2018 PENNSYLVANIA TRAUMA SYSTEMS FOUNDATION OPERATIONAL MANUAL FOR THE DATA BASE COLLECTION SYSTEM 1 TABLE OF CONTENTS TOPIC PAGE NUMBER PREFACE .................................................................................................................................................. 10 GENERAL INSTRUCTIONS ........................................................................................................................ 12 PTOS PATIENT INCLUSION CRITERIA ....................................................................................................... 14 SECTION I: DEMOGRAPHIC DATA .......................................................................................................... 18 INSTITUTION NUMBER .............................................................................................................. 19 ZIP CODE OF RESIDENCE ........................................................................................................... 19 RACE .......................................................................................................................................... 19 ETHNICITY ................................................................................................................................. 20 SEX ............................................................................................................................................. 20 DATE OF BIRTH .......................................................................................................................... 20 AGE ............................................................................................................................................ 20 PRIMARY ICD-10 MECHANISM (EXTERNAL CAUSE OF MORBIDITY (ICD-10-CM))/ PRIMARY CAUSE OF INJURY E-CODE (ICD-9) ............................................................................................ 21 PRIMARY CAUSE OF INJURY- External Cause of Morbidity (ICD-10-CM) SPECIFY/(E-CODE SPECIFY (ICD-9)) ........................................................................................................................ 21 SECONDARY ICD-10 MECHANISM - External Cause of Morbidity (ICD-10-CM)/(E-CODE (ICD-9)) ................................................................................................................................................... 22 HEIGHT OF FALL ........................................................................................................................ 22 PLACE OF INJURY OF THE EXTERNAL CAUSE (Y92)(ICD-10)/( PLACE OF INJURY E-CODE (E849.X)(ICD-9) .......................................................................................................................... 23 PLACE OF INJURY EXTERNAL CAUSE CODE- ICD-10-CM/ E-CODE (ICD-9) SPECIFY ................... 23 ACTIVITY E-CODE (OPTIONAL ELEMENT FOR ALL TRAUMA CENTERS) ..................................... 24 INJURY DATE ............................................................................................................................. 24 INJURY TIME .............................................................................................................................. 24 COUNTY OF INJURY (STATE IF NOT PA) .................................................................................... 24 COUNTY OF INJURY (STATE IF NOT PA) IF OTHER..................................................................... 24 PROTECTIVE DEVICES ................................................................................................................ 25 PRIMARY - TYPE OF INJURY ....................................................................................................... 25 SECONDARY -TYPE OF INJURY ................................................................................................... 26 TYPE OF BURN INJURY .............................................................................................................. 26 PRE-EXISTING CONDITIONS ...................................................................................................... 26 SECTION II: PREHOSPITAL DATA ............................................................................................................ 27 SECTION II: PREHOSPITAL DATA ............................................................................................... 28 WAS PATIENT EXTRICATED? ..................................................................................................... 28 WERE SCENE PROVIDER AND TRANSPORT PROVIDER THE SAME? .......................................... 28 ARE ANY SCENE PROVIDER DATA AVAILABLE? ......................................................................... 28 PROVIDER – SCENE AND/OR TRANSPORT ................................................................................ 