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National Trauma Registry Comprehensive Data Set—Data Dictionary

Standards and Data Submission

Our VisionBetter data. Better decisions. Healthier Canadians.

Our MandateTo lead the development and maintenance of comprehensive and integrated health information that enables sound policy and effective health system management that improve health and health care.

Our ValuesRespect, Integrity, Collaboration, Excellence, Innovation

Table of Contents

Revision History ............................................................................................................................ v

Acknowledgements ..................................................................................................................... vii

Section 1—Introduction ................................................................................................................. 1 History ....................................................................................................................................... 2 Participating Facilities and Provinces ........................................................................................ 4 Data Dictionary Layout .............................................................................................................. 5 Trauma Defined ......................................................................................................................... 5 Null Values ................................................................................................................................ 6

Section 2—Data Elements ............................................................................................................ 7

Section 2A—Demographic Data ................................................................................................... 7 Institution Number ..................................................................................................................... 7 Trauma Number ........................................................................................................................ 8 Fiscal Year of Patient Discharge ............................................................................................... 9 Province .................................................................................................................................. 10 Unique Personal Identifier ....................................................................................................... 11 Age .......................................................................................................................................... 12 Sex .......................................................................................................................................... 13 Postal Code ............................................................................................................................. 14

Section 2B—Injury Data .............................................................................................................. 15 Date of Injury ........................................................................................................................... 15 Time of Injury ........................................................................................................................... 16 Place of Incident (ICD-9-CM) .................................................................................................. 17 Place of Incident (ICD-10-CA) ................................................................................................. 18 Injury Etiology (ICD-9-CM) ...................................................................................................... 19 Injury Etiology (ICD-10-CA) ..................................................................................................... 20 Injury Type ............................................................................................................................... 21 Nature of Injury Codes (ICD-9-CM) ......................................................................................... 22 Nature of Injury Codes (ICD-10-CA)........................................................................................ 23 Sports/Recreational Activity Code ........................................................................................... 24 Work-Related Code ................................................................................................................. 25 Protective Devices ................................................................................................................... 26

Section 2C—Scene Data ............................................................................................................ 27 Modes of Transport to Trauma Centre .................................................................................... 27 Systolic Blood Pressure on Arrival at Scene ........................................................................... 28

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Unassisted Respiratory Rate on Arrival at Scene ................................................................... 29 Heart Rate on Arrival at Scene ................................................................................................ 30 Glasgow Coma Scale—Eye at Scene ..................................................................................... 31 Glasgow Coma Scale—Verbal at Scene ................................................................................. 32 Glasgow Coma Scale—Motor at Scene .................................................................................. 33 Total Glasgow Coma Scale at Scene ...................................................................................... 34

Section 2D—Lead/Trauma Hospital: Pre-Admission Data ......................................................... 35 Inter-Facility Transfer............................................................................................................... 35 Transferring Institution ............................................................................................................. 36 ED Bypass ............................................................................................................................... 37 Date of Arrival .......................................................................................................................... 38 Time of Arrival ......................................................................................................................... 39 Temperature on Arrival ............................................................................................................ 40 Systolic Blood Pressure on Arrival .......................................................................................... 41 Intubation Code on Arrival ....................................................................................................... 42 Unassisted Respiratory Rate on Arrival ................................................................................... 43 Heart Rate on Arrival ............................................................................................................... 44 Paralytic Agents ...................................................................................................................... 45 Glasgow Coma Scale—Eye .................................................................................................... 46 Glasgow Coma Scale—Verbal ................................................................................................ 47 Glasgow Coma Scale—Motor ................................................................................................. 48 Total Glasgow Coma Scale ..................................................................................................... 49 Total Revised Trauma Score on Arrival................................................................................... 50 Blood Alcohol Concentration ................................................................................................... 51 Post-ED/-Arrival Destination .................................................................................................... 52

Section 2E—Lead/Trauma Hospital: Post-Admission Data ........................................................ 53 Date of Admission ................................................................................................................... 53 Length of Stay ......................................................................................................................... 54 Intensive Care Unit Days ......................................................................................................... 55 Predot Injury Codes (AIS 1990) .............................................................................................. 56 Predot Injury Codes (AIS 2005, Update 2008) ........................................................................ 57 Severity Codes and ISS Body Regions (AIS 1990) ................................................................. 58 Severity Codes and ISS Body Regions (AIS 2005, Update 2008) .......................................... 59 MAIS Code by ISS Body Region (AIS 1990) ........................................................................... 60 MAIS Code by ISS Body Region (AIS 2005, Update 2008) .................................................... 61 Injury Severity Score (AIS 1990) ............................................................................................. 62 Injury Severity Score (AIS 2005, Update 2008)....................................................................... 63

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Number of Ventilator Days ...................................................................................................... 64 OR Procedures (ICD-9-CM) .................................................................................................... 65 OR Procedures (ICD-10-CA) ................................................................................................... 66 Date of OR Procedures (ICD-10-CA) ...................................................................................... 67 Comorbidities .......................................................................................................................... 68 Comorbidities (ICD-10-CA)...................................................................................................... 69 Complications .......................................................................................................................... 70 Complications (ICD-10-CA) ..................................................................................................... 71 Date of Discharge .................................................................................................................... 72 Separation Status .................................................................................................................... 73 Discharge Disposition .............................................................................................................. 74

Section 3—Appendices ............................................................................................................... 75 Appendix A: Sports/Recreational Activity Codes ..................................................................... 75 Appendix B: Inclusion Lists—ICD-10-CA ................................................................................ 79 Appendix C: Exclusion Lists—ICD-10-CA ............................................................................... 81 Appendix D: Injury Types ........................................................................................................ 83 Appendix E: List of Comorbidities and Accompanying Definitions .......................................... 85 Appendix F: List of Complications and Accompanying Definitions .......................................... 91 Appendix G: Definitions of Discharge Disposition Institutions ................................................. 97 Appendix H: Revised Trauma Score ....................................................................................... 99 Appendix J: Acceptable Procedures Performed in the ICU ................................................... 101

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Revision History Date Version Description Data Elements Affected

August 2010 1.0 Initial document N/A

March 2011 2.0 Definition and code corrections All

July 2012 3.0 Definition or value changes Postal Code Comorbidities Separation Status Intensive Care Unit Days

Code corrections Appendix F—Pneumonia Appendix J—Procedures Performed in the ICU

Clarifications Injury Type Protective Devices Modes of Transport Time of Arrival Blood Alcohol Concentration Number of Ventilator Days OR Procedures Comorbidities (ICD-10-CA) Complications (ICD-10-CA)

Effective date changed to 2012 All new and revised data elements

Deletion Appendix G—List of Valid Institution Numbers per Province

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Acknowledgements

This document was made possible by the contributions of the following people:

• Dr. Avery Nathens, Trauma Association of Canada

• Dr. Mary Van Wijngaarden Stephens, Trauma Association of Canada

• Ms. Maureen Brennan, Trauma Association of Canada/Trauma Registry Information Specialists of Canada

• Ms. Ali Moses McKeag, Canadian Institute for Health Information

• Ms. Tonia Forte, Canadian Institute for Health Information

• Ms. Tamara Williams, Canadian Institute for Health Information

• Ms. Beth Sealy, Provincial Trauma Registry Representative, Nova Scotia

• Ms. Sharon Kasic, Provincial Trauma Registry Representative, British Columbia

• Ms. Nasira Lakha, Provincial Trauma Registry Representative, British Columbia

• Ms. Christi Findlay, Provincial Trauma Registry Representative, Alberta

• Ms. Irma Brown, Provincial Trauma Registry Representative, Alberta

• Mr. Mike Hoppensack, Provincial Trauma Registry Representative, Manitoba

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Section 1—Introduction

The National Trauma Registry (NTR) is made up of two data sets: the minimal data Set (MDS) and the comprehensive data set (CDS). The NTR MDS is downloaded from the Discharge Abstract Database and Hospital Morbidity Database and includes all hospital admissions coded with a range of selected International Classification of Disease (ICD) cause of injury codes. The NTR CDS is made up of detailed trauma data that is collected at specific trauma hospitals across the country and submitted to CIHI. This document will focus on the NTR CDS. Details on the data elements included in the NTR MDS can be found on CIHI’s website at www.cihi.ca/ntr.

The purpose of the National Trauma Registry Comprehensive Data Set Data Dictionary is to provide a clear definition of and data entry instructions for each data element within the NTR CDS. This will provide consistency in data collection across the country as well as aid in the interpretation of this data. An additional benefit will be increased data quality.

The NTR CDS is managed by the Canadian Institute for Health Information (CIHI). Data is obtained from participating facilities in nine provinces (British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, New Brunswick, Nova Scotia and Newfoundland and Labrador).

The goals of the NTR are to

• Contribute to the reduction of injuries and related deaths in Canada by providing data which will allow for the examination of national injury epidemiology;

• Facilitate provincial and international injury comparisons;

• Increase awareness of injury as a public health problem in Canada;

• Assist injury prevention programs; and

• Facilitate injury research.

The NTR CDS consists of information on patients hospitalized with major trauma in participating hospitals in Canada. Trauma cases are selected based on an Injury Severity Score (ISS) greater than 12 and the presence of specific external cause of injury codes that meet the definition of trauma. Many participating provinces use specialized trauma software (such as Collector from Digital Innovation and Tri-Code from Tri-Analytics, Inc.) to collect the data on injury cases. NTR CDS data is a subset of participating provincial trauma registries and is electronically submitted to CIHI.

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A trauma case is included in the NTR CDS if it

• Has an ISS greater than 12, using an international scoring system created to calculate the severity of injury;

• Has an ICD external cause of injury code that meets the definition of trauma (see Appendix B for more detail); and

• Meets one of the following criteria:

− Admitted to a participating hospital; or

− Treated in the emergency department of a participating hospital (not admitted); or

− Died in the emergency department of a participating hospital after treatment was initiated (not admitted).

The NTR Advisory Committee (NTRAC) is co-chaired by members of the Trauma Association of Canada (TAC). Traditionally, the co-chair positions have been filled by a TAC full member and a member of the Trauma Registry Information Specialists of Canada (TRISC). NTRAC includes provincial representation from trauma care experts from across the country and has played a key role in the development of the NTR. The role of this group has included advising on the goals and objectives of the NTR, uses of the data, definitions, inclusion/exclusion criteria, data quality issues, report formats and development of promotional strategies.

Although an NTR CDS data submission specifications document exists, the need for a comprehensive NTR CDS data dictionary was identified. This project, a joint effort between TAC and CIHI, was initiated in 2005. An NTRAC subcommittee was formed with representation from TAC (members who are medical doctors), TRISC and CIHI. Input was sought from provincial trauma registry contacts from submitting provinces as well as NTRAC members. The process involved a comprehensive review of the existing NTR CDS data elements and existing definitions. Changes were made to some existing NTR CDS data element names and definitions, and new data elements were proposed for inclusion in the data set.

The American National Trauma Data Standard Dictionary was referred to during the development of the NTR data dictionary to guide decisions on data element definitions to allow for international data comparisons.

History

The establishment of the NTR, including the acquisition, analysis and dissemination of national injury data, is consistent with the mission, vision and corporate goals of CIHI. CIHI worked toward the establishment of the NTR from the creation of the Ontario Trauma Registry in May 1992 at the Hospital Medical Records Institute, one of CIHI’s founding organizations.

The number of data elements in the NTR CDS was expanded from 17 to 45 for the collection of 1999–2000 data, as approved by members of the NTR CDS Working Group and as part of CIHI’s Roadmap Initiative. Elements added include the following:

• Sports/Recreational Activity Code;

• Work-Related Code;

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• Protective Devices;

• Total Revised Trauma Score on Arrival;

• Severity Codes and ISS Body Regions (AIS 1990); and

• Various data elements related to vital signs upon arrival at the trauma hospital.

