11/24/2014 am revised: november 2014 · division of emergency medical services and trauma...

11/24/2014 AM

Revised: November 2014

Division of Emergency Medical Services and Trauma Reportable Hospital Trauma Registry Data Set

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Table of Contents

Introduction ......................................................................................................................................3

Definition of Trauma Patient ...........................................................................................................4

Registry Inclusion/Exclusion Criteria ..............................................................................................4

Data Elements

Demographic Information ................................................................................................................6

Injury Information ............................................................................................................................8

Pre Hospital Information................................................................................................................11

Emergency Department Information .............................................................................................19

Hospital Procedure Information .....................................................................................................23

Injury Severity ...............................................................................................................................25

Outcome Information .....................................................................................................................27


3

Introduction

This Data Dictionary contains inclusion and exclusion registry criteria and structured trauma data

element definitions. This manual is to be used as a guide to trauma centers in South Carolina. The Data

Dictionary serves to provide “help” to trauma professionals to understand data elements, as well as the

data functions and features.

The Data Dictionary is divided into logical sections allowing the user to locate information quickly and

easily.

The Data Dictionary provides the following:

Registry inclusion and exclusion criteria

Data element definitions and options

South Carolina Department of Health & Environmental Control

Division of Emergency Medical Services & Trauma

2600 Bull Street

Columbia, SC 29201-1708

Phone: (803) 545-4204 Fax: (803) 545-4563


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Definition of Trauma Patient

A trauma patient is defined as a patient who sustains a traumatic injury

and meets the inclusion/exclusion criteria approved by the Trauma

Advisory Council and included in this data dictionary.

Inclusion Criteria and Data Submit Dates

Include the following injuries:

At least one of the following injury diagnostic codes defined in the International Classification

of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM): 800 - 959.9

And MUST INCLUDE one of the following in addition to ICD-9-CM: 800 - 959.9

Hospital admission as defined by your trauma registry inclusion criteria; OR

Patient transfer via EMS transport (including air ambulance) from one hospital to another; OR

Death resulting from the traumatic injury (independent of hospital admission or hospital transfer

status)

Exclusion Criteria

Exclude the following injuries: 905 - 909.9 (late effects of injury)

910 - 924.9 (superficial injuries, including blisters, contusions, abrasions and insect bites)

930 - 939.9 (foreign bodies)

Age > 65 years with the same level fall (E code 885.9 & 888.9) and

o isolated hip fracture (ICD-9 820.0 – 820.9)

Trauma Registry Data Submission Schedule

ADMISSION PERIOD DUE DATE

January – March Due July 1

April – June Due October 1

July – September Due January 1

October – December Due April 1


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**Whether the data point is a “State Element” or

“National Element” is delineated in the right-hand

column. If the data point is a “National Element” refer to

the latest edition of the “ACS NTDB National Trauma

Data Standard: Data Dictionary” for further information.


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Demographics


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TRAUMA NUMBER Data Format [number] State Element

Definition: Indicates a unique number assigned to each trauma patient per visit at time of admission.

This number is unique to the trauma patient.

Required: Yes

Field Values: Auto-calculated with creation of new record

STATE Data Format [combo] single-choice State Element

Definition: Indicates if the trauma patient’s data is to be sent to the state central site registry.

Required: Yes

Field Values

Yes No

DATE OF BIRTH National Element

AGE National Element

AGE UNITS National Element

SEX National Element

RACE National Element

ETHNICITY National Element

PATIENT’S HOME ZIP CODE National Element

PATIENT’S HOME CITY National Element

PATIENT’S HOME STATE National Element

PATIENT’S HOME COUNTY National Element

ALTERNATE HOME RESIDENCE National Element

PATIENT’S HOME COUNTRY National Element


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Injury Information


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ICD-9 PLACE OF OCCURRENCE E-CODE National Element

ICD-10 PLACE OF OCCURRENCE E-CODE National Element

INJURY INCIDENT DATE National Element

INJURY INCIDENT TIME National Element

INDICATION LOCATION ZIP CODE National Element

INCIDENT CITY National Element

INCIDENT STATE National Element

INCIDENT COUNTY National Element

INCIDENT COUNTRY National Element

PROTECTIVE DEVICES National Element

CHILD SPECIFIC RESTRAINT National Element

AIRBAG DEPLOYMENT National Element

WORK-RELATED National Element

PATIENT’S OCCUPATION National Element

PATIENT’S OCCUPATIONAL INDUSTRY National Element

REPORT OF PHYSICAL ABUSE National Element

INVESTIGATION OF PHYSICAL ABUSE National Element

ICD-9 PRIMARY E-CODE National Element

ICD-10 PRIMARY E-CODE National Element

ICD-9 SECONDARY E-CODE National Element

ICD-10 SECONDARY E-CODE National Element


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INJURY TYPE (Blunt/Penetrating) Data Format [combo] single-choice State Element

Required: Yes

Definition: Indicates primary mechanism or type of force causing injury to trauma patient.

