American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

2019 Data Dictionary Frequently Asked Questions

General

NTDS Patient Inclusion Criteria (pg. iv & v)

Are in-house traumas reported to TQIP?

Patients who had a traumatic event that resulted in an injury while admitted at your hospital should go through the Performance Improvement process at your hospital so they are not reported to TQIP.

Are isolated hip fractures reported to TQIP?

The NTDS Patient Inclusion Criteria does not exclude patient's that sustained a traumatic isolated hip fracture (IHF). IHFs are risk-adjusted and do not negatively impact the TQIP Benchmark Report. IHFs are their own cohort are are excluded from all other cohorts.

Is the NTDS Patient Inclusion Criteria the same as the TQIP Inclusion Criteria?

No. Centers submitting data to TQIP must follow the NTDS Patient Inclusion Criteria. Then, TQIP determines which patients are included in the TQIP Benchmark Report using the internally-defined TQIP Patient Inclusion Criteria. The TQIP Patient Inclusion Criteria is included for each TQIP Benchmark Report in the References section and can change over time.

Miscellaneous

What is Glasgow Coma Scale (GCS) 40 and why are we reporting this?

The GCS at 40 assessment is a new approach to assessing the patient’s level of consciousness in response to specific stimuli. Not all centers are using the GCS at 40 quite yet because it’s still relatively new. It was added to the NTDS beginning with the 2019 patient arrival year because it was recently introduced in the 10th edition of ATLS and as such, some centers have started using the GCS at 40 assessment. Please note that the NTDS does not require that your center start using the GCS at 40 assessment for your patients and you should report what is documented in the patient’s medical record.

For more information regarding the specifics of the GCS at 40 assessment, you may consider reviewing the Glasgow Coma Score website.

Will TQIP still be accepting standard GCS if our facility is not using GCS 40?

Yes. Beginning with the 2019 patient arrival year, your center should report either the standard GCS or GCS 40, but not both.

I have a suggestion to add, remove, and or change an NTDS data element definition. How can I communicate this to TQIP?

Suggestions to add, improve, or remove an NTDS data element definition should be submitted at the NTDS Revision Site.

Injury Information

Protective Devices (pg. 28)

How should the Protective Devices data element be reported on a patient that was walking and tripped and fell? “Not Applicable”? Or, “1. None”?

The Protective Devices data element does not to consider the mechanism of injury. So, if no protective devices or safety equipment was being used by the patient at the time of injury, regardless of the mechanism, you should report the Field Value “1. None.”

Are things like a walker, wheelchair, etc., considered protective devices or equipment?

Wheelchairs, walkers, etc. are prescribed for medical use and not as protective equipment or devices.

Protective Devices; Airbag Deployment (pgs. 28 & 29)

What should be reported to TQIP when documentation states that there was no airbag deployment but did not state that airbags were present in the vehicle?

While most vehicles used today are equipped with airbags, we cannot assume that all vehicles are equipped with airbags. Therefore, if you do not have documentation to support that the vehicle was equipped with airbags, then you should not report Field Value “8. Airbag Present” for the Protective Devices data element. Since you did not report Field Value “8. Airbag Present,” you would then report the null value “Not Applicable” for the Airbag Deployment data element.

Pre-Hospital Information

Initial Field Systolic Blood Pressure (pg. 43)

The center that I am working for wants the first set of pre-hospital vital signs and GCS recorded no matter the time they were taken. Can we report the first pre-hospital vital signs to TQIP even if they were taken after EMS left the scene of injury?

No. Using the Initial Field Systolic Blood Pressure data element definition as an example, the definition states “First recorded systolic blood pressure measured at the scene of injury.” If your center wishes to collect additional sets of prehospital vital signs, you may certainly do so, you just wouldn’t report them to TQIP.

Initial Field Systolic Blood Pressure; Initial Field Pulse Rate; Initial Field Respiratory Rate; Initial Field Oxygen Saturation; Initial Field GCS—Eye, Verbal, Motor, Total; Initial Field GCS 40—Eye, Verbal, Motor (pgs. 43-53)

A patient fell at home and three days later called for EMS transport to our center. Can I report the EMS vitals for the Initial Field vitals, if taken on the scene, even though the injury occurred 3 days prior?

Yes. The scene of injury was the patient's home and EMS transported the patient from the scene of injury to the hospital.

If the patient is placed in the back of the ambulance as a “scoop and run” situation, and the first set of vitals are obtained en route, can those vitals be captured as the initial set of EMS vitals?

Vital signs measured after the EMS service leaves the scene of injury should not be reported to TQIP.

Initial Field GCS 40—Eye, Verbal, Motor (pgs. 51-53)

The EMS services in my area do not report GCS 40, they use the standard GCS. How do I report the Initial Field GCS 40-Eye, Verbal, and Motor data elements to TQIP?

Report the null value “Not Known/Not Recorded” to TQIP. This instruction is found in the Additional Information section of the Initial Field GCS 40-Eye, Verbal, and Motor data element definitions.

Inter-Facility Transfer (pg. 54)

A patient arrived by EMS from an urgent care clinic. Does TQIP consider this to be an inter-facility transfer?

The NTDS defines an inter-facility transfer as a patient who was transferred from an acute care facility to your hospital by EMS transport. Ultimately, it depends on your state. If the urgent care facility is licensed as an acute care facility, then yes. If not, then no.

Why does the COT VRC definition of an inter-facility transfer differ from the NTDS definition of an inter-facility transfer?

The COT VRC Program and TQIP are under the same umbrella at the American College of Surgeons; however, they are separate programs with different objectives.

What should be reported to TQIP when a patient is transferred from one center to another center but travels by private car, rather than EMS transport?

The NTDS definition requires that inter-facility transfer patients be transferred from an acute care center and transported by EMS. So, if the patient was transferred but traveled by private auto, then Field Value “2. No” should be reported for the Inter-facility Transfer data element.

