the intermediate facility.

Referring Physician – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_RP, F2_RP

State Required: Type of Field: Length: No Text 50 DEFINITIONS Referring Physician – The name of the patient’s referring physician Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Referring Physician / Not Applicable ? Unknown

Intermediate Facility Page 9 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Reason for Discharge – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_RS, F2_RS

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Reason for Discharge – The reason the patient was discharged from this facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Medical 2 Personal 3 Financial 4 Other ? Unknown

Discharge By – (Intermediate Facility) Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_RSBY, F2_RSBY

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Discharged by – Individual who made the decision for discharge of this patient from this facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option.

VALID OPTIONS 1 Physician 2 Patient 3 Payer 4 Other 5 Mid-Level Provider ? Unknown

ADDENDUM: Added Option “5 Mid-Level Provider” on entry form 15, June 27, 2014

Intermediate Facility Page 10 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Assessment Date – Month – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_DM, F2_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Date – Month – The month the Intermediate Facility provider personnel conducted a medical assessment of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Assessment Date – Day – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_DD, F2_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Date – Day – The day the Intermediate Facility provider personnel conducted a medical assessment of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Assessment Date – Year – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_DY, F2_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Assessment Date – Year – The year the Intermediate Facility provider personnel conducted a medical assessment of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Intermediate Facility Page 11 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Assessment Time – Hour – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_TH, F2_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Time – Hour – The hour the Intermediate Facility provider personnel conducted a medical assessment of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] / Not Applicable ? Unknown

Assessment Time – Minute – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_TM, F2_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Time – Minute – The minute the Intermediate Facility provider personnel conducted a medical assessment of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] / Not Applicable ? Unknown

 In Report Writer; search F1_EVENT, F2_EVENT – the Date and Time combined that the intermediate facility provider personnel conducted a medical assessment of the patient.

 In Report Writer; search F1_TIME, F2_TIME – the Hour and the Minute combined that the intermediate facility provider personnel conducted a medical assessment of the patient.

 In Report Writer; search F1_DATE, F2_DATE – the Month, Day and Year combined that the intermediate facility provider personnel conducted a medical assessment of the patient.

Intermediate Facility Page 12 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Paralytic Agents in Effect – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_PAR, F2_PAR

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Paralytic Agents in Effect – Administration of paralytic agents to patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Were paralytic agents administered to the patient in the Intermediate facility’s ED? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown

Sedated – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_SED, F2_SED

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Sedated – Administration of drugs to the patient for the purpose of sedation Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Have drugs been administered in the Intermediate facility’s ED to the patient for sedation? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown

Bagging or Ventilator – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_BAG, F2_BAG

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Bagging or Ventilator – Bagging of patient or placement of patient on a ventilator in order to provide respiratory assistance Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Has the patient been bagged or placed on a ventilator in the ED to provide respiratory assistance? Enter the appropriate option. VALID OPTIONS 1 Yes / Inappropriate 2 No ? Unknown

Intermediate Facility Page 13 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Intubated – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_INT, F2_INT

INSTRUCTIONS Answer the following question: Has the patient been intubated to provide an airway in Intermediate facility’s ED? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown

Systolic Blood Pressure – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_SBP, F2_SBP

State Required: Type of Field: Length: No Integer 3 DEFINITIONS Systolic Blood Pressure – Maximum blood pressure occurring during contraction of ventricles Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the patient’s initial systolic blood pressure upon arrival in the Intermediate facility’s ED. Use direct keyboard entry. VALID OPTIONS 0-300 / Not Applicable ? Unknown

Diastolic Blood Pressure – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_DBP, F2_DBP

State Required: Type of Field: Length: No Integer 3 DEFINITIONS Diastolic Blood Pressure – Period of least blood pressure in the arterial vascular system Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the patient’s initial diastolic blood pressure upon arrival in the ED. Use direct keyboard entry. VALID OPTIONS 0-200 / Not Applicable ? Unknown

Intermediate Facility Page 14 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Heart Rate – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_HR, F2_HR

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Heart Rate – Rate of the pulse palpated in beats per minute Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the patient’s initial radial or apical pulse upon arrival in the Intermediate facility’s ED. Do not use the cardiac monitor rate. Use direct keyboard entry. VALID OPTIONS 0-250 / Not Applicable ? Unknown

Unassisted Respiratory Rate – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_RR, F2_RR

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Unassisted Respiratory Rate – The act of breathing measured in spontaneous unassisted breaths per minute without the use of mechanical devices Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the patient’s actual respiratory rate upon arrival in the Intermediate facility’s ED. Use direct keyboard entry. VALID OPTIONS 0-99 / Not Applicable ? Unknown

O2 Administered – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_O2_YN, F2_O2_YN,

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS O2 Administered – Administration of oxygen to the patient to improve oxygenation Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Has oxygen been administered to the patient in the Intermediate facility’s ED to improve oxygenation? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown

Intermediate Facility Page 15 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility O2 Saturation – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_SAO2, F2_SAO2

State Required: Type of Field: Length: No Integer 3 DEFINITIONS O2 Saturation – Percentage level of oxygen saturation measured Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the patient’s initial O2 saturation reading upon arrival in the Intermediate facility’s ED. Use direct keyboard entry. VALID OPTIONS 0-99 / Not Applicable ? Unknown

GCS – Eye Opening – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_GCS_EO, F2_GCS_EO

State Required: Type of Field: Length: No Integer 1 DEFINITIONS GCS (Glasgow Coma Scale) – Eye Opening ADULT CHILD 2-5 years INFANT 0-23 SCORE months None None None 1 To pain To pain To pain 2 To voice To voice To voice 3 Spontaneous Spontaneous Spontaneous 4

Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the initial best eye opening score for the patient upon arrival in the Intermediate facility’s ED. Enter the appropriate option. VALID OPTIONS 1 None 3 To Voice ? Unknown 2 To Pain 4 Spontaneous

Intermediate Facility Page 16 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility GCS – Verbal Response – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_GCS_VR, F2_GCS_VR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS GCS (Glasgow Coma Scale) – Verbal Response ADULT CHILD 2-5 years INFANT 0-23 SCORE months None None None 1 Incomprehensible Incomprehensible Moans to pain 2 sounds words Inappropriate words Inappropriate cries Cries to pain 3 Confused Confused Irritable cries 4 Oriented Oriented Coos, babbles 5

Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the initial best verbal score for the patient upon arrival in the Intermediate facility’s ED. Enter the appropriate option. VALID OPTIONS 1 None 4 Confused 2 Incomprehensible 5 Oriented Sounds 3 Inappropriate Words ? Unknown

GCS – Motor Response – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_GCS_MR, F2_GCS_MR

State Required: Type of Field: Length: No Integer 1

DEFINITIONS GCS (Glasgow Coma Scale) – Motor Response ADULT CHILD 2-5 years INFANT 0-23 months SCORE None None None 1 Abnormal Extension in response to Decerebrate posturing in response 2 extension pain to pain Abnormal flexion Flexion in response to Decorticate posturing in response 3 pain to pain Withdraws to pain Withdraws in response to Withdraws in response to pain 4 pain Localizes pain Localizes painful stimulus Withdraws to touch 5 Obeys commands Obeys commands Moves spontaneously 6

Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the initial best motor response score for this patient upon arrival in the Intermediate facility’s ED. Enter the appropriate option. VALID OPTIONS 1 None 5 Localizes Pain 2 Abnormal Extension 6 Obeys Commands 3 Abnormal Flexion ? Unknown 4 Withdraws to Pain

Intermediate Facility Page 17 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility GCS – Total – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_GCS_TT, F2_GCS_TT

State Required: Type of Field: Length: No Integer 1 DEFINITIONS GCS (Glasgow Coma Scale) – Total – The total of the patient’s Eye opening, Verbal response, and Motor response scores

ADULT CHILD 2-5 years INFANT 0-23 months SCORE Eye Opening: None None None 1 To pain To pain To pain 2 To voice To voice To voice 3 Spontaneous Spontaneous Spontaneous 4

Total GCS = Eye Opening Score + Verbal Response Score + Motor Response Score (Ranges between 3 and 15)

Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS The total GCS Score for the patient recorded in the Intermediate facility’s ED will be computed by the program after all the GCS components are entered.

Intermediate Facility Page 18 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility RTS (Weighted) – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_RTS_W, F2_RTS_W

State Required: Type of Field: Length: No Fixed-2 4 DEFINITIONS Weighted RTS – Based on the values of the Glasgow Coma Scale, systolic blood pressure and respiratory rate. Raw values used for triage. Coded values are weighted and summed for outcome evaluation. Raw values (displayed):

Glasgow Coma Scale total points: 13-15 = 4 9-12 = 3 6-8 = 2 4-5 = 1 3 = 0 Respiratory Rate > 29 = 4 10-29 = 3 6-9 = 2 1-5 = 1 0 = 0 Systolic Blood Pressure –

> 89 = 4 76-89 = 3 50-75 = 2 1-49 = 1 0 = 0

Weighted RTS = 0.9368 * (Glasgow Coma value) + 0.7326 * (Systolic BP value) + 0.2908 *(Respiratory Rate value)

Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS The Weighted RTS is automatically calculated by the program after the GCS score, respiratory rate, and systolic blood pressure are entered. If one of these parameters is unknown, the RTS cannot be calculated.

Intermediate Facility Page 19 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility GCS Qualifier – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Facility 1, 2 F1_GCSQ_1, F1_GCSQ_2, F1_GCSQ_3 F2_GCSQ_1, F2_GCSQ_2, F2_GCSQ_3 F3_GCSQ_1, F3_GCSQ_2, F3_GCSQ_3

State Required: Type of Field: Length: No Integer 1 DEFINITIONS GCS Qualifier – Factors potentially affecting the assessment of the initial GCS taken in the Intermediate facility’s Emergency Department. Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter all qualifiers that could affect the initial assessment of GCS for this patient in the Intermediate Facilities ED. Enter the appropriate option. VALID OPTIONS 0 No Qualifier 3 Patient Intubated 1 Chemically altered mental status 9 Not documented 2 Obstruction to patient’s eye ? Unknown

Intermediate Facility Page 20 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility

Intermediate Facility – Facility Assessments (1-2)

Intermediate Facility Page 21 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Abdominal CT Results – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Assessments 1, 2 F1_ABD_CT, F2_ABD_CT

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Abdominal CT Results – The results from the patient's initial Abdominal CT Scan Abdomen – Portion of the body which lies between the chest and the pelvis CT Scan – Computerized Axial Tomography – A diagnostic procedure that utilizes a computer to analyze x-ray data Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Negative 2 Positive 3 Not Performed ? Unknown

Abdominal Ultrasound Results – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Assessments 1, 2 F1_ABD_UT, F2_ABD_UT

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Abdominal Ultrasound Results – The results from the patient's initial Abdominal Ultrasound Abdomen – Portion of the body between the chest and the pelvis Ultrasound – The diagnostic use of ultrasonic waves directed for imaging of internal body structures and the detection of bodily abnormalities Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 0 Not Performed 1 Negative 2 Positive 3 Indeterminate ? Unknown

Intermediate Facility Page 22 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Aortogram / Anteriogram / Angiogram Results – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Assessments 1, 2 F1_AOR_GR, F2_AOR_GR

Chest CT Results – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Assessments 1, 2 F1_CHE_CT, F2_CHE_CT

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Chest CT Results – The results from the patient's initial Chest CT Scan Chest – Portion of the body which lies between the head and the abdomen CT Scan – Computerized Axial Tomography – A diagnostic procedure that utilizes a computer to analyze x-ray data Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Negative 2 Positive 3 Not Performed ? Unknown

Intermediate Facility Page 23 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Head CT Results – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Assessments 1, 2 F1_HE_CT, F2_HE_CT

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Head CT Results – The results from the patient's initial Head CT Scan Head – Portion of the body which contains the brain and organs of sight, smell, hearing, and taste CT-Scan – A diagnostic procedure that utilizes a computer to analyze x-ray data Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Negative 2 Positive 3 Not Performed ? Unknown

Peritoneal Lavage – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Assessments 1, 2 F1_PER_LV, F2_PER_LV

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Peritoneal Lavage – Washing out of the peritoneal cavity Peritoneal Cavity – Region bordered by parietal layer of the peritoneum containing all the abdominal organs exclusive of the kidneys Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the results from the peritoneal lavage done in the intermediate facility VALID OPTIONS 0 Not Performed 1 Negative 2 Positive 3 Indeterminate 4 Unsuccessful ? Unknown

Intermediate Facility Page 24 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility ICU – (Intermediate Facility) Data Field Name: Window Location: Intermediate Facility : Assessments 1, 2 F1_ICU, F2_ICU

State Required: Type of Field: Length: No Integer 1 DEFINITIONS ICU – Intensive Care Unit Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Did the patient receive care in the intermediate facility’s ICU? Enter the appropriate option. VALID OPTIONS 1 ICU at transferring hospital 2 No ICU at transferring hospital ? Unknown

Airway – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Assessments 1, 2 F1_AR, F2_AR

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Airway – A device or procedure used to prevent or correct obstructed respiratory passage Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the most invasive airway adjunct used to assist the patient at the intermediate facility’s ED. Enter the appropriate option. VALID OPTIONS 00 No Intervention 09 Combi-Tube 01 Assisted by Bag and Mask 10 Nasal Pharyngeal Airway 02 Cricothyrotomy 11 Blow By 03 Esophageal Obturator Airway 12 Non-Rebreather Mask Oxygen 04 Nasal Endotracheal Tube 13 Nasal Cannula Oxygen 05 Oral Airway 14 Tracheostomy 06 Oral Endotracheal Tube 15 Unspecified 07 Oxygen Mask 16 Unsuccessful 08 LMA ? Unknown

Intermediate Facility Page 25 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility OR – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Assessments 1, 2 F1_OR, F2_OR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS OR – Operating Room Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Did the patient receive care in the intermediate facility’s OR? Enter the appropriate option. VALID OPTIONS 1 Operating room at the transferring hospital 2 No operating room at the transferring hospital ? Unknown

CPR – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Assessments 1, 2 F1_CPR, F2_CPR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS CPR (Cardiopulmonary Resuscitation) – Procedure for revival after lack of heart beat or respirations. Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Was CPR performed on the patient at the intermediate facility? Enter the appropriate option. VALID OPTIONS 1 Yes 2 No ? Unknown

Intermediate Facility Page 26 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Medications – (Intermediate Facility) -- RETIRED ADDENDUM Retired in March, 2012 update patch (version 12)

Window Location: Data Field Name: Intermediate Facility : Assessments 1, 2 F1_MEDS_1, F2_MEDS_1 F1_MEDS_2, F2_MEDS_2 F1_MEDS_3, F2_MEDS_3 F1_MEDS_4, F2_MEDS_4 F1_MEDS_5, F2_MEDS_5

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Medication – Medication given to the patient by the intermediate facility, can enter up to five medications. Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter categories of medication administered to the patient by the intermediate facility

RETIRED OPTIONS (March, 2012 update patch) 00 None 25 Corticosteroids (Prednisone) 01 ACE inhibitor (Enalapril, Captopril, Lisinopril) 26 Corticosteroids, Inhaled (Beclomethasone) 02 Acetaminophen 27 Diuretic (Hydrochlorothiazide, Furosemide) 03 Antiarrhythmics (Amiodarone, Procainamide, 28 Estrogen replacement (Conjugated Estrogen) Sotalol) 04 Antibacterials (Cefazolin, Augmentin) 29 Gout (Allopurinol, Colchicine, Probenecid) 05 Anticoagulants (Coumadin, Heparin, Enoxaparin) 30 H2 antagonist (Ranitidine, Famotidine) 06 Anticonvulsant (Phenytoin, Carbamazepine) 31 Hypoglycemic (Glyburide, Metformin) 07 Antidepressant (Fluoxetine, Sertraline, 32 Insulin Amitriptyline)) 08 Antifungal (Fluconazole) 33 Laxatives (Bisacodyl, Docusate) 09 Antihistamine (Astemizole, Loratidine) 34 Lithium 10 Antihyperlipedemic (Atorvastatin, Simvastatin) 35 Metoclopramide 11 Antiparkinsonian (Levodopa, Benztropine, 36 Muscle relaxants (Baclofen, Cyclobenzaprine) Amantadine) 12 Anti-platelet agent (Ticlopidine, Clopidogrel) 37 Narcotics (Morphine, Oxycodone, Codeine) 13 Antipsychotic (Haloperidol, Chlorpromazine, 38 Nitroglycerine Fluphenazine) 14 Antispasmodic (Oxybutynin) 39 Non-steroidal anti-inflammatory (Ibuprofen, Rofecoxib) 15 Antithyroid (Propylthiouracil, Methimazole) 40 Oral contraceptives 16 Antituberculosis (Isoniazid, Ethambutol) 41 Progesterone 17 Antiviral (Interferon, Azathioprine, 3TC, Indinavir ) 42 Protein pump inhibitor (Omeprazole, Pantoprazole) 18 ASA 43 Sucralfate 19 Barbiturates (Phenobarbital, Secobarbital) 44 Thyroid replacement (Eltroxin) 20 Benzodiazepines (Lorazepam, Diazepam) 45 Vasodilators (Hydralazine, Clonidine, Alpha Methyldopa) 21 Beta blocker (Metroprolol, Atenolol) 46 Other 22 Bronchodilators (Inhaled, e.g. Albuterol, 50 Neuromuscular Blocker Ipratropium Bromide) 23 Calcium channel blocker (Diltiazem, Verapamil, / Not Applicable Lisinopril) 24 Cardiac glycoside (Digoxin) ? Unknown

Intermediate Facility Page 27 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility

Intermediate Facility – Transfer Provider (1-2)

Intermediate Facility Page 28 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Transfer Provider Mode – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_MODE, F2_MODE

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Mode – The type of transportation provided by the intermediate transfer provider Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Land Ambulance 6 Private Vehicle/Wal-In 2 Helicopter Ambulance 7 Police 3 Fixed-Wing Ambulance 8 Commercial Flight 4 Charter Fixed-Wing 9 Other 5 Charter Helicopter ? Unknown

Transfer Provider Agency – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_AGEN, F2_AGEN

State Required: Type of Field: Length: No Integer 6 DEFINITIONS Agency – The name of the transfer agency Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS Agency ? Unknown / Not Applicable

Intermediate Facility Page 29 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Transfer Provider Level – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_LEVEL, F2_LEVEL

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Provider Level – The level of service provided by the transfer provider Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 1st Responder 2 BLS 3 ILS 4 ALS 5 Other ? Unknown

Report Available – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_R_AV, F2_R_AV

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Report Available – Availability of the ambulance report from the transport provider Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Was the ambulance report from the intermediate transfer provider available? Enter the appropriate option. VALID OPTIONS 1 Received, Complete, and Legible, in a Timely Manner 2 Received, Complete, and Legible, not in a Timely Manner 3 Received, Incomplete 4 Received, Illegible 5 Never Received ? Unknown

Intermediate Facility Page 30 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Report Number – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_R_NUM, F2_R_NUM

State Required: Type of Field: Length: No Alphanumeric 12 DEFINITIONS Report Number – The preprinted number on the transfer provider report Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Report Number / Not Applicable ? Unknown PCR Number – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2

State Required: Type of Field: Length: No Alphanumeric 32 DEFINITIONS PCR Number – The number that accompanies the patient care reports Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Report Number / Not Applicable ? Unknown

Call Received Date – Month – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_R_DM, F2_R_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Call Received Date – Month – The month the intermediate facility called the transfer provider for transportation of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Intermediate Facility Page 31 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Call Received Date – Day – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_R_DD, F2_R_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Call Received Date – Day – The day the intermediate facility called the transfer provider for transportation of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Call Received Date – Year – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_R_TY, F2_R_TY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Call Received Date – Year – The year the intermediate facility called the transfer provider for transportation of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Call Received Time – Hour – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_R_TH, F2_R_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Call Received Time – Hour – The hour the intermediate facility called the transfer provider for transportation of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Intermediate Facility Page 32 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Call Received Time – Minute – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_R_TM, F2_R_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Call Received Time – Minute – The minute the intermediate facility called the transfer provider for transportation of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search F1_R_EVENT, F2_R_EVENT – the Date and Time combined that the intermediate facility called the transfer provider for transportation of the patient.

 In Report Writer; search F1_R_TIME, F2_R_TIME – the Hour and the Minute combined that the intermediate facility called the transport provider for transportation of the patient.

 In Report Writer; search F1_R_DATE, F2_R_DATE – the Month, Day and Year combined that the intermediate facility called the transport provider for the transportation of the patient.

Dispatched Date – Month – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_D_DM, F2_D_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Dispatched Date – Month – The month the intermediate facility’s transfer provider was dispatched Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Intermediate Facility Page 33 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Dispatched Date – Day – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_D_DD, F2_D_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Dispatched Date – Day – The day the intermediate facility’s transfer provider was dispatched Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Dispatched Date – Year – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_D_DY, F2_D_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Dispatched Date – Year – The year the intermediate facility’s transfer provider was dispatched Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Dispatched Time – Hour – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_D_TH, F2_D_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Dispatched Time – Hour – The hour the intermediate facility’s transfer provider was dispatched Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Intermediate Facility Page 34 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Dispatched Time – Minute – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_D_TM, F2_D_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Dispatched Date – Minute – The minute the intermediate facility’s transfer provider was dispatched Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search F1_D_EVENT, F2_D_EVENT – the Date and Time combined that the intermediate facility’s transfer provider was dispatched.

 In Report Writer; search F1_D_TIME, F2_D_TIME – the Hour and the Minute combined that the intermediate facility’s transfer provider was dispatched.

 In Report Writer; search F1_D_DATE, F2_D_DATE – the Month, Day and Year combined that the intermediate facility’s transfer provider was dispatched.

En Route Date – Month – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_I_DM, F2_I_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS En Route Date – Month – The month the intermediate facility’s transfer provider began actual transport services to the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Intermediate Facility Page 35 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility En Route Date – Day – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_I_DD, F2_I_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS En Route Date – Day – The day the intermediate facility’s transfer provider began actual transport services to the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

En Route Date – Year – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_I_DY, F2_I_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS En Route Date – Year – The year the intermediate facility’s transfer provider began actual transport services to the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

En Route Time – Hour – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_I_TH, F2_I_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS En Route Time – Hour – The hour the intermediate facility’s transfer provider began actual transport services to the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Intermediate Facility Page 36 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility En Route Time – Minute – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_I_TM, F2_I_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS En Route Time – Minute – The minute the intermediate facility’s transfer provider began actual transport services to the intermediate facility Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search F1_I_EVENT, F2_I_EVENT – the Date and Time combined that the intermediate facility’s transfer provider began actual transport services to the intermediate facility.

 In Report Writer; search F1_I_TIME, F2_I_TIME – the Hour and the Minute combined that the intermediate facility’s transfer provider began actual transport services to the intermediate facility.

 In Report Writer; search F1_I_DATE, F2_I_DATE – the Month, Day and Year combined that the intermediate facility’s transfer provider began actual transport services to the intermediate facility.

Arrived Location Date – Month – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_A_DM, F2_A_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Arrived Location Date – Month – The month the intermediate facility’s transfer provider arrived to conduct transport of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Intermediate Facility Page 37 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Arrived Location Date – Day – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_A_DD, F2_A_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Arrived Location Date – Day – The day the intermediate facility’s transfer provider arrived to conduct transport of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Arrived Location Date – Year – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_A_DY, F2_A_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Arrived Location Date – Year – The year the intermediate facility’s transfer provider arrived to conduct transport of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Arrived Location Time – Hour – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_A_TH, F2_A_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Arrived Location Time – Hour – The hour the intermediate facility’s transfer provider arrived to conduct transport of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] / Not Applicable ? Unknown

Intermediate Facility Page 38 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Arrived Location Time – Minute – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_A_TM, F2_A_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Arrived Location Time – Minute – The minute the intermediate facility’s transfer provider arrived to conduct transport of the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search F1_A_EVENT, F2_A_EVENT – the Date and Time combined that the intermediate facility’s transfer provider arrived to conduct transport of the patient.

 In Report Writer; search F1_A_TIME, F2_A_TIME – the Hour and the Minute combined that the intermediate facility’s transfer provider arrived to conduct transport of the patient.

 In Report Writer; search F1_A_DATE, F2_A_DATE – the Month, Day and Year combined that the intermediate facility’s transfer provider arrived to conduct transport of the patient.

Patient Contact Date – Month – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_P_DM, F2_P_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Patient Contact Date – Month – The month the intermediate facility’s transfer provider had first contact with the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Intermediate Facility Page 39 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Patient Contact Date – Day – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_P_DD, F2_P_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Patient Contact Date – Day – The day the intermediate facility’s transfer provider had first contact with the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Patient Contact Date – Year – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_P_DY, F2_P_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Patient Contact Date – Year – The year the intermediate facility’s transfer provider had first contact with the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Patient Contact Time – Hour – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_P_TH, F2_P_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Patient Contact Time – Hour – The hour the intermediate facility’s transfer provider had first contact with the patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Intermediate Facility Page 40 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Patient Contact Time – Minute – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_P_TM, F2_P_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Patient Contact Time – Minute – The minute the intermediate facility’s transfer provider had first contact with the patient Intermediate Facility 1 – First facility the patient is transferred to after the initial facility Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search F1_P_EVENT, F2_P_EVENT – the Date and Time combined that the intermediate facility’s transfer provider had first contact with the patient.

 In Report Writer; search F1_P_TIME, F2_P_TIME – the Hour and the Minute combined that the intermediate facility’s transfer provider had first contact with the patient.

 In Report Writer; search F1_P_DATE, F2_P_DATE – the Month, Day and Year combined that the intermediate facility’s transfer provider had first contact with the patient.

Departed Location Date – Month – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_L_DM, F2_L_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Departed Location Date – Month – The month the intermediate facility’s transfer provider departed the patient’s location Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Intermediate Facility Page 41 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Departed Location Date – Day – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_L_DD, F2_L_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Departed Location Date – Day – The day the intermediate facility’s transfer provider departed the patient’s location Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Departed Location Date – Year – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_L_DY, F2_L_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Departed Location Date – Year – The year the intermediate facility’s transfer provider departed the patient’s location Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Departed Location Time – Hour – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_L_TH, F2_L_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Departed Location Time – Hour – The hour the intermediate facility’s transfer provider departed the patient’s location Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Intermediate Facility Page 42 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Departed Location Time – Minute – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_L_TM, F2_L_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Departed Location Time – Minute – The minute the intermediate facility’s transfer provider departed the patient’s location Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search F1_L_EVENT, F2_L_EVENT – the Date and Time combined that the intermediate facility’s transfer provider departed the patient’s location.

 In Report Writer; search F1_L_TIME, F2_L_TIME – the Hour and the Minute combined that the intermediate facility’s transfer provider departed the patient’s location.

 In Report Writer; search F1_L_DATE, F2_L_DATE – the Month, Day and Year combined that the intermediate facility’s transfer provider departed the patient’s location.

Cardiac Arrest – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_C_YN, F2_C_YN

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Cardiac Arrest – An episode of heart failure during patient transport Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Did the patient suffer cardiac arrest during transport? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown

Intermediate Facility Page 43 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Cardiac Arrest Date – Month – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_C_DM, F2_C_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Cardiac Arrest Date – Month – The month the cardiac arrest occurred during inter-facility transfer. Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Cardiac Arrest Date – Day – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_C_DD, F2_C_DD

State Required: Type of Field: Length: No Integer 2

DEFINITIONS Cardiac Arrest Date – Day – The day the cardiac arrest occurred during inter-facility transfer. Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Cardiac Arrest Date – Year – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_C_DY, F2_C_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Cardiac Arrest Date – Year – The year the cardiac arrest occurred during inter-facility transfer. Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Intermediate Facility Page 44 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Cardiac Arrest Time – Hour – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_C_TH, F2_C_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Cardiac Arrest Time – Hour – The hour the cardiac arrest occurred during inter-facility transfer. Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Cardiac Arrest Time – Minute – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Provider - 1, 2 F1_C_TM, F2_C_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Cardiac Arrest Time – Minute – The minute the cardiac arrest occurred during inter-facility transfer. Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search F1_C_EVENT, F2_C_EVENT – the Date and Time combined that the cardiac arrest occurred during inter-facility transfer.

 In Report Writer; search F1_C_TIME, F2_C_TIME – the Hour and the Minute combined that the cardiac arrest occurred during inter-facility transfer.

 In Report Writer; search F1_C_DATE, F2_C_DATE – the Month, Day and Year combined that the cardiac arrest occurred during inter-facility transfer.

Intermediate Facility Page 45 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility

Intermediate Facility – Transfer Provider Vitals (1-2)

Intermediate Facility Page 46 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Assessment Date – Month – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_C_TM, F2_C_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Date – Month – The month the intermediate facility conducted a patient assessment Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Assessment Date – Day – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F11_DD, F21_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Date – Day – The day the intermediate facility conducted a patient assessment Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Assessment Date – Year – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F11_DY, F21_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Assessment Date – Year – The year the intermediate facility conducted a patient assessment Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Intermediate Facility Page 47 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Assessment Time – Hour – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F11_TH, F21_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Time – Hour – The hour the intermediate facility conducted a patient assessment Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Assessment Time – Minute – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F11_TM, F21_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Time – Minute – The minute the intermediate facility conducted a patient assessment Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the appropriate option the [mm] format. Use direct keyboard entry. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search F11_EVENT, F21_EVENT – the Date and Time combined that the intermediate facility conducted a patient assessment.

 In Report Writer; search F11_TIME, F21_TIME – the Hour and the Minute combined that the intermediate facility conducted a patient assessment.

 In Report Writer; search F11_DATE, F21_DATE – the Month, Day and Year combined that the intermediate facility conducted a patient assessment.