The following data elements were added in 2012, as the outcome of the NTR data dictionary development project:

• Transferring Institution

• ED Bypass

• Systolic Blood Pressure on Arrival at Scene

• Heart Rate on Arrival at Scene

• Unassisted Respiratory Rate on Arrival at Scene

• Glasgow Coma Scale—Eye at Scene

• Glasgow Coma Scale—Verbal at Scene

• Glasgow Coma Scale—Motor at Scene

• Total Glasgow Coma Scale at Scene

• Time of Arrival

• Temperature on Arrival

• Heart Rate on Arrival

• Post-ED/-Arrival Destination

• Intensive Care Unit Days

• Date of OR Procedures

• Comorbidities

• Injury Severity Score (AIS 2005, Update 2008)

• Predot Injury Codes (AIS 2005, Update 2008)

• Severity Codes and ISS Body Region (AIS 2005, Update 2008)

• MAIS Code by ISS Body Region (AIS 2005)

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Participating Facilities and Provinces

Table 1: Participating Provinces and Number of Facilities, NTR CDS, 1999–2000 to 2010–2011

Province

Number of Participating Facilities by Fiscal Year

1999–2000

2000–2001

2001–2002

2002–2003

2003–2004

2004–2005

2005–2006

2006–2007

2007–2008

2008–2009

2009– 2010

2010–2011

B.C. 5 8 6 6 7 9 8 9 10 12 9 9

Alta. 4 4 4 4 4 4 4 4 4 9 10 11

Sask. 0 0 0 0 0 0 0 0 0 0 2 2

Man. 1 1 1 1 1 1 1 1 1 1 1 1

Ont. 13 13 13 13 13 13 13 13 13 13 13 13

Que. 0 6 6 6 6 6 6 59 59 59 59 61

N.B. 0 1 1 1 1 1 1 1 1 1 1 1

N.S. 2 9 10 10 10 10 10 10 10 10 10 10

P.E.I. 0 0 0 0 0 0 0 0 0 0 0 0

N.L. 0 0 0 0 3 3 3 3 3 3 3 3

In previous years, the number of participating provincial/regional trauma registries and facilities has differed slightly in the NTR CDS. As well, there is significant variation in trauma system configuration across provinces, as well as some re-assignments of facility numbers when mergers take place. Therefore, trends and comparisons over time and across provinces should be interpreted with caution.

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Data Dictionary Layout

The data elements are grouped according to the type of data they cover. Each data element will have the following specifications:

Name in Database The actual name of the field in the NTR CDS

Definition The NTR definition of the data element

Data Type The type of data that can be entered into the field, usually CHAR for character, DATE for date or NUMB for number. For instance, NUMB indicates that the field is restricted strictly to numeric values.

Data Element Length The number of characters required for that data element. For example, “21” cannot be entered into a field with a data element length of 1. When decimal places are accepted for a data element, they are denoted by a number following a comma. For example, “5, 2” denotes a total field length of 5, including 2 decimal places.

Mandatory A simple yes or no signifying whether the data element is mandatory for submission to the NTR CDS

Field Values A list of the possible values that may be entered into the field for the data element, either the format of the field or a range of accepted values

Constraints Any constraints on the values that can be input

Null Values Null values accepted in most fields. Submitted null values are transformed on site at CIHI into the required format for the database (see page 6).

Source Indicates whether the data is calculated or directly input

Hierarchy Source hierarchy for finding data elements in the patient’s chart

Additional Information Any additional directives for entering data into the data element will be written in this box. It also contains any other information that would be useful for someone who is either documenting the data or analyzing the information.

Uses of Data How the data element is used

History Historical changes to the data elements, with effective dates of changes

Trauma Defined

A trauma case is included in the NTR CDS if it

• Has an ISS greater than 12, using AIS 1990 or AIS 2005, an international scoring system created to calculate the severity of injury;

• Has an ICD external cause of injury code that meets the definition of trauma (see Appendix B for more detail); and

• Meets one of the following criteria:

− Admitted to a participating hospital; or

− Treated in the emergency department of a participating hospital (not admitted); or

− Died in the emergency department of a participating hospital after treatment was initiated (not admitted).

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Null Values

Missing Value Label Collector Value Database Value

Not Known (Unknown)

U 9; or 99 (for data elements with 9 as an allowable value); or 999 (for data elements with 99 as an allowable value)

Not Applicable (Inappropriate)

I 8; or 88 (for data elements with 8 as an allowable value); or 888 (for data elements with 88 as an allowable value)

• Not known: This null value applies if, at the time of patient care documentation or data abstraction, information was not known. Translating the Collector value to the database value is done when data is received at CIHI.

• Not applicable: This null value code applies if, at the time of patient care documentation, the information requested was not applicable to the patient, the hospitalization or the patient care event. For example, if the patient is not ventilated, then VENTILATION_DAYS is not applicable. Translating the Collector value to the database value is done when data is received at CIHI.

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Section 2—Data Elements

Section 2A—Demographic Data

Institution Number

Name in Database INSTITUTION_NUM

Definition Unique institution identifier

Data Type CHAR

Data Element Length 5

Mandatory Yes

Field Values Institution numbers as assigned by the provincial/territorial ministries of health

Constraints 00000–99999

Null Values No null values accepted

Source Direct data entry or software default

Hierarchy Provincial ministry of health Master Numbering System

Additional Information

Defined as a number assigned by the corresponding provincial ministry of health that identifies the institution that provided the care. The first digit identifies the province. Consistent with the institution’s DAD submission number. See Appendix G.

Uses of Data Report trauma by province and institution

History Effective April 1, 2012, institutions are required to submit under their DAD numbers (five-character codes assigned to reporting facilities by provincial/territorial ministries of health as described above)

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Trauma Number

Name in Database TRAUMA_NUM

Definition Unique injury event identifier assigned by the trauma centre

Data Type CHAR


Mandatory Yes

Field Values 0000000, 9999999

Constraints 0000000, 9999999


Source Direct data entry or auto-generated by software

Hierarchy


Defined as a unique number assigned by the trauma centre to identify each patient injury event. This data element can hold up to 15 digits.

Uses of Data Identify records

History

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Fiscal Year of Patient Discharge

Name in Database FISCAL_YEAR

Definition Fiscal year of patient discharge

Data Type CHAR


Mandatory Yes

Field Values Format: yyyy



Source Direct data entry

Hierarchy 1. Face sheet 2. Patient unit nursing notes 3. Physician orders


A fiscal year begins April 1 and ends March 31. A fiscal year is named by the year that it begins in (on April 1); for example, April 1, 2003, to March 31, 2004, is fiscal year 2003.

Uses of Data Report injury by year of patient discharge

History

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Province

Name in Database PROVINCE_CODE

Definition Submitting province identification

Data Type CHAR


Mandatory Yes

Field Values NL—Newfoundland and Labrador PE—Prince Edward Island NS—Nova Scotia NB—New Brunswick QC—Quebec ON—Ontario MB—Manitoba SK—Saskatchewan AB—Alberta BC—British Columbia NT—Northwest Territories YK—Yukon NV—Nunavut

Constraints Same as field values


Source Direct data entry or auto-generated by software

Hierarchy


Defined as the province submitting the data

Uses of Data Report injury by province

History

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Unique Personal Identifier

Name in Database HEALTH_CARD_NUM

Definition Provincial health care number

Data Type CHAR


Mandatory Yes

Field Values As per provincial health insurance lists

Constraints Within the ranges of provincial health insurance lists

Null Values Not known Not applicable


Hierarchy Face sheet

Additional Information Defined as provincial health care number (HCN).The HCN may be from a province other than the province of treatment; for example, if the patient is being treated in Ontario but lives in Quebec, the HCN would be patient’s Quebec HCN.

If the patient is an insured resident of a reporting province or territory but the HCN is not available, enter 0. If the patient is a resident of another country, has federal government coverage (RCMP, veterans, etc.) or has chosen not to register for health insurance, enter 1.

Stored in the database as an encrypted number (HEALTH_CARD_ENCRYPT_NUM). The encryption routine is performed by CIHI upon loading data into the database, with the exception of Manitoba Health (its HCNs are encrypted prior to data submission to CIHI).

Uses of Data Potentially link records Identify persons Track recurrence of trauma

History

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Age

Name in Database AGE

Definition The patient’s age in years at the time of arrival at the trauma centre

Data Type NUMB

Data Element Length 5, 2

Mandatory Yes

Field Values Age in years

Constraints 0–120

Null Value Not known

Source Calculated using 1. Date of birth And 2. Date of Admission (when patient is not admitted use Date of Arrival)

Hierarchy Date of birth (not transmitted to NTR CDS): 1. ED physician record 2. ED nursing record 3. Face sheet

Date of Admission or Date of Arrival

Additional Information For patients younger than 1 year old, express as a fraction using a decimal (for example, enter 0.25 for 3 months old)

Uses of Data Report by age

History

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Sex

Name in Database SEX_CODE

Definition The patient’s sex

Data Type CHAR


Mandatory Yes

Field Values M—Male F—Female

Constraints N/A



Hierarchy 1. Face sheet 2. ED physician record 3. ED nursing record


Uses of Data Report by sex (gender)

History

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Postal Code

Name in Database RECIPIENT_POSTAL_CODE

Definition The postal code of the patient’s usual residence

Data Type CHAR


Mandatory Yes

Field Values Format: A#A#A#, XX

Constraints 6 bytes, alphanumeric

Null Values Not known (UUUUUU) Not applicable (IIIIII)


Hierarchy 1. ED physician record 2. ED nursing record 3. Face sheet

Additional Information Postal Code is released as a three-digit forward sortation area only. If the patient resides out of the country, enter not applicable. If patient is homeless, enter XX.

Uses of Data Geospatially represent injury

History Effective April 1, 2012, change in field values to identify homeless patients

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Section 2B—Injury Data

Date of Injury

Name in Database INJURY_DATE

Definition The date the patient was injured

Data Type DATE


Mandatory Yes

Field Values Format: yyyymmdd

Constraints 19940101–20200101



Hierarchy 1. EMS run sheet 2. ED physician record 3. ED nursing record 4. Trauma nurse flow sheet 5. Trauma physician record

Additional Information If a partial date is known, enter U for the unknown portion; for example, enter 200107UU if the day is unknown

Uses of Data Report on time elapsed from injury to treatment

History

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Time of Injury

Name in Database INJURY_TIME

Definition The time the patient was injured, using the 24-hour clock

Data Type CHAR


Mandatory No

Field Values Format: hhmm

Constraints

Null Values If the value cannot be estimated, select U to record not known. If a value can be estimated to the hour only, use HHUU.


Hierarchy 1. EMS run sheet 2. ED physician notes 3. ED nursing notes 4. Trauma nurse flow sheet 5. Trauma physician record

Additional Information Estimates of time of injury should be based upon reports by the patient, witnesses, family or a health care provider. Other proxy measures (such as dispatch time) should not be used.

Uses of Data Report on time elapsed from injury to treatment

History

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Place of Incident (ICD-9-CM)

Name in Database CM_INJURY_PLACE_CODE (for ICD-9)

Definition The ICD-9-CM place of injury category that describes the place of injury for the patient’s most serious injuries

Data Type CHAR


Mandatory Yes

Field Values 0—Home 1—Farm 2—Mine 3—Industry 4—Recreation 5—Street 6—Public building 7—Residential institution 8—Other 9—Unspecified

Constraints 0–9





Uses of Data

History ICD-9-CM discontinued: B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002 Sask., Alta., N.W.T., Nun., Ont.: 2002–2003

N.B.: 2003–2004 Man.: 2004–2005 Que.: 2006–2007

Notes: ICD-9-CM codes may still be entered in the appropriate field past the adoption date of ICD-10-CA; however, these will not be populated in the NTR. If no longer entering ICD-9, these fields must be zero-filled before submission to the NTR.

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Place of Incident (ICD-10-CA)

Name in Database ICD10_ INJURY_PLACE_CODE (for ICD-10)

Definition The ICD-10-CA place of injury category that describes the place of injury for the patient’s most serious injuries

Data Type CHAR


Mandatory Yes

Field Values 0—Home 1—Residential institution 2—School, other institution and public area 3—Sports and athletic area 4—Street and highway 5—Trade and service area 6—Industrial and construction area 7—Farm 8—Other specified place 9—Unspecified place

Constraints 0–9





Uses of Data Report on location of injury (place of incident)

History ICD-10-CA adopted: B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002 Sask., Alta., N.W.T., Nun., Ont.: 2002–2003 N.B.: 2003–2004 Man.: 2004–2005 Que.: 2006–2007

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Injury Etiology (ICD-9-CM)

Name in Database CM_INJURY_ETIOLOGY_CODE

Definition The four-digit ICD-9-CM external cause of injury code (E code) that reflects the cause of the patient’s most serious injuries

Data Type CHAR


Mandatory Yes

Field Values ICD-9-CM E-codes

Constraints ICD-9-CM E-codes




Additional Information Accepted values may range from three to five digits. The decimal point should not be included.