Trauma Center Criteria (pg. 55)

When there are no criteria listed on the EMS Run Report from the scene, what do we report?

Report the null value “Not Known/Not Recorded” if there was not an identical Field Value listed on the EMS Run Report from the scene.

Vehicular, Pedestrian, Other Risk Injury (pg. 56)

What should be reported when there are not specific criteria listed on the EMS Run Report from the scene of injury?

Report the null value “Not Known/Not Recorded” if there was not an identical Field Value listed on the EMS Run Report from the scene.

Trauma Center Criteria; Vehicular, Pedestrian, Other Risk Injury (pgs. 55 & 56)

Are we to report data for the Trauma Center Criteria and Vehicular, Pedestrian, Other Risk Injury data elements if a patient is brought to us by an EMS provider regardless of origin i.e. injury at scene vs an outside facility? Or, are we only to complete these data elements if a patient was brought to us directly from the scene of injury?

Yes, these data elements should be reported on all patients as instruction in the NTDS data element definitions regardless if it is a scene EMS report or a transfer EMS report.

I do not believe any of our EMS providers are NEMSIS v3-compliant but would like to see what a NEMSIS v3-compliant Run Report looks like to make sure I'm not missing something.

There are many different software vendors that EMS services use for their run reports. As such, we suggest that you reach out to the EMS services to determine if they are NEMSIS v3-compliant. If they are not NEMSIS v3-compliant, then you should report the null value “Not Known/Not Recorded” to TQIP for the Trauma Center Criteria and Vehicular, Pedestrian, Other Risk Injury data elements. If they are NEMSIS v3-compliant, then consider asking them where on their forms they document the Trauma Center Criteria and Vehicular, Pedestrian, Other Risk Injury criteria.

If a patient went by EMS to an outside hospital first, and the EMS report is missing, what do we report for the Trauma Center Criteria and Vehicular, Pedestrian, Other Risk Injury data elements?

In the event that the scene EMS Run Report is missing or not available, the appropriate null value to report for the Trauma Center Criteria and the Vehicular, Pedestrian, Other Risky Injury data fields is the null value “Not Known/Not Recorded.”

Emergency Department Information

Initial ED/Hospital Systolic Blood Pressure (pg. 61)

Patient arrives to ED with CPR in progress. The Trauma physician describes in their narrative that the patient had no pulse, is in asystole and declares patient as expired. Can we report a “0” value for the Initial ED/Hospital Systolic Blood Pressure if there is no numerical value documented in the medical records?

No, you must report the value that was recorded in the patient's medical record. If there was no documented systolic blood pressure per the definition criteria, then the null value “Not Known/Not Recorded” should be reported.

Initial ED/Hospital Temperature (pg. 63)

Is it necessary to report the patient's temperature to TQIP?

Yes. It is the expectation that all centers reporting data to TQIP follow the NTDS data dictionary requirements. The patient's initial ED/hospital temperature is an important predictor of their outcome.

Initial ED/Hospital Respiratory Rate (pg. 64)

A patient came into the ED with a documented “0” for their pulse and blood pressure and expired within a few minutes of arrival to the ED. There was no documentation of respiratory rate. What should we report for the Initial ED/Hospital Respiratory Rate?

If a respiratory rate was not documented within 30 minutes or less of the patient’s arrival to your ED, then the appropriate null value to report for the Initial ED/Hospital Respiratory Rate data field is “Not Known/Not Recorded.”

For the purpose of entering the GCS Qualifier-Patient Intubated, would a patient who is mechanically or manually ventilated using a King airway or combitube be considered intubated?

Initial ED/Hospital GCS Assessment Qualifiers (pg. 72)

The data element definition does not specify the type of intubation required to report these data elements. The King airway and Combitube are different types of airway devices that interfere with the patient's ability to speak, so, if it were documented that the patient was mechanically or manually ventilated using a King airway or Combitube in conjunction with their initial ED/hospital GCS assessment, you should report the Field Value “3. Patient Intubated.”

Initial ED/Hospital GCS 40-Eye; Initial ED/Hospital GCS 40-Verbal; Initial ED/Hospital GCS 40-Motor (pgs. 73–75)

Is it true that the NTDS allows for either the standard GCS or GCS 40, but not both?

Yes. The Initial Field GCS 40, Initial ED/Hospital GCS 40, and Highest GCS 40 Motor data elements are reflective of the GCS 40 assessment criteria. If the providers at your hospital have not transitioned to using the GCS 40 criteria to assess your patients, and are using the standard GCS criteria, then report the null value “Not Known/Not Recorded” for the Initial ED/Hospital GCS 40-Eye/Verbal/Motor data elements.

Initial ED/Hospital Height; Initial ED/Hospital Weight (pgs. 76 & 77)

If the height and weight is recorded, but there is no date and time with it, what should we report?

Report the null value “Not Known/Not Recorded” to TQIP for the Initial ED/Hospital Heightand Initial ED/Hospital Weight data elements if the date and time of measurement was not recorded. Having to report the null value “Not Known/Not Recorded” due to lack of documentation in the patient’s medical record is a good way to show that your center is not documenting what is required to be reported to TQIP, which would make for a great PI project for your center.

Drug Screen (pg. 78)

If there is no drug screen done at our hospital, but the autopsy report shows a positive drug result for THC and Cocaine, can we report these results?

No. While the patient’s autopsy report included a positive drug screen result, you should only report positive drug screen results within 24 hours after the patient’s first hospital encounter. TQIP does not collect post-discharge data, so using an autopsy report for this data element would not be accurate.

A trauma patient tested positive on the drug screen for barbiturates but is prescribed them. How is this reported to TQIP?

If the patient was not administered a barbiturate during the patient event, but the patient’s first recorded drug screen results within 24 hours after the first hospital encounter was positive for barbiturates, then you should report the Field Value “2. BAR” to TQIP.