Intermediate Facility Page 48 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Paralytic Agents in Effect – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_PAR, F2_PAR

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Paralytic Agents in Effect – Administration of paralytic agents to patient Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Have paralytic agents been administered to the patient in the intermediate facility? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown

Sedated – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_SED, F2_SED

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Sedated – Administration of drugs to the patient for the purpose of sedation Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Have drugs been administered to the patient for sedation in the intermediate facility? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown

Bagging or Ventilator – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_BAG, F2_BAG

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Bagging or Ventilator – Bagging of patient or placement of patient on a ventilator in order to provide respiratory assistance Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Has the patient been bagged or placed on a ventilator to provide respiratory assistance in the intermediate facility? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown

Intermediate Facility Page 49 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Intubated – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_INT, F2_INT

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Intubated – Intubation of patient to provide a patent and protected airway Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Has the patient been intubated to provide an airway in the intermediate facility? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown

Systolic Blood Pressure – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_SBP, F2_SBP

State Required: Type of Field: Length: No Integer 3 DEFINITIONS Systolic Blood Pressure – Maximum blood pressure occurring during contraction of ventricles Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the patient’s first systolic blood pressure in the intermediate facility. Use direct keyboard entry. VALID OPTIONS 0-300 ? Unknown

Diastolic Blood Pressure – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_DBP, F2_DBP

State Required: Type of Field: Length: No Integer 3 DEFINITIONS Diastolic Blood Pressure –Period of least blood pressure in the arterial vascular system Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the patient’s first diastolic blood pressure in the intermediate facility. Use direct keyboard entry. VALID OPTIONS 0-200 ? Unknown

Intermediate Facility Page 50 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Heart Rate – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_HR, F2_HR

State Required: Type of Field: Length: No Integer 3 DEFINITIONS Heart Rate – Rate of the pulse palpated in beats per minute Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the patient’s initial radial or apical pulse in the intermediate facility. Do not use the cardiac monitor rate. Use direct keyboard entry. VALID OPTIONS 0-250 ? Unknown

Unassisted Respiratory Rate – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_RR, F2_RR

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Unassisted Respiratory Rate – The act of breathing measured in spontaneous unassisted breaths per minute without the use of mechanical devices Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the patient’s actual respiratory rate in the intermediate facility. Use direct keyboard entry. VALID OPTIONS 0-99 / Not Applicable ? Unknown

O2 Administered – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_O2_YN, F2_O2_YN

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS O2 Administered – Administration of oxygen to the patient to improve oxygenation Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Has oxygen been administered to the patient to improve oxygenation in the intermediate facility? Enter the appropriate option. VALID OPTIONS 1 Yes 2 No / Not Applicable ? Unknown

Intermediate Facility Page 51 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility O2 Saturation – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_SAO2, F2_SAO2

State Required: Type of Field: Length: No Integer 3 DEFINITIONS O2 Saturation – Percentage level of oxygen saturation measured Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the patient’s documented O2 saturation level in the intermediate facility. Use direct keyboard entry. VALID OPTIONS 0-100 / Inappropriate ? Unknown

GCS – Eye Opening -Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_GCS_EO, F2_GCS_EO

Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the initial best eye opening score for the patient in the intermediate facility. Enter the appropriate option. VALID OPTIONS 1 None 2 To Pain 3 To Voice 4 Spontaneous ? Unknown

Intermediate Facility Page 52 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility GCS – Verbal Response – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_GCS_VR, F2_GCS_VR

Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the initial best verbal score for the patient in the intermediate facility. Enter the appropriate option. VALID OPTIONS 1 None 2 Incomprehensible Sounds 3 Inappropriate Words 4 Confused 5 Oriented ? Unknown

GCS – Motor Response – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_GCS_MR, F2_GCS_MR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS GCS (Glasgow Coma Scale) – Motor Response ADULT CHILD 2-5 years INFANT 0-23 months SCORE None None None 1 Abnormal Extension in response to Decerebrate posturing in response 2 extension pain to pain Abnormal flexion Flexion in response to Decorticate posturing in response 3 pain to pain Withdraws to pain Withdraws in response to Withdraws in response to pain 4 pain Localizes pain Localizes painful stimulus Withdraws to touch 5 Obeys commands Obeys commands Moves spontaneously 6

Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the initial best motor response score for the patient in the intermediate facility. Enter the appropriate option. VALID OPTIONS 1 None 2 Abnormal Extension 3 Abnormal Flexion 4 Withdraws to Pain 5 Localizes Pain 6 Obeys Commands ? Unknown

Intermediate Facility Page 53 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility GCS – Total - Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_GCS_TT, F2_GCS_TT

State Required: Type of Field: Length: No Integer 2 DEFINITIONS GCS (Glasgow Coma Scale) – Total – The total of the patient’s Eye opening, Verbal response and Motor response scores

ADULT CHILD 2-5 years INFANT 0-23 months SCORE Eye Opening: None None None 1 To pain To pain To pain 2 To voice To voice To voice 3 Spontaneous Spontaneous Spontaneous 4

Motor Response: None None None 1 Abnormal extension Extension in response to Decerebrate posturing in pain response to pain 2 Abnormal flexion Flexion in response to Decorticate posturing in pain response to pain 3 Withdraws to pain Withdraws in response to pain Withdraws in response to pain 4 Localizes pain Localizes painful stimulus Withdraws to touch 5 Obeys commands Obeys commands Moves spontaneously 6

Total GCS = Eye Opening Score + Verbal Response Score + Motor Response Score (Ranges between 3 and 15)

Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS The total GCS Score for the patient recorded in the intermediate facility will be computed by the program after all the GCS components are entered.

Intermediate Facility Page 54 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility RTS (Unweighted) –Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_RTS_U, F2_RTS_U

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Unweighted RTS – Based on the values of the Glasgow Coma Scale, systolic blood pressure and respiratory rate. Raw values are used for triage.

Coded values are summed for outcome evaluation. Raw values (displayed):

Glasgow Coma Scale total points: 13-15 = 4 9-12 = 3 6-8 = 2 4-5 = 1 3 = 0 Respiratory Rate > 29 = 4 10-29 = 3 6-9 = 2 1-5 = 1 0 = 0 Systolic Blood Pressure –

> 89 = 4 76-89 = 3 50-75 = 2 1-49 = 1 0 = 0

Unweighted RTS = Glasgow Coma value + Systolic BP value + Respiratory Rate value

Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS The Unweighted RTS is automatically calculated by the program after the GCS score, respiratory rate, and systolic blood pressure are entered. If one of these parameters is unknown, the RTS cannot be calculated.

Intermediate Facility Page 55 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility GCS Qualifier – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_GCSQ_1, F1_GCSQ_2, F1_GCSQ_3 F2_GCSQ_1, F2_GCSQ_2, F2_GCSQ_3 F3_GCSQ_1, F3_GCSQ_2, F3_GCSQ_3

State Required: Type of Field: Length: No Integer 1 DEFINITIONS GCS Qualifier – Factors potentially affecting the assessment of the initial GCS taken during transport. Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter all qualifiers that could affect the initial assessment of GCS for this patient during transfer. Enter the appropriate option. VALID OPTIONS 0 No Qualifier 3 Patient Intubated 1 Chemically altered mental status 9 Not documented 2 Obstruction to patient’s eye ? Unknown

Airway – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_AR, F2_AR

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Airway – A device or procedure used to prevent or correct obstructed respiratory passage Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the most invasive airway adjunct used to assist the patient at the intermediate facility’s ED. Enter the appropriate option. VALID OPTIONS 00 No Intervention 09 Nasal Pharyngeal Airway 01 Assisted by Bag and Mask 10 Nasal Pharyngeal Airway 02 Cricothyrotomy 11 Blow By 03 Esophageal Obturator Airway 12 Non-Rebreather Mask Oxygen 04 Nasal Endotracheal Tube 13 Nasal Cannula Oxygen 05 Oral Airway 14 Tracheostomy 06 Oral Endotracheal Tube 15 Unspecified 07 Oxygen Mask 16 Unsuccessful 08 LMA ? Unknown

Intermediate Facility Page 56 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility CPR – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_CPR, F2_CPR

Fluids – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_FLUIDS, F2_FLUIDS

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Fluids – Crystalloid only, not to include blood or blood products Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the amount of IV fluid administered during transport. Enter the appropriate option. VALID OPTIONS 1 Less than 500 mL administered 7 Venous access – no fluids given 2 500 to 2000 mL administered 8 No venous access 3 Greater than 2000 mL 9 Patient Refused IV Fluids administered 4 IV Fluids unknown amount ? Unknown 5 Unsuccessful

Transfer Vitals Mast – RETIRED Jan. 2011 – (Intermediate Facility)

ADDENDUM This data element was retired as part of the Jan. 2011 Collector update.

Intermediate Facility Page 57 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Condition of Patient During Transfer – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_COND, F2_COND

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Condition of Patient During Transfer – AVPU – Neurologic evaluation from ATLS to establish the patient's level of consciousness (ATLS Course Manual) A = Alert, V = Responds to Verbal Stimuli, P = Responds to Painful Stimuli, U = Unresponsive Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the patient's condition at the originating facility as assessed using AVPU system. Enter the appropriate option. VALID OPTIONS 1 Alert 6 Unspecified 2 Responsive to Verbal 7 Combative Stimuli 3 Responsive to Painful / Not Applicable Stimuli 4 Unresponsive/Sedated ? Unknown 5 Unresponsive

Tube Thoracostomy – Transfer Provider – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_THOR, F2_THOR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Thoracentesis/Tube Thoracostomy – Surgical entry into the thoracic cavity to remove fluids, or resection of the chest wall to allow drainage of the chest cavity Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Have transport provider personnel performed a thoracentesis/tube thoracostomy on the patient? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown 3 Unsuccessful

Intermediate Facility Page 58 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Thoracentesis / Needle Thoracostomy – (Intermediate Facility)

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_NEED, F2_NEED

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Needle Thoracostomy – Use of needle during resuscitation to relieve pressure and/or allow drainage of the chest cavity Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Answer the following question: Have transport provider personnel performed a needle thoracostomy on the patient? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown 3 Unsuccessful

Intermediate Facility Page 59 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility Medication – RETIRED Jan. 2012 – (Intermediate Facility)

ADDENDUM This data element was retired as part of the Jan. 2012 Collector update.

Window Location: Data Field Name: Intermediate Facility : Transfer Vitals - 1, 2 F1_MEDS_1, F2_MEDS_1 F1_MEDS_2, F2_MEDS_2 F1_MEDS_3, F2_MEDS_3 F1_MEDS_4, F2_MEDS_4 F1_MEDS_5, F2_MEDS_5

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Medication – Medication given to the patient by the intermediate facility, can add up to five medications Intermediate Facility 1 – First facility the patient is transferred to from the scene Intermediate Facility 2 – Second facility the patient is transferred to after the initial facility INSTRUCTIONS Enter the categories of medication administered to the patient by the intermediate facility

VALID OPTIONS 00 None 25 Corticosteroids (Prednisone) 01 ACE inhibitor (Enalapril, Captopril, Lisinopril) 26 Corticosteroids, Inhaled (Beclomethasone) 02 Acetaminophen 27 Diuretic (Hydrochlorothiazide, Furosemide) 03 Antiarrhythmics (Amiodarone, Procainamide, 28 Estrogen replacement (Conjugated Estrogen) Sotalol) 04 Antibacterials (Cefazolin, Augmentin) 29 Gout (Allopurinol, Colchicine, Probenecid) 05 Anticoagulants (Coumadin, Heparin, Enoxaparin) 30 H2 antagonist (Ranitidine, Famotidine) 06 Anticonvulsant (Phenytoin, Carbamazepine) 31 Hypoglycemic (Glyburide, Metformin) 07 Antidepressant (Fluoxetine, Sertraline, 32 Insulin Amitriptyline)) 08 Antifungal (Fluconazole) 33 Laxatives (Bisacodyl, Docusate) 09 Antihistamine (Astemizole, Loratidine) 34 Lithium 10 Antihyperlipedemic (Atorvastatin, Simvastatin) 35 Metoclopramide 11 Antiparkinsonian (Levodopa, Benztropine, 36 Muscle relaxants (Baclofen, Cyclobenzaprine) Amantadine) 12 Anti-platelet agent (Ticlopidine, Clopidogrel) 37 Narcotics (Morphine, Oxycodone, Codeine) 13 Antipsychotic (Haloperidol, Chlorpromazine, 38 Nitroglycerine Fluphenazine) 14 Antispasmodic (Oxybutynin) 39 Non-steroidal anti-inflammatory (Ibuprofen, Rofecoxib) 15 Antithyroid (Propylthiouracil, Methimazole) 40 Oral contraceptives 16 Antituberculosis (Isoniazid, Ethambutol) 41 Progesterone 17 Antiviral (Interferon, Azathioprine, 3TC, Indinavir ) 42 Protein pump inhibitor (Omeprazole, Pantoprazole) 18 ASA 43 Sucralfate 19 Barbiturates (Phenobarbital, Secobarbital) 44 Thyroid replacement (Eltroxin) 20 Benzodiazepines (Lorazepam, Diazepam) 45 Vasodilators (Hydralazine, Clonidine, Alpha Methyldopa) 21 Beta blocker (Metroprolol, Atenolol) 46 Other 22 Bronchodilators (Inhaled, e.g. Albuterol, 50 Neuromuscular Blocker Ipratropium Bromide) 23 Calcium channel blocker (Diltiazem, Verapamil, / Not Applicable Lisinopril) 24 Cardiac glycoside (Digoxin) ? Unknown

Intermediate Facility Page 60 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Intermediate Facility

Intermediate Facility – Memos

Intermediate Facility 1 Memo

Window Location: Data Field Name: Intermediate Facility : Facility 1 - Memo MEMO_F1

State Required: Type of Field: Length: No Memo 5000 DEFINITIONS Intermediate Facility 1 Memo – Text field in which to record additional Intermediate Facility 1 information if needed Intermediate Facility 1 – First facility the patient is transferred to from the scene INSTRUCTIONS Use direct keyboard entry.

Intermediate Facility 2 Memo

Window Location: Data Field Name: Intermediate Facility : Facility 2 - Memo MEMO_F2

State Required: Type of Field: Length: No Memo 5000 DEFINITIONS Intermediate Facility 2 Memo – Text field in which to record additional Intermediate Facility 2 information if needed Intermediate Facility 2 – Second facility the patient is transferred to from the scene INSTRUCTIONS Use direct keyboard entry.

Intermediate Facility Page 61 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department SECTION 4 – EMERGENCY DEPARTMENT

Patient Access to this Facility ...... 8 Admitting Service ...... 8 Arrived From* ...... 9 Transferred From* ...... 9 Arrival Condition ...... 10 Referring Facility MRN* ...... 10 Admitting Physician ...... 10 Attending Physician ...... 11 Trauma Response ...... 11 Trauma Team Activation* ...... 12 Trauma Team Activation Date - Month ...... 12 Trauma Team Activation Date - Day ...... 13 Trauma Team Activation Date - Year ...... 13 Trauma Team Activation Time - Hour ...... 13 Trauma Team Activation Time - Minute...... 14 Injury Mechanism* ...... 14 Off – Road Vehicle* ...... 15 Signs Of Life * ...... 15 ED Arrival Date - Month* ...... 16 ED Arrival Date - Day* ...... 16 ED Arrival Date – Year* ...... 16 ED Arrival Time Hour* ...... 17 ED Arrival Time - Minute* ...... 17 ED Discharge Date - Month ...... 18 ED Discharge Date - Day ...... 18 ED Discharge Date - Year ...... 18 ED Discharge Time - Hour ...... 19 ED Discharge Time - Minute ...... 19 ED Disposition / Admit To* ...... 20 ED Disposition – If Other*...... 20 OR Disposition* ...... 21 OR Disposition – If Other* ...... 21 Assessment Date – Day (ED) ...... 23 Assessment Month – Day (ED) ...... 23 Assessment Month - Year ...... 23 Assessment Time – Hour ...... 24 Assessment Time - Minute ...... 24 Paralytic Agents in Effect ...... 25 Sedated ...... 25 Bagging or Ventilator ...... 25 Intubated ...... 26 Systolic Blood Pressure* ...... 26 Diastolic Blood Pressure* ...... 26 Heart Rate* ...... 27 Unassisted Respiratory Rate* ...... 27 O2 Administered* ...... 27 O2 Saturation* ...... 28

Emergency Department Page 1 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Hematocrit ...... 28 Hemoglobin ...... 28 Base Deficit* ...... 29 Temperature* ...... 29 Temperature Units* ...... 29 Temperature Route ...... 30 Height ...... 30 Weight ...... 30 Weight Units ...... 31 GCS – Eye Opening* ...... 31 GCS – Verbal Response* ...... 32 GCS – Motor Response* ...... 32 GCS – Total* ...... 33 RTS (Weighted)* ...... 34 GCS Qualifiers* ...... 34 ETOH/BAC Test* ...... 35 ETOH/BAC Test Results* ...... 35 Drug Screen* ...... 35 Drug Screen Result* ...... 36 Drug Screen Result - Other* ...... 36 Abdominal CT Results* ...... 38 Abdominal CT Date - Month ...... 38 Abdominal CT Date - Day...... 38 Abdominal CT Date – Year ...... 39 Abdominal CT Time – Hour ...... 39 Abdominal CT Time - Minute ...... 39 Abdominal Ultrasound Results ...... 40 Abdominal Ultrasound Date - Month ...... 40 Abdominal Ultrasound Date – Day ...... 40 Abdominal Ultrasound Date - Year ...... 41 Abdominal Ultrasound Time - Hour ...... 41 Abdominal Ultrasound Time - Minute ...... 41 Aortogram / Arteriogram / Angiogram Results ...... 42 Aortogram / Arteriogram / Angiogram Date - Month ...... 42 Aortogram / Arteriogram / Angiogram Date - Day ...... 43 Aortogram / Arteriogram / Angiogram Date - Year ...... 43 Aortogram / Arteriogram / Angiogram Time - Hour ...... 43 Aortogram / Arteriogram / Angiogram Time - Minute ...... 44 Chest CT Results* ...... 44 Chest CT Date - Month ...... 45 Chest CT – Date - Day ...... 45 Chest CT Date – Year ...... 45 Chest CT Time - Hour ...... 46 Chest CT Time - Minute ...... 46 Head CT Results* ...... 47 Head CT Date - Month ...... 47 Head CT Date - Day ...... 47 Head CT Date - Year ...... 48 Head CT Time – Hour ...... 48

Emergency Department Page 2 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Head CT Time - Minute ...... 48 Peritoneal Lavage Results...... 49 Peritoneal Lavage Date - Month ...... 49 Peritoneal Lavage Date – Day ...... 49 Peritoneal Lavage Date - Year ...... 50 Peritoneal Lavage Time - Hour ...... 50 Peritoneal Lavage Time - Minute ...... 50 Airway* ...... 51 CPR ...... 51 Consulting Service ...... 53 Consulting Physician ID...... 53 Consulting Service Date - Month ...... 54 Consulting Service Date - Day ...... 54 Consulting Service Date - Year ...... 54 Consulting Service Time - Hour ...... 55 Consulting Service Time – Minute ...... 55 Emergency Physican ...... 57 Emergency Physician – If Other ...... 57 Emergency Physician Called Date - Month ...... 57 Emergency Physician Called Date - Day ...... 58 Emergency Physican Called Date - Year ...... 58 Emergency Physican Called Time - Hour ...... 58 Emergency Physician Called Time – Minute ...... 59 Emergency Physican Responded Date - Month ...... 59 Emergency Physican Responded Date - Day ...... 60 Emergency Physican Responded Date – Year ...... 60 Emergency Physican Responded Time - Hour ...... 60 Emergency Physican Responded Time - Minute ...... 61 Emergency Physican Arrived Date - Month ...... 61 Emergency Physican Arrived Date - Day ...... 61 Emergency Physican Arrived Date - Year ...... 62 Emergency Physican Arrived Time - Hour ...... 62 Emergency Physican Arrived Time - Minute ...... 62 Emergency Physican - Timely Response ...... 63 Trauma Surgeon ...... 63 Trauma Surgeon – If Other ...... 63 Trauma Surgeon Called Date - Month ...... 64 Trauma Surgeon Called Date - Day ...... 64 Trauma Surgeon Called Date - Year ...... 64 Trauma Surgeon Called Time - Hour ...... 65 Trauma Surgeon Called Time - Minute ...... 65 Trauma Surgeon Responded Date - Month...... 66 Trauma Surgeon Responded Date - Day ...... 66 Trauma Surgeon Responded Date – Year ...... 66 Trauma Surgeon Responded Time - Hour ...... 67 Trauma Surgeon Resonded Time – Minute...... 67 Trauma Surgeon Arrived Date - Month ...... 68 Trauma Surgeon Arrived Date – Day ...... 68 Trauma Surgeon Arrived Date – Year ...... 68

Emergency Department Page 3 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Trauma Surgeon Arrived Time – Hour ...... 69 Trauma Surgeon Arrived Time - Minute ...... 69 Trauma Surgeon – Timely Response ...... 70 Neurosurgeon ...... 70 Neurosurgeon – If Other ...... 70 Neurosurgeon Called Date - Month ...... 71 Neurosurgeon Called Date - Day ...... 71 Neurosurgeon Called Date - Year ...... 71 Neurosurgeon Called Time - Hour ...... 72 Neurosurgeon Called Time _ Minute ...... 72 Neurosurgeon Responded Date - Month ...... 72 Neurosurgeon Responded Date - Day ...... 73 Neurosurgeon Responded Date - Year ...... 73 Neurosurgeon Responded Time - Hour ...... 73 Neurosurgeon Responded Time – Minute ...... 74 Neurosurgeon Arrived Date - Month ...... 74 Neurosurgeon Arrived Date - Day ...... 74 Neurosurgeon Arrived Date – Year ...... 75 Neurosurgeon Arrived Time - Hour ...... 75 Neurosurgeon Arrived Time - Minute ...... 75 Neurosurgeon – Timely Response ...... 76 Orthopedic Surgeon ...... 76 Orthopedic Surgeon – If Other ...... 76 Orthopedic Surgeon Called Date - Month...... 77 Orthopedic Surgeon Called Date - Day ...... 77 Orthopedic Surgeon Called Date Year ...... 77 Orthopedic Surgeon Called Time - Hour ...... 78 Orthopedic Surgeon Called Time - Minute ...... 78 Orthopedic Surgeon Responded Date - Month ...... 79 Orthopedic Surgeon Responded Date - Day ...... 79 Orthopedic Surgeon Responded Date - Year ...... 79 Orthopedic Surgeon Responded Time – Hour ...... 80 Orthopedic Surgeon Responded Time – Minute ...... 80 Orthopedic Surgeon Arrived Date - Month ...... 81 Orthopedic Surgeon Arrived Date – Day ...... 81 Orthopedic Surgeon Arrived Date – Year ...... 81 Orthopedic Surgeon Arrived Time – Hour ...... 82 Orthopedic Surgeon Arrived Time – Minute ...... 82 Orthopedic Surgeon – Timely Response ...... 83 Anesthesiologist ...... 83 Anesthesiologist – If Other ...... 83 Anesthesiologist Called Date - Month ...... 84 Anesthesiologist Called Date - Day ...... 84 Anesthesiologist Called Date - Day ...... 84 Anesthesiologist Called Time – Hour ...... 85 Anesthesiologist Called Time - Minute ...... 85 Anesthesiologist Responded Date - Month ...... 86 Anesthesiologist Responded Date - Day ...... 86 Anesthesiologist Responded Date - Year ...... 86

Emergency Department Page 4 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Anesthesiologist Responded Time – Hour ...... 87 Anesthesiologist Responded Time – Minute ...... 87 Anesthesiologist Arrived Date - Month ...... 88 Anesthesiologist Arrived Date - Day ...... 88 Anesthesiologist Arrived Date - Year ...... 88 Anesthesiologist Arrived Time - Hour ...... 89 Anesthesiologist Arrived Time – Minute ...... 89 Anesthesiologist – Timely Response ...... 90 Surgical Chief Resident ...... 90 Surgical Chief Resident – If Other ...... 90 Surgical Chief Resident Called Date - Month ...... 91 Surgical Chief Resident Called Date – Day ...... 91 Surgical Chief Resident Called Date - Year ...... 91 Surgical Chief Resident Called Time – Hour ...... 92 Surgical Chief Resident Called Time – Minute ...... 92 Surgical Chief Resident Responded Date - Month ...... 93 Surgical Chief Resident Responded Date - Day ...... 93 Surgical Chief Resident Responded Date - Year ...... 93 Surgical Chief Resident Responded Time – Hour ...... 94 Surgical Chief Resident Responded Time - Minute ...... 94 Surgical Chief Resident Arrived Date - Month ...... 95 Surgical Chief Resident Arrived Date – Day ...... 95 Surgical Chief Resident Arrived Date - Year ...... 95 Surgical Chief Resident Arrived Time – Hour ...... 96 Surgical Chief Resident Arrived Time - Minute ...... 96 Surgical Chief Resident – Timely Response ...... 97 Team Leader* ...... 97 Team Leader Called Date and Time * ...... 98 Team Leader Arrival Date and Time * ...... 98 Team Leader Threshold * ...... 98 Team Leader – Timely Response* ...... 99 ED – PRBC’s ...... 101 ED – FFP ...... 101 ED – Albumin ...... 101 ED – Whole Blood ...... 102 ED – Platelets ...... 102 ED – Cryoprecipitate ...... 102 ED – Other ...... 103 OR – PRBC’s ...... 103 OR – FFP ...... 103 OR – Albumin ...... 104 OR – Whole Blood ...... 104 OR– Platelets ...... 104 OR – Cryoprecipitate ...... 105 OR – Other ...... 105 ELSEWHERE – PRBC’S ...... 105 ELSEWHERE – FFP ...... 106 ELSEWHERE – Albumin ...... 106 ELSEWHERE – Whole Blood ...... 106

Emergency Department Page 5 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department ELSEWHERE – Platelets ...... 107 ELSEWHERE – Cryoprecipitate ...... 107 ELSEWHERE – Other ...... 107 TOTAL – PRBC’S ...... 108 TOTAL – FFP ...... 108 TOTAL – Albumin ...... 108 TOTAL – Whole Blood ...... 109 TOTAL – Platelets ...... 109 TOTAL – Cryoprecipitate ...... 109 TOTAL – Other ...... 110 Emergency Department Memo ...... 111

* Items are CORE (State Required) data elements

Emergency Department Page 6 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department

EMERGENCY DEPARTMENT – ED

Emergency Department Page 7 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Patient Access to this Facility

Window Location: Data Field Name: Emergency Department – ED ED_ACCESS

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Patient Access to This Facility – Manner in which the patient was admitted to your facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 ED 4 Direct Admit 2 Trauma Dept. (Independent from ED) 5 Transfer from Another Facility 3 ED - 23 Hour Observation ? Unknown

Admitting Service

Window Location: Data Field Name: Emergency Department – ED ADM_SER

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Admitting Service – Service to which the patient is designated upon admission to your facility as in-patients or for observation. For patients who die in the ED, are discharged from the ED, or are transferred from the ED for acute care, code this field as N/A. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 01 Allergy/Immunology 15 Nuclear Medicine 29 Vascular Surgery 02 Anesthesiology 16 OB/GYN 30 Other 03 Burn Care Specialist 17 Ophthalmology 33 OMFS 04 Cardiology 18 Orthopedics 34 Psych 05 Colon Rectal Surgery 19 Otolaryngology 35 Neurology 06 Dermatology 20 Pediatrics 36 Infectious Disease 07 Ear, Nose and Throat 21 Physical 37 Pediatric Medicine Specialist Medicine/Rehab 08 Emergency Medicine 22 Plastic Surgery 38 Pediatric Surgery 09 Family Practice 23 Pulmonary 39 Medical Critical Care Intensivist 10 General Surgery 24 Radiology 40 Surgical Critical Care Intensivist 11 Hand-Ortho Surgery 25 Renal 41 Pediatric Critical Care Intensivist 12 Internal Medicine 26 Thoracic Surgery / Not Applicable 13 Medical Genetics 27 Trauma Surgery ? Unknown 14 Neurosurgery 28 Urology

ADDENDUM: Was a core variable until January, 2012.

ADDENDUM: Added Options 39 Medical Critical Care Intensivist; 40 Surgical Critical Care Intensivist; 41 Pediatric Critical Care Intensivist on entry form 15, June 27, 2014.

Emergency Department Page 8 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Arrived From*

Window Location: Data Field Name: Emergency Department – ED ARR_FROM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Arrived From – The place where the patient was transported from or treated before reaching your facility. INSTRUCTIONS Enter the appropriate option.

CODING RULES Code Home if the patient went from where the injury occurred to their place of residence, and then to the ED.

Code Scene of Injury if the patient was transported to the hospital from where the injury occurred. If the injury occurred in patient’s home, this should be coded as scene of injury.

Code Referring Facility if the patient was treated at a previous facility regardless of admission status.

01 Home 08 Urgent Care Facility 02 Nursing Home 09 Jail/Prison 03 Referring Facility 10 Other 05 Scene of Injury 11 Unspecified 06 Office ? Unknown 07 Medical Emergency Clinic

Transferred From*

Window Location: Data Field Name: Emergency Department – ED TRAN_FROM

State Required: Type of Field: Length: Yes Alphanumeric 7 DEFINITIONS Transferred from – The name of the facility where the patient was given care before reaching your facility, admission to the referring facility is not necessary. INSTRUCTIONS Use direct keyboard entry. Do not leave blank. If patient was not referred / transferred to your hospital, enter “Not Applicable” in this field. If the field “Emergency Department – Arrived From” is valued with a “03” for referring facility, enter the Facility ID of the hospital where the patient was given initial care. VALID OPTIONS Facility ID Number / Not Applicable ? Unknown

Emergency Department Page 9 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Arrival Condition

Window Location: Data Field Name: Emergency Department – ED ARR_CON

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Arrival Condition –AVPU – Neurologic evaluation from ATLS to establish the patient's level of consciousness (ATLS Course Manual) A = Alert, V = Responds to Verbal Stimuli, P = Responds to Painful Stimuli, U = Unresponsive INSTRUCTIONS Enter the patient's condition on arrival as diagnosed using AVPU system. Enter the appropriate option. VALID OPTIONS 1 Alert 5 Unresponsive 2 Responsive to Verbal Stimuli 6 Combative 3 Responsive to Painful Stimuli ? Unknown 4 Unresponsive/Sedated / Not Applicable

Referring Facility MRN*

Window Location: Data Field Name: Emergency Department – ED RF_MRN

State Required: Type of Field: Length: Yes Alphanumeric 7 DEFINITIONS Referring Facility MRN– This is the medical record number from the hospital that transferred the patient to your hospital. INSTRUCTIONS Use direct keyboard entry. Enter all letters and numbers. VALID OPTIONS Facility ID Number / Not Applicable ? Unknown

Admitting Physician

Window Location: Data Field Name: Emergency Department – ED ED_ADMIT

State Required: Type of Field: Length: No Integer 6 DEFINITIONS Admitting Physician – Physician to which the patient is designated upon admission to your facility or; in the case of death in the ED, the physician which gives the patient primary care in the ED INSTRUCTIONS Use direct keyboard entry. Add physician name under the set up tab Physician / Providers. VALID OPTIONS User defined

Emergency Department Page 10 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Attending Physician

Window Location: Data Field Name: Emergency Department – ED ED_ATTEN

State Required: Type of Field: Length: No Integer 6

DEFINITIONS Attending Physician – Physician supervising medical students and/or fellows who is on call at the time of patient arrival. For hospitals without students, attending physician is the on-call/covering physician. INSTRUCTIONS Use direct keyboard entry. VALID OPTIONS User defined

Trauma Response

Window Location: Data Field Name: Emergency Department – ED ED_STATUS

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Trauma Response – Level of medical staff response by the facility to the treatment of the patient. For level 3 and 4 centers, the trauma response field usually does not apply since there is no trauma surgeon involvement in the patient response. However, if they do have a trauma protocol with a response, this can be applied to fit their protocol. Full – A full trauma response to the patient. This requires a dedicated trauma team which responds to the patient in a timely manner upon patient arrival. The team always includes the trauma surgeon (or trauma fellow/chief resident) and supporting team members from various specialties including but not limited to anesthesia, orthopedics, neurosurgery, cardiothoracic surgery. Partial – A partial trauma response to the patient. This requires a subset of the trauma team which responds to the patient in a timely manner upon patient arrival. NFS - A trauma response to the patient without indication to the level of response (Not Further Specified). Some level 2 and most level 3 centers do not have separate levels of response for trauma patients. The NFS category indicates a trauma response was done for the patient but no distinction as to the type of response (full vs. partial). Consult - The patient did not receive a trauma response but the trauma surgeon was consulted upon patient arrival. This indicates that response to the trauma was not necessary; however, the trauma surgeon was consulted and orders given by the trauma surgeon in regard to patient care and appropriate treatment. Readmission - The patient was previously seen for the SAME injury and within 72 hours was readmitted to the ED for trauma care. Non-Trauma Service - The patient did not have a trauma response nor was a trauma surgeon consulted and subsequently was admitted to non-trauma related service. NOTE: Some centers have a separate trauma service others classify trauma under cardiothoracic service, neurosurgery, or orthopedic service. These are still considered trauma services so long as the designated trauma surgeon was involved in the initial phase of care. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Full 5 Readmission 2 Partial 6 Non-Trauma Serv. 3 NFS / Not Applicable 4 Consult ? Unknown

Emergency Department Page 11 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Trauma Team Activation*

Window Location: Data Field Name: Emergency Department – ED TEAM_ACT

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Activation (Trauma Activation) – Hospital defined protocol for notifying the trauma team that a severely injured patient will be arriving at the hospital or is in the ED. All trauma centers have a trauma team activation protocol. INSTRUCTIONS Enter appropriate option. If the comprehensive variable “trauma response” is completed, this variable is auto-populated.

CODING RULES Code Yes if a trauma team was activated based on your institution’s activation protocol.

Code No if a trauma team was not activated based on your institution’s activation protocol.

Code N/A if either your institution does not have an activation protocol, or if your institution has an activation protocol and the patient is not treated in the emergency department, e.g. direct admit.

If Trauma Response (Comprehensive Variable above) is completed Trauma Team Activation is autopopulated (see table below for mapping rules).

Trauma Response Codes used to populate Trauma Team Activation Trauma Team Activation Full, Partial, NFS Y Consult, Readmission, non-trauma service N ? ? N/A N/A VALID OPTIONS Y Yes N/A Non-Applicable N No ? Unknown

ADDENDUM: This variable was added to the registry beginning on Entry Form #13.