30 DATES AND TIMES – SCENE AND/OR TRANSPORT ................................................................... 30 AMBULANCE SCENE TIME (auto calculation) ........................................................................... 31 AMBULANCE CODE – SCENE AND/OR TRANSPORT .................................................................. 31 2 January 2018 Grey Highlighted area = addition or revision AMBULANCE UNIT NUMBER – SCENE AND/OR TRANSPORT ................................................... 31 WAS PATIENT CARE RECORD (PCR) AVAILABLE? – SCENE AND/OR TRANSPORT (FLTR 2) ....... 31 PATIENT CARE RECORD NUMBER – SCENE AND/OR TRANSPORT ............................................ 32 LIFE SUPPORT – HIGHEST LEVEL OF PROVIDER (SCENE AND/OR TRANSPORT) ...................... 32 LIFE SUPPORT – HIGHEST LEVEL OF CARE (SCENE AND/OR TRANSPORT)............................... 32 WAS A COMPLETE SET OF VITAL SIGNS (INCLUDING GCS) TAKEN PRIOR TO THE PATIENT LEAVING THE SCENE OF INJURY? .............................................................................................. 33 PREHOSPITAL VITAL SIGNS – SCENE AND/OR TRANSPORT (PULSE RATE/MINUTE) ................ 33 PREHOSPITAL VITAL SIGNS – SCENE AND/OR TRANSPORT (UNASSISTED RESPIRATORY RATE/MINUTE) .......................................................................................................................... 34 PREHOSPITAL VITAL SIGNS – SCENE AND/OR TRANSPORT (SYSTOLIC BLOOD PRESSURE) ...... 34 PREHOSPITAL VITAL SIGNS – SCENE AND/OR TRANSPORT (GCS-EYE OPENING) ..................... 35 PREHOSPITAL VITAL SIGNS – SCENE AND/OR TRANSPORT (GCS-VERBAL RESPONSE) ............ 35 PREHOSPITAL VITAL SIGNS – SCENE AND/OR TRANSPORT (GCS-MOTOR RESPONSE) ............ 36 PREHOSPITAL VITAL SIGNS - GCS QUALIFIERS – Matches NTDB Initial ED/Hospital GCS Assessment Qualifiers ............................................................................................................... 37 PREHOSPITAL VITAL SIGNS – GCS QUALIFIERS – PARALYZING DRUGS SPECIFY ....................... 38 PREHOSPITAL VITAL SIGNS – SCENE AND/OR TRANSPORT (INTUBATED W/ ARTIFICIAL AIRWAY) .................................................................................................................................... 38 PREHOSPITAL VITAL SIGNS – SCENE AND/OR TRANSPORT - IS PATIENT’S RESPIRATORY RATE CONTROLLED? (BAGGING OR VENTILATOR) ............................................................................ 39 PREHOSPITAL VITAL SIGNS – SCENE AND/OR TRANSPORT-CONTROLLED RESPIRATORY RATE ................................................................................................................................................... 39 REFERRING FACILITY - IS THIS A TRANSFER PATIENT? .............................................................. 39 REFERRING FACILITY – IS THERE DATA/INFORMATION AVAILABLE FROM OUTSIDE FACILITY? ................................................................................................................................................... 40 REFERRING FACILITY - DATE AND TIME OF ADMISSION AT REFERRING FACILITY .................... 40 REFERRING FACILITY - DATE AND TIME OF DISCHARGE FROM REFERRING FACILITY .............. 40 REFERRING FACILITY LENGTH OF STAY (Auto Calculation) ....................................................... 40 REFERRING FACILITY - DIAGNOSTIC INTERVENTIONS AT REFERRING FACILITY ....................... 41 REFERRING FACILITY - THERAPEUTIC INTERVENTIONS AT REFERRING FACILITY ..................... 43 REFERRING FACILITY - REFERRAL FROM FACILITY NUMBER..................................................... 44 REFERRING FACILITY – UNRESOLVED OCCURRENCES .............................................................. 44 REFERRING FACILITY - IS REFERRAL FACILITY CLINICAL DATA AVAILABLE? .............................. 44 REFERRING FACILITY (PULSE RATE/MINUTE) ........................................................................... 44 REFERRING FACILITY (UNASSISTED RESPIRATORY RATE/MINUTE) .......................................... 45 REFERRING FACILITY (SYSTOLIC BLOOD PRESSURE) ................................................................. 45 REFERRING FACILITY (GCS-EYE OPENING) ................................................................................ 45 REFERRAL FACILITY (GCS-VERBAL RESPONSE) .......................................................................... 46 REFERRING FACILITY (GCS-MOTOR RESPONSE)........................................................................ 47 REFERRING FACILITY - GCS QUALIFIERS - Matches NTDB Initial ED/Hospital GCS ................... 47 Assessment Qualifiers ............................................................................................................... 47 REFERRING