Now that marijuana is legalized in a lot of states, do we report this if the patient has tested positive?

To answer your question, the NTDS definition does not consider the legality of a drug. Therefore, if a patient were to test positive on a drug screen for marijuana (assuming that it was not administered by a facility during the treatment for this injury event), then you should report the Field Value “12. THC (Cannabinoid).”

ED Discharge Disposition

We have a flexible ICU that admits ICU status patients and stepdown level patients... If the admission order states “admit to stepdown,” and the admission plan is documented as “observe in stepdown” but the room /unit is titled ICU what should we report for the ED Discharge Disposition?

To answer your question, if the bed the patient was admitted from the ED to a step-down bed, then you should report the Field Value “3. Telemetry/step-down unit” even if the step-down bed is located in a flexible ICU. However, if the patient was admitted from the ED to an ICU bed, then you should report the Field Value “8. Intensive Care Unit (ICU).”

For the ED Discharge Disposition Field Values, what is the difference between “4. Home with services” and “9. Home without services”?

The Field Value “4. Home with services” is reported to TQIP for patients discharged from the ED to their home with some type of ordered service such as home health. The Field Value “9. Home without services” is reported to TQIP for patients discharged home without any additional services.

What should be reported for the ED Discharge Disposition if the patient was discharged from the ED for observation and went to the telemetry floor?

Report the Field Value “3. Telemetry/step-down unit (less acuity than ICU)” for the ED Discharge Disposition data element. The reason being that the ED discharge disposition is the physical location that the patient was discharged to from the ED, not what the discharge order was written for or the level of care received.

For trauma patients discharged from the ED to Hospice (who did not come from SNF or hospice), which Field Value should be reported?

For patients discharged from the ED to home with hospice care, you should report Field Value “4. Home with services” because the patient is returning home, now with hospice services.

For patients discharged from the ED to a hospice care facility, you should report Field Value “6. Other (jail, institutional care, mental health, etc.)” because the patient is going to another institution that provides hospice care, instead of home.

Signs of Life (pg. 82)

If a patient arrives with a pulseless electrical activity (PEA), how should the Signs of Life data element be reported?

The Additional Information portion of the definition states “A patient with no signs of life is defined as having none of the following: organized EKG activity, pupillary responses, spontaneous respiratory attempts or movement, and unassisted blood pressure. This usually implies the patient was brought to the ED with CPR in progress.” Patients that exhibit PEA rhythm would show organized activity on an EKG, so you should report Field Value “2. Arrived with signs of life.”

ED Discharge Date; ED Discharge Time (pgs. 83 & 84)

What do I report for the date and time when the patient has multiple ED discharge orders? The first ED discharge order or the final ED discharge order?

If multiple ED discharge orders were written, the date and time that should be reported is the date and time the final discharge order was written by the physician that was ultimately responsible for the patient's care

What date and time do I report if the patient leaves the ED against medical advice (AMA)?

If a patient left the ED AMA, report the date and time the patient signed the AMA form. If the patient refused to sign the AMA form, report the date and time it was noted in the medical record that the patient left AMA, which could be documented in the nursing notes.

Hospital Procedure Information

ICD-10 Hospital Procedures (pgs. 86 & 87)

My center is a TQIP center so if transfusion data is being reported for the TQIP Measures for Processes of Care, why are they also reported for the ICD-10 Hospital Procedures?

The ICD-10 Hospital Procedures data element is reported on all patients and by all hospitals. TQIP centers who report Measures for Processes of Care data elements first follow collection criterions. In most of the blood products data elements, the collection criterion is “Collect on all patients with transfused packed red blood cells within first 4 hours after ED/hospital arrival” so not all patients would apply.

Sometimes a patient may have a procedure done that starts after their discharge order was written. Should we report these procedures to TQIP?

No. For TQIP purposes, anything that occurred after the patient was ordered to be discharged from your hospital is considered to be post-discharge data.

If the patient is intubated for surgery, remains intubated after surgery, and returns to the unit intubated, do we report the ICD-10 procedure code for the intubation?

If the only occurrence of the patient being intubated was in the operating room (OR), you should not report the intubation as an ICD-10 Hospital Procedure. This applies even if the patient remains intubated in the unit for several days following the surgery.

If a procedure is denoted in the NTDS definition with an asterisk and is performed multiple times in the operating room, should the procedure code only be reported once?

No. All procedures performed in the OR should be reported regardless if they have an asterisk or not. You should only report the first event for procedures with asterisks that were done in the ED, ICU, ward, or radiology department.

I noticed that in the 2019 dictionary that the code for REBOA is no longer referenced. Do you want this reported as “04L03DZ” as previously indicated?

No. The ICD-10 PCS code “04L03DZ” was removed starting with the 2019 patient admission year. There were updates to the ICD-10 PCS code set that now include multiple codes for REBOA depending on which zone of the aorta the balloon was deployed. Please follow the ICD-10 PCS coding rules and guidelines when reporting these codes.

I have a question about an ICD-10 PCS code and/or ICD-10 PCS coding rule. Can TQIP staff help with this?

No. For questions regarding an ICD-10 PCS coding rule or guideline, consider contacting the ICD-10 coding champion at your center as they are the experts in this area.

Pre-Existing Conditions

Miscellaneous (pgs. 90–115)

Can I report other pre-existing conditions or comorbidities that are not defined in the NTDS Data Dictionary?

No. The pre-existing conditions defined in the NTDS Data Dictionary are the only ones reported to TQIP. Centers may collect other pre-existing conditions in their registry per their data collection needs, but the only conditions reported to TQIP are those defined in the NTDS Data Dictionary.

Advanced Directive Limiting Care (pg. 91)

In the Advanced Directive Limiting Care definition, what does “present prior to arrival” mean?