Uses of Data

History ICD-9-CM discontinued: B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002 Sask., Alta., N.W.T., Nun., Ont.: 2002–2003 N.B.: 2003–2004 Man.: 2004–2005 Que.: 2006–2007


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Injury Etiology (ICD-10-CA)

Name in Database ICD_10_INJURY_ETIOLOGY_CODE

Definition The ICD-10-CA external cause of injury code that reflects the cause of the patient’s most serious injuries

Data Type CHAR


Mandatory Yes

Field Values ICD-10-CA external cause of injury codes as listed in Appendix B

Constraints External cause of injury codes as listed in Appendix B




Additional Information Submission must be made in ICD-10-CA. The decimal point must not be included.

Uses of Data Report on cause of injury

History ICD-10-CA adopted: B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002 Sask., Alta., N.W.T., Nun., Ont.: 2002–2003 N.B.: 2003–2004 Man.: 2004–2005 Que.: 2006–2007

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Injury Type

Name in Database INJURY_TYPE_CODE

Definition An indication of the type of mechanism leading to the patient’s most serious injury, defined by AIS severity

Data Type CHAR


Mandatory Yes

Field Values 1—Blunt 2—Penetrating 3—Burn 4—Drowning/asphyxia

Constraints 1–4




Additional Information An injury is defined as penetrating only if the patient is impaled by an object or if a missile enters or strikes the body. Missiles include bullets and pieces of glass or metal. Impaling objects may include, but are not limited to, knives, nails and fence posts. For patients with more than one injury type (for example, blunt and penetrating), consider the most serious injury to determine injury type.

Injury type 4 (Drowning/asphyxia) should be used for cases of drowning, near drowning or asphyxiation, including suffocation, hanging, etc.

Blast injuries should be coded as blunt.

Uses of Data Report by type of injury

History Effective April 1, 2012, change in allowable field values: addition of field value 4

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Nature of Injury Codes (ICD-9-CM)

Name in Database CM_DIAG_CODE

Definition ICD-9-CM diagnosis codes that reflect the patient’s injuries

Data Type CHAR


Mandatory Yes

Field Values All ICD-9-CM codes in the range 800 to 959

Constraints Limited to codes 800 to 959 in the appropriate ICD-9-CM manual



Hierarchy 1. Composite of a. Medical progress reports b. Radiology reports c. Operative reports d. Autopsy reports

2. Discharge summary 3. ED physician notes

Additional Information The decimal point should not be included.

Up to 27 codes can be reported per patient record; field therefore recurs 27 times.

Uses of Data Report injury diagnoses

History Effective April 1, 2012, change in data element name (previously INJURY_CM_DIAG_CODE)

ICD-9-CM discontinued: B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002 Sask., Alta., N.W.T., Nun., Ont.: 2002–2003 N.B.: 2003–2004 Man.: 2004–2005 Que.: 2006–2007


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Nature of Injury Codes (ICD-10-CA)

Name in Database ICD10_DIAG_CODE

Definition ICD-10-CA diagnosis codes that reflect the patient’s injuries

Data Type CHAR


Mandatory Yes

Field Values All ICD-10-CA codes in the range S to T

Constraints Limited to S and T codes in the appropriate ICD-10-CA manual



Hierarchy 1. Composite of a. Medical progress reports b. Radiology reports c. Operative reports d. Autopsy reports

2. Discharge summary 3. ED physician notes

Additional Information The decimal point should not be included.

It is expected that the most up-to-date version of ICD-10-CA Folio will be used when coding.

Up to 27 codes can be reported per patient record; field therefore recurs 27 times.

Uses of Data Report injury diagnoses

History Effective April 1, 2012, change in data element name (previously INJURY_ICD10_DIAG_CODE)

ICD-10-CA adopted: B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002 Sask., Alta., N.W.T., Nun., Ont.: 2002–2003 N.B.: 2003–2004 Man.: 2004–2005 Que.: 2006–2007

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Sports/Recreational Activity Code

Name in Database ACTIVITY_CODE

Definition The sport or recreational activity the injured person was participating in when injured

Data Type CHAR


Mandatory No

Field Values See Appendix A

Constraints Codes outlined in Appendix A




Additional Information Select the appropriate activity if the person was injured while participating in or observing any sports or recreational activity, regardless of whether the person was being paid to participate

Uses of Data Report by sports and recreational activity

History

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Work-Related Code

Name in Database WORK_RELATED_FLAG

Definition Indication of whether the injury occurred during paid employment

Data Type CHAR


Mandatory Yes

Field Values Y—Yes N—No

Constraints Y/N





Uses of Data Track occupational injuries

History

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Protective Devices

Name in Database PROTECTIVE_DEVICE_CODE

Definition Protective devices (safety equipment) in use or worn by the patient at the time of the injury

Data Type CHAR


Mandatory Yes

Field Values 0—None 1—Seatbelt: Lap and shoulder belt 2—Seatbelt: Lapbelt only 6—Airbag deployment 8—Helmet 12—Other 13—Rear-Facing Infant Seat 14—Forward-Facing Child Seat (With Harness) 15—Booster Seat 16—Seatbelt NFS 18—Child Safety Seat, Unspecified as to Type 19—Eye Protection/Visor (Sports/Recreational) 20—Lifejacket/Personal Floatation Device 21—Sports-Specific Pads 22—Hard Hat (Work-Related) 23—Safety Harness/Restraining Bar (Work-Related) 24—Safety/Protective Clothing (Work-Related) 25—Goggles/Eye Protection (Work-Related)

Constraints 0–2, 6, 8, 12–16, 18–25




Additional Information Field recurs four times.

Use values

• 0–2, 6, 8, 12–16 and 18 for vehicle-related injuries; • 0, 8, 12 and 19–21 for sports and recreation-related injuries; and • 0, 12 and 22–25 for work-related injuries.

This element is to be collected for any case where a protective device could have been used.

Uses of Data Better define injury cause and characterize injury patterns

History Effective April 1, 2012, change in allowable field values: field values 3–5, 7, 9–11 and 17 will be retired

27


Section 2C—Scene Data

Modes of Transport to Trauma Centre

Name in Database TRANSPORTATION_MODE_CODE

Definition Indicates the type of vehicle used to first transport the patient to the trauma centre

Data Type CHAR


Mandatory Yes

Field Values 1—Land Ambulance 2—Helicopter Ambulance 3—Fixed-Wing Ambulance 6—Private Vehicle 7—Walk-in 8—Other

Constraints 1–3, 6–8



Hierarchy 1. EMS run sheet 2. ED physician record 3. ED nursing record

Additional Information This field recurs five times to allow for more than one mode of transport, if applicable. These should be captured sequentially. Only the transport of a patient to the trauma centre (that is, to the centre that is reporting to the NTR CDS) should be captured. If an ambulance is a charter fixed-wing ambulance, indicate “3—Fixed-Wing Ambulance,” as the term “charter” has been discontinued.

Uses of Data Evaluate data based on mode of transport utilized to reach the hospital

History Effective April 1, 2012, change in data element definition and field values 4 and 5 will be retired

28


Systolic Blood Pressure on Arrival at Scene

Name in Database SYSTOLIC_BLOOD_PRESSURE_SCENE

Definition Patient’s first recorded systolic blood pressure (SBP) at the scene

Data Type CHAR


Mandatory Yes

Field Values 000–250

Constraints Valid SBP



Hierarchy Air or land EMS run sheet

Additional Information Defined as the patient’s first recorded SBP upon arrival of EMS personnel at the scene. If the SBP is not taken or not documented, document as not known.

Uses of Data Assess baseline physiologic response to injury

History Effective April 1, 2012, new data element

29


Unassisted Respiratory Rate on Arrival at Scene

Name in Database UNASSISTED_RESPIRATORY_RATE_SCENE

Definition Patient’s first unassisted respiratory rate (RR) per minute at the scene

Data Type CHAR


Mandatory Yes

Field Values 0–99

Constraints Valid RR values

Null Values Not known (if RR is not documented) Not applicable (if patient is intubated prior to assessment of RR)


Hierarchy Air or land EMS run sheet

Additional Information Defined as the patient’s first recorded unassisted RR upon arrival of EMS personnel at the scene. Enter 0 if patient is documented as vital signs absent (VSA) before assistance is initiated. If the RR is not documented, enter not known. Enter not applicable if patient respirations are assisted, that is, patient is intubated or being bagged.



30


Heart Rate on Arrival at Scene

Name in Database HEART_RATE_SCENE

Definition Patient’s first heart rate (rather) per minute at the scene

Data Type CHAR


Mandatory Yes


Constraints Valid HR values

Null Value Not known (if HR is not documented)


Hierarchy Land or air EMS run sheets

Additional Information Defined as the patient’s first recorded HR upon arrival of EMS personnel at the scene. Enter 0 if patient is documented as vital signs absent (VSA) before assistance is initiated. If the HR is not documented, enter not known.



31


Glasgow Coma Scale—Eye at Scene

Name in Database GCS_EYE_CODE_SCENE

Definition Patient’s first eye-opening response for the Glasgow Coma Scale (GCS) taken at the scene

Data Type CHAR


Mandatory Yes

Field Values 1—None 2—To pain 3—To voice 4—Spontaneous

Constraints 1–4



Hierarchy Land or air EMS run sheets

Additional Information Defined as the patient’s first eye-opening response for the GCS documented upon arrival of EMS personnel. If the eye-opening response is not documented or if the patient’s eyes are swollen shut, enter not known.

Uses of Data Assess baseline physiologic response to head injury


32


Glasgow Coma Scale—Verbal at Scene

Name in Database GCS_VERBAL_CODE_SCENE

Definition Patient’s first verbal response for the Glasgow Coma Scale (GCS) taken at the scene

Data Type CHAR


Mandatory Yes

Field Values 1—None 2—Incomprehensible sounds 3—Inappropriate words 4—Confused 5—Oriented

Constraints 1–5



Hierarchy Land or air EMS run sheet

Additional Information Defined as the patient’s first verbal response for the GCS documented upon arrival of EMS personnel at the scene. If the verbal response is not documented or if the patient is intubated, enter not known.



33


Glasgow Coma Scale—Motor at Scene

Name in Database GCS_MOTOR_CODE_SCENE

Definition Patient’s first motor response for the Glasgow Coma Scale (GCS) taken at the scene

Data Type CHAR


Mandatory Yes

Field Values 1—None 2—Extension 3—Flexion 4—Withdraws 5—Localizes 6—Obeys

Constraints 1–6

Null Value Not known Not applicable



Additional Information Defined as the patient’s first motor response for the GCS documented upon arrival of EMS personnel at the scene. If the motor response of the GCS is not documented, enter not known.



34


Total Glasgow Coma Scale at Scene

Name in Database TOTAL_GCS_SCENE

Definition Patient’s first total Glasgow Coma Scale (GCS) at the scene

Data Type CHAR


Mandatory Yes

Field Values 3–15

Constraints 3–15


Source Direct data entry or calculated value from eye, verbal and motor responses


Additional Information Defined as the total GCS documented upon arrival of EMS personnel at the scene. If the GCS or any component of the GCS is not documented or if the patient was intubated at the time GCS was calculated, enter not known.

If the individual components are not documented but the total GCS is documented, this value may be used. If the documentation reflects the patient is awake, alert and oriented, the total GCS may be assumed to be 15.



35


Section 2D—Lead/Trauma Hospital: Pre-Admission Data

Inter-Facility Transfer

Name in Database INTER_FACILITY_TRANSFER

Definition Indicates whether the patient was transported directly from the scene or was transferred from another hospital

Data Type CHAR


Mandatory Yes


Constraints Y/N


Source Direct data entry or report development language populates NTR field as per NTR definition.