Trauma Team Activation Date - Month

Window Location: Data Field Name: Emergency Department - ED TT_ACT_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Team Activation Date – Month – The month the trauma team was activated Trauma team activation – Announcement of incoming trauma patient via pager system to assemble all members of the trauma team in the ED resuscitation area INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Emergency Department Page 12 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Trauma Team Activation Date - Day

Window Location: Data Field Name: Emergency Department – ED TT_ACT_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Team Activation Date – Day – The day the trauma team was activated Trauma team activation – Announcement of incoming trauma patient via pager system to assemble all members of the trauma team in the ED resuscitation area INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Trauma Team Activation Date - Year

Window Location: Data Field Name: Emergency Department – ED TT_ACT_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Trauma Team Activation Date – Year – The year the trauma team was activated Trauma team activation – Announcement of incoming trauma patient via pager system to assemble all members of the trauma team in the ED resuscitation area INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Trauma Team Activation Time - Hour

Window Location: Data Field Name: Emergency Department – ED TT_ACT_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Team Activation Time – Hour – The hour the trauma team was activated Trauma team activation – Announcement of incoming trauma patient via pager system to assemble all members of the trauma team in the ED resuscitation area INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Emergency Department Page 13 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Trauma Team Activation Time - Minute

Window Location: Data Field Name: Emergency Department – ED TT_ACT_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Team Activation Time – Minute – The minute the trauma team was activated Trauma team activation – Announcement of incoming trauma patient via pager system to assemble all members of the trauma team in the ED resuscitation area INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search TT_ACT_EVENT – the Date and Time combined that the trauma team was activated.

 In Report Writer; search TT_ACT_TIME – the Hour and the Minute combined that the trauma team was activated.

 In Report Writer; search TT_ACT_DATE – the Month, Day and Year combined that the trauma team was activated.

Injury Mechanism*

Window Location: Data Field Name: Emergency Department – ED CHIEF_COM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Injury Mechanism – Injury mechanism that caused the patient to come to your facility. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 01 Assault 09 Motor Vehicle Crash 17 Pedestrian Injury 02 Bicycle Crash 10 Rape 18 Plane Crash 03 Burn 11 Stab Wound 19 Railway Injury 04 Electrical Injury 12 Other Mechanism 20 Watercraft Injury 05 Fall 13 Unspecified 21 Sports Injury 06 Gunshot Wound 14 Animal 22 Power Equipment/Machinery 07* Farm/Heavy Equipment 15 Drowning ? Unknown Incident 08 Motorcycle Crash 16* *Off Road Vehicle

______*07 Farm/Heavy Equipment option enables the off road vehicle variable (see below) *16 Off Road Vehicle option enables the off road vehicle variable (see below).

ADDENDUM: This variable was added to the core data set beginning on entry form number 14. This variable was formerly Chief Complaint

ADDENDUM: Option 23 “Hanging” is added on entry form number 15, June 27, 2014.

Emergency Department Page 14 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Off – Road Vehicle*

Window Location: Data Field Name: Emergency Department – ED ATV_INJ

State Required: Type of Field: Length: Yes Integer 1

DEFINITIONS When “Injury Mechanism” (see above) is coded as 07 - Farm/Heavy Equipment or 16 - Off Road Vehicle, this field is enabled. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 All Terrain Vehicle 4 Farm Implement Vehicle 2 Off-road motorcycle ? Unknown 3 Other off-road vehicle / Not Applicable

ADDENDUM: This variable was added to the registry beginning on Entry Form 9.

Signs Of Life *

Window Location: Data Field Name: Emergency Department – ED SIGN_Life

State Required: Type of Field: Length: Yes Integer 1

DEFINITIONS If a patient is “DOA” or has no organized EKG activity, No pupillary responses, No spontaneous respiratory attempts or movement, and no assisted blood pressure (usually implies that patient was brought to hospital with CPR in progress) then code Arrived with NO signs of life. NOTE: If a patient dies and is brought in with NO Signs of Life you would code patient as dying in ED and arriving with no signs of life. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Arrived with No Signs of / Not Applicable Life 2 Arrived with Signs of ? Unknown Life

ADDENDUM: This variable was added to the registry beginning on Entry Form 15, June 27, 2014.

Emergency Department Page 15 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department ED Arrival Date - Month*

Window Location: Data Field Name: Emergency Department – ED EDA_DM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS ED Arrival Date – Month – The month the patient arrived at the ED or was directly admitted to the hospital INSTRUCTIONS If the patient was not a direct admit, enter the date the patient arrived at your ED. This information should be taken from your ED log system or ED documentation. If the patient was a direct admit (i.e., Direct Admit 'Y'), enter the date the patient was admitted to your facility. Enter the appropriate option using the [mm] format. VALID OPTIONS 01 through 12 [mm] ? Unknown

ED Arrival Date - Day*

Window Location: Data Field Name: Emergency Department – ED EDA_DD

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS ED Arrival Date – Day – The day the patient arrived at the ED or was directly admitted to the hospital INSTRUCTIONS If the patient was not a direct admit, enter the date the patient arrived at your ED. This information should be taken from your ED log system or ED documentation. If the patient was a direct admit (i.e., Direct Admit 'Y'), enter the date the patient was admitted to your facility. Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

ED Arrival Date – Year*

Window Location: Data Field Name: Emergency Department – ED EDA_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS ED Arrival Date – Year – The year the patient arrived at the ED or was directly admitted to the hospital INSTRUCTIONS If the patient was not a direct admit, enter the date the patient arrived at your ED. This information should be taken from your ED log system or ED documentation. If the patient was a direct admit (i.e., Direct Admit 'Y'), enter the date the patient was admitted to your facility. Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 16 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department ED Arrival Time Hour*

Window Location: Data Field Name: Emergency Department – ED EDA_TH

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS ED Arrival Time – Hour – The hour the patient arrived at the ED or was directly admitted to the hospital INSTRUCTIONS If the patient was not a direct admit, enter the date the patient arrived at your ED. This information should be taken from your ED log system or ED documentation. If the patient was a direct admit (i.e., Direct Admit 'Y'), enter the date the patient was admitted to your facility. Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

ED Arrival Time - Minute*

Window Location: Data Field Name: Emergency Department – ED EDA_TM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS ED Arrival Time – Minute – The minute the patient arrived at the ED or was directly admitted to the hospital INSTRUCTIONS If the patient was not a direct admit, enter the date the patient arrived at your ED. This information should be taken from your ED log system or ED documentation. If the patient was a direct admit (i.e., Direct Admit 'Y'), enter the date the patient was admitted to your facility. Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search EDA_EVENT – the Date and Time combined that the patient arrived at the ED or was directly admitted to the hospital.

 In Report Writer; search EDA_TIME – the Hour and the Minute combined that the patient arrived at the ED or was directly admitted to the hospital.

 In Report Writer; search EDA_DATE – the Month, Day and Year combined that the patient arrived at the ED or was directly admitted to the hospital.

Emergency Department Page 17 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department ED Discharge Date - Month

Window Location: Data Field Name: Emergency Department – ED EDD_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS ED Discharge Date – Month – The month of the patient’s discharge from the ED INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

ED Discharge Date - Day

Window Location: Data Field Name: Emergency Department – ED EDD_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS ED Discharge Date – Day – The day of the patient’s discharge from the ED INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

ED Discharge Date - Year

Window Location: Data Field Name: Emergency Department – ED EDD_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS ED Discharge Date – Year – The year of the patient’s discharge from the ED INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 18 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department ED Discharge Time - Hour

Window Location: Data Field Name: Emergency Department – ED EDD_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS ED Discharge Time – Hour – The hour of the patient’s discharge from the ED INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

ED Discharge Time - Minute

Window Location: Data Field Name: Emergency Department – ED EDD_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS ED Discharge Time – Minute – The minute of the patient’s discharge from the ED INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search EDD_EVENT – the Date and Time combined that the patient’s discharged from the ED.

 In Report Writer; search EDD_TIME – the Hour and the Minute combined that the patient’s discharged from the ED.

 In Report Writer; search EDD_DATE – the Month, Day and Year combined that the patient’s discharged from the ED.

Emergency Department Page 19 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department ED Disposition / Admit To*

Window Location: Data Field Name: Emergency Department – ED EDD_DISP

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS ED Disposition – Location of the patient following treatment in the ED INSTRUCTIONS Enter the appropriate option. Do not leave blank. Selection of VALID OPTIONS of “02” for OR and “99” for Other will enable additional core fields for completion. CODING RULES Code Floor Bed if a patient is kept for observation only.

Code N/A if a patient is a direct admit.

VALID OPTIONS (where admitted to from the ED) 00 Dead on Arrival 08 Burn Unit 22 Morgue/Died 02 OR 09 Floor Bed 23 AMA 03 ICU 16 Monitored Telemetry Bed 24 Correctional Facility 04 Medical ICU (MICU) 17 Coronary ICU 30 Labor & Delivery 05 Neonatal ICU (NICU) 18 Neuro ICU 98 Unspecified 06 Pediatric ICU (PICU) 20 Discharged Home 99 Other 07 Surgical ICU (SICU) 21 Transfer to Other Hospital ? Unknown N/A Not Applicable

ADDENDUM: Option 00 “Dead on arrival” is retired on entry form 15, June 27, 2014.

ED Disposition – If Other*

Window Location: Data Field Name: Emergency Department – ED ED_DISP_O

State Required: Type of Field: Length: Yes Text 50 DEFINITIONS ED Disposition – If Other –Text field in which to record additional ED Disposition information if needed INSTRUCTIONS Use direct keyboard entry. Answer this only if “99” Other is selected for “Emergency Department – ED Disposition” field above.

Emergency Department Page 20 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department OR Disposition*

Window Location: Data Field Name: Emergency Department – ED OR_DISP

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS ED Disposition – Location of the patient following treatment in the OR INSTRUCTIONS Enter the appropriate option. This field becomes required only if “02” OR is selected for “Emergency Department – ED Disposition” field above. VALID OPTIONS (where admitted to from the OR) 03 ICU 17 CCU 04 MICU 18 NCCU 05 NICU 21 Transferred to Other Hospital 06 PICU 22 Morgue/Died 07 SICU 98 Unspecified 08 Burn Unit 99 Other 09 Floor Bed ? Unknown 16 Monitored Telemetry Bed

OR Disposition – If Other*

Window Location: Data Field Name: Emergency Department – ED OR_DISP_O

State Required: Type of Field: Length: Yes Text 50 DEFINITIONS OR Disposition – If Other –Text field in which to record additional OR Disposition information if needed INSTRUCTIONS Use direct keyboard entry. This field becomes required only if “02” OR is selected for “Emergency Department – ED Disposition” field and “99” Other is selected for “Emergency Department - OR Disposition” above.

Emergency Department Page 21 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department

EMERGENCY DEPARTMENT - VITALS

Emergency Department Page 22 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Assessment Date – Day (ED)

Window Location: Data Field Name: Emergency Department – Vitals E1_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Date – Month – The month the Emergency Department provider personnel conducted a medical assessment of the patient INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Assessment Month – Day (ED)

Window Location: Data Field Name: Emergency Department – Vitals E1_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Date – Day – The day the Emergency Department provider personnel conducted a medical assessment of the patient INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Assessment Month - Year

Window Location: Data Field Name: Emergency Department – Vitals E1_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Assessment Date – Year – The year the Emergency Department provider personnel conducted a medical assessment of the patient INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 23 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Assessment Time – Hour

Window Location: Data Field Name: Emergency Department – Vitals E1_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Time – Hour – The hour the Emergency Department provider personnel conducted a medical assessment of the patient INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] Not Applicable ? Unknown

Assessment Time - Minute

Window Location: Data Field Name: Emergency Department – Vitals E1_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Assessment Time – Minute – The minute the Emergency Department provider personnel conducted a medical assessment of the patient INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] / Not Applicable ? Unknown

 In Report Writer; search E1_EVENT – the Date and Time combined that the Emergency Department provider personnel conducted a medical assessment of the patient.

 In Report Writer; search E1_TIME – the Hour and the Minute combined that the Emergency Department provider personnel conducted a medical assessment of the patient.

 In Report Writer; search E1_DATE – the Month, Day and Year combined that the Emergency Department provider personnel conducted medical assessment of the patient.

Emergency Department Page 24 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Paralytic Agents in Effect

Window Location: Data Field Name: Emergency Department – Vitals E1_PAR

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Paralytic Agents in Effect – Administration of paralytic agents to patient INSTRUCTIONS Answer the following question: Have paralytic agents been administered to the patient in the ED? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown

Sedated

Window Location: Data Field Name: Emergency Department – Vitals E1_SED

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Sedated – Administration of drugs to the patient for the purpose of sedation INSTRUCTIONS Answer the following question: Have drugs been administered in the ED to the patient for sedation? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown

Bagging or Ventilator

Window Location: Data Field Name: Emergency Department – Vitals E1_BAG

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Bagging or Ventilator – Bagging of patient or placement of patient on a ventilator in order to provide respiratory assistance INSTRUCTIONS Answer the following question: Has the patient been bagged or placed on a ventilator in the ED to provide respiratory assistance? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown

Emergency Department Page 25 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Intubated

Window Location: Data Field Name: Emergency Department – Vitals E1_INT

State Required: Type of Field: Length: No Yes/No 1 DEFINITIONS Intubated – Intubation of patient to provide a patent and protected airway INSTRUCTIONS Answer the following question: Has the patient been intubated to provide an airway in ED? Enter the appropriate option. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown

Systolic Blood Pressure*

Window Location: Data Field Name: Emergency Department – Vitals E1_SBP

State Required: Type of Field: Length: Yes Integer 3 DEFINITIONS Systolic Blood Pressure – Maximum blood pressure occurring during contraction of ventricles INSTRUCTIONS Enter the first recorded systolic blood pressure in the ED/hospital within 30 minutes or less of ED/hospital arrival. VALID OPTIONS 0-300 / Inappropriate ? Unknown

Diastolic Blood Pressure*

Window Location: Data Field Name: Emergency Department – Vitals E1_DBP

State Required: Type of Field: Length: Yes Integer 3 DEFINITIONS Diastolic Blood Pressure – Period of least blood pressure in the arterial vascular system INSTRUCTIONS Enter the first recorded diastolic blood pressure in the ED/hospital within 30 minutes or less of ED/hospital arrival. VALID OPTIONS 0-200 / Not Applicable ? Unknown

Emergency Department Page 26 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Heart Rate*

Window Location: Data Field Name: Emergency Department – Vitals E1_HR

State Required: Type of Field: Length: Yes Integer 3 DEFINITIONS Heart Rate – Rate of the pulse palpated in beats per minute INSTRUCTIONS First recorded pulse (heart rate) in the ED/hospital (palpated or auscultated) within 30 minutes or less of ED/hospital arrival (expressed as a number per minute). VALID OPTIONS 0-250 / Not Applicable ? Unknown

Unassisted Respiratory Rate*

Window Location: Data Field Name: Emergency Department – Vitals E1_RR

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Unassisted Respiratory Rate – The act of breathing measured in spontaneous unassisted breaths per minute without the use of mechanical devices INSTRUCTIONS Enter the patient’s actual respiratory rate upon arrival in the ED. Use direct keyboard entry. VALID OPTIONS 0-99 / Not Applicable ? Unknown

O2 Administered*

Window Location: Data Field Name: Emergency Department – Vitals E1_O2_YN

State Required: Type of Field: Length: Yes Yes/No 1 DEFINITIONS O2 Administered – Administration of oxygen to the patient during assessment of oxygen saturation. INSTRUCTIONS Determination of the presence of supplemental oxygen during assessment of initial ED/hospital oxygen saturation level within 30 minutes or less of ED/hospital arrival. VALID OPTIONS 1 Yes / Not Applicable 2 No ? Unknown

Emergency Department Page 27 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department O2 Saturation*

Window Location: Data Field Name: Emergency Department – Vitals E1_SAO2

State Required: Type of Field: Length: Yes Integer 3 DEFINITIONS O2 Saturation – Percentage level of oxygen saturation measured. INSTRUCTIONS First recorded oxygen saturation in the ED/hospital within 30 minutes or less of ED/hospital arrival (expressed as a percentage). VALID OPTIONS 0-100

Hematocrit

Window Location: Data Field Name: Emergency Department – Vitals E1_HEMOCR

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Hematocrit – Volume percentage of erythrocytes in whole blood with a normal range of 45%-52% for men and 37%-48% for women. INSTRUCTIONS Enter the patient's initial hematocrit value obtained in your facility. Use direct keyboard entry. Hematocrit values may be entered with two places before and after (xx.xx). VALID OPTIONS 0-80

Hemoglobin

Window Location: Data Field Name: Emergency Department – Vitals E1_HEMOGL

State Required: Type of Field: Length: No Integer 3 DEFINITIONS Hemoglobin – The iron-containing oxygen transport protein in red blood cells INSTRUCTIONS Enter the patient's initial hemoglobin value at your facility. Hemoglobin values may now be entered with two places before and one place after (xx.x). Use direct keyboard entry. VALID OPTIONS 0.1-99.9

Emergency Department Page 28 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Base Deficit*

Window Location: Data Field Name: Emergency Department – Vitals E1_BASE

State Required: Type of Field: Length: Yes Signed Integer 4 DEFINITIONS Base Deficit – Arterial blood gas component showing the degree of acid/base balance with a normal range being - 2 mEq/L to 2 mEq/L INSTRUCTIONS Enter the patient's base deficit from the first arterial blood gas obtained at your facility. Base deficit values may be entered with two values before and after (xx.xx) Use direct keyboard entry. If your facility does not test for base deficit, use ‘/’ not applicable for this field. Coding Rule Code N/A if your facility does not test for base deficit or if an arterial blood gas was not drawn. VALID OPTIONS +/- 80 / Not applicable ? Unknown

Temperature*

Window Location: Data Field Name: Emergency Department – Vitals E1_TEMP

State Required: Type of Field: Length: Yes Fixed-1 4 DEFINITIONS Temperature – Patient’s body temperature, normally 98.6 degrees Fahrenheit, 37 degrees Centigrade. INSTRUCTIONS Enter the patient's initial recorded temperature on the Fahrenheit or Centigrade scales. Use direct keyboard entry. VALID OPTIONS 0-110 (Fahrenheit or Celsius)

Temperature Units*

Window Location: Data Field Name: Emergency Department – Vitals E1_TEMPU

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Temperature Units – Measurement unit used to record the patient’s temperature INSTRUCTIONS Enter the method used to record the patient's heat measurement unit in either Fahrenheit or Celsius degrees. Enter the appropriate option. VALID OPTIONS 1 F ? Unknown 2 C

Emergency Department Page 29 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department

Temperature Route

Window Location: Data Field Name: Emergency Department – Vitals E1_TEMPR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Temperature Route – Method used to measure the patient’s temperature INSTRUCTIONS Enter the appropriate option.

VALID OPTIONS 1 Tympanic 5 Foley 2 Oral 6 Other 3 Axillary ? Unknown 4 Rectal

Height

Window Location: Data Field Name: Emergency Department – Vitals E1_HGT

State Required: Type of Field: Length: No Integer 3 DEFINITIONS Height – Patient’s initial recorded height, recorded in centimeters INSTRUCTIONS Use direct keyboard entry. VALID OPTIONS Height in centimeters (cm)

Weight

Window Location: Data Field Name: Emergency Department – Vitals E1_WGT

State Required: Type of Field: Length: No Fixed 1 4 DEFINITIONS Weight – Patient’s initial recorded weight INSTRUCTIONS Use direct keyboard entry. VALID OPTIONS Weight

Emergency Department Page 30 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Weight Units

Window Location: Data Field Name: Emergency Department – Vitals E1_WGTU

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Weight Units – Measurement unit used to record the patient’s weight INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Pounds ? Unknown 2 Kilograms

GCS – Eye Opening*

Window Location: Data Field Name: Emergency Department – Vitals E1_GCS_EO

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS GCS (Glasgow Coma Scale) – Eye Opening ADULT CHILD 2-5 years INFANT 0-23 SCORE months None None None 1 To pain To pain To pain 2 To voice To voice To voice 3 Spontaneous Spontaneous Spontaneous 4 INSTRUCTIONS First recorded Glasgow Coma Score (Eye) in the ED/hospital within 30 minutes or less ED/hospital arrival. VALID OPTIONS 1 None 3 To Voice ? Unknown 2 To Pain 4 Spontaneous

Emergency Department Page 31 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department

GCS – Verbal Response*

Window Location: Data Field Name: Emergency Department – Vitals E1_GCS_VR

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS GCS (Glasgow Coma Scale) – Verbal Response ADULT CHILD 2-5 years INFANT 0-23 SCORE months None None None 1 Incomprehensible Incomprehensible Moans to pain 2 sounds words Inappropriate words Inappropriate cries Cries to pain 3 Confused Confused Irritable cries 4 Oriented Oriented Coos, babbles 5 INSTRUCTIONS First recorded Glasgow Coma Score (Verbal) in the ED/hospital within 30 minutes or less ED/hospital arrival. VALID OPTIONS 1 None 4 Confused 2 Incomprehensible 5 Oriented Sounds 3 Inappropriate Words ? Unknown

GCS – Motor Response*

Window Location: Data Field Name: Emergency Department – Vitals E1_GCS_MR

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS GCS (Glasgow Coma Scale) – Motor Response ADULT CHILD 2-5 years INFANT 0-23 months SCORE None None None 1 Abnormal Extension in response to Decerebrate posturing in response 2 extension pain to pain Abnormal flexion Flexion in response to Decorticate posturing in response 3 pain to pain Withdraws to pain Withdraws in response to Withdraws in response to pain 4 pain Localizes pain Localizes painful stimulus Withdraws to touch 5 Obeys commands Obeys commands Moves spontaneously 6 INSTRUCTIONS First recorded Glasgow Coma Score (Motor) in the ED/hospital within 30 minutes or less ED/hospital arrival. VALID OPTIONS 1 None 5 Localizes Pain 2 Abnormal Extension 6 Obeys Commands 3 Abnormal Flexion ? Unknown 4 Withdraws to Pain

Emergency Department Page 32 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department GCS – Total*

Window Location: Data Field Name: Emergency Department – Vitals E1_GCS_TT

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS GCS (Glasgow Coma Scale) – Total – The total of the patient’s Eye opening, Verbal response, and Motor response scores

ADULT CHILD 2-5 years INFANT 0-23 months SCORE Eye Opening: None None None 1 To pain To pain To pain 2 To voice To voice To voice 3 Spontaneous Spontaneous Spontaneous 4

Total GCS = Eye Opening Score + Verbal Response Score + Motor Response Score (Ranges between 3 and 15)

INSTRUCTIONS The total GCS Score for the patient recorded in the ED will be computed by the program after all the GCS components are entered.

If one or two of the individual components are missing, code the total GCS field as “?” unknown.

If all individual components are missing and the total GCS is recorded in the medical record, code the individual components as “?” unknown and enter the total GCS.

If a patient does not have a numeric GCS recorded, but there is documentation related to their level of consciousness such as “AAOx3” “awake, alert and oriented”, or “patient with normal mental status,” interpret this as a GCS of 15 IF there is no other contradicting documentation.

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Emergency Department RTS (Weighted)*

Window Location: Data Field Name: Emergency Department – Vitals E1_RTS_W

State Required: Type of Field: Length: Yes Fixed-2 4 DEFINITIONS Weighted RTS – Based on the values of the Glasgow Coma Scale, systolic blood pressure and respiratory rate. Raw values used for triage. Coded values are weighted and summed for outcome evaluation. Raw values (displayed):

Glasgow Coma Scale total points: 13-15 = 4 9-12 = 3 6-8 = 2 4-5 = 1 3 = 0 Respiratory Rate > 29 = 4 10-29 = 3 6-9 = 2 1-5 = 1 0 = 0 Systolic Blood Pressure –

> 89 = 4 76-89 = 3 50-75 = 2 1-49 = 1 0 = 0

Weighted RTS = 0.9368 * (Glasgow Coma value) + 0.7326 * (Systolic BP value) + 0.2908 * (Respiratory Rate value) INSTRUCTIONS The Weighted RTS is automatically calculated by the program after the GCS score, respiratory rate, and systolic blood pressure are entered. If one of these parameters is unknown, the RTS cannot be calculated.

GCS Qualifiers*

Window Location: Data Field Name: Emergency Department – Vitals E1_GCSQ_1, E1_GCSQ_2, E1_GCSQ_3

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS GCS Qualifier – Factors potentially affecting the assessment of the initial GCS taken in the Emergency Department within 30 minutes or less of ED/hospital arrival). INSTRUCTIONS Enter all qualifiers that could affect the initial assessment of GCS for this patient in the Emergency Department. Enter the appropriate option. VALID OPTIONS 1 No Qualifier 4 Patient Intubated 2 Chemically altered mental status 9 Not documented 3 Obstruction to patient’s eye ? Unknown

Emergency Department Page 34 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department ETOH/BAC Test*

Window Location: Data Field Name: Emergency Department – Vitals ETOH_TEST

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS ETOH/BAC Test – Measurement of ethyl alcohol in the bloodstream from a sample of serum obtained for laboratory examination INSTRUCTIONS Answer the following question: Was an ETOH/BAC test performed on the patient? Enter the appropriate option. VALID OPTIONS 1 Suspected 5 Not Tested 2 Yes, Positive Results 6 Patient Refused 3 Yes, Negative Results ? Unknown 4 Yes, Unknown Results

ETOH/BAC Test Results*

Window Location: Data Field Name: Emergency Department – Vitals ETOH_RES

State Required: Type of Field: Length: Yes Integer 3 DEFINITIONS ETOH/BAC Test Results– Measurement of ethyl alcohol in the bloodstream from a sample of serum obtained for laboratory examination with units: mg/dl with a range of 0-700 INSTRUCTIONS Enter the patient's first ethyl alcohol level obtained. Use direct keyboard entry. VALID OPTIONS Ethyl alcohol level / Not Applicable ? Unknown

Drug Screen*

Window Location: Data Field Name: Emergency Department – Vitals DRUG_TEST

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Drug Screen – Laboratory test used to detect the presence of drugs in the patient's blood or urine INSTRUCTIONS Answer the following question: Was a drug screen performed on the patient? Enter the appropriate option. VALID OPTIONS 1 Suspected 5 Not Tested 2 Yes, Positive Results 6 Patient Refused 3 Yes, Negative Results ? Unknown 4 Yes, Unknown Results

Emergency Department Page 35 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Drug Screen Result*

Window Location: Data Field Name: Emergency Department – Vitals DRUG_R01, DRUG_R02, DRUG_R03, DRUG_R04, DRUG_R05, DRUG_R06, DRUG_R07, DRUG_R08, DRUG_R09, DRUG_R10

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Drug Screen Result – Measurement of various drug components in the blood stream from a sample of serum obtained for laboratory examination INSTRUCTIONS Enter the drugs present when drug screening was performed in the ED. Do not include drugs given to the patient during any phase of resuscitation. Enter the appropriate option. VALID OPTIONS 01 Amphetamines 07 Opiates 02 Barbiturates 08 PCP 03 Benzodiazepines 09 Tricyclic Antidepressants 04 Cocaine 10 Unspecified 05 Ethyl Alcohol 12 Other 06 Marijuana Derivatives ? Unknown

Drug Screen Result - Other*

Window Location: Data Field Name: Emergency Department – Vitals DRUG_RO

State Required: Type of Field: Length: Yes Text 50 DEFINITIONS Drug Screen Result- Other –Text field in which to record additional Emergency Department – Drug Screen Result information if needed INSTRUCTIONS Use direct keyboard entry.

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Emergency Department

EMERGENCY DEPARTMENT - ASSESSMENTS \

Emergency Department Page 37 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Abdominal CT Results*

Window Location: Data Field Name: Emergency Department – Assessment E1_ABD_CT

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Abdominal CT Results – The results from the patient's initial Abdominal CT Scan upon arrival in the ED Abdomen – Portion of the body which lies between the chest and the pelvis CT Scan – Computerized Axial Tomography – A diagnostic procedure that utilizes a computer to analyze x-ray data Negative – A negative finding means that the diagnostic study resulted with unremarkable findings (i.e. normal). Positive – A positive finding means that an abnormality or injury was detected during the diagnostic study that would likely (but not always) require treatment. There can be a positive result but no action taken to treat it except leave it alone. Unknown – Unknown would indicate that results were examined but inconclusive to either a positive finding or negative finding. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Negative 3 Not Performed 2 Positive ? Unknown

Abdominal CT Date - Month

Window Location: Data Field Name: Emergency Department – Assessment E1_A1_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Abdominal CT Date – Month – The month the abdominal CT was performed INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Abdominal CT Date - Day

Window Location: Data Field Name: Emergency Department – Assessment E1_A1_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Abdominal CT Date – Day – The day the abdominal CT was performed INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Emergency Department Page 38 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Abdominal CT Date – Year

Window Location: Data Field Name: Emergency Department – Assessment E1_A1_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Abdominal CT Date – Year – The year the abdominal CT was performed INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Abdominal CT Time – Hour

Window Location: Data Field Name: Emergency Department – Assessment E1_A1_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Abdominal CT Time – Hour – The hour the abdominal CT was performed INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Abdominal CT Time - Minute

Window Location: Data Field Name: Emergency Department – Assessment E1_A1_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Abdominal CT Time – Minute – The minute the abdominal CT was performed INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search E1_A1_EVENT – the Date and Time combined that the abdominal CT was performed.

 In Report Writer; search E1_A1_TIME – the Hour and the Minute combined that the abdominal CT was performed.

 In Report Writer; search E1_A1_DATE – the Month, Day and Year combined that the abdominal CT was performed.

Emergency Department Page 39 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Abdominal Ultrasound Results

Window Location: Data Field Name: Emergency Department – Assessment E1_ABD_UT

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Abdominal Ultrasound Results – The results from the patient’s initial Abdominal Ultrasound upon arrival at the ED Ultrasound – The diagnostic use of ultrasonic waves directed for imaging of internal body structures and the detection of bodily abnormalities Negative – A negative finding means that the diagnostic study resulted with unremarkable findings (i.e. normal). Positive – A positive finding means that an abnormality or injury was detected during the diagnostic study that would likely (but not always) require treatment. There can be a positive result but no action taken to treat it except leave it alone. Indeterminate – Indicates that results were examined but inconclusive to either a positive finding or negative finding. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 0 Not Performed 3 Indeterminate 1 Positive ? Unknown 2 Negative

Abdominal Ultrasound Date - Month

Window Location: Data Field Name: Emergency Department – Assessment E1_A2_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Abdominal Ultrasound Date – Month – The month the abdominal ultrasound was performed INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Abdominal Ultrasound Date – Day

Window Location: Data Field Name: Emergency Department – Assessment E1_A2_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Abdominal Ultrasound Date – Day – The day the abdominal ultrasound was performed INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

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Emergency Department Abdominal Ultrasound Date - Year

Window Location: Data Field Name: Emergency Department – Assessment E1_A2_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Abdominal Ultrasound Date – Year – The year the abdominal ultrasound was performed INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Abdominal Ultrasound Time - Hour

Window Location: Data Field Name: Emergency Department – Assessment E1_A2_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Abdominal Ultrasound Time – Hour – The hour the abdominal ultrasound was performed INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Abdominal Ultrasound Time - Minute

Window Location: Data Field Name: Emergency Department – Assessment E1_A2_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Abdominal Ultrasound Time – Minute – The minute the abdominal ultrasound was performed INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search E1_A2_EVENT – the Date and Time combined that the abdominal ultrasound was performed.

 In Report Writer; search E1_A2_TIME – the Hour and the Minute combined that the abdominal ultrasound was performed.

 In Report Writer; search E1_A2_DATE – the Month, Day and Year combined that the abdominal ultrasound was performed.