The patient’s advanced directive to limit life-sustaining treatment must have been present on their person prior to arrival, already on file at your center, and in line with your center's policy to limit life-sustaining treatment to honor the patient's pre-arrival request, in order to report Field Value “1. Yes” to TQIP.

If on arrival to your hospital the patient states that they are a DNR and the family will be bringing the paperwork later, what should we report for the Advanced Directive Limiting Care data element since the paperwork was not present prior to arrival?

In this instance, the Field Value “2. No” should be reported for the Advanced Directive Limiting Care data element. The patient did not have a written request to limit life-sustaining therapy that was present prior to arrival at your facility. Had the patient had the written request on their person on arrival at your facility, then Field Value “1. Yes” should be reported.

Can the advanced directive limiting care be taken from past admissions? If so how far back should we look for it?

If the patient’s advanced directive to limit life-sustaining therapy was on file from a past admission, then you should consider it present prior to arrival at your center. Regarding a timeframe, the definition does not specify a timeframe, just that the directive must limit your center from providing life-sustaining therapy.

Alcohol Use Disorder (pg. 92)

If “alcoholism,” “alcohol dependence,” or “chronic alcohol abuse” is documented, can I report the Field Value “1. Yes” for Alcohol Use Disorder?

No. This definition is consistent with the American Psychiatric Association (APA) DSM-5, 2013 and requires that the specific diagnosis of “Alcohol Use Disorder” be documented in the patient’s medical record. Earlier versions of the DSM may have accepted “alcoholism” to meet the definition of “Alcohol Use Disorder”; however, with the implementation of the DSM-5 alcohol abuse and alcohol dependence have been combined into one disorder, “Alcohol Use Disorder.”

Bleeding Disorder (pg. 96)

Should I report the Field Value “1. Yes” for the Bleeding Disorder data element if the patient has a diagnosis sickle cell anemia?

No. TQIP is only collecting conditions where the blood does not clot properly. Sickle cell anemia is not a clotting disorder so if that is their only bleeding disorder then the Field Value “2. No” should be reported.

Should I report the Field Value “1. Yes” for the Bleeding Disorder data element if the patient has a diagnosis of thrombocytopenia?

Yes. Thrombocytopenia is a condition in which the patient’s blood cannot clot properly, so if there is documentation in the patient’s medical record that the patient's thrombocytopenia was present prior to their injury, then it meets the NTDS definition criteria.

Should I report the Field Value “1. Yes” for the Bleeding Disorder data element if “bleeding disorder” is documented but doesn't specify what kind of bleeding disorder the patient has?

No. There are many types of bleeding disorders, but the qualifying disorders that meet the NTDS definition are the disorders in which the blood cannot clot properly. Consider investigating to see what type of bleeding disorder the patient has and whether it meets the NTDS definition criteria.

Current Smoker (pg. 103)

Do e-cigarettes or vape pens meets the definition criteria to report the Field Value “1. Yes” for Current Smoker?

No. The NTDS definition excludes patients who report smoking cigars, pipes, or smokeless tobacco. E-cigarettes and vape pens are considered smokeless tobacco.

If a patient states they smoke marijuana, should we report the Field Value “1. Yes”?

No. The NTDS definition is specific to cigarette smoking. Patients who only report smoking marijuana do not meet the NTDS definition criteria and Field Value “2. No” should be reported.

Functionally Dependent Health Status (pg. 108)

Does dependency on an oxygen tank meet the definition criteria to report the Field Value “1. Yes” for the Functionally Dependent Health Status data element?

No. A patient on chronic oxygen therapy does not meet the NTDS definition criteria. The patient must be partially or completely dependent on a devise or person to perform their ADLs due to a cognitive or physical limitation, not a physiological limitation. In this instance, Field Value “2. No” should be reported.

Does anyone living in Assisted Living, Adult Foster Care, or a Skilled Nursing Facility met the definition criteria of the Functionally Dependent Health Status data element by virtue of the fact that they do not live independently?

Yes. The NTDS definition is based on the inability of patients to complete age appropriate ADLs due to cognitive or physical limitations. Since patients who reside in an assisted living, adult foster care, or skilled nursing facility are partially dependent or completely dependent upon equipment, devices, or another person to complete some or all their ADLs, you should report the Field Value “1. Yes” for these patients.

Hypertension (pg. 109)

A patient has a diagnosis of pre-injury hypertension and it is managed by diet and exercise. Does this meet the Hypertension data element definition criteria?

Yes. For TQIP purposes, if a patient has a diagnosis of hypertension and their treatment includes diet and exercise, then that is considered “medical therapy.”

A patient was prescribed and administered antihypertensive medication during their initial stay at their hospital, but a diagnosis of “hypertension” was not documented prior to their arrival. For this patient, should I report Field Value “1. Yes” for the Hypertension data element?

No. A diagnosis of hypertension must be documented in the patient's medical record and the patient's hypertension must have been present prior to injury.

Mental/Personality Disorders (pg. 110)

Does a diagnosis of anxiety disorder meet the Mental/Personality Disorders data element definition criteria?

No. There must be a diagnosis of pre-injury depressive disorder, bipolar disorder, schizophrenia, borderline or antisocial personality disorder, and/or adjustment disorder/post-traumatic stress disorder. Anxiety is not included in this list of mental/personality disorders.

Should I report the Field Value “1. Yes” for the Mental/Personality Disorders data element if the patient had a diagnosis of depression and the patient takes medication for depression?

If the medical record documents “depression” or “depression with medication for depression,” then this does not satisfy the NTDS definition criteria and Field Value “2. No” should be reported. The NTDS definition is consistent with the APA DSM 5, 2013 and documentation of “depression” is not the same as the diagnosis of a depressive disorder; the latter being consistent with the APA DSM 5, 2013.

Peripheral Arterial Disease (PAD) (pg. 112)

Does a diagnosis of peripheral vascular disease (PVD) meet the PAD definition criteria?

