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American College of Surgeon: Resources for Optimal Care of the Injured Patient - ANSWER-- Definition of a "Trauma Patient" can be found here: Any patient that has an injury in the code range between 800 and 959.9, but not one of the exclusion codes, for late effects of injury (905-909.9), superficial injuries, including blisters, contusions, abrasions, insect bites (910-924.9), and foreign bodies (930-939.9). and meets one of the three event criteria: Hospital admission; Patient transfer via emergency medical services transport from one hospital to another hospital; or, Death resulting from the traumatic injury. - ANSWER--ACS inclusion criteria Three Types of Data Abstraction - ANSWER-- Concurrent, Retrospective & Hybrid Concurrent Abstraction - ANSWER--Daily abstraction while the patient is in house Retrospective Abstraction - ANSWER--Abstraction after patient discharge.
Hybrid Abstraction - ANSWER--Data entry is begun during the patient encounter but the record is closed after patient discharge. The American College of Surgeons registry staffing recommendation for manual data entry: - ANSWER-- 1 full-time equivalent employee dedicated to the registry to process the data for approximately 750 to 1,000 patients annually In order to run data for reporting the registrar needs to know several basic details: - ANSWER--What information is needed to identify the correct data fields, the time frame that is of interest, any related filters, and what format for display grouping, such as year, month, ISS range, age range, etc. Format - ANSWER--Presentation Concept of the way that the viewer wishes to view the result of the data compiled. The format identifies how the data is to be displayed such as paper, website, dashboard, PowerPoint presentation, etc. Tables - ANSWER--Show the actual data elements arranged in rows and columns.
Dashboard - ANSWER--A compact visual presentation of critical data, usually at a higher level, to be easily understood at a glance. Spreadsheet - ANSWER--A collection of data in columns and rows that hold the data detail -- usually produced in an "Excel" type of document. Scatter Grams - ANSWER--Displays values for two variables showing the distribution of the values. Pareto Chart - ANSWER--Typically a chart showing data from most to least frequently occurring information from left to right. These are used to clearly identify higher valued items (e.g., The highest frequency or priority for resolution). Radar Chart/Spider Gram - ANSWER--Shows the relationship between multiple variables with one or more axis. Tree Chart/Fishbone Diagram - ANSWER--Used to identify all of the various issues/tasks that go into development of a single outcome.
Volume Interpretation - ANSWER--Data Totals, such as total patients. These can be easily visualized by a bar chart (similar to a histogram) showing different heights depicting variance from comparative items or periods of time. Trends - ANSWER--A trend is a series of consecutive information/data that is all moving upward or downward as time progresses. A trend line can be overlaid onto the chart information/ data for the reader to more easily visualize if there is a trend over time. PIPS - ANSWER--Process Improvement Patient Safety PIPS Process Improvement Patient Safety - ANSWER--Uses the continuous process of recognition, assessment, and correction. This includes processes such as data collection, collation, analysis, modification, and instruction. American College of Surgeons - ANSWER--An educational association of surgeons created in 1913 to improve the quality of care for the surgical patient
providers, or with a recommended or desired outcome/standard. Filters - ANSWER--Tools that can be used to gather data into specifically defined groups, or a single item. PI and Loop Closure Identification of Issues - ANSWER--Issues can be identified through many different avenues such as, communication from staff, patient satisfaction, risk management, chart review processes, trauma meetings/rounds, and direct patient interaction. PI and Loop Closure Review of Issues - ANSWER-- PI review process whereby the issue is brought to the Trauma Medical Director for evaluation, determination of issue and if there is a need for corrective action. PI and Loop Closure Corrective Action - ANSWER-- Examples of corrective actions are: new guidelines, protocol change , or pathway development and review, targeted education, enhanced resources/facilities, or communication, process improvement team implementation, counseling, peer
review presentation, change in provider privileges or credentials, or external review. PI and Loop Closure Result Evaluation - ANSWER-- Demonstration that a corrective action has the desired effect determined by on-going or repeat evaluation. Population Demographics - ANSWER--The demographics of a population involves analysis of differing grouping of items such as the population age, gender, residence, nationality, etc. Sampling - ANSWER--The process of taking a small portion of a larger set of data to study in order to obtain a picture of the probable larger total population. This can save time and money. Frequencies - ANSWER--Frequency is the number of occurrences of a repeating similar event that is identified within a defined set of reference. Two Types of Statistics - ANSWER--Population Demographics and Sampling
Median - ANSWER--The integer holding the middle position in a sequential listing of numbers. The median when arranged : 9 8 7 6 5 5 5 3 2 Mode - ANSWER--The integer that occurs most often (i.e., 5 7 5 9 3 5 2 6 8) in this cluster is 5. Therefore, the mode would be 5. Standard Deviation - ANSWER--A measure to quantify the difference between the values in the data set. Types of Calculations - ANSWER--Frequencies, Averages, Percentages, Ranges, Ratios, Mean, Median, Mode & Standard Deviation Bones in the Head - ANSWER--Ethmoid bone, frontal bone, occipital bone, parietal bones x 2, sphenoid bone, temporal bone x 2. Brain - ANSWER--Adult average brain weighs approximately 3 pounds with 500 milliliters of cerebral spinal fluid (CSF).