Uses of Data Evaluate data based on presence of an inter-facility transfer

History Effective April 1, 2012, change in data element name (previously DIRECT_ADMISSION_FLAG)

36


Transferring Institution

Name in Database TRANSFER_INST

Definition Indicates the institution that the patient is being transferred from (to the reporting trauma centre)

Data Type CHAR


Mandatory Yes

Field Values Defined as a number assigned by the corresponding provincial ministry of health that identifies the institution that provided the care

Constraints Limited to valid Institution Numbers




Additional Information Defined as a number assigned by the corresponding provincial ministry of health that identifies the institution that provided the care. The first digit identifies the province. Consistent with institution’s DAD submission number.

Uses of Data Assess regional patient flow


37


ED Bypass

Name in Database ED_BYPASS

Definition Indicates whether the patient was admitted directly to an inpatient unit, bypassing the emergency department at a trauma centre

Data Type CHAR


Mandatory Yes


Constraints Y/N



Hierarchy 1. Nursing progress notes 2. Medical progress notes 3. EMS run sheet


Uses of Data Identify patients who bypass the emergency department


38


Date of Arrival

Name in Database ARRIVAL_DATE

Definition Date the patient arrived at the trauma centre

Data Type DATE


Mandatory Yes


Constraints 19940101–20200101



Hierarchy 1. EMS run sheet 2. ED nursing notes 3. ED physician notes 4. Inpatient unit nursing notes

Additional Information Date of arrival at ED or inpatient unit (if bypasses ED). Note: Can be different from Date of Admission.

Uses of Data Report on length of hospital stay Report on month of arrival at hospital due to injury

History

39


Time of Arrival

Name in Database ARRIVAL_TIME

Definition Time the patient arrived at the trauma centre

Data Type CHAR


Mandatory Yes

Field Values Format: hhmm




Hierarchy 1. EMS run sheet 2. ED nursing notes 3. ED physician notes 4. Inpatient unit nursing notes

Additional Information Time of arrival at ED or inpatient unit (if bypasses ED). Note: Can be different from time of admission. Capture the actual time the patient was received or offloaded to whichever unit receives him or her.

Uses of Data Report on length of time from injury to definitive care


40


Temperature on Arrival

Name in Database TEMPERATURE

Definition Patient’s first recorded temperature within 15 minutes of arrival at trauma centre

Data Type CHAR


Mandatory Yes


Constraints Valid temperature values



Hierarchy 1. ED nursing notes 2. Inpatient nursing flow sheet 3. ED physician notes 4. Trauma resuscitation record

Additional Information Defined as the patient’s first recorded temperature upon arrival at the trauma centre (ED or inpatient unit if ED bypass), within 15 minutes of arrival. If vitals are not taken in first 15 minutes, document as not known.



41


Systolic Blood Pressure on Arrival

Name in Database SYSTOLIC_BLOOD_PRESSURE

Definition Patient’s first recorded systolic blood pressure (SBP) at the trauma centre, within 15 minutes of arrival at trauma centre

Data Type CHAR


Mandatory Yes


Constraints Valid systolic blood pressure



Hierarchy 1. ED nursing notes 2. Inpatient nursing flow sheet 3. Trauma resuscitation record 4. ED physician notes

Additional Information Defined as the patient’s first recorded SBP upon arrival at the trauma centre (ED or inpatient unit if ED bypass), within 15 minutes of arrival. If vitals are not taken in first 15 minutes, document as not known.


History Effective April 1, 2012, change in data element definition: the observation interval is 15 minutes

42


Intubation Code on Arrival

Name in Database INTUBATION_FLAG

Definition Code indicating whether patient was intubated prior to arrival at trauma centre

Data Type CHAR


Mandatory No


Constraints Y/N



Hierarchy 1. EMS run sheet 2. Transferring hospital ED notes 3. ED nursing notes (trauma centre) 4. Transfer referral form

Additional Information Patients intubated at transferring institution, scene or en route to trauma centre

Uses of Data Indicate patients who have been intubated

History Effective April 1, 2012, change in data element definition

43


Unassisted Respiratory Rate on Arrival

Name in Database UNASSISTED_RESPIRATORY_RATE

Definition Patient’s first recorded unassisted respiratory rate (RR) per minute, within 15 minutes of arrival at trauma centre

Data Type CHAR


Mandatory Yes

Field Values 0–99

Constraints Valid RR values




Additional Information Defined as the patient’s first recorded unassisted RR upon arrival at the trauma centre (ED or inpatient unit if ED bypass) within 15 minutes of arrival. Enter 0 if patient is documented as vital signs absent (VSA) before assistance is initiated. If the RR is not documented within the first 15 minutes, enter not known. If patient respirations are assisted (that is, patient is intubated, ventilated or being bagged), enter not applicable.



44


Heart Rate on Arrival

Name in Database HEART_RATE

Definition Patient’s first recorded heart rate (HR) per minute, within 15 minutes of arrival at trauma centre

Data Type CHAR


Mandatory Yes


Constraints Valid HR values




Additional Information Defined as the patient’s first recorded HR upon arrival at the trauma centre (ED or inpatient unit if ED bypass), within 15 minutes of arrival. Enter 0 if patient is documented as vital signs absent (VSA) before assistance is initiated. If the HR is not documented within the first 15 minutes, enter not known.



45


Paralytic Agents

Name in Database PARALYTIC_AGENTS_FLAG

Definition Paralytic agents administered when the Glasgow Coma Scale (GCS) was calculated at the trauma centre

Data Type CHAR


Mandatory No


Constraints Y/N



Hierarchy 1. EMS run sheet 2. Transferring hospital ED notes 3. ED nursing notes (trauma centre) 4. Transfer referral form

Additional Information Common paralytic agents include rocuronium (Zemuron), vecuronium, cisatracurium (Nimbex), succinylcholine, pancuronium (Pavulon) and atracurium

Uses of Data Identify the validity of the motor component of the GCS

History Effective April 1, 2012, change in data element definition

46


Glasgow Coma Scale—Eye

Name in Database GCS_EYE_CODE

Definition Patient’s first eye-opening response for the Glasgow Coma Scale (GCS) taken within the first 15 minutes of arrival at the trauma centre

Data Type CHAR


Mandatory Yes

Field Values 1—None 2—To pain 3—To voice 4—Spontaneous

Constraints 1–4




Additional Information Defined as the patient’s first eye-opening response for the GCS, documented within 15 minutes of arrival at the trauma centre. Enter not known if not documented or if patient’s eyes are swollen shut.



47


Glasgow Coma Scale—Verbal

Name in Database GCS_VERBAL_CODE

Definition Patient’s first verbal response for the Glasgow Coma Scale (GCS), taken within 15 minutes of arrival at the trauma centre

Data Type CHAR


Mandatory Yes

Field Values 1—None 2—Incomrehensible sounds 3—Inappropriate words 4—Confused 5—Oriented

Constraints 1–5




Additional Information Defined as the patient’s first verbal response for the GCS, documented within 15 minutes of arrival at the trauma centre. If the verbal response is not documented within the first 15 minutes or if the patient is intubated within the first 15 minutes of arrival at the trauma centre, enter not known.



48


Glasgow Coma Scale—Motor

Name in Database GCS_MOTOR_CODE

Definition Patient’s first motor response for the Glasgow Coma Scale (GCS), taken within 15 minutes of arrival at the trauma centre

Data Type CHAR


Mandatory Yes

Field Values 1—None 2—Extension 3—Flexion 4—Withdraws 5—Localizes 6—Obeys

Constraints 1–6

Null Value Not known Not applicable



Additional Information Defined as the patient’s first motor response for the GCS, documented within 15 minutes of arrival at the trauma centre. If the motor response of the GCS is not documented within 15 minutes of arrival at the trauma centre, enter not known.



49


Total Glasgow Coma Scale

Name in Database TOTAL_GCS

Definition Patient’s total Glasgow Coma Scale (GCS), within 15 minutes of arrival at trauma centre

Data Type CHAR


Mandatory Yes

Field Values 3–15

Constraints 3–15


Source Direct data entry or calculated value from eye, verbal and motor responses


Additional Information Defined as the total GCS, documented within 15 minutes of patient arrival at the trauma centre. If the GCS or any component of the GCS is not documented or if the patient is intubated within 15 minutes of the arrival at the trauma centre, enter not known.

If the individual components are not documented but the total GCS is documented within 15 minutes of arrival at the trauma centre, this value may be used. If the documentation reflects the patient is awake, alert and oriented, the total GCS may be assumed to be 15.



50


Total Revised Trauma Score on Arrival

Name in Database TOTAL_RTS

Definition Calculated field based on Glasgow Coma Scale, systolic blood pressure and unassisted respiratory rate

Data Type CHAR


Mandatory Yes

Field Values 0–7.84

Constraints 0–7.84


Source Calculated using 1. Glasgow Coma Scale And 2. Systolic blood pressure And 3. Unassisted respiratory rate


Additional Information If any component required to calculate the Revised Trauma Score (RTS) is not applicable or unknown, enter not known.

See Appendix I for calculation of the RTS.


History

51


Blood Alcohol Concentration

Name in Database BLOOD_ALCOHOL_CONCENTRATION

Definition The patient’s blood alcohol concentration (BAC) in SI units at the trauma centre

Data Type NUMB


Mandatory Yes

Field Values Format: ####.#

Constraints



Hierarchy 1. Lab results 2. ED physician notes

Additional Information Defined as the first blood alcohol levels (in mmol/L) drawn at the trauma centre, regardless of time elapsed since the injury.

Results less than 2 count as 0.

Enter not known if the BAC was not drawn or is not documented.

Enter the value or not known.

Uses of Data Report incidence of alcohol in relation to injury

History Effective April 1, 2012, change to allowable null values (not applicable no longer allowed; age younger than 9 removed)

52


Post-ED/-Arrival Destination

Name in Database POST_ED_DESTINATION

Definition The destination of the patient after discharge from the emergency department or arrival at the hospital if ED bypass

Data Type NUMB


Mandatory Yes

Field Values 1—Another acute care hospital 2—Another trauma centre 3—OR 4—ICU 5—Ward 6—Died in emergency (DIE) 7—Discharge home 8—Other

Constraints 1–8



Hierarchy 1. ED physician record 2. ED nursing notes 3. Inpatient nursing notes


Uses of Data Report on post-ED destination


53


Section 2E—Lead/Trauma Hospital: Post-Admission Data

Date of Admission

Name in Database ADMISSION_DATE

Definition Date the patient is registered as an inpatient at the trauma centre

Data Type DATE


Mandatory Yes


Constraints 19940101–20200101

Null Value Not applicable


Hierarchy 1. Face sheet 2. Physician orders 3. Inpatient nursing notes

Additional Information Defined as the date that the patient is registered as an inpatient.

If the patient died in the emergency department or was discharged home from the emergency department, enter not applicable.

Can be different from Date of Arrival or date registered in the ED.

Uses of Data Report injury by patient length of stay

History

54


Length of Stay

Name in Database LOS_DAYS

Definition Total number of hospital days from Date of Admission to Date of Discharge (including death)

Data Type NUMB


Mandatory Yes

Field Values ≥1

Constraints 1, 9999


Source Calculated field using 1. Date of Admission and 2. Date of Discharge (including death)

Hierarchy

Additional Information Defined as the total number of hospital days from Date of Admission to Date of Discharge (including death). Include alternative level of care days. Do not include days following transfer to a rehabilitation facility, whether or not it is included in the same institution.

Patients who were admitted and discharged or died on the same day have a length of stay (LOS) of 1 day. LOS must be included for all admitted patients.

If the patient is not admitted, LOS should be not applicable.

Uses of Data Report on patient length of stay

History

55


Intensive Care Unit Days

Name in Database ICU_LOS

Definition The total days spent in any intensive care unit (ICU) in the trauma centre

Data Type NUMB


Mandatory Yes

Field Values ≥1

Constraints 1–999



Hierarchy 1. ICU flow sheet 2. Medical progress notes 3. Physician orders

Additional Information If the patient does not stay in an ICU, enter not applicable.

An ICU is defined as having a nurse-to-patient ratio ≤1:2.

Uses of Data Report on intensive care unit days and severity of patient injury


56


Predot Injury Codes (AIS 1990)

Name in Database AIS_PREDOT_CODE_90

Definition Abbreviated Injury Scale (AIS) 1990 predot codes that describe all injuries

Data Type CHAR


Mandatory Yes

Field Values Valid AIS code



Source Direct data entry or software-generated coding from injury text or ICD codes

Hierarchy Injuries as described in the medical record and supporting documentation: 1. Trauma physician notes 2. Operative notes 3. Radiology reports 4. Autopsy reports 5. Medical progress notes

Additional Information Predot is the first six digits of the AIS code (digits preceding the decimal point). It may be manually entered or coded using coding software.