Emergency Department Page 41 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Aortogram / Arteriogram / Angiogram Results

Window Location: Data Field Name: Emergency Department – Assessment E1_AOR_GR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Aortogram/Arteriogram/Angiogram Results – The results from the patient's initial Aortogram/Arteriogram/Angiogram upon arrival at the ED Aortogram – X-ray film of the aortic arch after the injection of a dye Arteriogram – X-ray film of the arteries after the injection of a dye Angiogram – Serial reentgenography of a blood vessel taken n rapid sequence following the injection of a radiopaque substance into the vessel Negative – A negative finding means that the diagnostic study resulted with unremarkable findings (i.e. normal). Positive – A positive finding means that an abnormality or injury was detected during the diagnostic study that would likely (but not always) require treatment. There can be a positive result but no action taken to treat it except leave it alone. Unknown – Unknown would indicate that results were examined but inconclusive to either a positive finding or negative finding. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Negative 3 Not Performed 2 Positive ? Unknown

Aortogram / Arteriogram / Angiogram Date - Month

Window Location: Data Field Name: Emergency Department – Assessment E1_A3_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Aortogram/Arteriogram/Angiogram Date – Month – The month the aortogram, arteriogram, or angiogram was performed INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Emergency Department Page 42 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Aortogram / Arteriogram / Angiogram Date - Day

Window Location: Data Field Name: Emergency Department – Assessment E1_A3_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Aortogram/Arteriogram/Angiogram Date – Day – The day the aortogram, arteriogram, or angiogram was performed INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Aortogram / Arteriogram / Angiogram Date - Year

Window Location: Data Field Name: Emergency Department – Assessment E1_A3_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Aortogram/Arteriogram/Angiogram Date – Year – The year the aortogram, arteriogram, or angiogram was performed INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Aortogram / Arteriogram / Angiogram Time - Hour

Window Location: Data Field Name: Emergency Department – Assessment E1_A3_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Aortogram/Arteriogram/Angiogram Time – Hour – The hour the aortogram, arteriogram, or angiogram was performed INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Emergency Department Page 43 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Aortogram / Arteriogram / Angiogram Time - Minute

Window Location: Data Field Name: Emergency Department - Assessment E1_A3_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Aortogram/Arteriogram/Angiogram Time – Minute – The minute the aortogram, arteriogram, or angiogram was performed INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search E1_A3_EVENT – the Date and Time combined that the aortogram, arteriogram or angiogram was performed.

 In Report Writer; search E1_A3_TIME – the Hour and the Minute combined that the aortogram, arteriogram or angiogram was performed.

 In Report Writer; search E1_A3_DATE – the Month, Day and Year combined that the aortogram, arteriogram or angiogram was performed.

Chest CT Results*

Window Location: Data Field Name: Emergency Department - Assessment E1_CHE_CT

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Chest CT Results – The results from the patient's initial Chest CT Scan upon arrival at the ED CT Scan (Computerized Axial Tomography) – A diagnostic procedure that utilizes a computer to analyze x-ray data Negative – A negative finding means that the diagnostic study resulted with unremarkable findings (i.e. normal). Positive – A positive finding means that an abnormality or injury was detected during the diagnostic study that would likely (but not always) require treatment. There can be a positive result but no action taken to treat it except leave it alone. Unknown – Unknown would indicate that results were examined but inconclusive to either a positive finding or negative finding. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Negative 2 Positive 3 Not Performed ? Unknown

Emergency Department Page 44 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Chest CT Date - Month

Window Location: Data Field Name: Emergency Department - Assessment E1_C_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Chest CT Date – Month – The month the chest CT was performed INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Chest CT – Date - Day

Window Location: Data Field Name: Emergency Department - Assessment E1_C_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Chest CT Date – Day – The day the chest CT was performed INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Chest CT Date – Year

Window Location: Data Field Name: Emergency Department - Assessment E1_C_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Chest CT Date – Year – The year the chest CT was performed INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

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Emergency Department Chest CT Time - Hour

Window Location: Data Field Name: Emergency Department - Assessment E1_C_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Chest CT Time – Hour – The hour the chest CT was performed INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Chest CT Time - Minute

Window Location: Data Field Name: Emergency Department - Assessment E1_C_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Chest CT Time – Minute – The minute the chest CT was performed INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search E1_C_EVENT – the Date and Time combined that the chest CT was performed.

 In Report Writer; search E1_C_TIME – the Hour and the Minute combined that the chest CT was performed.

 In Report Writer; search E1_C_DATE – the Month, Day and Year combined that the chest CT was performed.

Emergency Department Page 46 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Head CT Results*

Window Location: Data Field Name: Emergency Department - Assessment E1_HE_CT

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Head Ct Results – The results from the patient's initial Head CT Scan upon arrival at the ED CT Scan (Computerized Axial Tomography) – A diagnostic procedure that utilizes a computer to analyze x-ray data Negative – A negative finding means that the diagnostic study resulted with unremarkable findings (i.e. normal). Positive – A positive finding means that an abnormality or injury was detected during the diagnostic study that would likely (but not always) require treatment. There can be a positive result but no action taken to treat it except leave it alone. Unknown – Unknown would indicate that results were examined but inconclusive to either a positive finding or negative finding. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Negative 3 Not Performed 2 Positive ? Unknown

Head CT Date - Month

Window Location: Data Field Name: Emergency Department - Assessment E1_H_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Head CT Date – Month – The month the Head CT was performed INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Head CT Date - Day

Window Location: Data Field Name: Emergency Department - Assessment E1_H_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Head CT Date – Day – The day the Head CT was performed INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Emergency Department Page 47 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Head CT Date - Year

Window Location: Data Field Name: Emergency Department - Assessment E1_H_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Head CT Date – Year – The year the Head CT was performed INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Head CT Time – Hour

Window Location: Data Field Name: Emergency Department - Assessment E1_H_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Head CT Time – Hour – The hour the Head CT was performed INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Head CT Time - Minute

Window Location: Data Field Name: Emergency Department - Assessment E1_H_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Head CT Time – Minute – The minute the Head CT was performed INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search E1_H_EVENT – the Date and Time combined that the head CT was performed.

 In Report Writer; search E1_H_TIME – the Hour and the Minute combined that the head CT was performed.

 In Report Writer; search E1_H_DATE – the Month, Day and Year combined that the head CT was performed.

Emergency Department Page 48 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Peritoneal Lavage Results

Window Location: Data Field Name: Emergency Department - Assessment E1_PER_LV

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Peritoneal Lavage Results – The results from the first peritoneal lavage done in your facility Peritoneal Lavage – Washing out of the peritoneal cavity Peritoneal Cavity – Region bordered by parietal layer of the peritoneum containing all the abdominal organs excluding the kidneys Negative – A negative finding means that the diagnostic study resulted with unremarkable findings (i.e. normal) Positive – A positive finding means that an abnormality or injury was detected during the diagnostic study that would likely (but not always) require treatment. There can be a positive result but no action taken to treat it except leave it alone Indeterminate – Indicates that results were examined but inconclusive to either a positive finding or negative finding INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 0 Not Performed 3 Indeterminate 1 Negative 4 Unsuccessful 2 Positive ? Unknown

Peritoneal Lavage Date - Month

Window Location: Data Field Name: Emergency Department - Assessment E1_P_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Peritoneal Lavage Date – Month – The month the peritoneal lavage was completed INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Peritoneal Lavage Date – Day

Window Location: Data Field Name: Emergency Department - Assessment E1_P_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Peritoneal Lavage Date – Day – The day the peritoneal lavage was completed INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Emergency Department Page 49 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Peritoneal Lavage Date - Year

Window Location: Data Field Name: Emergency Department - Assessment E1_P_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Peritoneal Lavage Date – Year – The year the peritoneal lavage was completed INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Peritoneal Lavage Time - Hour

Window Location: Data Field Name: Emergency Department - Assessment E1_P_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Peritoneal Lavage Time – Hour – The hour the peritoneal lavage was completed INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Peritoneal Lavage Time - Minute

Window Location: Data Field Name: Emergency Department - Assessment E1_P_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Peritoneal Lavage Time – Minute – The minute the peritoneal lavage was completed INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search E1_P_EVENT – the Date and Time combined that the peritoneal lavage was completed.

 In Report Writer; search E1_P_TIME – the Hour and the Minute combined that the peritoneal lavage was completed.

 In Report Writer; search E1_P_DATE – the Month, Day and Year combined that the peritoneal lavage was completed.

Emergency Department Page 50 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Airway*

Window Location: Data Field Name: Emergency Department - Assessment E1_AIR

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Airway – A device or procedure used to prevent or correct obstructed respiratory passage INSTRUCTIONS Enter the most invasive airway adjunct to assist the patient used in your ED. Enter the appropriate option. CODING RULE If more than one airway is used in your ED, please use the table located below the “Valid Options” list to determine which airway is most invasive. VALID OPTIONS 00 No Intervention 09 Combi-Tube 01 Assisted by Bag and Mask 10 Nasal Pharyngeal Airway 02 Cricothyrotomy 11 Blow By 03 Esophageal Obturator Airway 12 Non-Rebreather Mask Oxygen 04 Nasal Endotracheal Tube 13 Nasal Cannula Oxygen 05 Oral Airway 14 Tracheostomy 06 Oral Endotracheal Tube 15 Unspecified 07 Oxygen Mask 16 Unsuccessful 08 LMA ? Unknown Airways least invasive to most invasive No Intervention Oral Airway Nasal Pharyngeal Airway Nasal Cannula Oxygen Blow-by Oxygen Mask Non-rebreather Mask Oxygen Assisted by Bag and Mask (also called BVM for bag Value Mask Laryngeal Mask Airway (LMA) King/Combitube Oral Endotracheal tube Nasal Endotracheal tube Cricothyrotomy Tracheostomy

CPR

Window Location: Data Field Name: Emergency Department - Assessment E1_CPR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS CPR (Cardiopulmonary Resuscitation) – Procedure for revival after lack of heart beat or respirations. INSTRUCTIONS Answer the following question: Has CPR been performed on the patient? Enter the appropriate option. VALID OPTIONS 1 Yes 2 No ? Unknown

Emergency Department Page 51 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department

EMERGENCY DEPARTMENT - PROVIDER

Emergency Department Page 52 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Consulting Service

Window Location: Data Field Name: Emergency Department – Provider E1_CONS_01 TO E1_CONS_10

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Consulting Service – Medical service who gives advice regarding treatment of the patient based on area of practice INSTRUCTIONS Enter the appropriate option(s). You may select up to 10 consulting services. VALID OPTIONS 01 Allergy/Immunology 15 Nuclear Medicine 29 Vascular Surgery 02 Anesthesiology 16 OB/GYN 30 Other 03 Burn Care Specialist 17 Ophthalmology 33 OMFS 04 Cardiology 18 Orthopedics 34 Psych 05 Colon Rectal Surgery 19 Otolaryngology 35 Neurology 06 Dermatology 20 Pediatrics 36 Infectious Disease 07 Ear, Nose and Throat 21 Physical 37 Pediatric Medicine Specialist Medicine/Rehab 08 Emergency Medicine 22 Plastic Surgery 38 Pediatric Surgery 09 Family Practice 23 Pulmonary 39 Medical Critical Care Intensivist 10 General Surgery 24 Radiology 40 Surgical Critical Care Intensivist 11 Hand-Ortho Surgery 25 Renal 41 Pediatric Critical Care Intensivist 12 Internal Medicine 26 Thoracic Surgery / Not Applicable 13 Medical Genetics 27 Trauma Surgery ? Unknown 14 Neurosurgery 28 Urology

ADDENDUM: Added Options 39 Medical Critical Care Intensivist; 40 Surgical Critical Care Intensivist; 41 Pediatric Critical Care Intensivist on entry form 15, June 27, 2014. Consulting Physician ID

Window Location: Data Field Name: Emergency Department – Provider E1_CO1_ID to E1_C10_ID

State Required: Type of Field: Length: No Integer 6 DEFINITIONS Consulting Physician – Enter your facility’s identifying code for the Consulting Physician INSTRUCTIONS You may add as many codes and/or names as are applicable, but once entered, they cannot be deleted or changed. Use direct keyboard entry. VALID OPTIONS User defined ? Unknown

Emergency Department Page 53 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Consulting Service Date - Month

Window Location: Data Field Name: Emergency Department – Provider E1_C01_DM TO E1_C10_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Consulting Service Date – Month – The month the consulting service performed the evaluation on the patient INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Consulting Service Date - Day

Window Location: Data Field Name: Emergency Department – Provider E1_C01_DD TO E1_C10_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Consulting Service Date – Day – The day the consulting service performed the evaluation on the patient INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Consulting Service Date - Year

Window Location: Data Field Name: Emergency Department – Provider E1_C01_DY TO E1_C10_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Consulting Service Date – Year – The year the consulting service performed the evaluation on the patient INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 54 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Consulting Service Time - Hour

Window Location: Data Field Name: Emergency Department – Provider E1_C01_ TH TO E1_C10_ TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Consulting Service Time – Hour – The hour the consulting service performed the evaluation on the patient INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Consulting Service Time – Minute

Window Location: Data Field Name: Emergency Department – Provider E1_C01_ TM TO E1_C10_ TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Consulting Service Time – Minute – The minute the consulting service performed the evaluation on the patient INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search E1_C01_EVENT to E1_C10_EVENT – the Date and Time combined that the consulting service performed the evaluation on the patient.

 In Report Writer; search E1_C01_TIME to E1_C10_TIME – the Hour and the Minute combined that the consulting service performed the evaluation on the patient.

 In Report Writer; search E1_C01_DATE to E1_C10_DATE – the Month, Day and Year combined that the consulting service performed the evaluation on the patient.

Emergency Department Page 55 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department

EMERGENCY DEPARTMENT – TRAUMA TEAM

Emergency Department Page 56 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Emergency Physician

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_ID

State Required: Type of Field: Length: No Integer 6 DEFINITIONS Emergency Physician – Physician who specializes in care for persons requiring immediate medical attention who responded to a trauma activation in Emergency Department. INSTRUCTIONS Enter your facility’s identifying code for the Emergency Physician. You may add as many codes and/or names as are applicable, but once entered, they cannot be deleted or changed. Use direct keyboard entry. VALID OPTIONS User defined ? Unknown

Emergency Physician – If Other

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_ID_O

State Required: Type of Field: Length: No Text 50 DEFINITIONS Emergency Physician – If Other –Text field in which to record additional information if needed INSTRUCTIONS Use direct keyboard entry.

Emergency Physician Called Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_C_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Emergency Physician Called Date – Month – The month the Emergency Physician was called by ED personnel INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Emergency Department Page 57 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Emergency Physician Called Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_C_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Emergency Physician Called Date – Day – The day the Emergency Physician was called by ED personnel INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Emergency Physician Called Date - Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_C_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Emergency Physician Called Date – Year – The year the Emergency Physician was called by ED personnel INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Physician Called Time - Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_C_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Emergency Physician Called Time – Hour – The hour the Emergency Physician was called by ED personnel INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Emergency Department Page 58 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Emergency Physician Called Time – Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_C_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Emergency Physician Called Time – Minute – The minute the Emergency Physician was called by ED personnel INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED91_C_EVENT – the Date and Time combined that the Emergency Physician was called by ED personnel.

 In Report Writer; search ED91_C_TIME – the Hour and the Minute combined that the Emergency Physician was called by ED personnel.

 In Report Writer; search ED91_C_DATE – the Month, Day and Year combined that the Emergency Physician was called by ED personnel.

Emergency Physician Responded Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_R_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Emergency Physician Responded Date – Month – The month the Emergency Physician responded to the initial call by ED personnel INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Emergency Department Page 59 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Emergency Physician Responded Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_R_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Emergency Physician Responded Date – Day – The day the Emergency Physician responded to the initial call by ED personnel INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Emergency Physician Responded Date – Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_R_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Emergency Physician Responded Date – Year – The year the Emergency Physician responded to the initial call by ED personnel INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Physician Responded Time - Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_R_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Emergency Physician Responded Time – Hour – The hour the Emergency Physician responded to the initial call by ED personnel INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Emergency Department Page 60 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Emergency Physician Responded Time - Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_R_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Emergency Physician Responded Time – Minute – The minute the Emergency Physician responded to the initial call by ED personnel INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED91_R_EVENT – the Date and Time combined that the Emergency Physician responded to the initial call by ED personnel.

 In Report Writer; search ED91_R_TIME – the Hour and the Minute combined that the Emergency Physician responded to the initial call by ED personnel.

 In Report Writer; search ED91_R_DATE – the Month, Day and Year combined that the Emergency Physician responded to the initial call by ED personnel.

Emergency Physician Arrived Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_A_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Emergency Physician Arrived Date – Month – The month the Emergency Physician arrived in the ED INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Emergency Physician Arrived Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_A_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Emergency Physician Arrived Date – Day – The day the Emergency Physician arrived in the ED INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd]? Unknown

Emergency Department Page 61 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Emergency Physician Arrived Date - Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_A_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Emergency Physician Arrived Date – Year – The year the Emergency Physician arrived in the ED INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Physician Arrived Time - Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_A_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Emergency Physician Arrived Time – Hour – The hour the Emergency Physician arrived in the ED INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Emergency Physician Arrived Time - Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_A_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Emergency Physician Arrived Time – Minute – The minute the Emergency Physician arrived in the ED INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED91_A_EVENT – the Date and Time combined that the Emergency Physician arrived in the ED.

 In Report Writer; search ED91_A_TIME – the Hour and the Minute combined that the Emergency Physician arrived in the ED.

 In Report Writer; search ED91_A_DATE – the Month, Day and Year combined that the Emergency Physician arrived in the ED.

Emergency Department Page 62 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Emergency Physician - Timely Response

Window Location: Data Field Name: Emergency Department – Trauma Team ED91_TR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Emergency Physician – Timely Response – The physical presence of the emergency physician in the Emergency Department within a short period of time, defined by the facility in the by-laws INSTRUCTIONS Answer the following question: Did the Emergency Physician respond to the call to see the patient in a timely manner? VALID OPTIONS 1 or Y Yes 2 or N No ? Unknown

Trauma Surgeon

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_ID

State Required: Type of Field: Length: No Integer 6 DEFINITIONS Trauma Surgeon – Fourth year surgical resident or attending INSTRUCTIONS Use direct keyboard entry. VALID OPTIONS User defined

Trauma Surgeon – If Other

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_ID_O

State Required: Type of Field: Length: No Text 50 DEFINITIONS Trauma Surgeon – If Other – Text field in which to record additional information if needed INSTRUCTIONS Use direct keyboard entry.

Emergency Department Page 63 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Trauma Surgeon Called Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_C_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Surgeon Called Date – Month – The month the Trauma Surgeon was called by ED personnel INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Trauma Surgeon Called Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_C_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Surgeon Called Date – Day – The day the Trauma Surgeon was called by ED personnel INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Trauma Surgeon Called Date - Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_C_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Trauma Surgeon Called Date – Year – The year the Trauma Surgeon was called by ED personnel INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 64 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Trauma Surgeon Called Time - Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_C_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Surgeon Called Time – Hour – The hour the Trauma Surgeon was called by ED personnel INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Trauma Surgeon Called Time - Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_C_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Surgeon Called Time – Minute – The minute the trauma surgeon was called by ED personnel INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED92_C_EVENT – the Date and Time combined that the Trauma Surgeon was called by ED personnel.

 In Report Writer; search ED92_C_TIME – the Hour and the Minute combined that the Trauma Surgeon was called by ED personnel.

 In Report Writer; search ED92_C_DATE – the Month, Day and Year combined that the Trauma Surgeon was called by ED personnel.

Emergency Department Page 65 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Trauma Surgeon Responded Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_R_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Surgeon Responded Date – Month – The month the Trauma Surgeon responded to the initial call by ED personnel INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Trauma Surgeon Responded Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_R_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Surgeon Responded Date – Day – The day the Trauma Surgeon responded to the initial call by ED personnel INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Trauma Surgeon Responded Date – Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_R_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Trauma Surgeon Responded Date – Year – The year the Trauma Surgeon responded to the initial call by ED personnel INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 66 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Trauma Surgeon Responded Time - Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_R_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Surgeon Responded Time – Hour – The hour the Trauma Surgeon responded to the initial call by ED personnel INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Trauma Surgeon Responded Time – Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_R_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Surgeon Responded Time – Minute – The minute the Trauma Surgeon responded to the initial call by ED personnel INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED92_R_EVENT – the Date and Time combined that the Trauma Surgeon responded to the initial call by ED personnel.

 In Report Writer; search ED92_R_TIME – the Hour and the Minute combined that the Trauma Surgeon responded to the initial call by ED personnel.

 In Report Writer; search ED92_R_DATE – the Month, Day and Year combined that the Trauma Surgeon responded to the initial call by ED personnel.

Emergency Department Page 67 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Trauma Surgeon Arrived Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_A_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Surgeon Arrived Date – Month – The month the Trauma Surgeon arrived in the ED INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Trauma Surgeon Arrived Date – Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_A_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Surgeon Arrived Date – Day – The day the Trauma Surgeon arrived in the ED INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Trauma Surgeon Arrived Date – Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_A_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Trauma Surgeon Arrived Date – Year – The year the Trauma Surgeon arrived in the ED INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 68 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Trauma Surgeon Arrived Time – Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_A_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Surgeon Arrived Time – Hour – The hour the Trauma Surgeon arrived in the ED INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Trauma Surgeon Arrived Time - Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_A_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Trauma Surgeon Arrived Time – Minute – The minute the Trauma Surgeon arrived in the ED INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED92_A_EVENT – the Date and Time combined that the Trauma Surgeon arrived in the ED.

 In Report Writer; search ED92_A_TIME – the Hour and the Minute combined that the Trauma Surgeon arrived in the ED.

 In Report Writer; search ED92_A_DATE – the Month, Day and Year combined that the Trauma Surgeon arrived in the ED.

Emergency Department Page 69 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Trauma Surgeon – Timely Response

Window Location: Data Field Name: Emergency Department – Trauma Team ED92_TR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Trauma Surgeon Timely Response – The physical presence of the trauma surgeon in the Emergency Department within a short period of time, defined by the facility in the by-laws INTRUCTIONS Answer the following question: Did the Trauma Surgeon respond to the call to see the patient in a timely manner? Enter the appropriate option. VALID OPTIONS 1 or Y Yes 2 or N No / Inappropriate ? Unknown

Neurosurgeon

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_ID

State Required: Type of Field: Length: No Integer 6 DEFINITIONS Neurosurgeon – Attending neurosurgeon or "surgeon" who has special competence as judged by the chief of neurosurgery. INSTRUCTIONS Enter your facility’s identifying code for the Neurosurgeon who responded to an activation in the Emergency Department. You may add as many codes and/or names as are applicable, but once entered, they cannot be deleted or changed. Use direct keyboard entry.

VALID OPTIONS User defined

Neurosurgeon – If Other

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_ID_O

State Required: Type of Field: Length: No Text 50 DEFINITIONS Emergency Physician – If Other – Text field in which to record additional information if needed INSTRUCTIONS Use direct keyboard entry.

Emergency Department Page 70 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Neurosurgeon Called Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_C_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Neurosurgeon Called Date – The month – The month the Neurosurgeon was called by ED personnel INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Neurosurgeon Called Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_C_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Neurosurgeon Called Date – Day – The day the Neurosurgeon was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Neurosurgeon Called Date - Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_C_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Neurosurgeon Called Date – Year – The year the Neurosurgeon was called by ED personnel INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 71 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Neurosurgeon Called Time - Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_C_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Neurosurgeon Called Time – Hour – The hour the Neurosurgeon was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Neurosurgeon Called Time _ Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_C_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Neurosurgeon Called Time – Minute – The minute the Neurosurgeon was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED93_C_EVENT – the Date and Time combined that the Neurosurgeon was called by ED personnel.

 In Report Writer; search ED93_C_TIME – the Hour and the Minute combined that the Neurosurgeon was called by ED personnel.

 In Report Writer; search ED93_C_DATE – the Month, Day and Year combined that the Neurosurgeon was called by ED personnel.

Neurosurgeon Responded Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_R_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Neurosurgeon Responded Date – Month – The month the Neurosurgeon responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

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Emergency Department Neurosurgeon Responded Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_R_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Neurosurgeon Responded Date – Day – The day the Neurosurgeon responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Neurosurgeon Responded Date - Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_R_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Neurosurgeon Responded Date – Year – The year the Neurosurgeon responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Neurosurgeon Responded Time - Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_R_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Neurosurgeon Responded Time – Hour – The hour the Neurosurgeon responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Emergency Department Page 73 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Neurosurgeon Responded Time – Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_R_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Neurosurgeon Responded Time – Minute – The minute the Neurosurgeon responded to the initial call by ED personnel INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED93_R_EVENT – the Date and Time combined that the Neurosurgeon responded to the initial call made by ED personnel.

 In Report Writer; search ED93_R_TIME – the Hour and the Minute combined that the Neurosurgeon responded to the initial call made by ED personnel

 In Report Writer; search ED93_R_DATE – the Month, Day and Year combined that the Neurosurgeon responded to the initial call made by ED personnel.

Neurosurgeon Arrived Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_A_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Neurosurgeon Arrived Date – Month – The month the Neurosurgeon arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Neurosurgeon Arrived Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_A_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Neurosurgeon Arrived Date – Day – The day the Neurosurgeon arrived in the ED. INSTRUCTIONS Enter the day the Neurosurgeon arrived in the ED using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Emergency Department Page 74 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Neurosurgeon Arrived Date – Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_A_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Neurosurgeon Arrived Date – Year – The year the Neurosurgeon arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Neurosurgeon Arrived Time - Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_A_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Neurosurgeon Arrived Time – Hour – The hour the Neurosurgeon arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Neurosurgeon Arrived Time - Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_A_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Neurosurgeon Arrived Time – Minute – The minute the Neurosurgeon arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED93_A_EVENT – the Date and Time combined that the Neurosurgeon arrived in the ED.

 In Report Writer; search ED93_A_TIME – the Hour and the Minute combined that the Neurosurgeon arrived in the ED.

 In Report Writer; search ED93_A_DATE – the Month, Day and Year combined that the Neurosurgeon arrived in the ED.

Emergency Department Page 75 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Neurosurgeon – Timely Response

Window Location: Data Field Name: Emergency Department – Trauma Team ED93_TR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Neurosurgeon – Timely Response – The physical presence of the neurosurgeon in the Emergency Department within a short period of time, defined by the facility in the by-laws INSTRUCTIONS Answer the following question: Did the Neurosurgeon respond to the call to see the patient in a timely manner? Enter the appropriate option. VALID OPTIONS 1 Yes 2 No / Not Applicable ? Unknown

Orthopedic Surgeon

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_ID

State Required: Type of Field: Length: No Integer 6 DEFINITIONS Orthopedic Surgeon – Surgeon who specializes in the musculoskeletal system INSTRUCTIONS Enter your facility’s identifying code for the Orthopedic Surgeon. You may add as many codes and/or names as are applicable, but once entered, they cannot be deleted or changed. Use direct keyboard entry. VALID OPTIONS User defined

Orthopedic Surgeon – If Other

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_ID_O

State Required: Type of Field: Length: No Text 50 DEFINITIONS Orthopedic Surgeon – If Other – Text field in which to record additional information if needed. INSTRUCTIONS Use direct keyboard entry.

Emergency Department Page 76 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Orthopedic Surgeon Called Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_C_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Orthopedic Surgeon Called Date – Month – The month the Orthopedic Surgeon was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Orthopedic Surgeon Called Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_C_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Orthopedic Surgeon Called Date – Day – The day the Orthopedic Surgeon was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Orthopedic Surgeon Called Date Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_C_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Orthopedic Surgeon Called Date – Year – The year the Orthopedic Surgeon was called by ED personnel. INSTRUCTIONS Enter the appropriate option the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 77 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Orthopedic Surgeon Called Time - Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_C_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Orthopedic Surgeon Called Time – Hour – The hour the Orthopedic Surgeon was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Orthopedic Surgeon Called Time - Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_C_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Orthopedic Surgeon Called Time – Minute – The minute the Orthopedic Surgeon was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED94_C_EVENT – the Date and Time combined that the Orthopedic Surgeon was called by ED personnel.

 In Report Writer; search ED94_C_TIME – the Hour and the Minute combined that the Orthopedic Surgeon was called by ED personnel.

 In Report Writer; search ED94_C_DATE – the Month, Day and Year combined that the Orthopedic Surgeon was called by ED personnel.

Emergency Department Page 78 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Orthopedic Surgeon Responded Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_R_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Orthopedic Surgeon Responded Date – Month – The month the Orthopedic Surgeon responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Orthopedic Surgeon Responded Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_R_DD

State Required: Type of Field: Length: No Integer 2 Data Field Name: ED94_R_DD DEFINITIONS Orthopedic Surgeon Responded Date – Day – The day the Orthopedic Surgeon responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Orthopedic Surgeon Responded Date - Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_R_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Orthopedic Surgeon Responded Date – Year – The year the Orthopedic Surgeon responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 79 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Orthopedic Surgeon Responded Time – Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_R_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Orthopedic Surgeon Responded Time – Hour – The hour the Orthopedic Surgeon responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Orthopedic Surgeon Responded Time – Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_R_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Orthopedic Surgeon Responded Time – Minute – The minute the Orthopedic Surgeon responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED94_R_EVENT – the Date and Time combined that the Orthopedic Surgeon responded to the initial call made by ED personnel.

 In Report Writer; search ED94_R_TIME – the Hour and the Minute combined that the Orthopedic Surgeon responded to the initial call made by ED personnel.

 In Report Writer; search ED94_R_DATE – the Month, Day and Year combined that the Orthopedic Surgeon responded to the initial call made by ED personnel.

Emergency Department Page 80 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Orthopedic Surgeon Arrived Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_A_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Orthopedic Surgeon Arrived Date – Month – The month the Orthopedic Surgeon arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Orthopedic Surgeon Arrived Date – Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_A_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Orthopedic Surgeon Arrived Date – Day – The day the Orthopedic Surgeon arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Orthopedic Surgeon Arrived Date – Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_A_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Orthopedic Surgeon Arrived Date – Year – The year the Orthopedic Surgeon arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 81 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Orthopedic Surgeon Arrived Time – Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_A_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Orthopedic Surgeon Arrived Time – Hour – The hour the Orthopedic Surgeon arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Orthopedic Surgeon Arrived Time – Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_A_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Orthopedic Surgeon Arrived Time – Minute – The minute the Orthopedic Surgeon arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED94_A_EVENT – the Date and Time combined that the Orthopedic Surgeon arrived in the ED.

 In Report Writer; search ED94_A_TIME – the Hour and the Minute combined that the Orthopedic Surgeon arrived in the ED.

 In Report Writer; search ED94_A_DATE – the Month, Day and Year combined that the Orthopedic Surgeon arrived in the ED.

Emergency Department Page 82 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Orthopedic Surgeon – Timely Response

Window Location: Data Field Name: Emergency Department – Trauma Team ED94_TR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Timely Response – The physical presence of the orthopedic surgeon in the Emergency Department within a short period of time, defined by the facility in the by-laws. INSTRUCTIONS Answer the following question: Did the Orthopedic Surgeon respond to the call to see the patient in a timely manner? Enter the appropriate option. VALID OPTIONS 1 or Y Yes 2 or N No / Not Applicable ? Unknown

Anesthesiologist

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_ID

State Required: Type of Field: Length: No Integer 6 DEFINITIONS Anesthesiologist – Physician specializing in the induction of anesthesia agents necessary for patient treatment. INSTRUCTIONS Enter your facility’s identifying code for the Anesthesiologist. You may add as many codes and/or names as are applicable, but once entered, they cannot be deleted or changed. Use direct keyboard entry. VALID OPTIONS User defined

Anesthesiologist – If Other

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_ID

State Required: Type of Field: Length: No Text 50 DEFINITIONS Anesthesiologist – If Other – Text field in which to record additional demographic information if needed. INSTRUCTIONS Use direct keyboard entry.

Emergency Department Page 83 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Anesthesiologist Called Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_C_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Anesthesiologist Called Date – Month – The month the Anesthesiologist was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Anesthesiologist Called Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_C_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Anesthesiologist Called Date – Day – The day the Anesthesiologist was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Anesthesiologist Called Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_C_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Anesthesiologist Called Date – Year – The year the Anesthesiologist was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 84 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Anesthesiologist Called Time – Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_C_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Anesthesiologist Called Time – Hour – The hour the Anesthesiologist was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Anesthesiologist Called Time - Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_C_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Anesthesiologist Called Time – Minute – The minute the Anesthesiologist was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED95_C_EVENT – the Date and Time combined that the Anesthesiologist was called by ED personnel.

 In Report Writer; search ED95_C_TIME – the Hour and the Minute combined that the Anesthesiologist was called by ED personnel.

 In Report Writer; search ED95_C_DATE – the Month, Day and Year combined that the Anesthesiologist was called by ED personnel.

