Requested Change

PTOS 2016 Registry, Manual & Collector Approved Changes

Updated: 10/13/2015

#

Requested/Change

Notes

PTSF Recommendations

Committee Actions/Questions

PTOS Page #

Type of change

1

Add additional custom elements slots.

Requested by Dorris at 2014 Fall Conference

Add additional slots for custom elements.

N/A

N/A

Software

2

Must K.00-obesity be documented by the physician, or can the registrar calculate the patients BMI using height and weight and assign K.00-obesity if appropriate?

Question received 9-09-14 via e-mail

BMI Categories:Underweight = 64

PTSF staff sent out an e-mail 5/21/15 regarding MTP. Received a response from about 15 centers.

Centers that are capturing turnaround time for MTP have created custom elements under the Clinical tab such as Was MTP initated? and Time MTP initiated. The PI coordinator then follows these patients to track timeliness.

Some centers blood bank personnel enter MTP related information following all MTPs into a separate spreadsheet. This information includes: patient identifiers, start, stop, blood products, reversal agents, wasted products, and outcome.

The PTSF currently only captures information regarding child abuse ( 380 C or < 360 C

2. white blood cell count > 12,000 or < 4,000 or > 10% immature bands

3. positive blood cultures (excluding contaminants)

4. clinically obvious source of infection

5. heart rate > 90 beats/min or respiratory rate > 20 breaths/min

77 = Septicemia: positive blood culture, excluding isolates that are thought to be contaminants.

There has been much confusion for registrars when coding sepsis vs. septicemia in the past.

ICD-10 replaced the term septicemia with sepsis.

The NTDB only captures Severe Sepsis.

The PTSF recommends occurrence 77-septicemia be removed from PTOS.

6/24/15: The registry committee approved the removal of occurrence 77-septicemia from PTOS.

Board approved 7-30-15.

123

Software/ Manual

17

Can a timeframe be added to the Urinary Tract Infection definition to clearly exclude UTIs present on admission?

97 = Urinary Tract Infection (UTI) (not present on admission): clean voided or other catheter urine specimen with > 100,000 organisms/ml on C/S. Physician institutes appropriate therapy for a urinary tract infection

CDC guidelines used as reference.

The CDCs Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [CAUTI] and Non-Catheter-Associated Urinary Tract Infection [UTI]) and Other Urinary System Infection [USI]) Events Guidelines were used as a reference when creating this definition.

An infection is considered Present on Admission (POA) if the date of event of the NHSN site-specific infection criterion occurs during the POA time period, which is defined as the day of admission to an inpatient location (calendar day 1), the 2 days before admission, and the calendar day after admission.

Please see Handout #5 for complete CDC Guidelines.

The PTSF recommends following the CDC guidelines.

6/24/15: The registry committee recommends the exact terminology from the CDC guidelines be placed within the PTOS manual for clarification.

An infection is considered Present on Admission (POA) if the date of event of the NHSN site-specific infection criterion occurs during the POA time period, which is defined as the day of admission to an inpatient location (calendar day 1), the 2 days before admission, and the calendar day after admission.

123

Manual

18

Can an option for in-house Pediatric Unit be added to the Post ED Destination menu?

POST ED DESTINATION:

Record the patients final destination from the ED

Field Values

1 = ICU/Critical Care Unit 2 = OR (including pre-op area)

3 = Med/Surg Unit 4 = Prison Ward (In-House)

5 = Step Down

6 = Morgue (Coroner, death, DOA)

7 = Transfer to Other Hospital/Trauma Center

8 = Labor & Delivery

9 = Burn Unit (In-House)

10 = Home

Unit/Intermediate

11 = Interventional Angiography

The PTSF recommends adding an option for an in-house pediatric unit to the Post ED Destination menu.

6/24/15: The registry committee approved of a Med/Surg Pediatric Unit (In-House) being added to the Post ED Destination menu.

Board approved 7-30-15.

53

Software/ Manual

19

Can during ED/resuscitative phase of care be added to the Was CT scan of head performed element on the Acute Care Arrival/Admission tab within COLLECTOR?