Field Values:

1. Blunt 2. Penetrating 3. Burn 4. Other

/- Not Applicable U- Unknown

Additional Information

Blunt- Non penetrating injury, from an external force causing injury.

Penetrating- Injury resulting from a projectile force, piercing instrument, and entering deeply

causing tissue and/or organ injury.

Burn- Tissue injury from excessive exposure to chemical, thermal, electrical, or radioactive

agents.

Injury Mechanism (Cause of Injury) Data Format [combo] single-choice State Element

Required: Yes

Definition: The event(s) that occurred to cause injury to patient.

Field Values 01. MVC 02. Motor Water Related Injury 03. Pedestrian

04. Bicycle 05. Motorcycle 06. Cut/Piercing

07. Stab 08. Gunshot Wound 09. Assault

10. Industrial 11. Farm 12. Fall

13. Sports 14. Burn 15. Other

16. Snake Bite 17. Asphyxiation 18. Injury by Animal

19. Moped 20. Four Wheel/ATV

U- Unknown


02. Motor Water Related - Includes boating, water skiing, jet skiing, para-sailing, etc.

04. Bicycle - Non-motorized two to four wheeled pedal cycle

10. Industrial - Accidents that occur in industry, plant, or factory facilities

11. Farm - Includes farming equipment or actual farming, whether private or non-private

13. Sports - Includes organized or recreational activity

14. Burn - Includes chemical, electrical, thermal, and radiation

15. Other- Includes Lawnmowers; Golf Cart

17. Asphyxiation - Includes hanging, drowning, and suffocation

18. Injury by Animal Related - Includes marine life, dog bites, etc.

19. Moped- Includes Motorized Scooters

21. Motor Water Related - Includes boating, water skiing, jet skiing, para-sailing, etc.


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Pre-hospital Information


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TRANSPORT MODE National Element

OTHER TRANSPORT MODE National Element

PREHOSPITAL EMS AGENCY (DHEC Number) Data Format [combo] single-choice State Element

Definition:

Pre-hospital EMS Agency Name/DHEC Permit Number (including “0’s”) is shown on the ambulance

run report and is the same as the providers license number.

Required - Yes

Field Values

Relevant code value for EMS agency


List is provided of all EMS/Air Medical providers in the state.

Data Source Hierarchy

1. EMS Run Sheet

ROLE Data Format [combo] single-choice State Element

Definition: The role EMS provider played in transport to facility.

Required - Yes

Field Values

1-Transport from scene 2-Transport from rendezvous 3-Non-transport

/- N/A ? - Unknown


None


1. EMS Run Sheet


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SCENE EMS REPORT: Data Format [combo] single-choice State Element

Definition: Indicates if the EMS Run Form was available

Required - Yes

Field Values

1- Complete 2- Incomplete 3- Missing 4-Unreadable

/- Not Applicable U- Unknown


1. EMS Run Sheet

PATIENT CARE REPORT NUMBER (PCR#) Data Format –Alpha_Numeric State Element

Definition:

This number is unique per patient per incident. Pre-printed reports have six digits, and letters, however,

electronic run reports may have any number of digits.

Required - Yes

Field Values

Relevant from the PCR


EMS Report Number


1. EMS Run Sheet

EMS DISPATCH DATE National Element

EMS DISPATCH TIME National Element

EMS UNIT ARRIVAL DATE AT SCENE OR TRANSFERRING FACILITY National Element


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EMS UNIT ARRIVAL TIME AT SCENE OR TRANSFERRING FACILITY National Element

EMS UNIT DEPARTURE DATE FROM SCENE OR TRANSFERRING

FACILITY National Element

EMS UNIT DEPARTURE TIME FROM SCENE OR TRANSFERRING

FACILITY National Element

EMS SCENE TIME ELAPSED Data Format: numerical State Element

Definition

Total EMS Scene Time (elapsed time from EMS scene arrival to EMS departure from scene)

Required - Yes


Auto calculated


1. EMS Run Sheet

TRAUMA CENTER CRITERIA National Element

**This data element should be “U-Unknown” until NEMSIS 3 is live in the State of South Carolina.

As of 11/2014, NEMSIS 3 is not live in South Carolina. After go-live of NEMSIS 3, the pre-hospital

provider will choose the corresponding field value as to specific reason the patient was transported to

a Trauma Center.