Neck - ANSWER--Cervical vertebrae x 7, trachea, esophagus, larynx, pharynx, hyoid bone. Facial Bones - ANSWER--14 stationary bones and a lower jaw bone. Inferior nasal conchae x 2, lacrimal bones x 2, mandible, maxilla x 2, nasal bones and septum, palatine bones x 2, vomer, zygomatic bones x 2, eye, ear. Chest - ANSWER--Thoracic spine, ribs 1-12, sternum, heart, bronchi and lungs, thoracic aorta, diaphragm, thoracic esophagus. Abdomen - ANSWER--Liver, spleen, colon, rectum, small bowel, pancreas, kidneys, pelvis, uterus, bladder, stomach, gallbladder, retroperitoneum, abdominal aorta and other vessels. Spinal Column - ANSWER--Cervical--7, thoracic--12, lumbar--5, sacrum—5 (fused), coccyx (tailbone)—2, 3, or 4. Note: C1 = Atlas, C2 = Axis and has a "dens" (spikelike projection) that projects upward on which the atlas 14 rotates.
Hand - ANSWER--Carpal bones x 8 (scaphoid, locate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate), metacarpals x 5, and phalanges (proximal x 5, middle x 5, distal x 5). Upper Extremity Joints - ANSWER-- Acromioclavicular, carpal bones (wrist), elbow, sternoclavicular, glenohumeral, metacarpophalangeal, interphalangeal. Lower Extremities - ANSWER--Pelvic girdle, pelvis, legs, joints, ankle bones foot Pelvis - ANSWER--Ilium, iliac crest, acetabulum, ischium, pubis, sacrum and sacroiliac joints. Legs - ANSWER--Femur, patella (knee cap), tibia, fibula. Lower Extremity Joints - ANSWER--Hip, knee, and ankle. Ankle Bones - ANSWER--Lateral malleolus, medial malleolus
Foot - ANSWER--Tarsal bones (7), calcaneus (heel bone), talus, cuboid, navicular, first, second and third cuneiform), metatarsals, phalanges. Skin - ANSWER--The largest organ, approximately 8 pounds for adult. Three layers: epidermis, dermis, hypodermis. Number of Bones in Body - ANSWER--There are typically 206 bones in the body, though there may be up to about 226. Amount of Blood in Adult Body - ANSWER--There are approximately 5 liters of blood in the average adult male of 75 kg. Plain Films - ANSWER--Regular x-rays. Good for injuries involving bones and joints. FAST - ANSWER--Focused Assessment with Sonography for Trauma is used as an initial diagnostic tool to identify intraperitoneal or pericardial free fluid. Types of Radiology Imaging - ANSWER--Plain Films, Ultrasound, CT Scan, MRI, DPL, PET Scan
PET Scans - ANSWER--Positron Emission Tomography, or PET scan, uses a radioactive isotope injection along with a radiology scanning to obtain structural detailed 16 images of the organ as it functions Interventional Radiology Procedure - ANSWER--A procedure performed by a radiologist, usually in the radiology department, such as arteriography, angiography, or placement of a filter in a vein as a therapy for DVT's. Types of Laboratory Tests - ANSWER--Toxicology, Chemistry, Hematology, Coagulation, Blood Gases, Infection Control, Urine Toxicology Labs - ANSWER--Toxicology can involve either a blood or urine sample. Toxicology labs tests look for levels of alcohol (BAC) or drugs that may have been used. Chemistry Labs - ANSWER--Chemistry labs typically include electrolyte levels with other options that may vary at different labs. Some of the tests included in a chemistry are: sodium, potassium chloride, calcium,
creatinine (blood), glucose(blood sugar), magnesium, phosphorus, etc. Hematology Labs - ANSWER--Involves testing on the blood itself to determine the patient blood volumes in relation to the normal values. It includes a: CBC (complete blood count) and differential. The CBC includes: WBC, hemoglobin, hematocrit, MCV, platelets, etc. The differential includes such things as neutrophils, lymphocytes, basophils, etc. Coagulation Labs - ANSWER--Protime, PTT, INR Studies to determine the length of time for blood to clot for the patient compared to what is expected. Blood Gas Labs - ANSWER--ABG: Arterial blood gases measure the amount of oxygen, carbon dioxide, sodium bicarbonate, base excess, etc., in the arterial blood. This involves a special blood draw from an artery. Infection Control Labs - ANSWER--Infection control testing usually involves a culture of a certain part of the body/fluid. This can be a wound culture, urine culture, blood culture, oral culture. It can also include a culture of a foreign body that was in the
Sequelae - ANSWER--A pathological condition that can be considered "commonly resulting" from the actual disease process, injury, or trauma. Complication - ANSWER--A complication is an undesired, unintended injury or disease process that occurs to the patient that is not part of the expected result of the injury or disease process. Abbreviated Injury Scale - ANSWER--Originally developed by the AAAM, the Association for the Advancement of Automotive Medicine.2 AIS is an anatomically based international injury scaling system. There is a strong correlation between AIS severity and survival (and mortality). AIS Scoring - ANSWER--An AIS code follows a seven digit format for example, _ _ _ _ _ _. _ as in 752401.2 The first 6 digits are called the pre-dot code. The single digit after the dot is called the post- dot digit or severity number. The pre-dot code represents the body area of injury, the anatomical structure(s) involved, the level of injury.
6 Main Body Regions of AIS Codes - ANSWER-- Region 1: Head/Neck, Region 2: Face, Region 3: Chest/Thorax, Region 4: Abdomen - Lumbar Spine, Region 5: Extremities, Shoulder & Pelvic Girdles, Region 6: External Including Burn, hypothermia, Asphyxiation, Drowning, Electrocution and Full Body Explosion AIS Post-Dot Code - ANSWER--A numerical value that is assigned according to the severity of the injury: .1 -- Minor .2 - Moderate .3 - Serious .4 - Severe .5 - Critical .6 - Maximum (not fatal, currently untreatable) A .6 is automatically an ISS = 75, code other injuries but don't add to this highest ISS total (.9 -- indicates injury present but no severity value) E Codes - ANSWER--Classify the environmental events, circumstances, and conditions as the cause of injury, poisoning or other adverse event related to the external cause of the injury.