Emergency Department Page 85 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Anesthesiologist Responded Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_R_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Anesthesiologist Responded Date – Month – The month the Anesthesiologist responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Anesthesiologist Responded Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_R_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Anesthesiologist Responded Date – Day – The day the Anesthesiologist responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Anesthesiologist Responded Date - Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_R_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Anesthesiologist Responded Date – Year – The year the Anesthesiologist responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 86 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Anesthesiologist Responded Time – Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_R_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Anesthesiologist Responded Time – Hour – The hour the Anesthesiologist responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Anesthesiologist Responded Time – Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_R_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Anesthesiologist Responded Time – Minute – The minute the Anesthesiologist responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED95_R_EVENT – the Date and Time combined that the Anesthesiologist responded to the initial call by ED personnel.

 In Report Writer; search ED95_R_TIME – the Hour and the Minute combined that the Anesthesiologist responded to the initial call by ED personnel.

 In Report Writer; search ED95_R_DATE – the Month, Day and Year combined that the Anesthesiologist responded to the initial call by the ED personnel.

Emergency Department Page 87 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Anesthesiologist Arrived Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_A_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Anesthesiologist Arrived Date – Month – The month the Anesthesiologist arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Anesthesiologist Arrived Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_A_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Anesthesiologist Arrived Date – Day – The day the Anesthesiologist arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Anesthesiologist Arrived Date - Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_A_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Anesthesiologist Arrived Date – Year – The year the Anesthesiologist arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 88 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Anesthesiologist Arrived Time - Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_A_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Anesthesiologist Arrived Time – Hour – The hour the Anesthesiologist arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Anesthesiologist Arrived Time – Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_A_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Anesthesiologist Arrived Time – Minute – The minute the Anesthesiologist arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED95_A_EVENT – the Date and Time combined that the Anesthesiologist arrived in the ED.

 In Report Writer; search ED95_A_TIME – the Hour and the Minute combined that the Anesthesiologist arrived in the ED.

 In Report Writer; search ED95_A_DATE – the Month, Day and Year combined that the Anesthesiologist arrived in the ED.

Emergency Department Page 89 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Anesthesiologist – Timely Response

Window Location: Data Field Name: Emergency Department – Trauma Team ED95_TR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Anesthesiologist – Timely Response – The physical presence of the anesthesiologist in the Emergency Department within a short period of time, defined by the facility in the by-laws. INSTRUCTIONS Answer the following question: Did the Anesthesiologist respond to the call to see the patient in a timely manner? Enter the appropriate option. VALID OPTIONS 1 or Y Yes 2 or N No / Not Applicable ? Unknown

Surgical Chief Resident

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_ID

State Required: Type of Field: Length: No Integer 6 DEFINITIONS Surgical Chief Resident – Surgical medical resident in charge of care of the patient. INSTRUCTIONS Enter your facility’s identifying code for the Surgical Chief Resident. You may add as many codes and/or names as are applicable, but once entered, they cannot be deleted or changed. Use direct keyboard entry. VALID OPTIONS User defined

Surgical Chief Resident – If Other

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_ID_O

State Required: Type of Field: Length: No Text 50 DEFINITIONS Surgical Chief Resident – If Other – Text field in which to record additional information if needed. INSTRUCTIONS Use direct keyboard entry.

Emergency Department Page 90 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Surgical Chief Resident Called Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_C_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Surgical Chief Resident Called Date – Month – The month the Surgical Chief Resident was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Surgical Chief Resident Called Date – Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_C_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Surgical Chief Resident Called Date – Day – The day the Surgical Chief Resident was called by ED personnel. INSTRUCTION.S Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Surgical Chief Resident Called Date - Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_C_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Surgical Chief Resident Called Date – Year – The year the Surgical Chief Resident was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 91 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Surgical Chief Resident Called Time – Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_C_TH

State Required: Type of Field: Length: No Integer 2 Data Field Name: ED96_C_TH DEFINITIONS Surgical Chief Resident Called Time – Hour – The hour the Surgical Chief Resident was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Surgical Chief Resident Called Time – Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_C_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Surgical Chief Resident Called Time – Minute – The minute the Surgical Chief Resident was called by ED personnel. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED96_C_EVENT – the Date and Time combined that the Surgical Chief Resident was called by ED personnel.

 In Report Writer; search ED96_C_TIME – the Hour and the Minute combined that the Surgical Chief Resident was called by ED personnel.

 In Report Writer; search ED96_C_DATE – the Month, Day and Year combined that the Surgical Chief Resident was called by ED personnel.

Emergency Department Page 92 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Surgical Chief Resident Responded Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_R_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Surgical Chief Resident Responded Date – Month – The month the Surgical Chief Resident responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Surgical Chief Resident Responded Date - Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_R_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Surgical Chief Resident Responded Date – Day – The day the Surgical Chief Resident responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Surgical Chief Resident Responded Date - Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_R_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Surgical Chief Resident Responded Date – Year – The year the Surgical Chief Resident responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Emergency Department Page 93 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Surgical Chief Resident Responded Time – Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_R_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Surgical Chief Resident Responded Time – Hour – The hour the Surgical Chief Resident responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Surgical Chief Resident Responded Time - Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_R_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Surgical Chief Resident Responded Time – Minute – The minute the Surgical Chief Resident responded to the initial call by ED personnel. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED96_R_EVENT – the Date and Time combined that the Surgical Chief Resident responded to the initial call by ED personnel.

 In Report Writer; search ED96_R_TIME – the Hour and the Minute combined that the Surgical Chief Resident responded to the initial call by the ED personnel.

 In Report Writer; search ED96_R_DATE – the Month, Day and Year combined that the Surgical Chief Resident responded to the initial call by the ED personnel.

Emergency Department Page 94 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Surgical Chief Resident Arrived Date - Month

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_A_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Surgical Chief Resident Arrived Date – Month – The month the Surgical Chief Resident arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Surgical Chief Resident Arrived Date – Day

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_A_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Surgical Chief Resident Arrived Date – Day – The day the Surgical Chief Resident arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Surgical Chief Resident Arrived Date - Year

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_A_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Surgical Chief Resident Arrived Date – Year – The year the Surgical Chief Resident arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

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Emergency Department Surgical Chief Resident Arrived Time – Hour

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_A_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Surgical Chief Resident Arrived Time – Hour – The hour the Surgical Chief Resident arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Surgical Chief Resident Arrived Time - Minute

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_A_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Surgical Chief Resident Arrived Time – Minute – The minute the Surgical Chief Resident arrived in the ED. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search ED96_A_EVENT – the Date and Time combined that the Surgical Chief Resident arrived in the ED.

 In Report Writer; search ED96_A_TIME – the Hour and the Minute combined that the Surgical Chief Resident arrived in the ED.

 In Report Writer; search ED96_A_DATE – the Month, Day and Year combined that the Surgical Chief Resident arrived in the ED.

Emergency Department Page 96 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Surgical Chief Resident – Timely Response

Window Location: Data Field Name: Emergency Department – Trauma Team ED96_TR

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Surgical Chief Resident – Timely Response – The physical presence of the surgical chief resident in the Emergency Department within a short period of time, defined by the facility in the by-laws. INSTRUCTIONS Answer the following question: Did the Surgical Chief Resident respond to the call to see the patient in a timely manner? Enter the appropriate option. VALID OPTIONS 1 or Y Yes 2 or N No / Not Applicable ? Unknown

Team Leader*

Window Location: Data Field Name: Emergency Department – Trauma Team TL_LEAD

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS The Trauma Team Leader is identified by using one of the following criteria:

If your hospital has an identified trauma team, the team leader is a pre-defined physician when the trauma team is activated.

If your hospital does not have an identified trauma team, or there is no activation of the team, the team leader is the physician (mid-level practioner or higher) responsible for managing the patient’s immediate care. The term immediate care encompasses the decision to triage and includes management in the ED. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Emergency Physician 2 Trauma Surgeon 3 Neurosurgeon 4 Orthopedic Surgeon 5 Anesthesiologist 6 Surgical Chief Resident 7 Other Health Care Professional 8 Nurse Practitioner/Physician Assistant ? Unknown / Not applicable

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Emergency Department

Team Leader Called Date and Time *

Window Location: Data Field Name: Emergency Department – Trauma Team TL_CLL_EVENT

State Required: Type of Field: Length: Yes Integer 12 DEFINITIONS The date and time the Trauma Team Leader was called. INSTRUCTIONS If you are a core data collector, enter the appropriate Team Leader called date/time using the mm/dd/yyyy: hh:mm (military time). If you are a comprehensive data collector, this field will be auto-populated with Team Leader called data previously entered.

Team Leader Arrival Date and Time *

Window Location: Data Field Name: Emergency Department – Trauma Team TL_ARR_EVENT

State Required: Type of Field: Length: Yes Integer 12 DEFINITIONS The date and time the Trauma Team Leader arrived. INSTRUCTIONS If you are a core data collector, enter the appropriate arrival date/time using the mm/dd/yyyy: hh:mm (military time). If you are a comprehensive data collector, this field will be auto-populated with Team Leader arrival data previously entered.

Team Leader Threshold *

Window Location: Data Field Name: Emergency Department – Trauma Team TL_THRV

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS The Team Leader threshold determines the length of time that is considered timely.

The default for this threshold is 30 minutes, but facilities can set this time to be less than 30 minutes.

Emergency Department Page 98 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department Team Leader – Timely Response*

Window Location: Data Field Name: Emergency Department – Trauma Team TL_LEAD_TL

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Trauma Team Leader Timely Response - Timely Response is a calculation based on:

Date/Time Team Leader arrived (minus) Date/Time Team Leader called.

If Date/Time Team Leader called is unknown then timely response will be calculated as follows:

Date/Time Team Leader arrived (minus) ED arrival Date/Time

INSTRUCTIONS This value will auto-populate based on the response time in minutes compared to the Team Leader threshold time.

VALID OPTIONS “Y” Yes “N” No

Emergency Department Page 99 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department

EMERGENCY DEPARTMENT – BLOOD PRODUCTS

Emergency Department Page 100 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department ED – PRBC’s

Window Location: Data Field Name: Emergency Department – Blood Products ED_RBC

State Required: Type of Field: Length: No Integer 5 DEFINITIONS PRBC’s – Red blood cells that have been separated from the plasma. INSTRUCTIONS Enter the number of units of Packed Red Blood Cells given to the patient in the ED in the first 24 hours after injury, including PRBC’s given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Packed Red Blood Cells / Not Applicable ? Unknown

ED – FFP

Window Location: Data Field Name: Emergency Department – Blood Products ED_FFP

State Required: Type of Field: Length: No Integer 5 DEFINITIONS FFP – Fluid portion of one unit of human blood that has been centrifuged, separated, and frozen solid within 6 hours of collection. INSTRUCTIONS Enter the number of units of fresh frozen plasma given to the patient in the ED in the first 24 hours after injury, including FFP given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Fresh Frozen Plasma / Not Applicable ? Unknown

ED – Albumin

Window Location: Data Field Name: Emergency Department – Blood Products ED_ALB

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Albumin – One of a group of simple proteins found in the blood. INSTRUCTIONS Enter the number of units of albumin given to the patient in the ED in the first 24 hours after injury, including albumin given at the referring facility. Use direct keyboard entry or enter the appropriate option VALID OPTIONS Number of units of Albumin / Not Applicable ? Unknown

Emergency Department Page 101 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department ED – Whole Blood

Window Location: Data Field Name: Emergency Department – Blood Products ED_WHL

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Whole Blood –The cell-containing fluid that carries electrolytes, hormones, vitamins, antibodies, heat, and oxygen to the tissues and takes away waste matter and carbon dioxide. Unit of Blood – Whole blood, packed red blood cells, auto-transfused or cell saver blood that does not include platelets, fresh frozen plasma, or cryoprecipitate with a volume of 300 cc for adults or approximately 100 cc for children. INSTRUCTIONS Enter the number of units of blood given to the patient in the ED in the first 24 hours after injury, including blood given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Whole Blood / Not Applicable ? Unknown

ED – Platelets

Window Location: Data Field Name: Emergency Department – Blood Products ED_PLA

State Required: Type of Field: Length: No Integer 5 DEFINITIONS ED – Platelets – Cell fragments in the blood involved in the early steps of clot formation after injury. INSTRUCTIONS Enter the number of units of platelets given to the patient in the ED in the first 24 hours after injury, including platelets given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Platelets / Not Applicable ? Unknown

ED – Cryoprecipitate

Window Location: Data Field Name: Emergency Department – Blood Products ED_CRY

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Cryoprecipitate – The precipitate formed when serum from patients with pathogenic immune complexes is stored at 4 degrees Celsius. INSTRUCTIONS Enter the number of units of cryoprecipitate given to the patient in the ED in the first 24 hours after injury, including cryoprecipitate given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Cryoprecipitate / Not Applicable ? Unknown

Emergency Department Page 102 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department ED – Other

Window Location: Data Field Name: Emergency Department – Blood Products ED_OTH

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Other Fluids – Any other fluid product given. INSTRUCTIONS Enter the number of units of other fluid products given to the patient in the first 24 hours after injury given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of other fluid products / Not Applicable ? Unknown

OR – PRBC’s

Window Location: Data Field Name: Emergency Department – Blood Products OR_RBC

State Required: Type of Field: Length: No Integer 5 DEFINITIONS PRBC’s – Red blood cells that have been separated from the plasma. INSTRUCTIONS Enter the number of units of Packed Red Blood Cells given to the patient in the OR in the first 24 hours after injury, including PRBC’s given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Packed Red Blood Cells / Not Applicable ? Unknown

OR – FFP

Window Location: Data Field Name: Emergency Department – Blood Products OR_FFP

State Required: Type of Field: Length: No Integer 5 DEFINITIONS FFP – Fluid portion of one unit of human blood that has been centrifuged, separated, and frozen solid within 6 hours of collection. INSTRUCTIONS Enter the number of units of fresh frozen plasma given to the patient in the OR in the first 24 hours after injury, including FFP given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Fresh Frozen Plasma / Not Applicable ? Unknown

Emergency Department Page 103 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department OR – Albumin

Window Location: Data Field Name: Emergency Department – Blood Products OR_ALB

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Albumin – One of a group of simple proteins found in the blood. INSTRUCTIONS Enter the number of units of albumin given to the patient in the OR in the first 24 hours after injury, including albumin given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Albumin / Not Applicable ? Unknown

OR – Whole Blood

Window Location: Data Field Name: Emergency Department – Blood Products OR_WHL

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Whole Blood – The cell containing fluid that carries electrolytes, hormones, vitamins, antibodies, heat and oxygen to the tissue and takes away waste matter and carbon dioxide. Unit of Blood – Whole blood, packed red blood cells, auto-transfused or cell saver blood that does not include platelets, fresh frozen plasma, or cryoprecipitate with a volume of 300 cc for adults or approximately 100 cc for children. INSTRUCTIONS Enter the number of units of blood given to the patient in the OR in the first 24 hours after injury, including blood given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Whole Blood / Not Applicable ? Unknown

OR– Platelets

Window Location: Data Field Name: Emergency Department – Blood Products OR_PLA

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Platelets – Cell fragments in the blood involved in the early steps of clot formation after injury. INSTRUCTIONS Enter the number of units of blood given to the patient in the OR in the first 24 hours after injury, including platelets given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Platelets / Not Applicable ? Unknown

Emergency Department Page 104 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department OR – Cryoprecipitate

Window Location: Data Field Name: Emergency Department – Blood Products OR_CRY

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Cryoprecipitate – The precipitate formed when serum from patients with pathogenic immune complexes is stored at 4 degrees Celsius. INSTRUCTIONS Enter the number of units of cryoprecipitate given to the patient in the OR in the first 24 hours after injury, including cryoprecipitate given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Cryoprecipitate / Not Applicable ? Unknown

OR – Other

Window Location: Data Field Name: Emergency Department – Blood Products OR_OTH

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Other Fluids – Any other fluid product given. INSTRUCTIONS Enter the number of units of other products given to the patient in the OR in the first 24 hours after injury, including other fluid products given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of other fluid products / Not Applicable ? Unknown

ELSEWHERE – PRBC’S

Window Location: Data Field Name: Emergency Department – Blood Products EW_RBC

State Required: Type of Field: Length: No Integer 5 DEFINITIONS PRBC’s – Red blood cells that have been separated from the plasma. INSTRUCTIONS Enter the number of units of Packed Red Blood Cells given to the patient in other than the ED or OR in the first 24 hours after injury, including PRBC’s given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Packed Red Blood Cells / Not Applicable ? Unknown

Emergency Department Page 105 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department ELSEWHERE – FFP

Window Location: Data Field Name: Emergency Department – Blood Products EW_FFP

State Required: Type of Field: Length: No Integer 5 DEFINITIONS FFP – Fluid portion of one unit of human blood that has been centrifuged, separated, and frozen solid within 6 hours of collection. INSTRUCTIONS Enter the number of units of fresh frozen plasma given to the patient in other than the ED or OR in the first 24 hours after injury, including FFP given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Fresh Frozen Plasma / Not Applicable ? Unknown

ELSEWHERE – Albumin

Window Location: Data Field Name: Emergency Department – Blood Products EW_ALB

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Albumin – One of a group of simple proteins found in the blood. INSTRUCTIONS Enter the number of units of albumin given to the patient in other than the ED or OR in the first 24 hours after injury, including blood given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Albumin / Not Applicable ? Unknown

ELSEWHERE – Whole Blood

Window Location: Data Field Name: Emergency Department – Blood Products EW_WHL

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Whole Blood - The cell-containing fluid that carries electrolytes, hormones, vitamins, antibodies, heat and oxygen to the tissues and takes away waste matter and carbon dioxide. Unit of Blood – Whole blood, packed red blood cells, auto-transfused or cell saver blood that does not include platelets, fresh frozen plasma, or cryoprecipitate with a volume of 300 cc for adults or approximately 100 cc for children. INSTRUCTIONS Enter the number of units of blood given to the patient in other than the ED or OR in the first 24 hours after injury, including blood given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Whole Blood / Not Applicable ? Unknown

Emergency Department Page 106 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department ELSEWHERE – Platelets

Window Location: Data Field Name: Emergency Department – Blood Products EW_PLA

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Platelets – Cell fragments in the blood involved in the early steps of clot formation after injury. INSTRUCTIONS Enter the number of units of blood given to the patient in other than the ED or OR in the first 24 hours after injury, including platelets given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Platelets / Not Applicable ? Unknown

ELSEWHERE – Cryoprecipitate

Window Location: Data Field Name: Emergency Department – Blood Products EW_CRY

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Cryoprecipitate – The precipitate formed when serum from patients with pathogenic immune complexes is stored at 4 degrees Celsius. INSTRUCTIONS Enter the number of units of cryoprecipitate given to the patient in other than the ED or OR in the first 24 hours after injury, including cryoprecipitate given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Cryoprecipitate / Not Applicable ? Unknown

ELSEWHERE – Other

Window Location: Data Field Name: Emergency Department – Blood Products EW_OTH

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Other Fluids – Any other fluid product given. INSTRUCTIONS Enter the number of units of other products given to the patient I in other than the ED or n the first 24 hours after injury, including other fluid products given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of other fluid products / Not Applicable ? Unknown

Emergency Department Page 107 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department TOTAL – PRBC’S

Window Location: Data Field Name: Emergency Department – Blood Products TT_RBC

State Required: Type of Field: Length: No Integer 6 DEFINITIONS PRBC’s – Red blood cells that have been separated from the plasma. INSTRUCTIONS Enter the total number of units of Packed Red Blood Cells given to the patient in the first 24 hours after injury, including PRBC’s given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Packed Red Blood Cells / Not Applicable ? Unknown

TOTAL – FFP

Window Location: Data Field Name: Emergency Department – Blood Products TT_FFP

State Required: Type of Field: Length: No Integer 6 DEFINITIONS FFP – Fluid portion of one unit of human blood that has been centrifuged, separated, and frozen solid within 6 hours of collection. INSTRUCTIONS Enter the total number of units of fresh frozen plasma given to the patient in the first 24 hours after injury, including FFP given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Fresh Frozen Plasma / Not Applicable ? Unknown

TOTAL – Albumin

Window Location: Data Field Name: Emergency Department – Blood Products TT_ALB

State Required: Type of Field: Length: No Integer 6 DEFINITIONS Albumin - One of a group of simple proteins found in the blood. INSTRUCTIONS Enter the total number of units of albumin given to the patient in the first 24 hours after injury, including albumin given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Albumin / Not Applicable ? Unknown

Emergency Department Page 108 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department TOTAL – Whole Blood

Window Location: Data Field Name: Emergency Department – Blood Products TT_WHL

State Required: Type of Field: Length: No Integer 6 DEFINITIONS Whole Blood – The cell-containing fluid that carries electrolytes, hormones, vitamins, antibodies, heat and oxygen to the tissues and takes away waste matter and carbon dioxide. Unit of Blood – Whole blood, packed red blood cells, auto-transfused or cell saver blood that does not include platelets, fresh frozen plasma, or cryoprecipitate with a volume of 300 cc for adults or approximately 100 cc for children. INSTRUCTIONS Enter the total number of units of blood given to the patient in the first 24 hours after injury, including blood given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Whole Blood / Not Applicable ? Unknown

TOTAL – Platelets

Window Location: Data Field Name: Emergency Department – Blood Products TT_PLA

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Platelets – Cell fragments in the blood involved in the early steps of clot formation after injury. INSTRUCTIONS Enter the total number of units of platelets given to the patient in the first 24 hours after injury, including blood given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Platelets / Not Applicable ? Unknown

TOTAL – Cryoprecipitate

Window Location: Data Field Name: Emergency Department – Blood Products TT_CRY

State Required: Type of Field: Length: No Integer 6 DEFINITIONS Cryoprecipitate – The precipitate formed when serum from patients with pathogenic immune complexes is stored at 4 degrees Celsius. INSTRUCTIONS Enter the total number of units of cryoprecipitate given to the patient in the first 24 hours after injury, including cryoprecipitate given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of Cryoprecipitate / Not Applicable ? Unknown

Emergency Department Page 109 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department TOTAL – Other

Window Location: Data Field Name: Emergency Department – Blood Products TT_OTH

State Required: Type of Field: Length: No Integer 5 DEFINITIONS Other Fluids – Any other fluid product given. INSTRUCTIONS Enter the total number of units of other fluid products given to the patient in the first 24 hours after injury, including cryoprecipitate given at the referring facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Number of units of other fluid products / Not Applicable ? Unknown

Emergency Department Page 110 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY

Emergency Department

EMERGENCY DEPARTMENT – MEMO

Emergency Department Memo

Window Location: Data Field Name: Emergency Department – Memo MEMO_ED

State Required: Type of Field: Length: No Memo 5000 DEFINITIONS Emergency Department Memo – Text field in which to record additional Emergency Department information if needed INSTRUCTIONS Use direct keyboard entry.

Emergency Department Page 111 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures Section 5 - PROCEDURES

Procedure Entered* ...... 3 Procedure Code* ...... 3 Visit Number ...... 3 Location ...... 4 Notification Date – Month ...... 4 Notification Date – Day ...... 5 Notification Date – Year...... 5 Notified Time – Hour ...... 5 Notified Time – Minute...... 6 Performed on Date – Month* ...... 6 Performed on Date – Day* ...... 6 Performed on Date – Year* ...... 7 Start Time - Hour* ...... 7 Start Time – Minute* ...... 7 Stop Time – Hour* ...... 8 Stop Time – Minute* ...... 8 Physician ID ...... 8 Ventilator Start Date ...... 10 Ventilator Start Time ...... 11 Ventilator Stop Date ...... 12 Ventilator Stop Time ...... 13 Ventilator Days* ...... 14 Total Ventilator Time ...... 14 Procedures Memo ...... 15

* Items are CORE (state required) data elements

Procedures Page 1 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures

Procedures – Procedure

Procedures Page 2 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures Procedure Entered*

Window Location: Data Field Name: Procedure: Procedure PX_YN

State Required: Type of Field: Length: Yes Checkbox 1 DEFINITIONS Procedures Entered – Indicates whether there are ICD-9 codes for procedures to report or not. INSTRUCTIONS Check this box if there are no procedures to report. If there are procedures, leave the box unchecked. VALID OPTIONS 1-Yes (Checked) – No procedures. 2-No (Not Checked)

Procedure Code*

Window Location: Data Field Name: Procedure: Procedure PX_01_PR TO, PX_88_PR

State Required: Type of Field: Length: Yes Float 5 DEFINITIONS Procedure code or P-Code – Code which provides a "...classification of a different mode of therapy, e.g. surgery, radiology, and laboratory procedures". Operative and non-operative procedures conducted during the patient’s hospital stay that are essential to diagnose, treat or stabilize a patient’s specific injuries or complications.

INSTRUCTIONS Enter a valid ICD-9-CM Procedure Code using direct keyboard entry or by using the search feature in Collector. Include only procedures performed at your institution. Capture all procedures performed in the operating room. Capture all procedures in the ED, ICU, ward, or radiology department that are essential to diagnose, treat or stabilize the patient’s injuries or complications.

VALID OPTIONS

ICD-9-CM Procedure Code

Visit Number

Window Location: Data Field Name: Procedure: Procedure PX_01_VT TO PX_88_VT

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Visit Number – Instance in which the mode of therapy took place INSTRUCTIONS Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Visit Number / Not Applicable ? Unknown

Procedures Page 3 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures Location

Window Location: Data Field Name: Procedure: Procedure PX_01_LC TO PX_88_LC

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Location – Locale in which the mode of therapy took place INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 01 ED 13 Physical Medical Rehabilitation 02 OR 14 Minor Surgery Unit 03 ICU 15 Trauma Resuscitation Room 04 Medical ICU 17 Coronary ICU 05 Neonatal ICU 18 Neuro ICU 06 Pediatric ICU 30 Prehospital (NFS) 07 Surgical ICU 31 Scene/Enroute from scene 08 Burn Unit 32 Referring Facility 09 Medical/Surgical Floor 33 Enroute from referring facility 10 Stepdown Unit 98 Unspecified 11 Radiology 99 Other 12 Nuclear Medicine ? Unknown

Notification Date – Month

Window Location: Data Field Name: Procedure: Procedure PX_01_B_DM TO PX_88_B_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Notified Date – Month – The month the procedure was scheduled INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Procedures Page 4 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures Notification Date – Day

Window Location: Data Field Name: Procedure: Procedure PX_01_B_DD TO PX_88_B_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Notified Date – Day – The day the procedure was scheduled. INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Notification Date – Year

Window Location: Data Field Name: Procedure: Procedure PX_01_B_DY TO PX_88_B_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Notified Date – Year – The year the procedure was scheduled. INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Notified Time – Hour

Window Location: Data Field Name: Procedure: Procedure PX_01_B_TH TO PX_88_B_TH

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Notified Time – Hour – The hour the procedure was scheduled INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Procedures Page 5 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures Notified Time – Minute

Window Location: Data Field Name: Procedure: Procedure PX_01_B_TM TO PX_88_B_TM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Notified Time – Minute – The minute the procedure was scheduled INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search PX_01_B_EVENT to PX_88_B_EVENT – the Date and Time combined that the procedure was scheduled.

 In Report Writer; search PX_01_B_TIME to PX_88_B_TIME – the Hour and the Minute combined that the procedure was scheduled.

 In Report Writer; search PX_01_B_DATE to PX_88_B_DATE – the Month, Day and Year combined that the procedure was scheduled.

Performed on Date – Month*

Window Location: Data Field Name: Procedure: Procedure PX_01_DM TO PX_88_DM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Performed on Date – Month – The month the procedure was actually performed INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Performed on Date – Day*

Window Location: Data Field Name: Procedure: Procedure PX_01_DD TO PX_88_DD

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Performed on Date – Day – The day the procedure was actually performed INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

Procedures Page 6 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures Performed on Date – Year*

Window Location: Data Field Name: Procedure: Procedure PX_01_DY TO PX_88_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS Performed on Date – Year – The year the procedure was actually performed INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Start Time - Hour*

Window Location: Data Field Name: Procedure: Procedure PX_01_TH TO PX_88_TH

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Start Time – Hour – The hour the procedure was started INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Start Time – Minute*

Window Location: Data Field Name: Procedure: Procedure PX_01_TM TO PX_88_TM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Start Time – Minute – The minute the procedure was started INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search PX_01_TIME to PX_88_TIME – the Hour and the Minute combined that the procedure was started.

Procedures Page 7 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures Stop Time – Hour*

Window Location: Data Field Name: Procedure: Procedure PX_01_S_TH TO PX_88_S_TH

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Stop Time – Hour – The hour the procedure was stopped INSTRUCTIONS Enter the appropriate option using the [hh] format. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Stop Time – Minute*

Window Location: Data Field Name: Procedure: Procedure PX_01_S_TM TO PX_88_S_TM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Stop Time – Minute – The minute the procedure was stopped INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search PX_01_S_TM to PX_88_S_TM – the Hour and the Minute combined that the procedure was started.

Physician ID

Window Location: Data Field Name: Procedure: Procedure PX_01_ID TO PX_88_ID

State Required: Type of Field: Length: No Integer 6 DEFINITIONS Procedure – Classification of a different mode of therapy, e.g. surgery, radiology, and laboratory procedures Physician ID – The physician (or applicable facility personnel) who performed the procedure INSTRUCTIONS Enter your facility’s identifying code for the attending Physician. You may add as many codes and/or names as are applicable, but once entered, they cannot be deleted or changed. Use direct keyboard entry. VALID OPTIONS User defined

Procedures Page 8 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures

Procedures – Ventilator

Procedures Page 9 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures Ventilator Start Date

Window Location: Data Field Name: Procedure: Ventilator VX_01_B_DATE to VX_10_B_DATE

State Required: Type of Field: Length: No Integer 8 DEFINITIONS Start Date – The date the patient was placed on the ventilator or arrived at your hospital on the ventilator. INSTRUCTIONS Enter the appropriate date using mm/dd/yyyy format. Enter each time the patient is started on the ventilator.

CODING RULES

If the patient arrived at your facility from a transferring facility, enter the date the patient arrived at your facility. Enter each date the patient is started on the ventilator.

Do not include the date patient is started on a ventilator in the OR.

Non-invasive means of ventilatory support (CPAP or BIPAP) should not be considered in the calculation of ventilator days.

VALID OPTIONS Month Day Year 01 January 01 through 31 1980-2099 02 February 01 through 29 1980-2099 03 March 01 through 31 1980-2099 04 April 01 through 30 1980-2099 05 May 01 through 31 1980-2099 06 June 01 through 30 1980-2099 07 July 01 through 31 1980-2099 08 August 01 through 31 1980-2099 09 September 01 through 30 1980-2099 10 October 01 through 31 1980-2099 11 November 01 through 30 1980-2099 12 December 01 through 31 1980-2099 ? Unknown ? Unknown ? Unknown

 In Report Writer; search VX_B_Date [Start Date (L)] for the Dates patients were put on a ventilator if used in dbf export.  In Report Writer; search VX_B_Date_LIST [Start Date (D)] for the Dates patients were put on a ventilator if used in a data table.  In Report Writer; search Any (VX_B_Date) [Start Date (Q)] for the Date/Dates patients were put on a ventilator if used in a query.

 In Report Writer; search VX_B_EVENT [Start Event (D)] for the Date and Time combined for when patients are started on a ventilator if used in a dbf export.  In Report Writer; search VX_B_EVENT_LIST [Start Event (D)] for the Date and Time combined for when patients are started on a ventilator if used in a data table.  In Report Writer; search ANY (VX_B_EVENT) [Start Event (Q)] for the Date and Time combined for when patients are started on a ventilator if used in a query.

ADDENDUM Added to Collector on Entry Form Number 13.

Procedures Page 10 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures Ventilator Start Time

Window Location: Data Field Name: Procedure: Ventilator VX_01_B_TIME to VX_10_B_TIME

State Required: Type of Field: Length: No Integral 4 DEFINITIONS Start Time – The time when the patient was placed on the ventilator. INSTRUCTIONS Enter the appropriate time using the hh/mm format. Enter each time the patient is started on the ventilator.

CODING RULES

If the patient arrived at your facility from a transferring facility, enter the time the patient arrived at your facility on a ventilator.

Do not include the time patient is started on the ventilator in the OR.

Non-invasive means of ventilatory support (CPAP or BIPAP) should not be considered in the calculation of ventilator days.