Refer to the AIS 90 dictionary for more details related to the interpretation of the six digits of the predot code.

Up to 27 predot codes can be accepted per patient record; field therefore recurs 27 times.

Uses of Data Report injury by AIS body region and specific injury details

History Effective April 1, 2012, change in data element name (previously AIS_PREDOT_CODE)

57


Predot Injury Codes (AIS 2005, Update 2008)

Name in Database AIS_PREDOT_CODE_05

Definition Abbreviated Injury Scale (AIS) 2005 (update 2008) predot codes that describe all injuries

Data Type CHAR


Mandatory Yes

Field Values Valid AIS code





Additional Information Predot is the first six digits of the AIS code (digits preceding the decimal point). It may be manually entered or coded using coding software.

Refer to the AIS 2005 dictionary for more details related to the interpretation of the six digits of the predot code.

Up to 27 predot codes can be accepted per patient record; field therefore recurs 27 times.

Uses of Data Report injury by AIS body region and specific injury details


58


Severity Codes and ISS Body Regions (AIS 1990)

Name in Database SEVERITY_CODE_90

Definition Abbreviated Injury Scale (AIS) 1990 severity and ISS body region codes that reflect the patient’s injuries

Data Type CHAR


Mandatory No

Field Values 1st digit: 0, 1, 2, 3, 4, 5, 6, 9 2nd digit: 1, 2, 3, 4, 5, 6, 9

Constraints 1st digit: 0–6, 9 2nd digit: 1–6, 9


Source Direct data entry (manual coding) or software-generated (Tri-Code) coding from injury text or ICD codes


Additional Information The first digit represents severity, ranging from 1 (minor) to 6 (major), with 9 representing unknown severity. Tri-Code will display 0 when an ICD-9 code generates more than one predot code. In the case of a manually coded record, this does not apply. In certain instances, an ICD-9 code will be generated without an AIS code; therefore, the AIS will be blank.

The second digit designates the ISS body region as defined in the AIS 90 dictionary. A 9 will be generated for certain injuries that are listed in the AIS that are included for reporting frequency of injury but for which an ISS is not generated.

This is a recurring field with 27 possible entries.

Uses of Data Report by AIS 90 severity and ISS body region

History Effective April 1, 2012, name change

59


Severity Codes and ISS Body Regions (AIS 2005, Update 2008)

Name in Database SEVERITY_CODE_2005

Definition Abbreviated Injury Scale (AIS) 2005 (update 2008) severity and ISS body region codes that reflect the patient’s injuries

Data Type CHAR


Mandatory Yes

Field Values 1st digit: 0, 1, 2, 3, 4, 5, 6, 9 2nd digit: 1, 2, 3, 4, 5, 6, 9

Constraints 1st digit: 0–6, 9 2nd digit: 1–6, 9


Source Direct data entry (manual coding) or software-generated coding from injury text, AIS drill-down or ICD code to AIS look-up table


Additional Information The first digit represents severity, ranging from 1 (minor) to 6 (major), with 9 representing unknown severity.

The second digit designates the ISS body region as defined in the AIS 2005 dictionary.

This is a recurring field with 27 possible entries.

Uses of Data Report by AIS 2005 severity and ISS body region

History Effective April 1, 2012, additional field and name

60


MAIS Code by ISS Body Region (AIS 1990)

Name in Database MAXIMUM_CODE_BY_ISS _90 (1–6)

Definition Calculated field based on the highest Abbreviated Injury Scale (AIS) score, based on AIS 90, recorded by ISS body region

Data Type CHAR


Mandatory Yes

Field Values 1—Minor 2—Moderate 3—Serious 4—Severe 5—Critical 6—Maximum

Constraints 1–6




Additional Information Defined as the maximum AIS code per body region injured, based on AIS 90. ISS body regions are 1—Head or neck 2—Face 3—Chest 4—Abdominal or pelvic contents 5—Extremities or pelvic girdle 6—External

Uses of Data

History Effective April 1, 2012, change in data element name (previously BODY_REGION_CODE_(1–6))

61


MAIS Code by ISS Body Region (AIS 2005, Update 2008)

Name in Database MAXIMUM_CODE_BY_ISS_2005_(1–6)

Definition Calculated field based on the highest Abbreviated Injury Scale (AIS) score, based on AIS 2005 (update 2008), recorded by ISS body region

Data Type CHAR


Mandatory Yes

Field Values 1—Minor 2—Moderate 3—Serious 4—Severe 5—Critical 6—Maximum

Constraints 1–6




Additional Information Defined as the maximum AIS code per body region injured, based on AIS 2005. ISS body regions are 1—Head or neck 2—Face 3—Chest 4—Abdominal or pelvic contents 5—Extremities or pelvic girdle 6—External

Uses of Data Calculate ISS and report by maximum AIS by body region in AIS 2005


62


Injury Severity Score (AIS 1990)

Name in Database INJURY_SEVERITY_SCORE_90

Definition The patient’s Injury Severity Score (ISS) for this injury event as calculated based on the Abbreviated Injury Scale (AIS) 90 once all injury information is available or at the time of patient discharge

Data Type CHAR


Mandatory Yes

Field Values 0–75

Constraints 13–75


Source Calculated field using 1. AIS severity code and 2. ISS body region


Additional Information Calculated field based on the AIS severity code. The ISS is the sum of the squares of the highest AIS code in each of the three most severely injured ISS body regions. The six body regions are 1—Head or neck 2—Face 3—Chest 4—Abdominal or pelvic contents 5—Extremities or pelvic girdle 6—External

Uses of Data Report by injury severity

History Effective April 1, 2012, change in data element name (previously INJURY_SEVERITY_SCORE)

63


Injury Severity Score (AIS 2005, Update 2008)

Name in Database INJURY_SEVERITY_SCORE_05

Definition The patient’s Injury Severity Score (ISS) for this injury event as calculated based on the Abbreviated Injury Scale (AIS 2005, update 2008) once all injury information is available or at the time of patient discharge

Data Type CHAR


Mandatory Yes

Field Values 0–75

Constraints None


Source Calculated field using 1. AIS severity code and 2. ISS body region


Additional Information Calculated field based on the AIS severity code. The ISS is the sum of the squares of the highest AIS code in each of the three most severely injured ISS body regions. The six body regions are 1—Head or neck 2—Face 3—Chest 4—Abdominal or pelvic contents 5—Extremities or pelvic girdle 6—External

Uses of Data Report by injury severity


64


Number of Ventilator Days

Name in Database VENTILATION_DAYS

Definition The number of days the patient was intubated and mechanically ventilated intermittently or continuously, excluding non-intubated patients on BIPAP and intubated patients on CPAP at the hospital

Data Type NUMB


Mandatory Yes

Field Values ≥1

Constraints 1–999



Hierarchy 1. Respiratory therapy flow sheet 2. Special care unit flow sheet

Additional Information Only the number of ventilator days at the trauma centre (the reporting hospital) should be captured, not the ones from the transferring hospital. The number of ventilator days does not include the day ventilation is begun (unless there is only one day of ventilation, in which case the number of ventilator days = 1).

For example, if a patient is on a ventilator from March 3 to March 5, the number of ventilator days = 2.

Patients on BIPAP are not counted as having ventilator days. The time patients are ventilated solely while in the OR is not counted as ventilator days.

If a patient is not mechanically ventilated at any time during the hospital stay, enter not applicable. If the patient is mechanically ventilated but the length of time is not documented, enter not known.

Uses of Data Report ventilation requirements of trauma patients

History

65


OR Procedures (ICD-9-CM)

Name in Database CM _PROC_CODE

Definition ICD-9-CM codes describing operative procedures performed on the patient; procedures must be related to the injury (that is, do not enter operative procedures performed as a result of a complication)

Data Type CHAR


Mandatory No

Field Values Valid ICD-9-CM procedure code

Constraints ICD-9-CM procedure codes



Hierarchy 1. Operative reports 2. Medical progress notes

Additional Information Up to 10 procedure codes may be collected.

The decimal point should not be included and fields should be left justified.

Uses of Data Report on operative management of trauma patients

History ICD-9-CM discontinued: B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002 Sask., Alta., N.W.T., Nun., Ont.: 2002–2003

N.B.: 2003–2004Man.: 2004–2005 Que.: 2006–2007


66


OR Procedures (ICD-10-CA)

Name in Database CCI_PROC_CODE

Definition CCI codes describing operative procedures performed on the patient

Data Type CHAR


Mandatory Yes

Field Values Valid CCI procedure codes

Constraints CCI procedure codes




Additional Information Up to 10 procedure codes can be recorded per patient visit to the OR, with the possibility of 25 operative visits.

Only those procedures performed at the trauma centre (the reporting hospital) should be included, not those performed at the referring hospital.

Procedures must be performed in the OR or, in certain instances, in the ICU (see Appendix J for a list of acceptable procedures performed in the ICU).

If the patient is not operatively managed, enter not applicable.

The decimal point should not be included.


History Up to 15 additional operative episodes can be recorded, for a total of 25; include procedures performed in the ICU

ICD-10-CA adopted: B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002 Sask., Alta., N.W.T., Nun., Ont.: 2002–2003 N.B.: 2003–2004 Man.: 2004–2005 Que.: 2006–2007

67


Date of OR Procedures (ICD-10-CA)

Name in Database DATE_OR_PROCEDURE

Definition Date the operative procedure was performed

Data Type DATE


Mandatory Yes


Constraints 19940101–20200101




Additional Information Date is collected for up to 25 operative visits.

Must be performed in the OR or in the ICU (refer to Appendix J for a list of valid procedures performed in the ICU).

If the patient is not operatively managed, enter not applicable.


History Effective April 1, 2012, new data element.

Number of operative visits expanded from 10 to 25 and definition expanded to include all operative visits within the hospitalization, not only those associated with the injury.

68


Comorbidities

Name in Database COMORBIDITIES

Definition A condition present at the beginning of hospital observation and/or treatment that may or may not have a significant influence on the patient’s hospitalization (LOS) and/or significantly influence the management or treatment of the patient

Data Type CHAR


Mandatory Yes, unless data element COMORBIDITIES_ICD10_DIAG_CODE is completed

Field Values 1—No NTR comorbidities are present 2—Alcoholism 3—Ascites within 30 days 4—Attention deficit disorder/attention deficit hyperactivity disorder 5—Autism/Asperger’s 6—Bleeding disorder 7—Chemotherapy for cancer within 30 days 8—Cirrhosis 9—Congenital anomalies 10—Congestive heart failure 11—Current smoker 12—Currently requiring or on dialysis 13—CVA/residual neurological deficit 14—Diabetes mellitus 15—Disseminated cancer 16—Do not resuscitate (DNR) status 17—Drug use 18—Esophageal varices 19—Functionally dependent health status 20—History of angina within past one month 21—History of myocardial infarction within past six months 22—History of revascularization/amputation for PVD 23—Hypertension requiring medication 24—Impaired sensorium 25—Obesity 26—Prematurity 27—Respiratory disease 28—Steroid use

Constraints Valid comorbid condition from approved list; see Appendix E for conditions and definitions

Null Value Unknown


Hierarchy 1. Patient history and physical 2. Medical progress notes 3. Medical consultation notes 4. Discharge summary

Additional Information Enter any comorbid conditions from the approved list, regardless of condition influence on LOS or treatment.

Up to 10 comorbidities can be accepted per patient record; field therefore recurs 10 times.

See Appendix E for definitions of comorbid conditions.

Uses of Data Report on common comorbid conditions

History Option to use this field or data element COMORBIDITIES_ICD10_DIAG_CODE

69


Comorbidities (ICD-10-CA)

Name in Database COMORBIDITIES_ICD10_DIAG_CODE

Definition A condition present at the beginning of hospital observation and/or treatment that may or may not have a significant influence on the patient’s hospitalization (LOS) and/or significantly influence the management or treatment of the patient

Data Type CHAR


Mandatory Yes, if data element COMORBIDITIES is not collected

Field Values Valid ICD-10 codes for comorbidities

Constraints Valid ICD-10 codes for comorbidities



Hierarchy 1. Patient history and physical 2. Medical progress notes 3. Medical consultation notes 4. Discharge summary

Additional Information Enter any comorbid conditions from the approved list, regardless of condition influence on LOS or treatment. Up to 10 comorbidities can be accepted per patient record; field therefore recurs 10 times. See Appendix E for definitions of comorbid conditions. In the event there is no corresponding ICD-10 code, yes, no or not applicable should be entered in a separate data field to capture this information.