VEHICULAR, PEDESTRIAN, OTHER RISK INJURY National Element

PRE-HOSPITAL CARDIAC ARREST National Element


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INTUBATED State Element Data Format: Single-Choice

Definition

Was the patient intubated by EMS

Required-Yes

Field Values:

Yes No /-Not Applicable ?-Unknown


1. EMS Run Sheet

IF YES, METHOD Data Format: Single-Choice State Element

Definition

If the patient was intubated by EMS, what was the method used for intubation

Required- Yes

Field Values:

1. Combitube 2. Cricothyrotomy

4. Endotracheal Tube-Nasal 5. Endotracheal tube-Oral

6. Endotracheal Tube0 Route NFS 7. Esophageal Obturator Airway

8. Laryngeal Mask Airway 9. LT Blind Insertion Airway Device

10. Tracheostomy ?-Unknown


1. EMS Run Sheet

INITIAL FIELD SYSTOLIC BLOOD PRESSURE National Element

INITIAL FIELD PULSE RATE National Element

INITIAL FIELD RESPIRATORY RATE National Element

INITIAL FIELD OXYGEN SATURATION National Element

INITIAL FIELD GCS – EYE National Element


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INITIAL FIELD GCS – VERBAL National Element

INITIAL FIELD GCS – MOTOR National Element

INITIAL FIELD GCS – TOTAL National Element

RTS (Revised Trauma Score) Data Format [number] State Element

Definition

Is based on the values of the Glasgow Coma Scale, systolic blood pressure and respiratory rate. This

field is calculated automatically or may be entered manually.

Required – Yes

Field Values

Between 0 to 12 – Auto calculated if all designated values completed.


1. EMS Run Sheet

INTER-FACILITY TRANSFER National Element

REFERRING FACILITY (ID) Data Format [combo choice] State Element

Definition

The name (or identifying number of the referring facility).

Required- Yes

Field Values

Relevant value for data element.



1. Hospital Record


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REFERRING FACILITY/HOSPITAL ARRIVAL Data Format [date and time] State Element

Definition

The date the patient arrived at the referring hospital.

Required- Yes

Field Values



Used to auto-generate an additional calculated field: Length of Hospital Stay (elapsed time from

arrival to departure)


1. Hospital Record

REFERRING FACILITY/HOSPITAL DEPARTED Data Format [date and time] State Element

Definition

The date the patient departed from the referring hospital.

Required- Yes

Field Values



Used to auto-generate an additional calculated field: Length of Hospital Stay (elapsed time from

arrival to departure)


1. Hospital Record


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REFERRING FACILITY LOS Data Format [numerical] State Element

Definition

The length of time the patient was at the referring facility in hours.

Required- Yes

Field Values



Auto-calculated if Referring Facility/Hospital Arrival Data and Time and Departed Date and

Time are entered.


1. Hospital Record


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Emergency Department Information


20

DIRECT ADMIT State Element Data Format [combo] single-choice

Definition

Patient admitted directly to the floor or ICU without being resuscitated in the emergency department.

Required- Yes

Field Values

1. Yes 2. No


1. History & Physical

2. Nurses Notes

3. Hospital Discharge Summary

4. EMS Sheet

5. Consults

ED/HOSPITAL ARRIVAL DATE National Element

ED/HOSPITAL ARRIVAL TIME National Element

ED DISCHARGE DATE National Element

ED DISCHARGE TIME National Element

TIME IN ED State Element Data Format [numerical]

Definition

The length of time the patient was in the Emergency Department.

Required- Yes

Field Values



Auto-calculated if ED/Hospital Arrival Date/Time and ED Discharge Date and Time entered.