Yes. Peripheral vascular disease (PVD) can occur in both arterial and venous vessels and PVD can sometimes be used interchangeably in documentation with PAD because PAD is a type of PVD.

Substance Abuse Disorder (pg. 115)

Does the term “disorder” need to be documented or does documentation of “substance abuse” meet the Substance Abuse Disorder data element definition criteria?

Yes. The patient must have a diagnosed substance abuse disorder that was present prior to injury. As indicated in the definition, the NTDS definition is consistent with the APA DSM 5, 2013. Documentation of “substance abuse” alone does not meet the NTDS definition.

Does occasional cocaine or methamphetamine use count as a substance abuse disorder?

If you would like further information regarding the substance use disorder diagnosis criteria as indicated in the DSM 5, 2013, you may consider reaching out to the psychiatric liaison at your center, as this is their area of expertise.

Does documentation of drug/substance dependence meet the Substance Abuse Disorder data element definition? The DSM-5 definition combines dependence and abuse into a one category of substance use disorder.

Documentation of “drug/substance dependence” alone does not meet the NTDS definition criteria of a substance use disorder. To report the Field Value “1. Yes,” the patient must have diagnosis of a substance use disorder diagnosis that was present prior to their injury.

Diagnosis Information

ICD-10 Injury Diagnoses (pg. 117)

I have a question about an ICD-10-CM code and/or ICD-10-CM coding rule. Can TQIP staff help with this?

No. For questions regarding an ICD-10-CM coding rule or guideline, consider contacting the ICD-10 coding champion at your center, as they are the experts in this area.

AIS Predot Code; AIS Severity (pgs. 118 & 119)

I have a question about an AIS code and/or AIS coding rule. Can TQIP staff help with this?

No. For questions regarding AIS coding rules and guidelines, please contact the AIS coding experts at the AAAM: info@aaam.org.

AIS Version (pg. 120)

When will AIS 2015 be required and AIS 2005, Update 2008 no longer be accepted?

It has not been determined when the AIS 05, 08 code set will be retired. We will be sure to give centers ample time to prepare for the complete transition to AIS 2015. In the meantime, TQIP accepts both AIS 05,08 and AIS 2015 code sets.

Hospital Events

Acute Kidney Injury (AKI) (pg. 122)

I have a patient that arrived at our hospital with an serum creatinine (SCr) level three times their baseline and they were diagnosed with an AKI. Does this meet the AKI data element definition criteria?

No. The patient's AKI was present on admission, so it did not occur during their initial stay at your hospital.

In the AKI data element definition, how is the patient's baseline serum creatinine (SCr) defined?

The NTDS definition of AKI is consistent with the March 2012 KDIGO Guideline. A patient's baseline SCr is their normal SCr level given the patient's age, race, and gender.

Where can I find more information about the March 2012 KDIGO Guideline?

You can find more information about the March 2012 KDIGO Guideline.

Alcohol Withdrawal Syndrome (pg. 125)

If a patient is admitted with a known alcohol abuse disorder and is started on alcohol detox initiatives, should I report Field Value “1. Yes” for the Alcohol Withdrawal Syndrome data element?

No. The patient must have experienced the signs and symptoms of alcohol withdrawal per the Alcohol Withdrawal Syndrome data element definition criteria.

We have a patient who had the signs and symptoms of alcohol withdrawal upon arrival. Should I report Field Value “1. Yes” for the Alcohol Withdrawal Syndrome data element?

No. The patient's alcohol withdrawal was present on admission and did not occur during their initial stay at your hospital.

Does the term “alcohol withdrawal syndrome” need to be documented to meet the Alcohol Withdrawal Syndrome data element definition criteria?

No. Only the signs and symptoms of alcohol withdrawal must be documented in the patient's medical record.

Cardiac Arrest with CPR (pg. 126)

A patient arrived with CPR in progress, and then had return of spontaneous circulation (ROSC). It was documented that the patient went into cardiac arrest again 4 minutes later and received CPR. Is this patient excluded from the Cardiac Arrest with CPR data element definition?

No. In this instance, report the Field Value “1. Yes” for the Cardiac Arrest with CPR data element. Patients receiving CPR on arrival are excluded, however, if cardiac arrest with CPR happens again at any time during their stay, then it meets the NTDS definition criteria.

A patient meets the criteria for the Cardiac Arrest with CPR data element on three different days during their hospital stay. Do we report each event or just the first occurrence of cardiac arrest with CPR?

TQIP collects data only for the first occurrence of Cardiac Arrest with CPR. The same is true of all Hospital Events defined in the NTDS Data Dictionary.

If a patient had documented loss of heart rate and had compressions started, but “cardiac arrest” was not documented in the chart, what should be reported for the Cardiac Arrest with CPR data element?

In this instance, report the Field Value “2. No” for the Cardiac Arrest with CPR data element because the definition requires “cardiac arrest” be documented in the medical record.

On hospital day 11, a patient was transferred off the trauma service to a medical service for further medical management and develops a CAUTI on hospital day 12. The patient meets all the definition criteria of the CAUTI data element. Since trauma is no longer following this patient, which Field Value should be reported?

Catheter-Associated Urinary Tract Infection (CAUTI) (pgs. 127 & 128)

If a patient meets the criteria of the NTDS definition of the CAUTI data element and the UTI occurred during the patient’s initial stay at your hospital, then Field Value “1. Yes” should reported, regardless of the attending service. Upon review of the definition, you’ll see that the NTDB does not consider the hospital service that was treating the patient at the time of the hospital event, just that the event occurred during the patient’s stay at your hospital.

Should patients who are transferred to our hospital from another facility with an indwelling catheter already in place be considered for the CAUTI data element?