Provinces have the ability to collect additional comorbid conditions but must collect those listed in Appendix E at a minimum. Comorbidity data may be captured using data element, COMORBIDITIES, which has comorbidities listed in a drop-down menu, as an alternative to this data element, which captures comorbidities as ICD-10 codes.

Uses of Data Report on common comorbid conditions


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Complications

Name in Database COMPLICATION_CM_DIAG_CODE

Definition A condition arising after the beginning of hospital observation and/or treatment that usually has a significant influence on the patient’s hospitalization (LOS) and/or significantly influences the management or treatment of the patient

Data Type CHAR


Mandatory Yes, unless COMPLICATION_ICD10_DIAG_CODE is completed

Field Values 1—No NTR-listed medical complications occurred 2—Abdominal compartment syndrome 3—Abdominal fascia left open 4—Acute renal failure 5—Acute respiratory distress syndrome (ARDS) 6—Bleeding 7—Cardiac arrest with CPR 8—Coagulopathy 9—Decubitus ulcer 10—Deep surgical site infection 11—Drug or alcohol withdrawal syndrome 12—Deep vein thrombosis (DVT)/thrombophlebitis 13—Extremity compartment syndrome 14—Graft/prosthesis/flap failure 15—Intracranial pressure elevation 16—Myocardial infarction 17—Organ space surgical site infection 18—Osteomyelitis 19—Pneumonia 20—Pulmonary embolism 21—Stroke/CVA 22—Superficial surgical site infection 23—Systemic sepsis 24—Unplanned intubation 25—Unplanned return to the ICU 26—Unplanned return to the OR 27—Urinary tract infection 28—Wound disruption

Constraints Valid complications from approved NTR list; see Appendix F



Hierarchy 1. Medical progress notes 2. Medical consultation notes 3. Discharge summary

Additional Information Up to 10 complications can be accepted per patient record; field therefore recurs 10 times. See Appendix F for definitions of complications.

Provinces have the ability to collect more complications but must collect those listed in Appendix F at a minimum.

Provinces have the choice of populating this data element or data element COMPLICATION_ICD10_DIAG_CODE.

Uses of Data Report on common complications

History Effective April 1, 2012, change in data element name

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Complications (ICD-10-CA)

Name in Database COMPLICATION_ICD10_DIAG_CODE

Definition A condition arising after the beginning of hospital observation and/or treatment that usually has a significant influence on the patient’s hospitalization (LOS) and/or significantly influences the management or treatment of the patient

Data Type CHAR


Mandatory Yes, if data element COMPLICATION_CM_DIAG_CODE is not collected

Field Values Valid ICD-10 codes for complications

Constraints Valid ICD-10 codes for complications



Hierarchy 1. Medical progress notes 2. Medical consultation notes 3. Discharge summary

Additional Information Up to 10 complications can be accepted per patient record; field therefore recurs 10 times. See Appendix F for a list of mandatory complications, their definitions and corresponding ICD-10 codes. In the event there is no corresponding ICD-10 code, yes, no or not applicable should be entered in a separate data field to capture this information.

Provinces have the ability to collect additional complications but must collect those listed in Appendix F at a minimum. Complication data may be captured using data element, COMPLICATION_CM_DIAG_CODE, which has complications listed in a drop down menu, as an alternative to this data element, which captures complications as ICD-10 codes.

Uses of Data Report on common complications

History Option to use this field or data element COMPLICATION_CM_DIAG_CODE to capture complication.

Mandatory capturing of specific complications as listed in Appendix F.

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Date of Discharge

Name in Database DISCHARGE_DATE

Definition The date the patient was discharged from hospital or the emergency department or the date the patient died in hospital

Data Type DATE


Mandatory Yes


Constraints 19940101–20200101



Hierarchy Inpatient discharge and death: 1. Face sheet 2. Physician discharge order 3. Inpatient nursing notes 4. Death certificate

ED visit only (alive or dead): 1. ED nursing notes 2. ED physician notes 3. Death certificate

Additional Information Defined as the date the patient was discharged from hospital, died or was discharged from the emergency department (if not admitted). Include alternative level of care days. Do not include days following transfer to a rehabilitation facility, whether or not it is included in the same institution.

Uses of Data Generate length-of-stay numbers

History

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Separation Status

Name in Database SEPARATION_STATUS_CODE

Definition The status of the patient at discharge from the trauma centre

Data Type CHAR


Mandatory Yes

Field Values 6—Discharged alive 7—Died in hospital after admission 8—Died in emergency, other than failed resuscitation attempt 9—Died after failed resuscitation attempt lasting between 5 and 15 minutes 10—DOA (declared dead on arrival) less than 5 minutes after presentation/resuscitation

efforts or no resuscitation attempt

Constraints 6–10



Hierarchy Inpatient discharge and death: 1. Face sheet 2. Physician discharge order 3. Inpatient nursing notes 4. Death certificate

ED visit only (alive or dead): 1. ED nursing notes 2. ED physician notes 3. Trauma flow sheet 4. Death certificate

Additional Information Enter 6 if the patient is discharged alive.

Enter 7 if the patient dies after admission to the hospital.

Enter 8 if the patient dies in the ED but resuscitation attempts take longer than 15 minutes or patient decompensates after arrival and expires.

Enter 9 if the patient presents vital signs absent (VSA) and is pronounced after resuscitation attempts lasting between 5 and 15 minutes.

Enter 10 if the patient presents VSA and has less than 5 minutes of resuscitation attempts or no resuscitation efforts.

Uses of Data Report trauma patient outcomes

History Effective April 1, 2012, change in data element allowable field values: differentiation between died in emergency (DIE) and dead on arrival (DOA)

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Discharge Disposition

Name in Database DISCHARGE_DISPOSITION_CODE

Definition The location to which the patient is discharged or the service arranged for the patient immediately upon discharge from hospital

Data Type CHAR


Mandatory Yes

Field Values 1—Home 2—Home with support services 3—Another acute care facility 4—General rehabilitation facility 5—Chronic care facility 6—Nursing home 7—Special rehabilitation facility 8—Foster care and/or children’s aid 9—Other 10—Died

Constraints 1–10



Hierarchy 1. Inpatient nursing notes 2. Medical progress notes 3. Physician orders 4. Discharge summary

Additional Information Document for all admitted and non-admitted patients who are discharged alive from the hospital or who died in the hospital or in the emergency department.

See Appendix H for definitions of each field value.

Uses of Data Report on patient outcomes

History Effective April 1, 2012, change in data element allowable field values

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Section 3—Appendices

Appendix A: Sports/Recreational Activity Codes

Sports and Recreation

1 Aerobics

2 Aircraft—Recreational Motorized (e.g. Fixed Wing)

3 Aircraft—Recreational Non-Motorized (e.g. Glider)

4 All-Terrain Vehicle (ATV)

5 Amusement Rides

6 Auto Racing

7 Badminton

8 Baseball (Hard Ball, Soft Ball, T-Ball, Slo-Pitch)

9 Basketball

10 Billiards/Pool/Shuffleboard

11 Boating—Motorized

12 Boating—Non-Motorized (Canoe, Kayak, Rowboat, Sailboat, Pedal Boat)

16 Boating—Windsurf/Sail Board

18 Boating—Waverunners, SeaDoos, etc.

19 Boating—Other, Unspecified

20 Boxing (Organized, Would Not Include Children at Play)

21 Bowling (5 or 10 Pin)

22 Cricket

23 Croquet/Lawn Bowling

24 Curling

25 Cycling—Driver (if Unspecified, Assume Driver)

26 Cycling—Passenger

27 Cycling—Unicycles

28 Dancing

29 Darts

30 Dirt Biking/Mini Biking/Motocross

31 Diving

32 Fencing

33 Fire (Open Flames Outdoors—e.g. Charcoal and Gas Barbecues, Camp Fires)

34 Fireworks—User

35 Fireworks—Observer

36 Fishing

37 Football

38 Go-Carting

39 Golf

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Sports and Recreation (cont’d)

40 Gymnastics (Organized—Would Not Include Children at Play)

41 Handball

42 Hang-Gliding/Para-Sailing

43 Hiking

44 Horseback Riding

45 Hockey—Ice (if Type of Hockey Is Unspecified, Assume Ice or Street Depending on Season)

46 Hockey—Non-Ice, Non-Inline Hockey

48 Hockey—Inline

49 Horseshoes

50 Hunting—Bow and Arrow, Gun, Knives

53 Jogging/Running

54 Lacrosse

55 Lawn Darts

56 Luge/Bobsled

57 Martial Arts (Judo, Kendo, Karate, Tae Kwon-Do, Jiu-Jitsu, etc.)

58 Mountaineering/Rock Climbing

59 Playground Equipment (Swings, Slides, Monkey Bars, Teeter-Totter in Any Location)

60 Play Not Further Specified (i.e. Running, Jumping, Skipping, General Play Activities)

61 Racquetball

62 Ringette

63 Rugby

64 Scuba Diving

65 Shooting—Bow and Arrow (i.e. Targets), Gun (i.e. Non-Hunting Use of Firearm, Targets, Rifle Range, Skeet)

67 Skateboarding

68 Skating—Ice (Use in Winter Season if Type of Skating Is Not Specified)

69 Skating—Inline

70 Skating—Roller

71 Skiing—Downhill—Recreational (Use if Type of Skiing Is Not Specified)

72 Skiing—Downhill—Racing

73 Skiing—Cross-Country

74 Ski Jumping (Includes Moguls and Aerial Stunts)

75 Sky Diving/Parachuting

76 Snowboarding

77 Snowmobiling—Driver (Assume Driver if Not Specified)

78 Snowmobiling—Passenger

79 Snowmobiling—Towed Behind on Toboggan, Tube, Sleigh

80 Soccer

81 Squash

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Sports and Recreation (cont’d)

82 Swimming—Pool

83 Swimming—Open Water

84 Swimming—Wading Pool, Location Unspecified

85 Tennis

86 Tobogganing/Sledding/Snow Tubing (Not Towed)

87 Track and Field (Organized)

88 Trampoline

89 Volleyball

90 Walking (for Exercise)

91 Water Polo

92 Waterskiing/Tubing

93 Weightlifting (Recreational or Organized, Includes Exercise Equipment)

94 Wrestling (Organized, Does Not Include Children at Play)

95 Observer of Sporting Event

97 Non-Motorized Scooters

98 Rodeo Sports

999 Other

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Appendix B: Inclusion Lists—ICD-10-CA

The following lists the categories used for trauma reporting purposes based on the NTR definition. “Incident” and “unintentional” have been substituted for the terms “accident” and “accidental” used in the ICD definitions.

ICD-10-CA

External Cause Code Category Definition

V01–V99 Transport Incidents

V01–V06, V09–V90 Land Transport Incidents

V91–V94 Water Transport Incidents

V95–V97 Air and Space Transport Incidents

V98–V99 Other and Unspecified Transport Incidents

W00–W19 Unintentional Falls

W20–W46, W49 Exposure to Inanimate Mechanical Forces

W50–W60, W64 Exposure to Animate Mechanical Forces

W65–W70, W73, W74 Unintentional Drowning and Submersion

W75, W76, W77, W81, W83, W84 Other Unintentional Threats to Breathing, Except Due to Inhalation of Gastric Contents, Food or Other Objects

W85–W94, W99 Exposure to Electric Current, Radiation and Extreme Ambient Air Temperature and Pressure

X00–X06, X08, X09 Exposure to Smoke, Fire and Flames

X10–X19 Contact With Heat and Hot Substances

X30–X39 Exposure to Forces of Nature

X50 Overexertion and Strenuous or Repetitive Movements

X52 Prolonged Stay in Weightless Environment

X58–X59 Unintentional Exposure to Other and Unspecified Factors

X70–X84 Intentional Self-Harm, Excluding Poisoning

X86, X91–X99, Y00–Y05, Y07–Y09 Assault, Excluding Poisoning

Y20–Y34 Event of Undetermined Intent, Excluding Poisonings

Y35–Y36 Legal Intervention and Operations of War

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Appendix C: Exclusion Lists—ICD-10-CA

The following lists the ICD-10-CA external cause codes that are excluded from the National Trauma Registry based on the definition of trauma.