VALID OPTIONS Valid Options for Hour: 00 (12 o’clock am through) through 23 (11 o’clock pm) [hh] Valid Options for Minute: 00 through 59 [mm] ? Unknown

 In Report Writer; search VX_B_Time [Start Time (L)] for the Times patients are started on a ventilator if used in dbf export.  In Report Writer; search VX_B_Time_LIST [Start Time (D)] for the Times patients are started on a ventilator if used in a data table.  In Report Writer; search ANY (VX_B_Time) [Start Time (Q)] for the Times patients are started on a ventilator if used in a query.

ADDENDUM Added to Collector on Entry Form Number 13.

Procedures Page 11 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures Ventilator Stop Date

Window Location: Data Field Name: Procedure: Ventilator VX_01_E_DATE to VX_10_E_DATE

State Required: Type of Field: Length: No Integer 8 DEFINITIONS Start Date – The date when the patient was taken off the ventilator. INSTRUCTIONS Enter the appropriate date using mm/dd/yyyy format. Enter each time the patient is taken off the ventilator.

CODING RULES Do not include the date patient is taken off a ventilator in the OR.

If the patient is on a ventilator and is discharged to another hospital, enter the date the patient was transferred on the ventilator.

Non-invasive means of ventilatory support (CPAP or BIPAP) should not be considered in the calculation of ventilator days.

 In Report Writer; search VX_E_Date [Stop Date (L)] for the Dates patient are taken off a ventilator if used in a dbf export.  In Report Writer; search VX_E_Date_LIST [Stop Date (D)] for the Dates patients are taken off a ventilator if used in a data table.  In Report Writer; search Any (VX_E_Date) [Stop Date (Q)] for the Date/Dates patients are taken off a ventilator if used in a query.

 In Report Writer; search VX_E_EVENT [Stop Event (D)] for the Date and Time combined for when a patient is taken off a ventilator if used in a data table.  In Report Writer; search VX_E_EVENT_LIST [Stop Event (D)] for the Date and Time combined for when a patient is taken off a ventilator if used in a data table.  In Report Writer; search ANY (VX_E_EVENT) [Stop Event (Q)] for the Date and Time combined for when a patient is taken off of a ventilator if used in a query.

ADDENDUM Added to Collector on Entry Form Number 13.

Procedures Page 12 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures Ventilator Stop Time

Window Location: Data Field Name: Procedure: Ventilator VX_01_E_TIME to VX_10_E_TIME

State Required: Type of Field: Length: No Integral 4 DEFINITIONS Start Time – The time when the patient was taken off the ventilator. INSTRUCTIONS Enter the appropriate time using the hh/mm format. Enter each time the patient is taken off the ventilator. CODING RULES Do not include the time patient is taken off the ventilator in the OR.

If the patient is on a ventilator and is discharged to another hospital, enter the time the patient was transferred on the ventilator.

Non-invasive means of ventilatory support (CPAP or BIPAP) should not be considered in the calculation of ventilator days. VALID OPTIONS Valid Options for Hour: 00 (12 o’clock am through) through 23 (11 o’clock pm) [hh] Valid Options for Minute: 00 through 59 [mm] ? Unknown

 In Report Writer; Search VX_E_Time [Stop Time (L)] for the Time patients are taken off a ventilator if used in a dbf export.  In Report Writer; Search VX_E_Time_LIST [Stop Time (D)] for the Times patients are taken off a ventilator if used in a data table.  In Report Writer; Search ANY (VX_E_Time) [Stop Time (Q)] for the Times patients are taken off a ventilator if used in a query.

 In Report Writer; Search VX_E_EVENT_LIST (D) for the Date and Time combined for when patients are taken off on a ventilator if used in a data table.  In Report Writer; Search VX_E_EVENT (Q) for the Date and Time combined for when patients are taken off a ventilator if used in a query.

ADDENDUM Added to Collector on Entry Form Number 13.

Procedures Page 13 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures Ventilator Days*

Window Location: Data Field Name: Procedure: Ventilator VENT_DAYS

State Required: Type of Field: Length: Yes Integer 3 DEFINITIONS Ventilator days – The number of days the patient spent on a ventilator in your facility (See coding rules below). INSTRUCTIONS Use direct keyboard entry. If you enter each time the patient is started and taken off a ventilator, this field will be populated automatically. If your facility does not have ventilator capacity, enter “/”.

CODING RULES Ventilator Days is populated automatically according to rules stated in the National Trauma Data Standard (NTDS) data dictionary if the start date/time and stop date/time values are entered.

Total Ventilator Days is the cumulative amount of time spent on the ventilator. Each partial or full day should be measured as one calendar day.

At no time should total ventilator days exceed the Hospital LOS VALID OPTIONS Ventilator days / Not Applicable ? Unknown ADDENDUM Moved from outcome tab to procedures tab on Entry Form Number 13.

Total Ventilator Time

Window Location: Data Field Name: Procedure: Ventilator VENT_MINS

State Required: Type of Field: Length: No Integer 3 DEFINITIONS Ventilator minutes – The actual number of minutes a patient is on the ventilator. The value is stored as minutes but displayed on the Collector screen as xx days xx hours xx minutes.

INSTRUCTIONS You must enter each time the patient is started and taken off a ventilator for this field to be populated automatically.

ADDENDUM Added to Collector on Entry Form Number 13.

Procedures Page 14 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Procedures

Procedures – Memo

Procedures Memo

Window Location: Data Field Name: Procedure: Memo MEMO_DFPR

State Required: Type of Field: Length: No Memo 5000 DEFINITIONS Procedures Memo – Text field in which to record additional Procedures information if needed INSTRUCTIONS Use direct keyboard entry.

Procedures Page 15 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Diagnosis

SECTION 6 - DIAGNOSIS

Injury Diagnoses* ...... 3 Injury Severity Score (ISS)* ...... 3 TRISS* ...... 3 AIS Version* ...... 4 ICD-9-CM Diagnosis Codes* ...... 4 AIS Severity / Body Region Code* ...... 4 Predot Code Area* ...... 5 No Comorbidity* ...... 7 Comorbidity Diagnosis* ...... 7 Comorbidity Diagnosis – Specify Further* ...... 7

* Items are CORE (state required) data elements

Diagnosis Page 1 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Diagnosis

Diagnosis – Injury Narrative

Diagnosis Page 2 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Diagnosis Injury Diagnoses*

Window Location: Data Field Name: Diagnoses: Injury Narrative INJ_TXT

State Required: Type of Field: Length: Yes Memo 1750 DEFINITIONS International Classification of Diseases, Index to Diseases and Injuries.

Diagnoses codes or D Codes related to trauma diagnoses. The inclusion criteria in the Introduction Section of this data dictionary define relevant ICD-9 diagnosis trauma codes. INSTRUCTIONS Enter trauma related diagnoses made at your facility. Enter one ICD-9 diagnosis code per line or describe the injuries using “text to coding” conventions.

Click the TRI-CODE button to autopopulate the grey fields with ICD-9 injury codes, ISS Score, ISS body Region, Severity, and AIS scores.

Injury Severity Score (ISS)*

Window Location: Data Field Name: Diagnoses: Injury Narrative ISS

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Injury Severity Score (ISS) – The ISS is a sum of the squares of the highest AIS code in each of the three most severely injured ISS body regions. The six body regions of injury used in the ISS are: Head; Face; Chest; Abdominal or Pelvic contents; Extremities or Pelvic girdle; and External. INSTRUCTIONS The total ISS Score for the patient will be computed by the program after all the ICD9 components are entered and the TriCode button is clicked.

TRISS*

Window Location: Data Field Name: Diagnoses: Injury Narrative TRISS

State Required: Type of Field: Length: Yes Float 5 DEFINITIONS Trauma Score/Injury Severity Score (TRISS) – A weighted score derived from age, physiological (Weighted RTS) and anatomical (ISS) measures of injury severity INSTRUCTIONS The total TRISS Score for the patient will be computed by the program after all the ICD9 components are entered and the TriCode button is clicked.

Diagnosis Page 3 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Diagnosis AIS Version*

Window Location: Data Field Name: Diagnoses: Coding Section AIS_VER

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS AIS – Abbreviated Injury Scale– A consensus derived, anatomically based system that classifies individual injuries by body region on a 6-point ordinal severity scale ranging from AIS 1 (minor) to AIS 6 (currently untreatable). AIS Version - The Abbreviated Injury Scale version that the coding is based from INSTRUCTIONS The AIS version number will be computed by the program. Note: As of the Jan. 2011 update, all Trauma Records entered with an EDA Date of 12/31/2010 or earlier, will default to AIS Version 90. All Trauma Records with an EDA Date of 1/1/2011 or greater will automatically default to AIS Version 2005.

ICD-9-CM Diagnosis Codes*

Window Location: Data Field Name: Diagnoses: Coding Section ICD9_01 to ICD9_27

State Required: Type of Field: Length: Yes Fixed 1-5 5 DEFINITIONS Relevant trauma diagnosis codes will be copied into this field after injury diagnoses are entered and the TriCode is clicked. INSTRUCTIONS The ICD-9-CM Diagnosis Codes will be computed by the program when the TriCode button is clicked.

AIS Severity / Body Region Code*

Window Location: Data Field Name: Diagnoses: Coding Section AIS_01 to AIS_27

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS AIS – Abbreviated Injury Scale– A consensus derived, anatomically based system that classifies individual injuries by body region on a 6-point ordinal severity scale ranging from AIS 1 (minor) to AIS 6 (Maximum Injury, Virtually Unsurvivable). A score of 9 means that the diagnosis code could not be assigned a severity. AIS Severity/Body Region Code - The Abbreviated Injury Scale Code section that identifies the body region of injury. Thee areas are comprised of Abdomen, Chest, Extremities, Face, Head/Neck, and Skin/Soft Tissue, INSTRUCTIONS The AIS Severity/Body Region Code will be computed by the program after ICD-9 information is entered and the TriCode is clicked.

Diagnosis Page 4 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Diagnosis

Predot Code Area*

Window Location: Data Field Name: Diagnoses: Coding Section PREDOT_01, TO PREDOT_27

State Required: Type of Field: Length: Yes Fixed 6 DEFINITIONS Abbreviated Injury Scale (AIS) – A consensus derived, anatomically based system that classifies individual injuries by body region on a 6-point ordinal severity scale ranging from AIS 1 (minor) to AIS 6 (currently untreatable). Predot Code Area - The Predot Code of the Abbreviated Injury Scale is a unique AIS specific code for each injury diagnosis. INSTRUCTIONS The Predot Code will be computed by the program after ICD9 information is entered.

Diagnosis Page 5 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Diagnosis

Diagnosis – Comorbidity

Diagnosis Page 6 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Diagnosis No Comorbidity*

Window Location: Data Field Name: Diagnoses: Comorbidity COMORB_YN

State Required: Type of Field: Length: Yes Checkbox 1 DEFINITIONS Comorbidity - the presence of one or more disorders (or diseases) in addition to a primary disease or disorder INSTRUCTIONS Check the box if there were “no comorbidities”, do not check the box if any comorbidities occurred. VALID OPTIONS 1 – Yes (Checked) – No Comorbidity 2 – No (Not Checked)

Comorbidity Diagnosis*

Window Location: Data Field Name: Diagnoses: Comorbidity COMORB_01 TO COMORB_15

State Required: Type of Field: Length: Yes Integer 6 DEFINITIONS Comorbidity Diagnosis – The code number assigned by the ACS Committee on Trauma to a comorbidity diagnosis factor INSTRUCTIONS Enter the appropriate ICD-9 code. See the Appendix for the types of comorbidities that you should make sure to capture.

Comorbidity Diagnosis – Specify Further*

Window Location: Data Field Name: Diagnoses: Comorbidity COMORBX_01 TO COMORBX_15

State Required: Type of Field: Length: Yes Text 100 DEFINITIONS Text field in which to record additional comorbidity diagnosis information if needed INSTRUCTIONS Use direct keyboard entry.

Diagnosis Page 7 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Section 7 - Outcomes

Discharge Date – Month* ...... 4 Discharge Date – Day* ...... 4 Discharge Date – Year* ...... 4 Discharge Time – Hour* ...... 5 Discharge Time – Minute* ...... 5 Discharge Status* ...... 6 Discharge Service ...... 6 Death Location ...... 7 Discharge To* ...... 7 Transport Mode At Discharge * ...... 8 Transport Mode Called At Discharge – Month* ...... 8 Transport Mode Called At Discharge– Day* ...... 9 Transport Mode Called At Discharge – Year* ...... 9 Transport Mode Called At Discharge– Hour* ...... 9 Transport Mode Called At Discharge – Minute* ...... 10 Transport Mode Arrived At Discharge – Month* ...... 10 Transport Mode Arrived At Discharge – Day* ...... 11 Transport Mode Arrived At Discharge – Year * ...... 11 Transport Mode Arrived At Discharge– Hour * ...... 11 Transport Mode Arrived At Discharge – Minute * ...... 12 Facility Transferred to * ...... 12 Facility transferred to – If Other * ...... 12 Discharged City – transferred facility * ...... 13 Discharged City – If Other ...... 13 Discharged State – facility transferred to ...... 13 Discharged State – If Other ...... 14 Reason for Discharge ...... 14 Discharged By Whom ...... 14 ICU Days* ...... 15 Final Discharge Memo* ...... 15 Rehabilitation Potential ...... 17 Pre-Injury – Feeding ...... 17 Pre-Injury – Feeding Qualifier ...... 18 Pre-Injury – Ambulation ...... 18 Pre-Injury – Ambulation Qualifier ...... 19 Pre-Injury – Communication ...... 19 Pre-Injury – Communication Qualifier ...... 20 Pre-Injury – FIM Score ...... 20 At Discharge – Feeding*...... 21 At Discharge – Feeding Qualifier* ...... 21 At Discharge – Ambulation* ...... 22 At Discharge – Ambulation Qualifier* ...... 23 At Discharge – Communication* ...... 23 At Discharge – Communication Qualifier* ...... 24 At Discharge – FIM Score* ...... 24 Was Organ Donation Requested? ...... 26 Was Organ Donation Request Granted? ...... 26 Organ Tissue Donated ...... 26

Outcomes Page 1 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Was an Autopsy Performed?* ...... 27 Autopsy Report Number ...... 27 Primary DRG – Retired Sept 2011 ...... 29 Account Number ...... 29 Primary Payor* ...... 29 Secondary Payor* ...... 30 Other Payor Source* ...... 30 Total Facility Charges* ...... 30 Total Facility Cost ...... 31 Total Facility Collection* ...... 31 Actual Variable Direct Cost ...... 31 Outcomes Memo ...... 32

* Items are CORE (state required) data elements

Outcomes Page 2 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes

Outcomes – Discharge

Outcomes Page 3 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Discharge Date – Month*

Window Location: Data Field Name: Outcome: Discharge DIS_DM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Discharge Date – Month – The month the patient was discharged from your facility INSTRUCTIONS Enter the appropriate option using the [mm] format. CODING RULES If a patient dies, enter the month the patient died. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Discharge Date – Day*

Window Location: Data Field Name: Outcome: Discharge DIS_DD

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Discharge Date – Day – The day the patient was discharged from your facility INSTRUCTIONS Enter the appropriate option using the [dd] format. CODING RULES If a patient dies, enter the day the patient died. VALID OPTIONS 01 through 31 [dd] ? Unknown

Discharge Date – Year*

Window Location: Data Field Name: Outcome: Discharge DIS_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS Discharge Date – Year – The year the patient was discharged from your facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. CODING RULES If a patient dies, enter the year the patient died. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Outcomes Page 4 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Discharge Time – Hour*

Window Location: Data Field Name: Outcome: Discharge DIS_TH

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Discharge Date – Hour – The hour the patient was discharged from your facility INSTRUCTIONS Enter the appropriate option using the [hh] format. CODING RULES If a patient dies, enter the hour the patient died. VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Discharge Time – Minute*

Window Location: Data Field Name: Outcome: Discharge DIS_TM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Discharge Date – Minute – The minute the patient was discharged from your facility INSTRUCTIONS Enter the appropriate option using the [mm] format. CODING RULES If a patient dies, enter the minute the patient died. VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search DIS_EVENT– the Date and Time combined that the patient was discharged from facility.

 In Report Writer; search DIS_TIME – the Hour and the Minute combined that the patient was discharged from facility.

 In Report Writer; search DIS_DATE – the Month, Day and Year combined that the patient was discharged from facility.

Outcomes Page 5 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Discharge Status*

Window Location: Data Field Name: Outcome: Discharge DIS_STATUS

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Discharge Status – The patient’s status upon discharge from your facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 6 Alive 7 Dead ? Unknown

Discharge Service

Window Location: Data Field Name: Outcome: Discharge DIS_SER

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Discharge Service – The service that authorizes patient discharge from your facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 01 Allergy/Immunology 15 Nuclear Medicine 29 Vascular Surgery 02 Anesthesiology 16 OB/GYN 30 Other 03 Burn Care Specialist 17 Ophthalmology 33 OMFS 04 Cardiology 18 Orthopedics 34 Psych 05 Colon Rectal Surgery 19 Otolaryngology 35 Neurology 06 Dermatology 20 Pediatrics 36 Infectious Disease 07 Ear, Nose and Throat 21 Physical 37 Pediatric Medicine Specialist Medicine/Rehab 08 Emergency Medicine 22 Plastic Surgery 38 Pediatric Surgery 09 Family Practice 23 Pulmonary 39 Medical Critical Care Intensivist 10 General Surgery 24 Radiology 40 Surgical Critical Care Intensivist 11 Hand-Ortho Surgery 25 Renal 41 Pediatric Critical Care Intensivist 12 Internal Medicine 26 Thoracic Surgery / Not Applicable 13 Medical Genetics 27 Trauma Surgery ? Unknown 14 Neurosurgery 28 Urology

ADDENDUM: Added Options 39 Medical Critical Care Intensivist; 40 Surgical Critical Care Intensivist; 41 Pediatric Critical Care Intensivist on entry form 15, June 27, 2014.

RETIRED OPTIONS 20. Pediatrics (2011) 31. Unspecified 32. Not Documented

Outcomes Page 6 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Death Location

Window Location: Data Field Name: Outcome: Discharge DIED_LOC

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Death Location – The location in which the patient died INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 01 ED 13 Physical Medical Rehabilitation 02 OR 14 Minor Surgery Unit 03 ICU 15 Trauma Resuscitation Room 04 MICU 17 CCU 05 NICU 18 NCCU 06 PICU 30 Pre-Facility (NFS) 07 SICU 31 Scene/Enroute from Scene 08 Burn Unit 32 Referring Facility 09 Med/Surg Floor 33 Enroute from Referring Facility 10 Stepdown Unit 99 Other 11 Radiology ? Unknown 12 Nuclear Medicine

Discharge To*

Window Location: Data Field Name: Outcome: Discharge DIS_TO

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Discharged To – The place to which the patient was released when discharged from your facility. INSTRUCTIONS Enter the appropriate option.

Note: Use “Acute Care Hospital” if you are transferring to another hospital, including transferring to higher level of trauma care. VALID OPTIONS 13 Against Medical Advice 10 Nursing Home 02 Death in ED 14 Other 03 Death in Hospital 23 Protective Services (Added Form 14) 07 Acute Care Hospital 11 Rehabilitation Center 04 Home 22 Repatriation (added Form 14) 05 Home with Health Care 08 Skilled Nursing (Facility, Unit, Swing Bed) 20 Hospice 12 Specialty Hospital 09 Jail or Prison 24 Women’s Shelter (Added Form 14) 06 Mental Health Facility ? Unknown 16 Non-Medical Transfer (patient choice)

RETIRED OPTIONS 21 Other Acute Care Hospital – Same or Lower Level of Trauma Care (Form 14) 01 Dead on Arrival (Form 15)

ADDENDUM: Option 7 Discharge to Acute Care Hospital now reads “Acute Care Hospital” on entry form 15, June 27, 2014

Outcomes Page 7 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Discharge To – If Other*

Window Location: Data Field Name: Outcome: Discharge DIS_TO_O

State Required: Type of Field: Length: Yes Text 50 DEFINITIONS Discharge To – If Other – Text field to record where patient was discharged if dis_to = 14 (Other) is used. INSTRUCTIONS Fill in this field only if you have selected “14” Other in the “Discharge To” field above.

Transport Mode At Discharge *

Window Location: Data Field Name: Outcome: Discharge DIS_MODE

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Transport Mode – How did the patient leave your facility? This field is enabled when DIS_TO = 7. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Ground Ambulance 9 Other 2 Helicopter Ambulance ? Unknown 3 Fixed-Wing Ambulance / Not Applicable 7 Police

CODING RULES Use 9 “other” if patient is discharged to higher level of care (acute care hospital- Dis_to = 7) and is transported by POV after EMS is recommended.

ADDENDUM: This variable was added to the registry beginning on entry form number 9

Transport Mode Called At Discharge – Month*

Window Location: Data Field Name: Outcome: Discharge DTM_C_DM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Transport Mode Called – Month – The month the mode of transportation was called INSTRUCTIONS Enter the appropriate option using the [mm] format. If the patient was transported by POV, code as / or “NA”. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Outcomes Page 8 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Transport Mode Called At Discharge– Day*

Window Location: Data Field Name: Outcome: Discharge DTM_C_DD

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Transport Mode Called - Day – The day the mode of transportation was called INSTRUCTIONS Enter the appropriate option using the [dd] format. If the patient was transported by POV, code as / or “NA VALID OPTIONS 01 through 31 [dd] ? Unknown

Transport Mode Called At Discharge – Year*

Window Location: Data Field Name: Outcome: Discharge DTM_C_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS Transport Mode Called - Year – The year the mode of transportation was called INSTRUCTIONS Enter the appropriate option using the [yyyy] format. If the patient was transported by POV, code as / or “NA VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Transport Mode Called At Discharge– Hour*

Window Location: Data Field Name: Outcome: Discharge DTM_C_TH

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Transport Mode Called - Hour – The hour the mode of transportation was called INSTRUCTIONS Enter the appropriate option using the [hh] format. If the patient was transported by POV, code as / or “NA VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Outcomes Page 9 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Transport Mode Called At Discharge – Minute*

Window Location: Data Field Name: Outcome: Discharge DTM_C_TM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Transport Mode Called - Minute – The minute the mode of transportation was called INSTRUCTIONS Enter the appropriate option using the [mm] format. If the patient was transported by POV, code as / or “NA VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search DTM_C_EVENT– the Date and Time combined that the patient was discharged from facility.

 In Report Writer; search DTM_C_TIME – the Hour and the Minute combined that the patient was discharged from facility.

 In Report Writer; search DTM_C_DATE – the Month, Day and Year combined that the patient was discharged from facility.

Transport Mode Arrived At Discharge – Month*

Window Location: Data Field Name: Outcome: Discharge DTM_A_DM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Transport Mode Arrived – Month – The month the mode of transportation arrived at facility INSTRUCTIONS Enter the appropriate option using the [mm] format. If the patient was transported by POV, code as / or “NA VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Outcomes Page 10 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Transport Mode Arrived At Discharge – Day*

Window Location: Data Field Name: Outcome: Discharge DTM_A_DD

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Transport Mode Arrived - Day – The day the mode of transportation arrived at facility INSTRUCTIONS Enter the appropriate option using the [dd] format. If the patient was transported by POV, code as / or “NA VALID OPTIONS 01 through 31 [dd] ? Unknown Transport Mode Arrived At Discharge – Year *

Window Location: Data Field Name: Outcome: Discharge DTM_A_DY

State Required: Type of Field: Length: Yes Integer 4 DEFINITIONS Transport Mode Arrived - Year – The year the mode of transportation arrived at facility INSTRUCTIONS Enter the appropriate option using the [yyyy] format. If the patient was transported by POV, code as / or “NA VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

Transport Mode Arrived At Discharge– Hour *

Window Location: Data Field Name: Outcome: Discharge DTM_A_TH

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Transport Mode Called - Hour – The hour the mode of transportation arrived at facility INSTRUCTIONS Enter the appropriate option using the [hh] format. If the patient was transported by POV, code as / or “NA VALID OPTIONS 00 (12 o’clock a.m.) through 23 (11 o’clock p.m.) [hh] ? Unknown

Outcomes Page 11 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Transport Mode Arrived At Discharge – Minute *

Window Location: Data Field Name: Outcome: Discharge DTM_A_TM

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Transport Mode Called - Minute – The minute the mode of transportation arrived at facility INSTRUCTIONS Enter the appropriate option using the [mm] format. If the patient was transported by POV, code as / or “NA VALID OPTIONS 00 through 59 [mm] ? Unknown

 In Report Writer; search DTM_A_EVENT– the Date and Time combined that the patient was discharged from facility.

 In Report Writer; search DTM_A_TIME – the Hour and the Minute combined that the patient was discharged from facility.

 In Report Writer; search DTM_A_DATE – the Month, Day and Year combined that the patient was discharged from facility.

Facility Transferred to *

Window Location: Data Field Name: Outcome: Discharge DIS_TO_F

State Required: Type of Field: Length: Yes AlphaNumeric 7 DEFINITIONS Discharge – Facility – The facility to which the patient was transferred, if applicable INSTRUCTIONS Enter the number of the facility to which the patient was transferred. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Facility number / Not Applicable ? Unknown

Facility transferred to – If Other *

Window Location: Data Field Name: Outcome: Discharge DIS_TO_F_O

State Required: Type of Field: Length: Yes Text 50 DEFINITIONS Discharge – Facility – If Other – Any other identifying facility not found in the available list of VALID OPTIONS to which the patient was discharged INSTRUCTIONS Use direct keyboard entry. Fill in this field only if you have selected “880000” Other in the “Discharge To - Facility” field above.

Outcomes Page 12 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Discharged City – transferred facility *

Window Location: Data Field Name: Outcome: Discharge DIS_TO_C

State Required: Type of Field: Length: No Integer 7 DEFINITIONS Discharge – City – The city in which the transfer facility is located INSTRUCTIONS Enter the number of the city in which the transfer facility is located. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS City number / Not Applicable ? Unknown

Discharged City – If Other

Window Location: Data Field Name: Outcome: Discharge DIS_TO_C_O

State Required: Type of Field: Length: No Text 50 DEFINITIONS Discharge– City – If Other – Any other identifying city not found in the available list of VALID OPTIONS to which the patient was discharged INSTRUCTIONS Use direct keyboard entry

Discharged State – facility transferred to

Window Location: Data Field Name: Outcome: Discharge DIS_TO_S

State Required: Type of Field: Length: No Alphanumeric 2 DEFINITIONS Discharge – State – The state in which the transfer facility is located INSTRUCTIONS Enter the number of the state in which the transfer facility is located. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS State number / Not Applicable 29 Missouri ? Unknown 31 Nebraska 20 Kansas 40 Oklahoma 08 Colorado

Outcomes Page 13 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Discharged State – If Other

Window Location: Data Field Name: Outcome: Discharge DIS_TO_S_O

State Required: Type of Field: Length: No Text 50 DEFINITIONS Discharged– State – If Other – Text field in which to record additional information if needed INSTRUCTIONS Use direct keyboard entry.

Reason for Discharge

Window Location: Data Field Name: Outcome: Discharge DIS_TO_RS

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Discharge – Reason – The reason for patient discharge from your facility and transferred to another facility INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Medical 4 Other 2 Personal ? Unknown 3 Financial

Discharged By Whom

Window Location: Data Field Name: Outcome: Discharge DIS_TO_BY

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Discharge– By – The authority responsible for the patient discharge INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Physician 4 Other 2 Patient ? Unknown 3 Payor

Outcomes Page 14 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes ICU Days*

Window Location: Data Field Name: Outcome: Discharge ICU_DAYS

State Required: Type of Field: Length: Yes Integer 3 DEFINITIONS ICU days – The number of days the patient spent in the ICU in your facility. Each partial or full day should be measured as 1 day. INSTRUCTIONS Use direct keyboard entry.

ICU days are entered in full day increments with any partial calendar day counted as a full calendar day. The date and time of starting and stopping an ICU episode must be recorded in the patient’s medical record. If any dates are missing, then ICU days cannot be calculated – record as “?” for unknown. If your facility does not have an ICU or the patient had no ICU days, enter “/” for “NA”.

If a patient has multiple ICU episodes on the same calendar day, count that day as one calendar day.

At no time should ICU days be greater than the hospital length of stay (LOS).

VALID OPTIONS ICU Days / Not Applicable ? Unknown

Final Discharge Memo*

Window Location: Data Field Name: Outcome: Discharge MEMO_FDIS

State Required: Type of Field: Length: Yes Memo 5000 DEFINITIONS Final Discharge Memo – Text field to record additional information about how patient outcome or how the patient was discharged. INSTRUCTIONS Do NOT put confidential PI information in this field.

Use this field to record if a patient is transported by POV after EMS was recommended for a transfer to higher level of care.

This memo field may be left blank if there is no additional information to add.

Outcomes Page 15 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Outcomes – Disabilities

Outcomes Page 16 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Rehabilitation Potential

Window Location: Data Field Name: Outcome: Disabilities REHAB_POT

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Rehabilitation Potential – The potential for rehabilitation of the patient in an affected area of Feeding, Ambulation, or Communication INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Improbable Improvement 2 Possible Improvement 3 Probable Improvement / Not Applicable ? Unknown

Pre-Injury – Feeding

Window Location: Data Field Name: Outcome: Disabilities P_DIS_F

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Feeding – Includes using suitable utensils to bring food to mouth, chewing, and swallowing once meal is appropriately prepared (Opening containers, cutting meat, buttering bread and pouring liquids are not included as they are often part of meal preparation)

FIM (Functional Independence Measure) – A score calculated to derive a baseline of trauma patient disability prior to injury, using three components: Feeding, Ambulation (Independence), and Motor (Expression)

1 = Dependent – Total help required: Either performs less than half of feeding tasks, or does not eat or drink full meals by mouth and relies at least in part on other means of alimentation, such as parental or gastrostomy feedings

2 = Dependent – Partial help required: Performs half or more of feeding tasks but requires supervision (e.g., standby, cuing, or coaxing), setup (application of orthoses), or other help

3 = Independent with device: Uses an adaptive or assistive device such as a straw, fork, or rocking knife or requires more than a reasonable time to eat

4 = Independent: Eats from a dish and drinks from a cup or glass presented in the customary manner on table or tray.; uses ordinary knife, fork, and spoon

INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Fully Dependent 4 Fully Independent 2 Partially Dependent / Not Applicable 3 Most Independent ? Unknown (Device Needed)

Outcomes Page 17 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Pre-Injury – Feeding Qualifier

Window Location: Data Field Name: Outcome: Disabilities P_DIS_FQ

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Feeding – Qualifier – Indication of whether the self-feeding of FIM score was temporary, permanent or unknown INSTRUCTIONS If self-feeding prior to injury was Independent, enter “/” for “N/A”. Enter the appropriate option. VALID OPTIONS 1 Temporary – Likely To Improve 2 Permanent – Unlikely To Improve / Not Applicable ? Unknown

Pre-Injury – Ambulation

Window Location: Data Field Name: Outcome: Disabilities P_DIS_L

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Ambulation (Independence): Includes walking once in a standing position or using a wheelchair once in a seated position indoors

1 = Dependent – Total help required: Performs less than half of locomotion effort to go a minimum of 50 feet, or does not walk or wheel a minimum of 50 feet. Requires assistance of one or more persons

2 = Dependent – Partial help required: If walking, requires standby supervision, cuing, or coaxing to go a minimum of 150 feet, or walks independently only short distances (a minimum of 50 feet); If not walking, requires standby supervision, cuing, or coaxing to go a minimum of 150 feet in wheelchair, or operates manual or electric wheelchair independently only short distances ( a minimum of 50 feet)

3 = Independent with Device: Walks a minimum of 150 feet but uses a brace (orthosis) or prosthesis on leg, special adaptive shoes, cane, crutches, or walkerette, takes more than a reasonable time, or there are safety considerations; If not walking, operates manual or electric wheelchair independently for a minimum of 150 feet, turns around, maneuvers the chair to a table, bed, toilet, negotiates at least a 3 % grade, maneuvers on rugs and over door sills

4 = Independent: Walks a minimum of 150 feet without assistive devices; does not use a wheelchair; performs safely

INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Fully Dependent 2 Partially Dependent 3 Mostly Independent (Devise Needed) 4 Fully Independent / Not Applicable ? Unknown

Outcomes Page 18 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Pre-Injury – Ambulation Qualifier

Window Location: Data Field Name: Outcome: Disabilities P_DIS_LQ

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Ambulation – Qualifier – Indication of whether the Self -Ambulation of FIM score was temporary, permanent or unknown. INSTRUCTIONS If self-ambulation prior to injury was independent, enter “/” for “N/A”. Enter the appropriate option. VALID OPTIONS 1 Temporary – Likely To Improve 2 Permanent – Unlikely To Improve / Not Applicable ? Unknown

Pre-Injury – Communication

Window Location: Data Field Name: Outcome: Disabilities P_DIS_E

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Communication (Expression): Includes clear expression of verbal or nonverbal language; expresses linguistic information verbally or graphically with appropriate and accurate meaning and grammar

FIM (Functional Independence Measure) – A score calculated to derive a baseline of trauma patient disability prior to injury, using three components: Feeding, Locomotion (Independence), and Motor (Expression).