Yes. The NTDS definition of CAUTI is consistent with the January 2016 CDC definition of CAUTI including the CDC transfer rule. If the catheter was placed at the referring facility, was in place for > 2 calendar days at your center (with Day 1 being the day the patient arrived with the catheter in place), then on the day of the event (the day the UTI was diagnosed) the patient met criterion 1 through 3 of the CAUTI Criterion SUTI 1a or SUTI 2, and the diagnosis of UTI was documented in the medical record, then Field Value “1. Yes” should be reported for the CAUTI data element.

If the patient arrived at your center with an indwelling catheter and was diagnosed with a UTI on the same day of arrival, then Field Value “2. No” should be reported for the CAUTI data element. The reason why is that this condition is considered to be present on admission and is consistent with the CDC’s “transfer rule.”

Where can I find more information about the January 2016 CDC definition of CAUTI?

The January 2016 CDC PCS Manual can be accessed online.

Deep Vein Thrombosis (DVT) (pg. 133)

During their initial stay at the hospital, a patient had an ultrasound that showed an acute deep vein thrombosis (DVT) in the right gastrocnemius vein. Given the distal location of the newly diagnosed DVT, the patient was not treated with anticoagulation, an IVC filter, or clipping of the vena cava. What should be reported for the DVT data element?

For this patient, report the Field Value “2. No” for the DVT data element. The patient's DVT was not treated with anticoagulation therapy and/or placement of a vena cava filter or clipping of the vena cava, as required by the definition criteria.

Pressure Ulcer (pg. 141)

To meet the definition criteria of the Pressure Ulcer data element, does the wound have to be “staged” and documented in the medical record?

No, the definition does not require that the wound has to be “staged,” however, the definition does require documentation that the pressure ulcer is consistent with the NPUAP 2014 criteria for either a stage II-IV pressure ulcer, unstageable/unclassified, or suspected deep tissue injury.

In the event a patient has clear documentation of deep tissue injury where a specialized wound care team is treating the patient but there is no documentation of “pressure ulcer” in the record, will deep tissue injury meet the definition criteria?

If there is documentation of a “deep tissue injury” that meets the NPUAP 2014 criteria, you should report Field Value “1. Yes” for the Pressure Ulcer data element.

Unplanned Admission to ICU (pg. 147)

For the Unplanned Admission to ICU data element definition, what is meant by “EXCLUDE: Patients in which ICU care was required for postoperative care of a planned surgical procedure”?

Excluded patients are those in which it was determined prior to their surgery that they would require ICU care post-operatively. If so, then the Field Value “2. No” should be reported for the Unplanned Admission to ICU data element. However, if an event occurred during the patient’s surgery that required them to be admitted to the ICU post-op, and this was not planned prior to their surgery, then Field Value “1. Yes” should be reported.

Does the Unplanned Admission to ICU data element only apply to patients moving between floor level and ICU level of care or should the move from an intermediate care/step-down/telemetry unit to ICU be included also?

The Unplanned Admission to ICU data element does not exclude patients that had an unplanned admission or return to the ICU from the intermediate care/step-down/telemetry unit. So, if the patient was on the intermediate care/step-down/telemetry unit and transferred to the ICU, report the Field Value “1. Yes” for the Unplanned Admission to ICU data element.

A patient went from the floor to the OR for an open reduction internal fixation of a fractured femur. While in the PACU, the patient had severe hypoxia and was then transferred to the ICU for closer monitoring. The following day the patient was transferred back to the floor. What should be reported for the Unplanned Admission to ICU data element in this instance?

Report Field Value “1. Yes” for the Unplanned Admission to ICU data element because it was not known prior going to the OR that the patient would require ICU care after surgery.

Unplanned Intubation (pg. 148)

What should be reported for the Unplanned Intubation data element if a patient was intubated in the operating room, crashes, and is unable to be extubated from surgery?

In this instance, report the Field Value “2. No” for the Unplanned Intubation data element. Patients who are intubated for surgery do not meet the definition criteria unless they are reintubated within 24 hours of being extubated from the surgery.

What should be reported for the Unplanned Intubation data element when a patient is high-risk for intubation gets admitted to the ICU with the known possibility that they may require intubation. The patient is given a trial of respiratory therapy but ends up being intubated due to hypoxia/ distress.

In this instance, report Field Value “1. Yes” for the Unplanned Intubation data element. The decision to intubate a patient isn’t always an immediate one. The patient’s respiratory status was being closely monitored, however, the patient developed hypoxia and respiratory distress, which required the patient to be intubated.

What should be reported for the Unplanned Intubation data element for patients that were intubated to protect their airway?

In this instance, report Field Value “2. No” for the Unplanned Intubation data element because the definition requires the patient be intubated due to severe respiratory distress. Patients are sometimes intubated due to a change in mental status or combative in order to protect their airway from potential compromise not due to respiratory failure.

Where can I find some additional examples of Unplanned Intubation?

The 2019 TQIP Online Course has a module dedicated to this and all NTDS Hospital Events. Additionally, there is an Unplanned Intubation tutorial available on the TQIP Education Portal.

Unplanned Return to the Operating Room (pg. 149)

A patient was taken to the operating room for damage control laparotomy. Knowing that the subsequent stage of the damage control surgery is going to be based on the patient’s physiology and response to the first stage, what should be reported for the Unplanned Return to the Operating Room data element?

If it was known that the patient would require subsequent or staged procedures after initial management of similar or related procedure, then they do not meet the Unplanned Return to the Operating Room definition criteria and Field Value “2. No” should be reported because the second/subsequent surgery was planned.

How should iatrogenic events occurring in the ED or ICU that prompt an unplanned trip to the OR be reported for the Unplanned Return to the Operating Room data element?

The Unplanned Return to the Operating Room data element definition does not exclude iatrogenic events or operative procedures performed in the emergency department (ED) or intensive care unit (ICU).

Where can I find more examples of the Unplanned Return to the Operating Room data element?