ICD-10-CA

ICD-10-CA Code Exclusions Definition

W78–W80 W78 Inhalation of Gastric Contents W79 Inhalation and Ingestion of Food Causing Obstruction of Respiratory Tract W80 Inhalation and Ingestion of Other Objects Causing Obstruction of Respiratory Tract

X20–X29 Contact With Venomous Animals and Plants

X40–X49* Unintentional Poisoning and Exposure to Noxious Substances

X51 Travel and Motion

X53, X54, X57, Y06 X53 Lack of Food X54 Lack of Water X57 Unspecified Privation Y06 Neglect and Abandonment

X60–X69* Intentional Self-Harm by Poisoning

X85, X87–X90* Assault by Poisoning

Y10–Y19* Poisoning of Undetermined Intent

Y40–Y59 Drugs, Medicaments and Biological Substances Causing Adverse Effects in Therapeutic Use

Y60–Y69 Misadventures to Patients During Surgical and Medical Care

Y70–Y82 Medical Devices Associated With Adverse Incidents in Diagnostic and Therapeutic Use

Y83–Y84 Surgical and Other Medical Procedures as the Cause of Abnormal Reaction of the Patient or of Later Complication, Without Mention of Misadventure at the Time of the Procedures

Y85–Y89 Sequelae of External Causes of Morbidity and Mortality

Y90–Y98 Supplementary Factors Related to Causes of Morbidity and Mortality Classified Elsewhere

Note * These cases will be excluded but will be reported on separately.

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Appendix D: Injury Types

The following provides information on the specific diagnosis codes for the injury types described in NTR reports.

Description ICD-10 Code Range

Superficial S00, S05.0, S05.1, S05.8, S05.9, S10, S20, S30, S40, S50, S60, S70, S80, S90, T00, T09.0, T11.0, T13.0, T14.0

Musculoskeletal S02, S12, S22, S32, S42, S52, S62, S72, S82, S92, T02, T08, T10, T12, T14.2, S03, S13, S23, S33, S43, S53, S63, S73, S83, S93, T03, T11.2, T13.2, T14.3, S09.10, S09.18, S16, S29.00, S29.08, S39.00, S39.08, S46, S56, S66, S76, S86, S96, T06.4, T09.5, T11.5, T13.5, T14.6

Burns and Corrosion T20, T32

Internal Organ S06, S09.7, S09.8, S09.9, S26, S27, S36, S37, S39.6, T06.5

Crushing S07, S17, S28.0, S38.0, S38.1, S47, S57, S67, S77, S87, S97, T04

Open Wound, Including Traumatic Amputation

S01, S05.2–S05.7, S09.2, S11, S21, S31, S41, S51, S61, S71, S81, S91, T01, T09.1, T11.1, T13.1, T14.1, S08, S18, S28.1, S38.2, S38.3, S48, S58, S68, S78, S88, S98, T05, T11.6, T13.6, T14.7

Blood Vessels S09.0, S15, S25, S35, S45, S55, S65, S75, S85, S95, T06.3, T11.4, T13.4, T14.5

Nerves and Spinal Cord S04, S14, S24, S34, S44, S54, S64, S74, S84, S94, T06.0, T06.1, T06.2, T11.3, T13.3, T14.4

Other and Unspecified S19, S29.7, S29.8, S29.9, S39.7, S39.8, S39.9, S49, S59, S69, S79, S89, S99, T06.8, T07, T09.8, T09.9, T11.8, T11.9, T13.8, T13.9, T14.8, T14.9, T15, T16, T18, T19, T33, T34, T35, T66, T67, T68, T69, T70, T71, T73 (Excludes T73.0, T73.1), T75 (Excludes T75.3)

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Appendix E: List of Comorbidities and Accompanying Definitions

Alcoholism: To be determined based upon the brief screening tool used at your institution.

ICD-10-CA codes: F10.0–F10.9, F19.0, F19.2, Z13.3

Attention deficit hyperactivity disorder (ADHD)

ICD-10-CA code: F90.0

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.

ICD-10-CA code: R18

Autism/Asperger’s

ICD-10-CA codes: F84.0, F84.1, F84.5

Bleeding disorder: Any condition that places the patient at risk for excessive bleeding due to a deficiency of blood clotting elements (such as vitamin K deficiency, hemophilia, thrombocytopenia or chronic anticoagulation therapy with Coumadin, Plavix or similar medications). Do not include patients on chronic aspirin therapy.

ICD-10-CA codes: D68.4, D66, D68.1, D67.1, D68.0, D68.3, D69.1, D69.4, D69.5, D69.6, D69.8, D69.9

Chemotherapy for cancer within 30 days: A patient who had any chemotherapy treatment for cancer in the 30 days 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.

ICD-10-CA code: Z51.1

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 at laparotomy/laparoscopy.

ICD-10-CA codes: K74.0–K74.6, K70.3, K70.4, K71.7

Congenital anomalies: Documentation of a cardiac, pulmonary, body wall, CNS/spinal, GI, renal, orthopedic or metabolic congenital anomaly.

ICD-10-CA codes: Q00.0–Q99.9

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Congestive heart failure: The inability of the heart to pump a sufficient quantity of blood to meet the metabolic needs of the body or the ability of the heart to 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

1. Abnormal limitation in exercise tolerance due to dyspnea or fatigue;

2. Orthopnea (dyspnea on lying supine);

3. Paroxysmal nocturnal dyspnea (awakening from sleep with dyspnea);

4. Increased jugular venous pressure;

5. Pulmonary rales on physical examination;

6. Cardiomegaly; and

7. Pulmonary vascular engorgement.

ICD-10-CA codes: I50.0, I50.1, I11, I13, I42.0–I42.9, I43.0–I43.8, I09.8

Current smoker: A patient who has smoked cigarettes in the year prior to admission. Do not include patients who smoke cigars or pipes or use chewing tobacco.

No corresponding ICD-10-CA code; therefore, yes, no or not applicable should be entered in a separate data field to capture this information.

Currently requiring or on dialysis: Acute or chronic renal failure prior to injury that was requiring periodic peritoneal dialysis, hemodialysis, hemofiltration or hemodiafiltration.

ICD-10-CA code: Z99.2

CVA/residual neurological deficit: A history prior to injury of a cerebrovascular accident (embolic, thrombotic or hemorrhagic) with persistent residual motor, sensory or cognitive dysfunction (such as hemiplegia, hemiparesis, aphasia, sensory deficit or impaired memory).

ICD-10-CA codes: I60.0–I69.8

Diabetes mellitus: Diabetes mellitus prior to injury that required exogenous parenteral insulin or an oral hypoglycemic agent.

ICD-10-CA codes: E10.0–E11.9, E13.0–E14.9

Disseminated cancer: Patients who have cancer

1. That has spread to one or more sites in addition to the primary site; AND

2. 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 (such as the brain, lung, liver, meninges, abdomen, peritoneum, pleura and bone).

ICD-10-CA codes: C77.0–C80.9

87


Do not resuscitate (DNR) status: The patient had a do not resuscitate (DNR) document or similar advance directive recorded prior to injury.

No corresponding ICD-10-CA code; therefore, yes, no, unknown or not applicable should be entered in a separate data field to capture this information.

Drug use: Mental and behavioural disorders due to the use of drugs.

ICD-10-CA codes: F11.0–F16.9, F19.0–F19.9, Z13.3

Esophageal varices: Engorged collateral veins in the esophagus that 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.

ICD-10-CA code: I86.4

Functionally dependent health status: Pre-injury functional status may be represented by the ability of the patient to complete activities of daily living (ADLs), including bathing, feeding, dressing, toileting and walking. This item is marked yes if the patient, prior to injury, was partially dependent or completely dependent upon equipment, devices or another person to complete some or all ADLs. Formal definitions of dependency are listed below:

1. Partially dependent: The patient requires the use of equipment or devices coupled with assistance from another person for some ADLs. Any patient coming from a nursing home setting who is not totally dependent would fall into this category, as would any patient who requires kidney dialysis, home ventilator support or chronic oxygen therapy yet maintains some independent functions.

2. Totally dependent: The patient cannot perform any ADLs for himself or herself. This would include a patient who is totally dependent upon nursing care or a dependent nursing home patient. All patients with psychiatric illnesses should be evaluated for their ability to function with or without assistance with ADLs, just as non-psychiatric patients are.

No corresponding ICD-10-CA code; therefore yes, no, unknown or not applicable should be entered in a separate data field to capture this information.

History of angina within past one month: Pain or discomfort between the diaphragm and the mandible resulting from myocardial ischemia. Typically, angina is a dull, diffuse (fist-sized or larger) substernal chest discomfort precipitated by exertion or emotion and relieved by rest or nitroglycerin. Radiation often occurs to the arms and shoulders and occasionally to the neck, jaw (mandible, not maxilla) or interscapular region. For patients on anti-anginal medications, enter yes only if the patient has had angina within one month prior to admission.


History of myocardial infarction within past six months: The history of a non–Q wave or a Q-wave infarction in the six months prior to injury as diagnosed in the patient’s medical record.


88


History of revascularization/amputation for peripheral vascular disease: Any type of angioplasty or revascularization procedure for atherosclerotic peripheral vascular disease (PVD) (for example, aorta–femoral, femoral–femoral and femoral–popliteal) or a patient who has had any type of amputation procedure for PVD (for example, toe amputations, transmetatarsal amputations and below-knee or above-knee amputations). Patients who have had an amputation for trauma or resection of abdominal aortic aneurysms would not be included.


Hypertension requiring medication: History of a persistent elevation of systolic blood pressure greater than 140 mm Hg and a diastolic blood pressure greater than 90 mm Hg requiring an antihypertensive treatment (such as diuretics, beta blockers, ACE inhibitors or calcium channel blockers).

ICD-10-CA codes: I10.0–I10.9, I11–I15

Impaired sensorium: Patients should be noted to have an impaired sensorium if they had mental status changes and/or delirium in the context of a current illness prior to injury. Patients with chronic or long-standing mental status changes secondary to chronic mental illness (such as schizophrenia) or chronic dementing illnesses (such as multi-infarct dementia or senile dementia of the Alzheimer’s type) should also be included. Mental retardation would qualify as impaired sensorium. For pediatric populations, patients with documented behaviour disturbances, attention disorders, delayed learning or delayed development should be included.

ICD-10-CA codes: F00.0–F09, F70.0–F79.9, G30.0–G30.9, F90.0, F91.8, F91.9, F84.0, F81.9, F80.0, F80.1, F80.8, F80.9, F81.3, F81.8

Obesity: A body mass index of 30 or greater.

ICD-10-CA codes: E66.0–E66.9

Prematurity: Documentation of premature birth, a history of bronchopulmonary dysplasia, ventilator support for longer than seven days after birth or the diagnosis of cerebral palsy. Premature birth is defined as infants delivered before 37 weeks from the first day of the last menstrual period.

ICD-10-CA codes: G80.0–G80.9, P07.0–P07.3, P27.0–P27.9 CCI code: 1.GZ.31

89


Respiratory disease: Severe chronic lung disease, chronic asthma, cystic fibrosis or chronic obstructive pulmonary disease (COPD) (such as emphysema and/or chronic bronchitis) resulting in any one or more of the following:

1. Functional disability from COPD (such as dyspnea or inability to perform ADLs);

2. Hospitalization in the past for treatment of COPD;

3. Requirement for chronic bronchodilator therapy with oral or inhaled agents; and/or

4. An FEV1 of less than 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.

ICD-10-CA codes: E84.0–E84.9, J40–J45.91

Steroid use: Patients who required the regular administration of oral or parenteral corticosteroid medications (such as prednisone or Decadron) in the 30 days prior to injury for a chronic medical condition (such as COPD, asthma, rheumatologic disease, rheumatoid arthritis or inflammatory bowel disease). Do not include topical corticosteroids applied to the skin or corticosteroids administered by inhalation or rectally.