1 = Dependent – Total help required: Expresses basic needs and ideas less than half of the time; needs prompting more than half the time or

2 = Dependent – Partial help required: Expresses basic needs and ideas about everyday situations half (50 %) or more than half of the time; requires some prompting, but requires that prompting less than half (50%) of the time

3 = Independent with Device: Expresses complex or abstract ideas with mild difficulty; may require an augmentative communication device or system

4 = Independent: Expresses complex or abstract ideas intelligibly and fluently, verbally or nonverbally, including signing or writing INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Fully Dependent 2 Partially Dependent 3 Mostly Independent 4 Fully Independent / Not Applicable ? Unknown

Outcomes Page 19 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Pre-Injury – Communication Qualifier

Window Location: Data Field Name: Outcome: Disabilities P_DIS_EQ

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Communication – Qualifier – Indication of whether the Self-Communication of FIM score was temporary, permanent or unknown INSTRUCTIONS If self-communication prior to injury was independent, enter “/” for “N/A”. Enter the appropriate option. VALID OPTIONS 1 Temporary - Likely To Improve 2 Permanent - Unlikely To Improve / Not Applicable ? Unknown

Pre-Injury – FIM Score

Window Location: Data Field Name: Outcome: Disabilities P_DIS_TOT

State Required: Type of Field: Length: No Integer 2 DEFINITIONS FIM score – Total of Pre-Injury Feeding, Ambulation, and Communication FIM scores

Outcomes Page 20 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes At Discharge – Feeding*

Window Location: Data Field Name: Outcome: Disabilities (Local Collector) D_DIS_F Outcome: Discharge (Web Collector)

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Feeding: Includes using suitable utensils to bring food to mouth, chewing, and swallowing (once meal is appropriately prepared); Opening containers, cutting meat, buttering bread and pouring liquids are not included as they are often part of meal preparation

FIM (Functional Independence Measure) – A score calculated to derive a baseline of trauma patient disability at discharge, using three components: Feeding, Locomotion (Independence), and Motor (Expression).

2 = Dependent – Partial help required: Performs half or more of feeding tasks but requires supervision (e.g., standby, cuing, or coaxing), setup (application of orthoses), or other help

3 = Independent with device: Uses an adaptive or assistive device such as a straw, fork, or rocking knife or requires more than a reasonable time to eat

4 = Independent: Eats from a dish and drinks from a cup or glass presented in the customary manner on table or tray. Uses ordinary knife, fork, and spoon INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Fully Dependent 2 Partially Dependent 3 Most Independent (Devise Needed) 4 Fully Independent / Not Applicable ? Unknown

At Discharge – Feeding Qualifier*

Window Location: Data Field Name: Outcome: Disabilities (Local Collector) D_DIS_FQ Outcome: Discharge (Web Collector)

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Feeding – Qualifier – Indication of whether the Self-Feeding of FIM score is temporary, permanent or unknown. INSTRUCTIONS If self-feeding at discharge was independent, enter “/” for “N/A”. Enter the appropriate option. VALID OPTIONS 1 Temporary – Likely To Improve 2 Permanent – Unlikely To Improve / Not Applicable ? Unknown

Outcomes Page 21 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes At Discharge – Ambulation*

Window Location: Data Field Name: Outcome: Disabilities (Local Collector) D_DIS_L Outcome: Discharge (Web Collector)

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Ambulation (Independence): Includes walking once in a standing position or using a wheelchair once in a seated position indoors

4 = Independent: Walks a minimum of 150 feet without assistive devices; does not use a wheelchair; performs safely INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Fully Dependent 2 Partially Dependent 3 Mostly Independent (Devise Needed) 4 Fully Independent / Not Applicable ? Unknown

Outcomes Page 22 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes At Discharge – Ambulation Qualifier*

Window Location: Data Field Name: Outcome: Disabilities (Local Collector) D_DIS_LQ Outcome: Discharge (Web Collector)

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Feeding – Qualifier – Indication of whether the Self –Ambulation of FIM score is temporary, permanent or unknown INSTRUCTIONS If self-ambulation at discharge was independent, enter “/” for “N/A”. Enter the appropriate option. VALID OPTIONS 1 Temporary – Likely To Improve 2 Permanent – Unlikely To Improve / Not Applicable ? Unknown

At Discharge – Communication*

Window Location: Data Field Name: Outcome: Disabilities (Local Collector) D_DIS_E Outcome: Discharge (Web Collector)

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Communication (Expression): Includes clear expression of verbal or nonverbal language; expresses linguistic information verbally or graphically with appropriate and accurate meaning and grammar

1 = Dependent – Total help required: Expresses basic needs and ideas less than half of the time; needs prompting more than half the time or

3 = Independent with Device: Expresses complex or abstract ideas with mild difficulty; may require an augmentative communication device or system

4 = Independent: Expresses complex or abstract ideas intelligibly and fluently, verbally or nonverbally, including signing or writing

INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Fully Dependent 2 Partially Dependent 3 Most independent (devise needed) 4 Fully independent / Not Applicable ? Unknown

Outcomes Page 23 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes At Discharge – Communication Qualifier*

Window Location: Data Field Name: Outcome: Disabilities (Local Collector) D_DIS_EQ Outcome: Discharge (Web Collector)

State Required: Type of Field: Length: Yes Integer 1 DEFINITIONS Communication – Qualifier – Indication of whether the Self –Communication of FIM score is temporary, permanent or unknown INSTRUCTIONS If self-communication at discharge was independent, enter “/” for “N/A”. Enter the appropriate option. VALID OPTIONS 1 Temporary – Likely To Improve 2 Permanent – Unlikely To Improve / Not Applicable ? Unknown

At Discharge – FIM Score*

Window Location: Data Field Name: Outcome: Disabilities (Local Collector) D_DIS_TOT Outcome: Discharge (Web Collector)

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS FIM score – Total of At Discharge Feeding, Ambulation, and Communication FIM scores

FIM (Functional Independence Measure) – A score calculated to derive a baseline of trauma patient disability at discharge from an acute care facility, using three components: Feeding, Locomotion (Independence), and Motor (Expression). This modified FIM ranges from 3 – 12 with higher scores indicating more functional independence. INSTRUCTIONS Auto-calculated

Outcomes Page 24 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes

Outcomes – If Death

Outcomes Page 25 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Was Organ Donation Requested?

Window Location: Data Field Name: Outcome: If Death ORG_REQ

State Required: Type of Field: Length: No Yes/No 1 INSTRUCTIONS Answer the following question: If the patient died, was the patient’s family approached to inquire about the possibility of the patient’s organs being donated for use? Enter the appropriate option. VALID OPTIONS 1 Yes 2 No 3 Unsuitable per Outside Agency ? Unknown

Was Organ Donation Request Granted?

Window Location: Data Field Name: Outcome: If Death ORG_APP_YN

State Required: Type of Field: Length: No Yes/No 1 INSTRUCTIONS Answer the following question: If the patient died, did the patient’s family grant the medical staff’s request for donation of the patient’s organs for use? Enter the appropriate option. VALID OPTIONS 1 Yes 2 No ? Unknown

Organ Tissue Donated

Window Location: Data Field Name: Outcome: If Death ORG_01 TO ORG_10

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Organ tissue donated – Type of organ tissue that was donated by the deceased patient INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 00 None 06 Kidney 12 Unsuitable 01 All 07 Liver 13 Not Documented 02 Multiple - NOS 08 Lung / Not Applicable 03 Bone 09 Skin ? Unknown 04 Cornea 10 Pancreas 05 Heart 11 Other

Outcomes Page 26 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Was an Autopsy Performed?*

Window Location: Data Field Name: Outcome: If Death (Local Collector) AUTOP Outcome: Discharge (Web Collector)

State Required: Type of Field: Length: Yes Yes/No 1 INSTRUCTIONS Answer the following question: Did medical staff or the coroner’s office perform an autopsy on the deceased patient? Enter the appropriate option. VALID OPTIONS 1 Yes 3 Refused by Coroner 2 No ? Unknown

Autopsy Report Number

Window Location: Data Field Name: Outcome: If Death AUTOP_NUM

State Required: Type of Field: Length: No Alphanumeric 15 DEFINITIONS Autopsy Report Number – The preprinted number on the autopsy report INSTRUCTIONS Enter the preprinted number from the autopsy report form. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Autopsy Report Number / Not Applicable ? Unknown

Outcomes Page 27 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes

Outcomes – Payors

Outcomes Page 28 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Primary DRG – Retired Sept 2011 ADDENDUM This data element was retired as part of the Sept. 2011 Collector update.

Account Number

Window Location: Data Field Name: Outcome: Payors FIN_ACC

State Required: Type of Field: Length: No Integer 10 DEFINITIONS Account Number – Financial record number located in billing information on the patient INSTRUCTIONS This field must be completed with a financial patient identifier. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Account number / Not Applicable ? Unknown

Primary Payor*

Window Location: Data Field Name: Outcome: Payors PAY_01

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Insurance – Health and medical policy carried to assist in payment of medical bills INSTRUCTIONS Enter the patient's primary insurance company or source of payment. Use direct keyboard entry. VALID OPTIONS 01 Auto 07 Self-Pay 02 Commercial 08 Military Insurance 03 Medicare 09 Other 04 Medicaid 10 Unspecified 05 Private Charity / Not Applicable 06 Workers ? Unknown Compensation

Outcomes Page 29 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Secondary Payor*

Window Location: Data Field Name: Outcome: Payors PAY_02, PAY_03, PAY_04, PAY_05

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Insurance – Health and medical policy carried to assist in payment of medical bills INSTRUCTIONS Enter the patient's secondary insurance company or source of payment. Use direct keyboard entry. VALID OPTIONS 01 Auto 07 Self-Pay 02 Commercial 08 Military Insurance 03 Medicare 09 Other 04 Medicaid 10 Unspecified 05 Private Charity / Not Applicable 06 Workers ? Unknown Compensation

Other Payor Source*

Window Location: Data Field Name: Outcome: Payors PAY_O

State Required: Type of Field: Length: Yes Text 50 DEFINITIONS Text field in which to record additional payer source information if needed INSTRUCTIONS Use direct keyboard entry.

Total Facility Charges*

Window Location: Data Field Name: Outcome: Payors H_CHRG

State Required: Type of Field: Length: Yes Integer 9 DEFINITIONS Total Facility Charges – The total amount charged for this admission at the acute care facility INSTRUCTIONS Enter the patient's total facility charges rounded off to the nearest dollar. Enter dollar amount only up to 6 months after the patient's discharge from your facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Total Facility Charges ? Unknown

Outcomes Page 30 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes Total Facility Cost

Window Location: Data Field Name: Outcome: Payors H_COST

State Required: Type of Field: Length: No Integer 9 DEFINITIONS Total Facility Cost – The total amount of cost the facility has underwritten for care of the patient INSTRUCTIONS Enter the dollar amount that your facility has charged off of payment due for the patient’s treatment. Enter dollar amount only up to 6 months after the patient's discharge from your facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Total Facility Cost ? Unknown

Total Facility Collection*

Window Location: Data Field Name: Outcome: Payors H_COLL

State Required: Type of Field: Length: Yes Integer 9 DEFINITIONS Facility Collection – The dollar amount that your facility has received for payment of the patient’s treatment INSTRUCTIONS Enter the dollar amount that your facility has received for payment of the patient’s treatment. Enter dollar amount only up to 6 months after the patient's discharge from your facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Total Facility Collection ? Unknown

Actual Variable Direct Cost

Window Location: Data Field Name: Outcome: Payors H_AVDC

State Required: Type of Field: Length: No Integer 9 DEFINITIONS Actual Variable Direct Cost – Total of variable direct costs charged to the patient’s account INSTRUCTIONS Enter the dollar amount that your facility has charged to the patient’s account for these expenses. Enter dollar amount only up to 6 months after the patient's discharge from your facility. Use direct keyboard entry or enter the appropriate option. VALID OPTIONS Actual Variable Direct Cost ? Unknown

Outcomes Page 31 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Outcomes

Outcomes – Memo

Outcomes Memo

Window Location: Data Field Name: Outcome: Memo MEMO_FIN

State Required: Type of Field: Length: No Memo 5000 DEFINITIONS Outcome Memo – Text field in which to record additional outcome information if needed INSTRUCTIONS Use direct keyboard entry.

Outcomes Page 32 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI

SECTION 8 – QUALITY ASSURANCE/QUALITY IMPROVEMENT

QA/QI Core – Non-injury related occurrences – occurrences entered * ...... 3 QA/QI Core – Non-injury related occurrences * ...... 3 Date (Core Non-Injury Related Occurrence) ...... 4 Non-Injury Related Occurrence -Comprehensive ...... 6 Performance Improvement ...... 8 Performance Improvement Filter Type ...... 9 Date (Non-injury related occurrence, Performance improvement, user defined) ...... 9 User Defined Performance Indicators ...... 9 Issue - QA Tracking ...... 11 Open Date – Month QA Tracking ...... 11 Open Date – Day QA Tracking ...... 11 Open Date – Year QA Tracking ...... 12 Closed Date – Month QA Tracking ...... 12 Closed Date – Day QA Tracking ...... 12 Closed Date – Year QA Tracking ...... 13 Provider ID - QA Tracking ...... 13 Department of Occurrence - QA Tracking ...... 14 Contributing Factor - QA Tracking ...... 15 Actions Taken - QA Tracking ...... 16 Action – Acceptability QA Tracking ...... 16 Level of Highest Review - QA Tracking ...... 17 Mortality - QA Tracking ...... 17 Morbidity - QA Tracking ...... 18 QA/QI Memo ...... 19 Receiving Hospital Diagnosis - ISS ...... 21 Receiving Hospital Diagnosis – Definitive Diagnosis Narrative ...... 21

* Items are CORE (state required) data elements

QA/QI Page 1 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI

QA/QI – CORE

QA/QI – COMPREHENSIVE

QA/QI Page 2 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI QA/QI Core – Non-injury related occurrences – occurrences entered *

Window Location: Data Field Name: QA/QI : Core NIRO_YN

State Required: Type of Field: Length: Yes Check Box 1 DEFINITIONS Non-Injury Related Occurrence - An event that is not an expected sequelae of a disease, illness, or injury. INSTRUCTIONS Check the “no occurrences” box if there are no occurrences to report. If there are non-injury-related occurrences, leave the box unchecked. VALID OPTIONS Visit Number 1 Yes (Checked) – No occurrences. 2 No (Note Checked) – Use grid to enter core non-injury-related occurrences.

QA/QI Core – Non-injury related occurrences *

Window Location: Data Field Name: QA/QI : Core NIRO_01 to NIRO_20

State Required: Type of Field: Length: Yes Integer 2 DEFINITIONS Non-Injury Related Occurrence - An event that is not an expected sequelae of a disease, illness, or injury. See appendix for definitions of options. INSTRUCTIONS Enter the appropriate option. These categories were adopted in Kansas and follow the corresponding list in the National Trauma Data Standard Dictionary. See appendix for definitions of the valid options below.

Comprehensive Data Collector: Code the comprehensive complications first. Some of these will autopopulate core complications. Then add the core complications that are not included in the comprehensive list or do not match exactly. VALID OPTIONS Infections/Wounds Cardiovascular 3 Decubitus Ulcer 16 Cardiac arrest with CPR 4 Deep surgical site infection 17 Deep Vein Thrombosis (DVT)/thrombophlebitis 10 Extremity compartment syndrome 20 Myocardial Infarction 11 Graft/prosthesis/flap failure 18 Pulmonary Embolism 5 Organ/space surgical site infection 19 Stroke/CVA 9 Pneumonia Other 6 Superficial surgical site infection 21 Unplanned intubation 25 Urinary Tract Infection 22 Unplanned readmission 26 Catheter-related blood stream infection 24 Drug or Alcohol Withdrawal Syndrome 27 Osteomyelitis 28 Unplanned return to the OR 30 Severe Sepsis 29 Unplanned return to the ICU Organ Failure 13 Acute renal failure 14 Acute respiratory distress syndrome (ARDS) RETIRED OPTIONS

1 Bleeding (Retired 2011) 15 Coma (Retired 2011) 2 Coagulopathy (Retired 2011) 7 Wound Disruption (Retired 2012) 8 Systemic Sepsis (Retired 2011) 12 Abdominal Compartment Syndrome (Retired 2011)

QA/QI Page 3 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI Date (Core Non-Injury Related Occurrence)

Window Location: Data Field Name: QA/QI : Comprehensive NIRO_DT

State Required: Type of Field: Length: No Date ----- DEFINITIONS Non-Injury Related Date – The event date that is not an expected sequelae of a disease, illness, or injury. This date refers to the date of a Core Non-injury-related occurrence. INSTRUCTIONS Enter the appropriate date.

QA/QI Page 4 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI

QA/QI – Comprehensive

QA/QI Page 5 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI Non-Injury Related Occurrence -Comprehensive

Window Location: Data Field Name: QA/QI : Comp FLTS (FLTS_TP=2)

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Non-Injury Related Occurrence - An event that is not an expected sequelae of a disease, illness, or injury Complication Occurrence - Individual numeric code assigned to complication occurrences listed in 1993 Resources for Optimal Care of the Injured Patient. INSTRUCTIONS Enter the appropriate option. This list corresponds to Performance Improvement Filter Type 2 (see “Performance Improvement Filter Type” section in this document). VALID OPTIONS Pre- 1001 Aspiration 3513 Hypotension Hospital 1002 Esophageal Intubation 3599 Other Cardiovascular 1003 Extubation, Unintentional 4001 Anastomotic Leak 1004 Mainstem Intubation 4002 Bowel Injury (Iatrogenic) 1005 Unable to Intubate 4003 Dehiscence/Evisceration 1099 Other Airway 4004 Enterotomy (Iatrogenic) 1501 Inappropriate Fluid Management 4005 Fistula 1502 Unable to Start an IV 4006 Hemorrhage (Lower GI) 1599 Other Fluid 4007 Hemorrhage (Upper GI) 2001 No EMS Form 4008 Ileus 2002 Incomplete EMS Form 4009 Peritonitis 2003 Prehospital Delay 4010 Small Bowel Obstruction (SBO) 2098 Failure to Notify ED of Arrival 4011 Ulcer (Duodenal/Gastric) 2099 Other Prehospital 4012 Abdominal Compartment Syndrome Hospital 3001 Abscess (Excludes Empyema) 4099 Other GI 3002 Adult Respiratory Distress Syndrome 4501 Acalculous Cholecystitis (ARDS) 3003 Pneumonia (Aspiration) 4502 Hepatitis 3004 Atelectasis 4503 Liver Failure 3005 Empyema 4504 Pancreatic Fistula 3006 Fat Embolus 4505 Pancreatitis 3007 Hemothorax 4506 Splenic Injury (Iatrogenic) 3008 Pneumonia (Infection) 4597 Hyperbilirubemia 3009 Pneumothorax (Barotrauma) 4598 Cholestasis 3010 Pneumothorax (Iatrogenic) 4599 Other Heptic/Biliary 3011 Pneumothorax (Recurrent) 5001 Coagulopathy (Intraoperative) 3012 Pneumothorax (Tension) 5002 Coagulopathy (Other) 3013 Pulmonary Edema 5003 Disseminated Intravascular Coagulation (DIC) 3014 Pulmonary Embolus 5004 Serum Sodium 160 (Iatrogenic) 3015 Respiratory Failure/Distress 5005 Transfusion Complication 3016 Upper Airway Obstruction 5099 Other Hematologic 3017 Pleural Effusion 5501 Cellulitis/Traumatic Injury 3018 Bronchitis 5502 Fungal Sepsis 3019 Emphysema 5503 Intra-abdominal Abscess 3020 Hypoxemia 5504 Line Infection 3098 Ventilator Associated Pneumonia 5505 Necrotizing Fasciitis (VAP) 3099 Other Pulmonary 5506 Sepsis-like Syndrome 3501 Arrhythmia 5507 Septicemia 3502 Cardiac Arrest 5508 Sinusitis 3503 Cardiogenic Shock 5509 Wound Infection 3504 Congestive Heart Failure (Iatrogenic) 5510 Yeast Infection 3505 Myocardial Infarction (MI) 5597 Surgical Site Infection 3506 Pericarditis 5598 Respiratory Infection 3507 Pericardial Effusion or Tamponade 5599 Other Infection 3508 Shock (NFS) 6001 Renal Failure 3509 Shock (Anaphylactic) 6002 Ureteral Injury (Iatrogenic)

QA/QI Page 6 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI 3510 Shock (Hypovolemic) 6003 Urinary Tract Infection, Early (<72hours) 3511 Aortic Stenosis 6004 Urinary Tract Infection, Late 3512 Anemia, Acute Blood Loss 6005 Urinary Tract Infection, Fungal 6006 Hematuria 7007 Nonoperative Subdural/Epidural Hematoma 6007 Acute Renal Insufficiency 7008 Progression of Original Neurologic Insult 6008 Chronic Renal Insufficiency 7009 Seizure in Facility 6099 Other Renal/GU 7010 Syndrome of Not Applicable Antidiuretic Hormone (SIADH) 6501 Compartment Syndrome 7011 Stroke/CVA 6502 Minor Decubitus (Stage I) 7012 Ventriculitis (Postsurgical) 6503 Blister Decubitus (Stage II) 7098 Hygroma 6504 Decubitus Open Sore (Stage III) 7501 Anastomosis Hemorrhage 6505 Decubitus (Stage IV) 7502 Deep Venous Thrombosis (Lower Extremity) 6506 Loss of Reduction/Fixation 7503 Deep Venous Thrombosis (Upper Extremity) 6507 Nonunion 7504 Embolus (Non-pulmonary) 6508 Osteomyelitis 7505 Gangrene 6509 Orthopedic Wound Infection 7506 Graft Infection 6510 Abscess - Other Wound 7507 Thrombosis 6511 Dehiscence/ w/o Evisceration (Post- 7508 Acute Arterial Occlusion op) 6512 Contracture – Volkmann’s Ischemic 7599 Other Vascular 6599 Other Musculoskeletal/Integumentary 8506 Unexpected Return to OR 7001 Alcohol Withdrawal 8507 Readmission 7002 Anoxic Encephalopathy 8508 Unexpected Post-Operative Hemorrhage 7003 Brain Death 7004 Diabetes Insipidus 7005 Meningitis / Inappropriate 7006 Neuropraxia (Iatrogenic) ? Unknown

QA/QI Page 7 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI

Performance Improvement

Window Location: Data Field Name: QA/QI : Comp FLTS (FLTS_TP = 1)

State Required: Type of Field: Length: No Integer 4 DEFINITIONS This is the standard set of performance indicators, as defined by the American College of Surgeons (ACS), for certain events resulting from care given by the prehospital personnel, technicians, nurses, or physicians leading to delays or errors in technique, judgment, treatment, or communication. Individual numeric codes assigned to occurrences as defined in the ACS TRACS data dictionary. INSTRUCTIONS Enter the appropriate performance improvement indicator. This list corresponds to Performance Improvement Filter (FLTS_TP = 1) Type 1 (see “Performance Improvement Filter Type” section in this document). VALID OPTIONS 9800 ACSAF1 – Missing EMS Report 9801 ACSAF2 – GCS<14, No Head CT 9802 ACSAF3 – GCS<8, No Endotracheal Tube or Surgical Airway 9803 ACSAF4 – Nonoperative RX of Gunshot Wound to the Abdomen 9804 ACSAF5A – No Laparotomy <=1Hour, Abdominal Injuries, and Systolic BP < 90 9805 ACSAF5B – Laparotomy after 4 Hours 9806 ACSAF6 – Craniotomy after 4 Hours, with Epid or Subd, Excluding ICP Monitoring 9807 ACSAF7 – Initial RX >8 hours of Open Tibia FX, Excluding ICP Monitoring 9808 ACSAF8 – Abdominal, thoracic, Vascular, or Cranial Surgery after 24 Hours 9809 ACSAF9 – Admit by Nonsurgeon 9810 ACSFA1 – Ambulance Scene Time > 20 Minutes 9811 ACSFA2 – Absent Hourly Charting 9812 ACSFA3 – Transfer after 6 Hours in the Initial Hospital 9813 ACSFA4 – Reintubation within 48 Hour of Extubation 9814 ACSAF10 – Nonfixation of Femoral Disphyseal Fracture in Adult 9815 ACSAF12 – Trauma Death 9901 ACS991 – Compliance with Guidelines, Protocols, and Pathways 9902 ACS992 – Appropriateness of Pre-hospital and ED Triage 9903 ACS993 – Delay in Assessment, Diagnosis, Technique, or Treatment 9904 ACS994 – Error in Judgment, Communication, or Treatment 9905 ACS995 – Appropriateness and Legibility of Documentation 9906 ACS996 – Timeliness and Availability of X-ray Reports 9907 ACS997 – Timely Participation of Sub-Specialists 9908 ACS998 – Availability of Operating Room - Acute and Subacute 9909 ACS999 – Timeliness of Rehabilitation 9910 ACS9910 – Professional Behavior 9911 ACS9911 - Availability of Family Services 9912 ACS9912 – Insurance Carrier Denials 9913 ACS9913 – Consistency of Outpatient Follow-Up 9914 ACS9914 – Patient Satisfaction ? Unknown / Not Applicable

QA/QI Page 8 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI

Performance Improvement Filter Type

Window Location: Data Field Name: QA/QI : Comp FLTS_TP

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Non-Injury Related Occurrence - An event that is not an expected sequelae of a disease, illness, or injury INSTRUCTIONS This derived variable shows whether a given filter is a Non-Injury Related Occurrence, performance improvement audit filter or user-defined audit filter. VALID OPTIONS 01 Performance Improvement 02 Non-Injury-Related Occurrences 03 User-Defined

Date (Non-injury related occurrence, Performance improvement, user defined)

Window Location: Data Field Name: QA/QI : Comprehensive FLTS_DT

State Required: Type of Field: Length: No Date ------DEFINITIONS Date – The event date that is not an expected sequelae of a disease, illness, or injury. This date may be a Core may be a non-injury related occurrence date, a performance improvement issue date or User-Defined event date. INSTRUCTIONS Enter the appropriate date for non-injury-related occurrences and performance improvement.

User Defined Performance Indicators

Window Location: Data Field Name: QA/QI : Comp FLTS_LIST (FLTS_TP=3)

State Required: Type of Field: Length: No Integer 4 DEFINITIONS User Defined Performance Indicator - Any facility defined event resulting from care given by the prehospital personnel, technicians, nurses, or physicians leading to delays or errors in technique, judgment, treatment, or communication. INSTRUCTIONS Enter the appropriate option from user-formatted occurrences. This list corresponds to Performance Improvement Filter Type 3 (see “Performance Improvement Filter Type” above). VALID OPTIONS User defined

QA/QI Page 9 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI

QA/QI – Tracking Comprehensive

QA/QI Page 10 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI Issue - QA Tracking

Window Location: Data Field Name: QA/QI : QA/QI Tracking IS01_IS to IS15_IS

State Required: Type of Field: Length: No Integer 4 DEFINITIONS QA Tracking Issue – Individual numeric code assigned to each non-injury related occurrence or performance improvement filter that is chosen for QA/QI tracking. The options match those for non-injury related occurrences core, non-injury related occurrences comprehensive, performance improvement (all described above in this section), and any user-defined performance indicators. INSTRUCTIONS Check the QA tracking box when entering the core non-injury related occurrences, comprehensive non-injury related occurrence, or performance improvement issues if this issue was reviewed. You may also enter these issues directly into the tracking page. VALID OPTIONS Options include all options listed for the following data elements: non-injury related occurrences core, non-injury related occurrences comprehensive, performance improvement (all described above), and any user-defined performance indicators.

Open Date – Month QA Tracking

Window Location: Data Field Name: QA/QI : QA/QI Tracking IS01_O_DM to IS15_O_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Opened Date - Month - The month the QA/QI issue was initiated by your facility’s Performance Improvement Committee. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Open Date – Day QA Tracking

Window Location: Data Field Name: QA/QI : QA/QI Tracking IS01_O_DD to IS15_O_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Opened Date - Day - The day the QA/QI issue was initiated by your facility’s Performance Improvement Committee.

INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

QA/QI Page 11 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI

Open Date – Year QA Tracking

Window Location: Data Field Name: QA/QI : QA/QI Tracking IS01_O_DY to IS15_O_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Opened Date - Year - The year the QA/QI issue was initiated by your facility’s Performance Improvement Committee.

INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

 In Report Writer; search _DATE – the Month, Day and Year combined that the patient’s issue was initiated by the performance improvement committee.

Closed Date – Month QA Tracking

Window Location: Data Field Name: QA/QI : QA/QI Tracking IS01_C_DM to IS15_C_DM

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Closed Date - Month - The month the QA/QI issue was closed by your facility’s Performance Improvement Committee. INSTRUCTIONS Enter the appropriate option using the [mm] format. VALID OPTIONS 01 January 05 May 09 September 02 February 06 June 10 October 03 March 07 July 11 November 04 April 08 August 12 December ? Unknown

Closed Date – Day QA Tracking

Window Location: Data Field Name: QA/QI : QA/QI Tracking IS01_C_DD to IS15_C_DD

State Required: Type of Field: Length: No Integer 2 DEFINITIONS Closed Date - Day - The day the QA/QI issue was closed by your facility’s Performance Improvement Committee. INSTRUCTIONS Enter the appropriate option using the [dd] format. VALID OPTIONS 01 through 31 [dd] ? Unknown

QA/QI Page 12 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI

Closed Date – Year QA Tracking

Window Location: Data Field Name: QA/QI : QA/QI Tracking IS01_C_DY to IS15_C_DY

State Required: Type of Field: Length: No Integer 4 DEFINITIONS Closed Date - Year - The year the QA/QI issue was closed by your facility’s Performance Improvement Committee. INSTRUCTIONS Enter the appropriate option using the [yyyy] format. VALID OPTIONS 1980 through 2099 [yyyy] ? Unknown

 In Report Writer; search _DATE – the Month, Day and Year combined that the patient issue was reviewed by the performance improvement committee.

Provider ID - QA Tracking

Window Location: Data Field Name: QA/QI : QA/QI Tracking IS01_ID to IS15_ID

State Required: Type of Field: Length: No Integer 6 DEFINITIONS Provider ID is the unique identifier assigned by the facility to identify individual providers of medical service. INSTRUCTIONS Enter the appropriate options provided by the facility. VALID OPTIONS Enter numbers by type of physician from drop down box (specific numbers are created by the Collector user).