1. ED Record

2. Nurses Records


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SIGNS OF LIFE National Element

MODE OF ARRIVAL Data Format [combo] single-choice State Element

Definition

The mode of arrival of the patient at the hospital

Required - Yes

Field Values

1- Ground Ambulance 2-Helicopter Ambulance

3- Fixed-Wing Ambulance 4- Private Vehicle or Walk-In

5-Police 6- Public Safety

7- Water Ambulance 8- Other

?- Unknown


1. Triage Form / Trauma Flow Sheet

2. ED Nurses’ Notes

INITIAL ED/HOSPITAL WEIGHT National Element

INITIAL ED/HOSPITAL HEIGHT National Element

INITIAL ED/HOSPITAL TEMPERATURE National Element

INITIAL ED/HOSPITAL GCS ASSESSMENT QUALIFIERS National Element

INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE National Element

INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE National Element

INITIAL ED/HOSPITAL PULSE RATE National Element

INITIAL ED/HOSPITAL RESPIRATORY RATE National Element

INITIAL ED/HOSPITAL OXYGEN SATURATION National Element

INITIAL ED/HOSPITAL SUPPLEMENTAL OXYGEN National Element

INITIAL ED/HOSPITAL GCS – EYE National Element

INITIAL ED/HOSPITAL GCS – VERBAL National Element


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INITIAL ED/HOSPITAL GCS – MOTOR National Element

INITIAL ED/HOSPITAL GCS – TOTAL National Element

REVISED TRAUMA SCORE (RTS) State Element

Data Element Name: RTS (Revised Trauma Score)

Definition

Physiologic Injury Severity Score

Required: Yes

Field Values

Relevant value for data element; Range from 0 to 12.


This field is calculated automatically or you can enter manually

Based on the values of the Glasgow Coma Scale, Systolic Blood Pressure and Respiratory Rate


1. Triage Form / Trauma Flow Sheet

2. ED Nurses’ Notes

ALCOHOL USE INDICATOR National Element

DRUG USE INDICATOR National Element

ED DISCHARGE DISPOSITION National Element


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Hospital Procedure Information


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ICD-9 HOSPITAL PROCEDURES National Element

ICD-10 HOSPITAL PROCEDURES National Element

HOSPITAL PROCEDURE START DATE National Element

HOSPITAL PROCEDURE START TIME National Element


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Injury Severity Information


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AIS VERSION National Element

LOCALLY CALCULATED ISS National Element

TRISS Data Format Numeric State Element

Definition

Trauma Score Injury Severity Score determines the probability of survival (Ps) of a patient using the ISS

and RTS.

Required: Yes

Field Values



Patients must have an ISS score and a RTS in the Acute Care section for Collector to calculate.

This field is automatically calculated.

You must have data in the following fields for a score to calculate:

the patient’s age

blunt or penetrating

WRTS

ISS

If any of these fields are blank or have unknown entered, the TRISS will not calculate.

ICD-9 INJURY DIAGNOSES National Element

ICD-10 INJURY DIAGNOSES National Element

AIS PREDOT CODE National Element

AIS SEVERITY National Element

ISS BODY REGION National Element

CO-MORBID CONDITIONS National Element


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Outcome Information


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HOSPITAL DISCHARGE DATE National Element

HOSPITAL DISCHARGE TIME National Element

TOTAL ICU LENGTH OF STAY National Element

TOTAL VENTILATOR DAYS National Element

TOTAL LENGTH OF STAY (Total LOS) State Element Data Formant [number]

Definition

The cumulative amount of time spent at your hospital. Each partial or full day is measure as one day.

Required-Yes

Field Values



Recorded in full day increments with any partial calendar day counted as a full calendar day.

If any dates are missing then a LOS cannot be calculated.


1. Nursing Flow Sheet//Progress Notes

2. Calculated Based on Admission Form and Discharge Sheet

HOSPITAL DISCHARGE DISPOSITION National Element


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IF TRANSFRRED, FACILITY Data Format [combo] single-choice State Element

Definition: Indicates the facility code to which the patient was transferred after admission to your

hospital

Required: Yes

Field Values Relevant value for data element


Please select the appropriate hospital from the menu. All facilities in SC are listed, as well as

common facilities in NC and GA. If a hospital is not on the list, choose, Other.


1. EMTALA Form

2. Discharge Summary

3. Doctor’s Orders

4. Nurses’ Notes

5. Case Manager’s Notes

WAS AUTOPSY PERFORMED Data Format [combo] single-choice State Element

O_05

Definition

Indicates if an autopsy was performed on deceased trauma patient

Required - Yes

Field Values

1. Yes 2. No /- Not Appropriate U- Unknown


1. Death Form

2. Hospital Discharge Summary

3. Nurses’ Notes

PRIMARY METHOD OF PAYMENT National Element

COMPLICATIONS National Element

11/24/2014 am revised: november 2014 · division of emergency medical services and trauma...

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