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Appendix F: List of Complications and Accompanying Definitions

Abdominal compartment syndrome: The sudden increase in intra-abdominal pressure resulting in alteration in the respiratory mechanism, hemodynamic parameters and renal perfusion. Typically, patients with this syndrome are critically ill and require ventilator support and/or reoperation.

ICD-10-CA code: T79.6

Abdominal fascia left open: No primary surgical closure of the fascia, or intra-abdominal packs left at conclusion of primary laparotomy (damage control).


Acute renal failure: A patient who did not require dialysis prior to injury, who has worsening renal dysfunction after injury requiring hemodialysis, ultrafiltration or peritoneal dialysis. If the patient refuses treatment (such as dialysis), the condition is still considered present.

ICD-10-CA codes: N17.0–N19, N25.0, N03.0–N05.9, I12, I13, T79.5

ARDS: Adult (acute) respiratory distress syndrome occurs in conjunction with catastrophic medical conditions, such as pneumonia, shock, sepsis (or severe infection throughout the body, sometimes also referred to as systemic infection, and possibly including or also called a blood or blood-borne infection) and trauma. It is a form of sudden and often severe lung failure characterized by PaO2/FiO2 of 200 or less, decreased compliance and diffuse bilateral pulmonary infiltrates without associated clinical evidence of CHF. The process must persist beyond 36 hours and require mechanical ventilation.

ICD-10-CA code: J80 CCI code: 1.GZ.31

Bleeding: Any transfusion (including autologous) of five or more units of packed red blood cells or whole blood given from the time the patient is injured up to and including 72 hours later. The blood may be given for any reason.

CCI code: 1.LZ.19

Cardiac arrest with CPR: The absence of a cardiac rhythm or presence of chaotic cardiac rhythm that results in loss of consciousness requiring the initiation of any component of basic and/or advanced cardiac life support. Excludes patients who arrive at the hospital in full arrest.


Coagulopathy: Twice the upper limit of the normal range for PT or PTT in a patient without a pre-injury bleeding disorder of this magnitude.

ICD-10-CA codes: D65–D68.2, D69.1, D69.30–D69.4

92


Decubitus ulcer: A pressure sore resulting from pressure exerted on the skin, soft tissue, muscle or bone by the weight of an individual against a surface beneath. Individuals unable to avoid long periods of uninterrupted pressure over bony prominences are at increased risk for the developing necrosis and ulceration.

ICD-10-CA codes: L89.0–L89.9

Deep surgical site infection: An infection that occurs within 30 days after an operation and that appears to be related to the operation. The infection should involve deep soft tissues (such as the fascial and muscle layers) at the site of incision and at least one of the following:

1. There is purulent drainage from the deep incision but not from the organ/space component of the surgical site.

2. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (greater than 38oC), localized pain or tenderness, unless site is culture-negative.

3. An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation or by histopathologic or radiologic examination.

4. A deep incision infection is diagnosed by a surgeon or attending physician.

Note: Report infections that involve both superficial and deep incision sites as deep surgical site infection. If a wound spontaneously opens as a result of infection, code for deep surgical site infection and wound disruption.


Drug or alcohol withdrawal syndrome: A set of symptoms that may occur when a person who has been drinking too much alcohol or habitually using certain drugs suddenly stops. Symptoms may include activation syndrome (that is, tremulousness, agitation, rapid heartbeat and high blood pressure), seizures, hallucinations or delirium tremens.

ICD-10-CA codes: F10.3–F10.5

Deep vein thrombosis (DVT)/thrombophlebitis: 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 scan. The patient must be treated with anticoagulation therapy and/or placement of a vena cava filter or clipping of the vena cava.


Extremity compartment syndrome: A condition in which there is swelling and an increase in pressure within a limited space (a fascial compartment) that presses on and compromises blood vessels, nerves and/or tendons that run through that compartment. Compartment syndromes usually involve the leg but can also occur in the forearm, arm, thigh and shoulder.

ICD-10-CA codes: M62.20–M62.29

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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.

ICD-10-CA codes: T82.0–T82.9

Intracranial pressure elevation: Intracranial pressure greater than 25 torr for longer than 30 minutes.

ICD-10-CA code: G93.2

Myocardial infarction: A new acute myocardial infarction occurring during hospitalization (within 30 days of injury).


Organ/space surgical site infection: An infection that occurs within 30 days after an operation and which involves any part of the anatomy (organs or spaces) other than the incision, which was opened or manipulated during a procedure. The infection must also involve at least one of the following:

1. There is purulent drainage from a drain that is placed through a stab wound or puncture into the organ/space.

2. Organisms are isolated from an aseptically obtained culture of fluid or tissue in the organ/space.

3. An abscess or other evidence of infection involving the organ/space is found on direct examination, during reoperation or by histopathologic or radiologic examination.

4. An organ/space SSI is diagnosed by a surgeon or attending physician.

ICD-10-CA codes: T81.4, T82.6, T82.7, T83.5, T83.6, T84.50–T84.58, T84.60–T84.69, T85.7, T87.40–T87.49, Y83.0–Y83.9, Y88.3

Osteomyelitis: A condition that meets at least one of the following criteria:

1. Organisms are cultured from bone.

2. There is evidence of osteomyelitis on direct examination of the bone during a surgical operation or histopathologic examination.

3. At least two of the following signs or symptoms with no other recognized cause are present: fever (38°C), localized swelling, tenderness, heat or drainage at the suspected site of bone infection and at least one of the following:

a. Organisms are cultured from blood;

b. There is a positive blood antigen test (such as H. influenzae or S. pneumoniae); and/or

c. There is radiographic evidence of infection, such as abnormal findings on X-ray, CT scan, MRI scan or radiolabel scan (gallium, technetium, etc.).

ICD-10-CA codes: H05.0, M86.00–M86.19

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Pneumonia: Patients with evidence of pneumonia that develops during the hospitalization. Patients with pneumonia must meet 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:

a. New onset of purulent sputum or change in character of sputum;

b. Organism isolated from blood culture; and/or

c. 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:

a. New onset of purulent sputum or change in character of sputum;

b. Organism isolated from the blood;

c. Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing or biopsy;

d. Isolation of virus or detection of viral antigen in respiratory secretions;

e. Diagnostic single antibody titer (IgM) or fourfold increase in paired serum samples (IgG) for pathogen; and/or

f. Histopathologic evidence of pneumonia.

ICD-10-CA codes: J12.0–J18.9, J95.88

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.


Stroke/CVA: Following injury, patient develops an embolic, thrombotic or hemorrhagic vascular accident or stroke with motor, sensory or cognitive dysfunction (such as hemiplegia, hemiparesis, aphasia, sensory deficit or impaired memory) that persists for 24 or more hours.

ICD-10-CA codes: I63.1–I63.9, I64

Superficial surgical site infection: Defined as an infection that occurs within 30 days after an operation and that involves only skin or subcutaneous tissue of the incision and at least one of the following:

1. There is purulent drainage, with or without laboratory confirmation, from the superficial incision.

2. Organisms are isolated from an aseptically obtained culture of fluid or tissue from the superficial incision.

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3. At least one of the following signs or symptoms of infection is present: pain or tenderness, localized swelling, redness or heat; and the superficial incision is deliberately opened by the surgeon, unless incision is culture-negative.

4. Superficial incisional surgical site infection is diagnosed 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 facial and muscle layers (see deep surgical site infection).


Systemic sepsis: Definitive evidence of infection, plus evidence of a systemic response to infection. This systemic response is manifested by the presence of infection and TWO or more of the following conditions:

1. Temperature higher than 38°C or lower than 36°C;

2. Sepsis with hypotension despite adequate fluid resuscitation combined with perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria or an acute alteration in mental status. Patients who are on inotropic or vasopressor agents may not be hypotensive at the time that perfusion abnormalities are measured;

3. HR higher than 90 BPM;

4. RR greater than 20 breaths/minute or PaCO2 lower than 32 mm Hg (less than 4.3 kPa); and

5. WBC greater than 12,000 cells/mm3, less than 4,000 cells/mm3 or greater than 10% immature (band) forms.

ICD-10-CA codes: A40.0–A41.9, A49.9

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 after being extubated.


Unplanned return to the ICU: Unplanned return to the intensive care unit after initial ICU discharge. Does not apply if ICU care is required for post-operative care of a planned surgical procedure.


Unplanned return to the OR: Unplanned return to the operating room after initial operation management for a similar or related previous procedure.

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Urinary tract infection: An infection anywhere along the urinary tract with clinical evidence of infection, which includes at least one of

1. Fever higher than 38.5°C;

2. WBC higher than 100,000 or less than 3,000 per cubic millimetre;

3. Urgency;

4. Dysuria; or

5. Suprapubic tenderness.

ICD-10-CA code: N39.0

Wound disruption: Separation of the layers of a surgical wound, which may be partial or complete, with disruption of the fascia.


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Appendix G: Definitions of Discharge Disposition Institutions

1. Home—no support service from an external agency required; patient functions independently

2. Home with support services—senior’s lodge, attendant care, home care, meals on wheels, homemaking, supportive housing, etc.

Examples:

a. A facility where supervisory care is not required on a continuing basis. The patient is discharged and able to function independently within a group setting. Community services would be brought in to provide support, when necessary.

b. The patient is discharged home with the support of home care workers who are providing daily dressing changes and wound care.

3. Another acute care facility: patient is transferred to an acute care inpatient institution (includes other acute, subacute, acute psychiatric, acute rehabilitation, acute cancer, acute pediatric, etc.)

4. General rehabilitation facility—a rehabilitation unit or collection of beds designated for rehabilitation purposes that is part of a general hospital offering multiple levels or types of care

5. Chronic care facility—patient is discharged to a reporting facility that provides continuing medical care by medical and allied medical staff

6. Nursing home—patient receives support services at some level

7. Special rehabilitation facility—a facility that may provide extensive and specialized inpatient rehabilitation services; commonly a free-standing facility or a specialized unit within a hospital

8. Foster care and/or children’s aid

9. Other

10. Died

Sources Canadian Institute for Health Information, DAD Abstracting Manual, 2010–2011 (Ottawa, Ont.: CIHI, 2010). Canadian Institute for Health Information, National Rehabilitation Reporting System Privacy Impact Assessment (Ottawa, Ont.: CIHI, 2009).

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Appendix H: Revised Trauma Score

Glasgow Coma Scale (GCS)

Systolic Blood Pressure (SBP)

Respiratory Rate (RR) Coded Value

13–15 90+ 10–29 4

9–12 76–89 30+ 3

6–8 50–75 6–9 2

4–5 1–49 1–5 1

3 0 0 0

Revised Trauma Score = 0.9368GCS + 0.7326SBP + 0.2908RR

RTS values range from 0 to 7.8408

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Appendix J: Acceptable Procedures Performed in the ICU

Cardiovascular

Open cardiac massage CCI codes: 1.HZ.09.LA-CJ

Angio-embolization CCI codes: Specific CCI code related to the vessel of the site being embolized

IVC filter CCI code: 1.IS.51.GR-KA

CNS

Insertion of ICP monitor CCI codes: 1.AA.53.SE-PL, 1.AA.53.SZ-PL, 1.AC.53.DA-PL, 1.AC.53.SZ-PL, 1.AN.53.SE-PL, 1.AN.53.SZ-PL

Ventriculostomy CCI codes: 1.AC.52.^^

Cerebral oxygen monitoring CCI code: 1.AA.53.SE-PL

Musculoskeletal

Fasciotomy CCI codes: 1.EP.72.WK, 1.SG.72.WK, 1.SY.72.WK, 1.TF.72.WK, 1.TQ.72.WK, 1.UY.72.WK, 1.VD.72.WK, 1.VR.72.WK, 1.WV.72.WK

Genitourinary

Ureteric catheterization (ureteric stent) CCI codes: 1.PG.50.^^

Suprapubic cystostomy CCI codes: 1.PM.52.HH-TS

Respiratory

Chest tube CCI codes: 1.GV.52.DA-TS, 1.GV.52.HA-HE, 1.GV.52.LA-TS

Tracheostomy CCI codes: 1.GJ.77.^^

Gastrointestinal

Gastrostomy/jejunostomy (percutaneous or endoscopic) CCI codes: 1.NF.53.^^, 1.NK.53.^^

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