0 ER Physician – Unspecified 80000 Admitting Physicians - Unspecified 10000 General / Trauma Surgeon - Unspecified 90000 Non-Surgical Specialty - Unspecified 20000 Neuro Surgeon – Unspecified 110000 Neurologist 30000 Orthopedic Surgery – Unspecified 120000 Oral Maxillary 50000 Anesthesiologist – Unspecified 100000- Other 109999 60000 Surgical Surgeon – Unspecified / Inappropriate 70000 Attending Physician – Unspecified ? Unknown

QA/QI Page 13 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI Department of Occurrence - QA Tracking

Window Location: Data Field Name: QA/QI : QA/QI Tracking IS01_DP to IS15_DP

State Required: Type of Field: Length: No Integer 4 DEFINITIONS QA Tracking – Department of Occurrence indicates where the issue occurred for each occurrence that is tracked. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1000 Anesthesiology 1015 Pediatric Unit 1001 Blood Bank 1016 Pharmacy 1002 Cardio Vascular Services 1017 Physical Therapy 1003 ED 1019 Prehospital Care 1005 ICU 1020 Radiology 1006 Interfacility Unit 1018 Recovery Unit 1007 Laboratory 1021 Rehabilitation 1004 Med / Surg Floor 1022 Respiratory Services 1008 Neuro Surgery 1023 Security Services 1009 Nursing Dept. 1024 Social Services 1010 Nutrition Services 1025 Step Down 1011 Observation 1026 Trauma Services 1012 Occupational Therapy / Inappropriate 1013 OR ? Unknown 1014 Orthopedics

QA/QI Page 14 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI Contributing Factor - QA Tracking

Window Location: Data Field Name: QA/QI : QA/QI Tracking IS01_CF1 to IS01_CF5 IS02_CF1 to IS02_CF5 Continue on 3 to 14 IS15_CF1 to IS15_CF5

State Required: Type of Field: Length: No Integer 1 DEFINITIONS QA Tracking Contributing Factors – A determined factor that was significant in the development of the QA/QI issue. INSTRUCTIONS Enter the appropriate contributing factor from the drop down list. VALID OPTIONS

9018 Complication occurrence during a major diagnostic procedure 9014 CT Tech Delay 9016 Delay in ED Disposition 9013 Delay in diagnosis 9002 Delay in obtaining consult –ortho/neuro 9015 Delay in obtaining Trauma consult 9013 Delay in Ortho MD Response 9011 Delay in Reporting Results 9000 Delay in Trauma Team Activation 9009 Delay in Treatment 9001 Delay to Operating Room 9021 Equipment Broken 9022 Equipment Missing/Unavailable 9004 Error in Diagnosis 9005 Error in Judgment 9006 Error in Technique 9010 Error in Treatment 9007 Incomplete Hospital Record 9012 Missed Injury 0000 None 9017 Non-compliance with ATLS 9008 Non Seen on Daily Rounds by Trauma Surgeon 9999 Other 9023 Patient Comorbidity 9024 Patient Refusal 9019 Policy Compliance 9020 Policy Content

QA/QI Page 15 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI Actions Taken - QA Tracking

Window Location: Data Field Name: QA/QI : QA/QI Tracking IS01_ACT1 to IS01_ACT5 IS02_ACT1 to IS02_ACT5 IS03_ACT1 to IS03_ACT5 Continue on 4 to 14 IS15_ACT1 to IS15_ACT5

State Required: Type of Field: Length: No Integer 1 DEFINITIONS QA Tracking – Actions indicates what actions were taken for each occurrence that is tracked. INSTRUCTIONS Enter the appropriate Action from drop down box VALID OPTIONS Enter the action from the list below.

3 Equipment Purchased/repaired 1 Policy – Provider Education 2 Policy – Revision/Creation 4 Provider – Discussion 6 Provider – Probation 7 Provider – Suspension 5 Provider – Warning 0 No Action Taken

Action – Acceptability QA Tracking

Window Location: Data Field Name: QA/QI : Tracking IS01_ACC1 to IS01_ACC5 IS02_ACC1 to IS02_ACC5 IS03_ACC1 to IS03_ACC5 Continue on 4 to 14 IS15_ACC1 to IS15_ACC5

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Action - Acceptability - the outcome of peer review of a QA/QI action Acceptable - QA/QI action determined as acceptable performance by peer review Acceptable with Reservation - QA/QI action is acceptable with noted exceptions as determined by peer review. Further explanation should document the issue discussed at the peer review process Not acceptable - QA/QI action determined as not acceptable by peer review, further follow up needed INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Acceptable 2 Acceptable with Reservations 3 Not Acceptable / Inappropriate ? Unknown

QA/QI Page 16 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI Level of Highest Review - QA Tracking

Window Location: Data Field Name: QA/QI : QA/QI Tracking IS01_BY,Issue1 IS02_BY,Issue2 Continue on 3 to 14 IS15_BY,Issue15

State Required: Type of Field: Length: No Integer 1 DEFINITIONS QA Tracking – Level of Highest Review indicates the highest provider level of peer review of the QA/QI issue. INSTRUCTIONS Enter the appropriate Level of Highest Review from drop down box VALID OPTIONS 4 Credentialing Committee 2 ED Medical Director 5 Employer 3 QI committee 6 Trauma Medical Director 1 Trauma Nurse Coordinator

Mortality - QA Tracking

Window Location: Data Field Name: QA/QI : QA/QI Tracking IS01_Mort,Issue01 IS02_Mort,Issue02 IS03_Mort,Issue03 Continue on 4 to 14 IS15_Mort,Issue15

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Mortality – QA/QI issue evaluated by peer review due to trauma death.

Unanticipated mortality with opportunity for improvement - The peer review committee determined that the trauma death was unanticipated and there was also opportunity for improvement. Further explanation field should document the issue(s) discussed in the review process. Anticipated mortality with opportunity for improvement - The peer review committee determined that the trauma death was anticipated and there was also opportunity for improvement. Further explanation field should document the issue(s) discussed in the review process. Mortality Without opportunity for improvement – The peer review committee determined that the trauma death did not have an opportunity for improvement. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS Enter the assessment from the list below.

1 Unanticipated Event with Opportunity for Improvement 2 Anticipated Event with Opportunity for Improvement 3 Event without Opportunity for Improvement ? Unknown / Not applicable

QA/QI Page 17 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI Morbidity - QA Tracking

Window Location: Data Field Name: QA/QI : QA/QI Tracking IS01_Morb,Issue01 IS02_Morb,Issue02 IS03_Morb,Issue03 Continue on 4 to 14 IS15_Morb,Issue15

State Required: Type of Field: Length: No Integer 1 DEFINITIONS Morbidity - The QA/QI issue has increased the relative incidence of disease. Unanticipated event with opportunity for improvement - The peer review committee determined that the QA/QI issue was unanticipated and resulted in an increased incidence of disease. There was also opportunity for improvement. Further explanation field should document the issue(s) discussed in the review process. Anticipated event with opportunity for improvement - The peer review committee determined that the QA/QI issue was anticipated and resulted in an increased incidence of disease. There was also opportunity for improvement. Further explanation field should document the issue(s) discussed in the review process. Event without opportunity for improvement – The peer review committee determined that the QA/QI issue did not have an opportunity for improvement. INSTRUCTIONS Enter the appropriate option. VALID OPTIONS 1 Unanticipated Event with Opportunity for Improvement 2 Anticipated Event with Opportunity for Improvement 3 Event without Opportunity for Improvement ? Unknown / Not applicable

QA/QI Page 18 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI

QA/QI – Memo

QA/QI Memo

Window Location: Data Field Name: QA/QI : Memo MEMO_QA

State Required: Type of Field: Length: No Memo 5000 DEFINITIONS QA/QI Memo - Text field in which to record additional QA/QI information if needed INSTRUCTIONS Use direct keyboard entry.

QA/QI Page 19 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI QA/QI Receiving Hospital Diagnosis

ADDENDUM: This section was added on entry form 15, June 27, 2014.

QA/QI Page 20 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY QA/QI Receiving Hospital Diagnosis - ISS

Window Location: Data Field Name: QA/QI : Receiving Hospital Diagnosis REF_ISS

State Required: Type of Field: Length: No Memo 2 DEFINITIONS Receiving Hospital Injury Severity Score - Text field to record definitive care ISS score made at the hospital where the patient was transferred to. INSTRUCTIONS Use direct keyboard entry. Please note: This ISS is not calculated using Tri-Code.

ADDENDUM: This field was added on entry form 15, June 27, 2014.

Receiving Hospital Diagnosis – Definitive Diagnosis Narrative

Window Location: Data Field Name: QA/QI : Receiving Hospital Diagnosis I_INJ_TXT

State Required: Type of Field: Length: No Memo 2700 DEFINITIONS Receiving Hospital Diagnosis - Text field to record definitive care diagnoses made at the hospital where the patient was transferred to. INSTRUCTIONS Use direct keyboard entry.

ADDENDUM: This field was added on entry form 15, June 27, 2014.

QA/QI Page 21 July 2014 Appendix: Glossary of Terms

Co-Morbid Conditions

Advanced directive limiting care: The patient had a Do Not Resuscitate (DNR) document or similar advance directive recorded prior to injury.

Alcohol use disorder: Evidence of chronic use, such as withdrawal episodes. Exclude isolated elevated blood alcohol level in absence of history of abuse.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 291.0 -291.3, 291.81, 291.9, 303.90-303.93, V11.3

Ascites within 30 days: The presence of fluid accumulation (other than blood) in the peritoneal cavity noted on physical examination, abdominal ultrasound, or abdominal CT/MRI.

Please Note: NTDB no longer includes these codes in their definition. Retired as of 2015 ICD-9 Code Range: 789.51, 789.59

Attention deficit disorder/Attention deficit hyperactivity disorder (ADD/ADHD): History of a disorder involving inattention, hyperactivity or impulsivity requiring medication for treatment.

Bleeding disorder: Any condition that places the patient at risk for bleeding in which there is a problem with the body’s blood clotting process (e.g., vitamin K deficiency, hemophilia, thrombocytopenia, chronic anticoagulation therapy with Coumadin, Plavix, or similar medications). Do not include patients on chronic aspirin therapy.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 286.0-286.9; 287.1-287.49; V58.61; V58.63

Cerebrovascular accident (CVA): A history prior to injury of a cerebrovascular accident (embolic, thrombotic, or hemorrhagic) with persistent residual motor sensory or cognitive dysfunction. (e.g., hemiplegia, hemiparesis, aphasia, sensory deficit, impaired memory).

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 434.01, 434.11, 434.91, 433.01-433.91, 438.0-438.9

Page 1 of 13

Appendix: Glossary of Terms

Chronic obstructive pulmonary disease (COPD): Severe chronic lung disease, chronic obstructive pulmonary disease (COPD) such as emphysema and/or chronic bronchitis resulting in any one or more of the following:

• Functional disability from COPD (e.g., dyspnea, inability to perform activities of daily living [ADLs]) • Hospitalization in the past for treatment of COPD • Requires chronic bronchodilator therapy with oral or inhaled agents • A Forced Expiratory Volume in 1 second (FEV1) of < 75% of predicted on pulmonary function testing

Do not include patients whose only pulmonary disease is acute asthma. Do not include patients with diffuse interstitial fibrosis or sarcoidosis.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 011.00-011.66, 011.8-011.99, 012.0-012.9, 277.02, 491.0-491.9, 492.0-492.8, 493.00-493.92, 494.0-494.1, 495.0-495.9, 496, 518.2, 518.83-518.89

Chronic renal failure: Acute or chronic renal failure prior to injury that was requiring periodic peritoneal dialysis, hemodialysis, hemofiltration, or hemodiafiltration.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 403.01, 403.11, 403.91, 404.02, 404.12, 404.03, 404.13, 404.92, 404.93

Cirrhosis: Documentation in the medical record of cirrhosis, which might also be referred to as end stage liver disease. If there is documentation of prior or present esophageal or gastric varices, portal hypertension, previous hepatic encephalopathy, or ascites with notation of liver disease, then cirrhosis should be considered present. Cirrhosis should also be considered present if documented by diagnostic imaging studies or a laparotomy/laparoscopy.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 571.2, 571.5, 571.6, 571.8, 571.9, 572.2, 572.3, 572.4, 572.8

Congenital Anomalies: Documentation of a cardiac, pulmonary, body wall, CNS/spinal, GI, renal, orthopaedic, or metabolic congenital anomaly.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 740.0 through 759.89

Page 2 of 13

Appendix: Glossary of Terms

Congestive heart failure: The inability of the heart to pump a sufficient quantity of blood to meet the metabolic needs of the body or can do so only at an increased ventricular filling pressure. To be included, this condition must be noted in the medical record as CHF, congestive heart failure, or pulmonary edema with onset or increasing symptoms within 30 days prior to injury. Common manifestations are:

• Abnormal limitation in exercise tolerance due to dyspnea or fatigue • Orthopnea (dyspnea on lying supine) • Paroxysmal nocturnal dyspnea (awakening from sleep with dyspnea) • Increased jugular venous pressure • Pulmonary rales on physical examination • Cardiomegaly • Pulmonary vascular engorgement

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 398.91, 428.0 - 428.9, 402.01, 402.11, 402.91, 404.11, 404.13, 404.91, 425.0- 425.4

Currently receiving chemotherapy for cancer: A patient who is currently receiving any chemotherapy treatment for cancer prior to admission. Chemotherapy may include, but is not restricted to, oral and parenteral treatment with chemotherapeutic agents for malignancies such as colon, breast, lung, head and neck, and gastrointestinal solid tumors as well as lymphatic and hematopoietic malignancies such as lymphoma, leukemia, and multiple myeloma.

Current smoker: A patient who reports smoking cigarettes every day or some days. Excludes patients who smoke cigars or pipes or use smokeless tobacco (chewing tobacco or snuff).

Dementia: With particular attention to senile or vascular dementia (e.g. Alzheimer’s).

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code range: 290.0-290.43, 294.0-294.11, 331.0-331.2, 331.82-331.89, 332.0-332.1, 333.0, 333.4.

Diabetes mellitus: Diabetes mellitus prior to injury that required exogenous parenteral insulin or an oral hypoglycemic agent.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 250.00-250.93

Disseminated cancer: Patients who have cancer that has spread to one or more sites in addition to the primary site. AND in whom the presence of multiple metastases indicates the cancer is widespread, fulminant, or near terminal. Other terms describing disseminated cancer include “diffuse,” “widely metastatic,” “widespread,” or “carcinomatosis.” Common sites of metastases include major organs (e.g., brain, lung, liver, meninges, abdomen, peritoneum, pleura, bone).

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 196.0-199.1

Page 3 of 13

Appendix: Glossary of Terms

Drug use disorder: With particular attention to opioid, sedative, amphetamine, cocaine, diazepam, alprazolam, or lorazepam dependence (excludes ADD/ADHD or chronic pain with medication use as- prescribed).

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 304.00-304.8, 305.2-305.9

Esophageal varices: Esophageal varices are engorged collateral veins in the esophagus which bypass a scarred liver to carry portal blood to the superior vena cava. A sustained increase in portal pressure results in esophageal varices which are most frequently demonstrated by direct visualization at esophagoscopy.

Please Note: NTDB no longer includes these codes in their definition. Retired as of 2015 ICD-9 Code Range: 456.0-456.21

Functionally dependent health status: Pre-injury functional status may be represented by the ability of the patient to complete activities of daily living (ADL) including: bathing, feeding, dressing, toileting, and walking. This item is marked YES if the patient, prior to injury, and as a result of cognitive or physical limitation relating to a pre-existing medical condition, was partially dependent or completely dependent upon equipment, devices or another person to complete some or all activities of daily living.

History of angina within 30 days: Documentation of chest pain or pressure, jaw pain, arm pain, or other equivalent discomfort suggestive of cardiac ischemia present within the last 30 days from hospital arrival date.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 413.0-413.9

History of myocardial infarction: The history of a non-Q wave or a Q wave infarction in the six months prior to injury and diagnosed in the patient's medical record.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 410.00, 410.01, 410.10, 410.11, 410.20, 410.21, 410.30, 410.31, 410.40, 410.41, 410.50, 410.51, 410.60, 410.61, 410.70, 410.71, 410.80, 410.81, 410.90, 410.91

History of peripheral vascular disease (PVD) Any type of operative (open) or interventional radiology angioplasty or revascularization procedure for atherosclerotic PVD (e.g., aorta-femoral, femoral- femoral, femoral-popliteal, balloon angioplasty, stenting, etc.). Patients who have had amputation from trauma or resection/repair of abdominal aortic aneurysms, including Endovascular Repair of Abdominal Aortic Aneurysm (EVAR), would not be included.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 440.20-440.29, 440.30-440.32 and 443.9

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Appendix: Glossary of Terms

Hypertension requiring medication: History of a persistent elevation of systolic blood pressure >140mm Hg and a diastolic blood pressure >90mm Hg requiring an antihypertensive treatment (e.g., diuretics, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers). . Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range 401.0, 401.1, 401.9, 642.00-642.04 642.20-642.24 642.30-642.34, 402.0-402.91; 403.00-403.91; 404.00-404.93; 405.01-405.99;

Major psychiatric illness: Documentation of the presence of pre-injury major depressive disorder, bipolar disorder, schizophrenia, anxiety/panic disorder, borderline or antisocial personality disorder, and/or adjustment disorder/post-traumatic stress disorder.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code range: 295.00-297.9, 300.0-300.09, 301.0-301.7, 301.83, 309.81, 311, V11.0-V11.2, V11.4-V11.8

Obesity: Defined as a Body Mass Index of 30 or greater.

Please Note: NTDB no longer includes these codes in their definition. Retired as of 2015 ICD-9 Code Range: 278.00-278.01,V85.3-V85.4

Prematurity: Documentation of premature birth, a history of bronchopulmonary dysplasia, or ventilator support for greater than 7 days after birth. Premature birth is defined as infants delivered before 37 weeks from the first day of the last menstrual period.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 765.00-765.19, 765.20-765.29, 770.7

Pre-hospital cardiac arrest with CPR: A sudden, abrupt loss of cardiac function which occurs outside of the hospital, prior to admission at the center in which the registry is maintained, that results in loss of consciousness requiring the initiation of any component of basic and/or advanced cardiac life support by a health care provider.

Please Note: Retired as of 2015

Steroid use: Patients that required the regular administration of oral or parenteral corticosteroid medications (e.g., prednisone, dexamethasone in the 30 days prior to injury for a chronic medical condition (e.g., COPD, asthma, rheumatologic disease, rheumatoid arthritis, inflammatory bowel disease). Do not include topical corticosteroids applied to the skin or corticosteroids administered by inhalation or rectally.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: V58.65

Page 5 of 13

Appendix: Glossary of Terms

Hospital Complications

Acute kidney injury: Acute kidney injury, AKI (stage 3), is an abrupt (within 48 hours) reduction of kidney function defined as:

• Increase in serum creatinine (SCr) of more than or equal to 3x baseline Or; • Increase in SCr to ≥ 4mg/dl (≥ 353.3µmol/l) Or; 2 • Patients > 18 years with a decrease in e GFR to < 35 ml/min per 1.73 m Or; • Reduction in urine output of < 0.3 ml/kg/hr for ≥ 24 hrs. Or; • Anuria ≥ 12 hrs. Or; • Requiring renal replacement therapy (e.g. continuous renal replacement therapy (CRRT) or periodic peritoneal dialysis, hemodialysis, hemofiltration, or hemodiafiltration).

Note: If the patient or family refuses treatment (e.g., dialysis), the condition is still considered to be present if a combination of oliguria and creatinine are present.

EXCLUDE patients with renal failure that were requiring chronic renal replacement therapy such as periodic peritoneal dialysis, hemodialysis, hemofiltration, or hemodiafiltration.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 584.5-584.9; 588.0-588.9 585.1, 585.89, 585.9, 593.9, 958.5

Adult respiratory distress syndrome (ARDS):

Timing: Within 1 week of know clinical insult or new or worsening respiratory symptoms. Chest imaging: Bilateral opacities – not fully explained by effusions, lobar/lung collage, or nodules Origin of edema: Respiratory failure not fully explained by cardiac failure of fluid overload. Need objective assessment (e.g. echocardiography) to exclude hybrostatic edema if no risk factor present Oxygenation: 200

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 518.5, 518.82

Cardiac arrest with CPR: Cardiac arrest is the sudden cessation of cardiac activity After hospital arrival. The patient becomes unresponsive with no normal breathing and no signs of circulation. If corrective measures are not taken rapidly, this condition progresses to sudden death.

INCLUDE patients who have had an episode of cardiac arrest evaluated by hospital personnel and either:

Received compressions or defibrillation or cardioversion or cardiac pacing to restore circulation. Or; Were pulseless but did not receive defibrillation attempts or CPR by hospital personnel.

Page 6 of 13

Appendix: Glossary of Terms

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 427.5 in conjunction with 99.60-99.69, 427.5 with 37.91; V12.53

Catheter-related blood stream infection: An organism cultured from the bloodstream that is not related to an infection at another site but is attributed to a central venous catheter. Patients must have evidence of infection including at least one of:

Criterion #1: Patient has a recognized pathogen cultured from one or more blood cultures and organism cultured from blood is not related to an infection at another site. Or; Criterion #2: Patient has at least one of the following signs or symptoms: • Fever ≥ 38○ C • Chills • WBC > 10,000 or < 3000 per cubic millimeter • Hypotension (SBP<90) or >25% drop in systolic blood pressure • Signs and symptoms and positive laboratory results are not related to an infection at another site AND • Common skin contaminant (i.e., diphtheroids [Corynebacterium spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. Or; Criterion #3: Patient < 1 year of age has at least one of the following signs or symptoms: . Fever > 38° C . Hypothermia < 36° C . Apnea, or bradycardia . Signs and symptoms and positive laboratory results are not related to an infection at another site and common skin contaminant (i.e., diphtheroids [Corynebacterium spp.], Baccillus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions.

Erythema at the entry site of the central line or positive cultures on the tip of the line in the absence of positive blood cultures is not considered a CRBSI

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 993.1, 790.7, 038.0, 038.1, 038.10, 038.11, 038.19, 038.3, 038.4-038.43, 038.49, 038.8, 038.9,

Decubitus ulcer: Any partial or full thickness loss of dermis resulting from pressure exerted by the patient’s weight against a surface. Deeper tissues may or may not be involved. Equivalent to NPUAP Stages II – IV and NPUAP “unstageable” ulcers.

EXCLUDES intact skin with nonblanching redness (NPUAP Stage I), which is considered reversible tissue injury.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 707.00 through 707.09 with one code from 707.22-707.25 to indicate the stage using the highest stage documented

Page 7 of 13

Appendix: Glossary of Terms

Deep surgical site infection: A deep incisional SSI must meet one of the following criteria:

Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure and involves deep soft tissues (e.g., fascial and muscle layers) of the incision AND; Patient has at least one of the following: • Purulent drainage from the deep incision but not from the organ/space component of the surgical site of the following: • A deep incision spontaneously dehisces or is deliberately opened by a surgeon and is culture- positive or not cultured when the patient has at least one of the following signs or symptoms: fever ( > 38° C), or localized pain or tenderness. A culture-negative finding does not meet this criterion. • An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination • Diagnosis of a deep incisional SSI by a surgeon or attending physician.

NOTE: There are two specific types of deep incisional SSIs:

• Deep Incisional Primary (DIP)- a deep incisional SSI that is identified in a primary incision in a patient that has had an operation with one or more incisions (e.g., C-section incision or chest incision for CBGB) • Deep Incisional Secondary (DIS)-a deep incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one incision (e.g., donor site [leg] incision for CBGB)

REPORTING INSTRUCTIONS: Classify infection that involves both superficial and deep incision sites as deep incisional SSI.

Please Note: NTDB no longer includes these codes in their definition. ICD9 Code Range: 674.30, 674.32, 674.34, 996.60-996.63; 996.66-996.69, 998.59

Deep vein thrombosis (DVT): The formation, development, or existence of a blood clot or thrombus within the vascular system, which may be coupled with inflammation. This diagnosis may be confirmed by a venogram, ultrasound, or CT. The patient must be treated with anticoagulation therapy and/or placement of a vena cava filter or clipping of the vena cava.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 451.0, 451.11, 451.19, 451.2, 451.81- 451.84, 451.89, 451.9, 453.40, 459.10- 459.19, 997.2, 999.2

Drug or alcohol withdrawal syndrome: A set of symptoms that may occur when a person who has been habitually drinking too much alcohol or habitually using certain drugs (e.g. narcotics, benzodiazepine) experiences physical symptoms upon suddenly stopping consumption. Symptoms may include: activation syndrome (i.e., tremulousness, agitation, rapid heartbeat and high blood pressure), seizures, hallucinations or delirium tremens.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 291.0, 291.3, 291.81, 292.0

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Appendix: Glossary of Terms

Extremity compartment syndrome: A condition not present at admission in which there is documentation of tense muscular compartments of an extremity through clinical assessment or direct measurement of intracompartmental pressure) requiring fasciotomy. Compartment syndromes usually involve the leg but can also occur in the forearm, arm, thigh, and shoulder. Record as a complication if it is originally missed, leading to late recognition, a need for late intervention, and has threatened limb viability.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 729.71, 729.72, 998.89, 958.91, 958.92, 958.90

Graft/prosthesis/flap failure: Mechanical failure of an extracardiac vascular graft or prosthesis including myocutaneous flaps and skin grafts requiring return to the operating room or a balloon angioplasty.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 996.00, 996.1, 996.52, 996.55, 996.61, 996.62, 996.72

Myocardial infarction: A new acute myocardial infarction occurring during hospitalization (within 30 days of injury).

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 414.8, 412

Organ/space surgical site infection: An infection that occurs within 30 days after an operation and infection involves any part of the anatomy (e.g., organs or spaces) other than the incision, which was opened or manipulated during a procedure; and at least one of the following, including: • Purulent drainage from a drain that is placed through a stab wound or puncture into the organ/space; • Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space; • An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination • Diagnosis of an organ/space SSI by a surgeon or attending physician.

Please Note: NTDB no longer includes these codes in their definition. ICD9 Code Range: 998.59

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Appendix: Glossary of Terms

Osteomyelitis: Defined as meeting at least one of the following criteria:

• Organisms cultured from bone. • Evidence of osteomyelitis on direct examination of the bone during a surgical operation or histopathologic examination. • At least two of the following signs or symptoms with no other recognized cause: o Fever (38° C) o Localized swelling at suspected site of bone infection o Tenderness at suspected site of bone infection o Heat at suspected site of bone infection o Drainage at suspected site of bone infection AND at least one of the following: o Organisms cultured from blood positive blood antigen test (e.g., H. influenzae, S. pneumoniae) o Radiographic evidence of infection, e.g., abnormal findings on x-ray, CT scan, magnetic resonance imaging (MRI), radiolabel scan (gallium, technetium, etc.).

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 730.00-730.29

Pneumonia: Patients with evidence of pneumonia that develops during the hospitalization and meets at least one of the following two criteria:

• Criterion #1: Rales or dullness to percussion on physical examination of chest AND any of the following: o New onset of purulent sputum or change in character of sputum o Organism isolated from blood culture o Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy

• Criterion #2: Chest radiographic examination shows new or progressive infiltrate, consolidation, cavitation, or pleural effusion AND any of the following: o New onset of purulent sputum or change in character of sputum o Organism isolated from the blood o Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy o Isolation of virus or detection of viral antigen in respiratory secretions o Diagnostic single antibody titer (IgM) or fourfold increase in paired serum samples (IgG) for pathogen o Histopathologic evidence of pneumonia

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 480.0-480.9, 481, 482.0-482.3, 482.30-483.39, 482.40-482.49, 482.81-48.89, 482.9, 483.0-483.8, 484.1-484.8, 485, 486, 997.31

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Appendix: Glossary of Terms

Pulmonary embolism: A lodging of a blood clot in a pulmonary artery with subsequent obstruction of blood supply to the lung parenchyma. The blood clots usually originate from the deep leg veins or the pelvic venous system. Consider the condition present if the patient has a V-Q scan interpreted as high probability of pulmonary embolism or a positive pulmonary arteriogram or positive CT angiogram.

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range 415.11; 415.12; 415.19; 416.2

Severe sepsis: Sepsis and/or Severe Sepsis defined as an obvious source of infection with bacteremia and two or more of the following:

• Temp > 38○ C or < 36○ C • White Blood Cell count >12,000/mm³, or > 20% immature (Source of Infection) • Hypotension – (Severe Sepsis) • Evidence of hypoperfusion: (Severe Sepsis) • Anion gap or lactic acidosis or Oliguria, or Altered mental status

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 785.52, 995.92

Stroke/CVA: A focal or global neurological deficit of rapid onset and NOT present on admission. The patient must have at least one of the following symptoms:

• Change in level of consciousness • Hemiplegia • Hemiparesis • Numbness or sensory loss affecting one side of the body • Dysphasia or aphasia • Hemianopia • Amaurosis fugax • Other neurological signs or symptoms consistent with stroke AND; • Duration of neurological deficit ≥ 24 h OR; • Duration of deficit <24 h, if neuroimaging (MR, CT, or cerebral angiography) documents a new hemorrhage or infarct consistent with stroke, or therapeutic intervention(s) were performed for stroke, or the neurological deficit results in death AND; • No other readily identifiable nonstroke cause, e.g., progression of existing traumatic brain injury, seizure, tumor, metabolic or pharmacologic etiologies, is identified AND; • Diagnosis is confirmed by neurology or neurosurgical specialist or neuroimaging procedure (MR, CT, angiography) or lumbar puncture (CSF demonstrating intracranial hemorrhage that was not present on admission).

Although the neurologic deficit must not present on admission, risk factors predisposing to stroke (e.g., blunt cerebrovascular injury, dysrhythmia) may be present on admission.

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Appendix: Glossary of Terms

Please Note: NTDB no longer includes these codes in their definition. ICD-9 Code Range: 434.01, 434.11, 434.91, 433.01-433.91, 997.02

Superficial surgical site infection: An infection that occurs within 30 days after an operation and infection involves only skin or subcutaneous tissue of the incision and at least one of the following:

• Purulent drainage, with or without laboratory confirmation, from the superficial incision. • Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision. • At least one of the following signs or symptoms of infection: o pain or tenderness o localized swelling o redness or heat o superficial incision is deliberately opened by the surgeon, unless incision is culture- negative. • Diagnosis of superficial incisional surgical site infection by the surgeon or attending physician.

Do not report the following conditions as superficial surgical site infection:

1. Stitch abscess (minimal inflammation and discharge confined to the points of suture penetration). 2. Infected burn wound. 3. Incisional SSI that extends into the fascial and muscle layers (see deep surgical site infection).

Please Note: NTDB no longer includes these codes in their definition. ICD9 Code Range: 998.59

Unplanned admission to ICU: INCLUDE: . Patients readmitted to the ICU after initial transfer to the floor. . Patients with an unplanned return to the ICU after initial ICU discharge. EXCLUDE: . Patients in which ICU care was required for postoperative care of a planned surgical procedure.

Unplanned intubation: Patient requires placement of an endotracheal tube and mechanical or assisted ventilation because of the onset of respiratory or cardiac failure manifested by severe respiratory distress, hypoxia, hypercarbia, or respiratory acidosis. In patients who were intubated in the field or Emergency Department, or those intubated for surgery, unplanned intubation occurs if they require reintubation > 24 hours after extubation.

Unplanned return to the OR: Unplanned return to the operating room after initial operation management for a similar or related previous procedure.

Please Note: Retired as of 2015

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Appendix: Glossary of Terms

Urinary tract infection: An infection anywhere along the urinary tract with clinical evidence of infection, which includes at least one of the following symptoms with no other recognized cause: . Fever ≥ 38○ C . WBC > 10,000 or < 3000 per cubic millimeter . Urgency . Frequency . Dysuria . Suprapubic tenderness AND; • Positive urine culture (≥ 100,000 microorganisms per cm3 of urine with no more than two species of microorganisms) OR; • At least two of the following signs or symptoms with no other recognized cause: Fever ≥ 38○ C o o WBC > 10,000 or < 3000 per cubic millimeter o Urgency o Frequency o Dysuria o Suprapubic tenderness AND at least one of the following: • Positive dipstick for leukocyte esterase and/or nitrate • Pyuria (urine specimen with >10 WBC/mm3 or >3 WBC/high power field of unspun urine) • Organisms seen on Gram stain of unspun urine • At least two urine cultures with repeated isolation of the same uropathogen (gram-negative bacteria or S. saprophyticus) with ≥102 colonies/ml in nonvoided specimens • ≤105 colonies/ml of a single uropathogen (gram-negative bacteria or S. saprophyticus) in a patient being treated with an effective antimicrobial agent for a urinary tract infection • Physician diagnosis of a urinary tract infection • Physician institutes appropriate therapy for a urinary tract infection

Excludes asymptomatic bacteriuria and “other” UTIs that are more like deep space infections of the urinary tract.

Please Note: NTDB no longer includes these codes in their definition. ICD9 Code Range: 595.0-595.9 or 599.0

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