The 2019 TQIP Online Course has a module dedicated to this and all NTDS Hospital Events. Additionally, there is an Unplanned Return to the Operating Room tutorial available on the TQIP Education Portal.

Ventilator-Associated Pneumonia (VAP) (pgs. 150–154)

I have questions about the January 2016 CDC VAP criteria. Where can I find more information regarding this?

The CDC specifications can be found in the 2016 CDC PSC Manual.

Our infection control department collects VAE and not VAP. Why does the NTDS still define VAP and not VAE?

Your team may be wondering why the NTDS definition of “VAP” is not consistent with the most up-to-date CDC definition of VAE. There are a couple of reasons why they currently do not match. First, the CDC’s revision cycle is on a much different schedule than the NTDS revision cycle to revise its definitions. This poses a problem because we do not have access to the updated CDC definitions until after TQIP has completed and released the NTDS Data Dictionary for the corresponding year of the CDC update. Second, in the past, we received many complaints from centers that found it confusing to frequently revise the NTDS definitions that are consistent with the CDC definitions. This was brought the NTDS Workgroup’s attention and they decided that the best course of action would be to keep the NTDS definitions consistent for a minimum of three revision cycles (or three data dictionaries in a row) to maintain the integrity of the data submitted to TQIP.

Outcome Information

Total ICU Length of Stay (pgs. 156 & 157)

Should the Total ICU Length of Stay be reported based on the time the patient was physically in the ICU or the time the patient received ICU level of care?

The cumulative amount of time the patient is physically in the ICU should be reported for the Total ICU Length of Stay data element. The definition does not consider the date and time the order to cease ICU care was placed just the cumulative amount of time the patient was in the ICU.

Total Ventilator Days (pgs. 158 & 159)

When reporting the Total Ventilator Days data element, should patients with tracheostomies that require ventilator support be included post trach placement?

Patients that had a tracheostomy and on mechanical ventilation are not excluded from the definition. So, if the patient remained on a mechanical ventilator (via endotracheal tube or tracheostomy), then that time should be calculated towards the cumulative amount of time to report for the Total Ventilator Days data element.

Would bag valve mask ventilation performed through an i-gel, King airway or other adjunct be included when reporting the Total Ventilator Days data element?

To answer your question, a bag valve mask (BVM) is a non-invasive means of ventilator support; therefore, you should not include the use of a BVM when calculating the total ventilator days.

If a patient is intubated and on the ventilator but the ventilator is on CPAP. Does this meet the Total Ventilator Days definition criteria?

CPAP and BIPAP are not included in the calculation of ventilator days. So, if the patient was on either CPAP or BIPAP (even CPAP and BIPAP modes on the ventilator) the entire 24 hours of any calendar day, you should not include that time in your total vent time calculation.

If a patient was taken to the OR at 22:42 on 01/01/2019, and then he went from the PACU to the ICU at 02:06 on 01/02/2019. He remained intubated in the ICU until 17:00 on 01/04/2019, when he was extubated. What should be reported for the Total Ventilator Days data element?

In the Additional Information section of the data element definition, there is an instruction to exclude vent time associated with the OR procedure. However, in this case, the patient remained ventilated beyond the OR procedure, or after leaving the PACU. So, you would start counting the vent time when the patient left the PACU. For this scenario, the Field Value “3” should be reported for the Total Ventilator Days data element.

Hospital Discharge Date; Hospital Discharge Time (pgs. 160 & 161)

When abstracting data for the Hospital Discharge Date and Hospital Discharge Time data elements, do we have to take the first hospital discharge order entered in the medical record?

Not necessarily. The Hospital Discharge Date and Hospital Discharge Time should be reported as the date/time the order was written by the physician who is ultimately responsible for the patients care and this is not always the first discharge order.

If a patient is transferred to inpatient hospice within our facility, what should be reported for the Hospital Discharge Date and Hospital Discharge Time data element? They are not “discharged” from the facility, but their care is transferred to the hospice provider.

Although the patient was transitioned to inpatient hospice care, they were not discharged from the hospital. So, the Hospital Discharge Date and Hospital Discharge Time data elements should be reported as the date the final discharge order was written for the patient to be discharged from the hospital.

When there is brain death, should we report the time that the brain death occurred, or the time physician pronounced the patient dead for the Hospital Discharge Date and Hospital Discharge Time data elements?

Report the time of death as it’s documented on the patient’s death certificate for the Hospital Discharge Date and Hospital Discharge Time data elements.

Hospital Discharge Disposition (pgs. 162 & 163)

If a patient comes in from a hospice facility and is discharged back to the hospice facility, what should be reported for the Hospital Discharge Disposition data element?

In the Additional Information section of the data field definition, it further specifies that “Field Value = 6, “Home” refers to the patient’s current place of residence (e.g., Prison, Child Protective Services etc.). If the patient’s current residence is at the hospice facility, and the patient was discharged back to the hospice facility, then the Hospital Discharge Disposition should be reported as Field Value “6. Discharge to home of self-care.”

If a patient was discharged from our facility to inpatient hospice care, is this patient not included in the benchmark reports?

For TQIP risk-adjusted benchmarking purposes, patients with a Hospital Discharge Disposition of “discharged/transferred to hospice care” are considered deaths and are not included in the TQIP Benchmark Report.

Which Hospital Discharge Disposition Field Value should be reported for patients who are discharged home with orders to start with physical therapy sessions?

If a patient was discharged home with orders to begin physical therapy on an outpatient basis, then Field Value “6. Discharged to home or self-care (routine discharge)” should be reported for the Hospital Discharge Disposition data element. If the patient was discharged home with a written order for home health services to provide physical therapy in their home, then Field Value “3. Discharged/Transferred to home under care of organized home health service” should be reported.