DID PATIENT RECEIVE A CT SCAN OF THE HEAD DURING THE RESUSCITATIVE PHASE? (FLTR 3)

Did the patient receive a CT of the head during the resuscitative phase

1 = Yes

2 = No

Additional Information

The resuscitative phase is the time between ED arrival and Time Transported to Post ED Destination

If a CT scan of the head is done at the referring facility, record yes

This question must be answered in all cases

The computer will match with GCS < 14 to identify applicable cases for review

Not taken to committee. Request made via e-mail on 8/4.

56

Software

20

The Orange Book requires the arrival times of all advanced practitioners to be captured if consulted. Emergent response must be within 30 minutes.

For example:

F. An attending Neurosurgeon or designee must be promptly available. If the attending Neurosurgeon is not in house when on call, they must be promptly available to come in house when requested by the trauma team leader.

i. The Trauma Program must define the parameters of immediate response based on level of acuity.

a. The immediate/ emergent response must be within 30 minutes.

The PTSF is required to comply with the ACS standards at a minimum. Elements must be added.

6/24/15: The registry committee thoroughly discussed this change. The PTSF will present the committee with a mockup of 3 options in August based upon the discussion.

Tabled to August.

8/31/15:

The registry committee approved the draft version of Mockup 1for 2016. Mockup 1 expands both the ED Response and Consults screens to include AP specialties. ED Response and Consults will remain on separate tabs. The ED Response tab will now provide a popup menu so registrars can select to add appropriate AP options as needed. There will be a Called, Arrived, and PGY column. The registrar will also have the ability to copy the information entered on the ED Response tab to the Consults tab. The consults tab will now look like the ED Response tab. Rules defining when Called, Arrived, and PGY columns will be disabled will be addressed in the Consults element definition within the PTOS manual.

Board approved 9-17-15

86

Software/ Manual

21

The NTDB has released the 2016 NTDS Data Dictionary. Any 2016 changes must be reviewed and incorporated into PTOS if applicable.

See Handout 3.

See Handout 3.

New discussion 8-27-15.

The Registry Committee approved the following changes for 2016:

On Admission-Systolic Blood Pressure: Add Measurement recorded must be without the assistance of CPR or any type of mechanical chest compression device. For those patients who are receiving CPR or any type of mechanical chest compressions, report the value obtained while compressions are paused.

On Admission (Pulse Rate/Minute): Add Measurement recorded must be without the assistance of CPR or any type of mechanical chest compression device. For those patients who are receiving CPR or any type of mechanical chest compressions, report the value obtained while compressions are paused.

Utilize the 2016 NTDB definition for Dementia for J.03= Alzheimers Disease and J.06= Chronic Dementia.

26=Pneumonia:

Retire 26= Pneumonia.

Add an occurrence for pneumonia utilizing 2015 definition with the addition of does not include VAP. Will be assigned 100 and placed in the pulmonary occurrences section.

Add an occurrence utilizing the 2016 NTDB name and definition for Ventilator-assisted Pneumonia. Will be assigned 207 and placed in the NTDB occurrences section.

97=Urinary Tract Infection (UTI) (not present on admission):

Retire 97=Urinary Tract Infection (UTI) (not present on admission).

Add an occurrence for Urinary Tract Infection (UTI) (not present on admission) with the addition of does not include CAUTI. Will be assigned 101 and placed in infection/ sepsis occurrences section.

Add an occurrence utilizing the 2016 NTDB name and definition for Catheter-associated Urinary Tract Infection. Will be assigned 208 and placed in the NTDB occurrences section.

Add an occurrence utilizing the 2016 name and definition for Central line-associated bloodstream infection (CLABSI). Will be assigned 209 and placed in NTDB occurrences section.

33=Deep Vein Thrombosis (DVT) / thrombophlebitis: Remove thrombophlebitis from the name of this occurrence. Will read, Deep vein thrombosis (DVT).

Add an element for Initial ED/Hospital Pupillary Response utilizing the 2016 NTDB definition. Will be placed on the Clinical tab under GCS-Total.

Add an element for Midline Shift utilizing the 2016 NTDB definition. Will be placed on the Procedures 2 tab under the new MTP element.