Measures for Processes of Care

(Level 1, 2, and Pediatric TQIP Participants ONLY)

Collection Criterion: Collect on patients with at least one injury in AIS head region, excluding patients with isolated scalp abrasion(s), scalp contusion(s), scalp laceration(s) and/or scalp avulsion(s)

Highest GCS Total (pg. 167)

When reporting the Highest GCS Total data element, is this to be reported as the highest documented “on” the next calendar day or “through” the next calendar day?

For patients that meet this Collection Criterion, report the patient’s highest total GCS on the calendar day after they arrived at your ED or hospital. For example, a trauma patient with a subdural hematoma arrived and was admitted to your hospital on 01-05-2019. The highest GCS total documented for the patient on 01-06-2019 was “13” at 22:45. Since 01-06-2019 was the calendar day after the patient arrived at your ED/hospital (01-05-2019), then “13” should be reported to TQIP for the Highest GCS Total data element, because that was the highest GCS total on 01-06-2019.

Initial ED/Hospital Pupillary Response (pg. 174)

For patients that meet this Collection Criterion, what should be reported for the Initial ED/Hospital Pupillary Response data element when the patient experiences trauma to one eye, but the other eye was documented as reactive within 30 minutes of ED/hospital arrival?

Report the null value “Not Known/Not Recorded” for the Initial ED/Hospital Pupillary Response data element because there is instruction in the Additional Information portion of the definition that states, “The null value "Not Known/Not Recorded" should be submitted if this information is not documented or if assessment is unable to be obtained due to facial trauma and/or foreign object in the eye.

For patients that meet this Collection Criterion, what should be reported for the Initial ED/Hospital Pupillary Response data element if the patient is blind in both eyes?

If the patient is blind in one or both eyes for reasons other than trauma, then you should report the appropriate Field Value (“1. Both Reactive”, “2. One Reactive”, “3. Neither Reactive”) that was documented within 30 minutes of the patient’s arrival to your ED or Hospital, because, depending on the etiology of their blindness, a patient may still have a pupillary response.

Midline Shift (pg. 175)

A patient suffered a fall and has an acute on chronic subdural hematoma (SDH) with a 6mm midline shift. How should the Midline Shift data element be reported?

These cases can be tricky because it is difficult to decipher if the shift is due to the acute or chronic subdural hematoma. However, the definition does not differentiate between the two; it only asks if there is a shift present within 24 hours of injury and if that shift is greater than 5mm. In this case, since the patient met the Collection Criterion for Midline Shift and there was documentation of an “acute on chronic subdural hematoma, with 6mm midline shift”, you should report Field Value “1. Yes” because there was documentation of a midline shift >5mm.

Collection Criterion: Collect on all patients

Venous Thromboembolism Prophylaxis Type (pg. 179)

Which Field Value should be reported for the Venous Thromboembolism Prophylaxis Type data element if the patient's first dose of VTE prophylaxis administered was Plavix?

The Field Value “10. Other” should be reported for patients whose first dose of VTE prophylaxis medication was not a LMWH, direct thrombin inhibitor, Xa inhibitor, or unfractionated heparin. As such, Plavix should be reported as Field Value “10. Other".

If a patient was on an anticoagulant at home (e.g., Eloquis, ASA) and they were started on the same medication while in the hospital, should we report this for the Venous Thromboembolism Prophylaxis Type data element?

Anticoagulant medications are prescribed for a number of reasons, however, to meet the definition criteria, the anticoagulant that the patient was administered at your hospital must be administered specifically for VTE prophylaxis. So, if the patient was started back on their routine anticoagulant while in the hospital, and it was specifically for VTE prophylaxis, then you should report the type of VTE prophylaxis administered to the patient.

Collection Criterion: Collect on all patients with transfused packed red blood cells within first 4 hours after ED/hospital arrival

Angiography; Embolization Site; Surgery for Hemorrhage Control Type (pgs. 195, 196, & 199)

For patients that meet this Collection Criterion, how should a thoracic endovascular aortic repair (TEVAR) be reported for the Angiography, Embolization Site, and Surgery for Hemorrhage Control Type data elements?

TQIP does not consider a thoracic endovascular aortic repair (TEVAR) an angiogram with embolization or a surgical procedure for hemorrhage control because the placement of stent grafts would not be considered an embolization and TEVAR is not one of the listed procedures for the Surgery for Hemorrhage Control Type data element. In this instance, for the Angiography data element, you should report the Field Value “2. Angiogram Only”. As indicated in the Additional Information portion of the definition for Embolization Site data element, the appropriate null value to report would be “Not Applicable”. Additionally, the Surgery for Hemorrhage Control data element does not include an option for TEVAR, so Field Value “1. None” should be reported.

Surgery for Hemorrhage Control Type (pg. 199)

How should this element be reported for patients that meet this Collection Criterion and had surgery within 24 hours, but it was not documented that the procedure was for hemorrhage control?

In order to report one of the listed procedures, there must be documentation in the patient’s medical record that the surgery was for hemorrhage control. If this is unclear, you may consider checking with your Trauma Medical Director or relevant surgeon to get clarification as to whether the surgery was for hemorrhage control or not.

Collection Criterion: Collect on all patients with any open fracture(s)

Miscellaneous (pgs. 205–207)

Does this Collection Criterion apply to all open fractures or just long-bone fractures?

The Collection Criterion “Collect on all patients with any open fracture(s)”, applies to all AIS open fracture and amputation codes and is not limited to specific subset of open fractures.

Antibiotic Therapy (pg. 205)

How should the Antibiotic Therapy data element be reported when the patient doesn’t have an open fracture, but the AIS code descriptor includes "open" in addition to other descriptors? For example, a patient with a closed, displaced, comminuted nasal fracture assigned an AIS code "251002.2".

If the AIS code meets the Collection Criterion “Collect on all patients with any fracture(s)” and the patient did not receive IV antibiotic therapy within 24 hours after the first hospital encounter, then report the Field Value “2. No” to TQIP for the Antibiotic Therapy data element.