TQIP Monthly Registry Staff Web Conference. July 31, 2014

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1 TQIP Monthly Registry Staff Web Conference July 31, 2014

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3 Your TQIP Staff Tammy Morgan National TQIP Educator Julia McMurray TQIP Program Manager

4 Announcements Registration for the 2014 TQIP conference is now open! Call for Data will open tomorrow, Friday, August 1. The deadline for submitting your data is Tuesday, September 2 nd.

5 Let s talk about blood!

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8 Let s get started!

9 TQIP Reports For hospitals joining TQIP in January, 2014, when will they receive their first report back from TQIP? If you joined TQIP before January 15, 2014 you should have received a TQIP report in March The next TQIP report will be released in the fall.

10 Data Submissions Our facility is new to TQIP, can you please let me know how to get help to submit data? 1. Work with your vendor to create your export 2. To submit to TQIP via the NTDB datacenter, please contact Quarter Apr Jun 2014 July Sep TQIP Data Submission Schedule Data submission deadline September 2, 2014 Patient admission and discharge must fall in this time frame January 1, 2013 June 30, 2014 December 2, 2014 April 1, 2013 September 30, 2014

11 NTDS Inclusion Criteria Does TQIP include periprosthetic hip fractures in data submission? Ex. A patient that has a traumatic mode of injury & fracture due to trauma? In regards to above question- It codes to a traumatic ICD-9 code when trauma related. Yes, periprosthetic hip fractures are included if caused by a traumatic mechanism.

12 External Cause Codes (pages 20-25) What constitutes "mass casualty" in the Casualty Type section? What constitutes multiple casualty?" Rules regarding external cause codes can be found in your ICD-9 or ICD-10 books.

13 Protective Devices (page 31) Why is "NA" not a choice in protective devices? Definition: Protective devices (safety equipment) in use or worn by the patient at the time of injury. This data field should be answered on all patients. So, reporting the null value Not Applicable for this field is not appropriate. All patients apply! If the patient was not using protective devices at the time of injury, report using the field value 1. None.

14 Airbag Deployment (page 33) The rule states that this field is only completed when Protective Devices include Airbag. If Airbag is not included in the Protective Devices, we are currently filling out this field as Not Applicable. Are we supposed to be selecting the Field Value 1. Airbag Not Deployed? And if so, that would contradict the rule as stated above; please explain?

15 Airbag Deployment (page 33) The data field values listed for this definition should only be reported if the Protective Devices field value 8. Airbag present is reported. If 8. Airbag present is not reported for the Protective Devices data field, then report the null value Not Applicable for Airbag Deployment.

16 Report of Physical Abuse (page 34) Any specific reason(s) you are not considering "Neglect" as Abuse especially on patients that have a report filed with CPS and are discharged to foster care? Any plans to include it in the future? The focus for these data fields are patients that are physically injured by another person, such as being shoved, hit, etc.

17 EMS Dispatch Date (page 38) In our submission frequency report, the total patient count for the EMS Dispatch Date is 667, however 80 of those patients were documented as Not Applicable because their arrival mode was either Private Vehicle or Police. Why are these patients included in the total count when calculating the percentage?

18 This report allows you to see what your data looks like once it has been submitted, and is a good tool to find mapping errors. In this case, the number of null values are being reported for this data field. This is important, since a very common mapping error is the number of null values reported. You are the one that has to determine if the numbers reported are correct, as no one knows your data more than you!

19 Other Transport Mode (page 45) The definition for Other Transport Mode states All other modes of transport used during patient care event (prior to arrival at your hospital), except the mode delivering the patient to the hospital. We just want to make sure that you do not want us to capture EMS mutual aid vehicles who arrive at the scene and treat the patient prior to the patient being transported (i.e., when patient is transported via helicopter but EMS is first on scene).

20 Other Transport Mode (page 45) The focus of this data field is the mode of transport. So, if the EMS ground ambulance did not move the patient, you would not report the field value 1. Ground ambulance for this patient.

21 Trauma Center Criteria (page 55) When collecting Trauma Center Criteria, is this on transfers from the scene only or from hospital to hospital? This data field should be completed on all patients. Even those that are transferred from another hospital. However, you should use the scene of injury EMS run sheet to complete this field, as directed in the definition.

22 Emergency Department Information (pages 57-79) What meds, if any, do you capture in the ED resuscitation tab? NTDS does not include a data field for ED resuscitation medications. The resuscitation tab that you are referring to is most likely in your trauma registry software. For more information on the tabs in your software, contact your software vendor.

23 Initial ED/Hospital Vital Sign Fields (pages 60-77) In terms of the referring hospital's vital signs, are these to be captured within 30 minutes of the patient's arrival? The NTDS does not include data fields for referring hospital vital signs. You are only reporting vital signs within 30 minutes or less of arrival at your ED/hospital.

24 Co-Morbid Conditions (page 88) What other documents are included in the comorbid advanced directive limiting care besides a DNR? Often, documents are titled differently in different locations. Taking this into consideration, the verbiage in the definition simply supports the different terminology used for an advanced directive.

25 Hospital Discharge Disposition (page 104) If a patient from a Skilled Nursing Facility is discharged from the hospital to a Skilled Nursing Facility would their hospital discharge disposition be 6. Discharge home with no home services or 7. Discharged/Transferred to Skilled Nursing Facility? This patient should be reported to have a hospital disposition of 6. Discharged home with no homes services.

26 Hospital Complications (page 109) Is there a timeframe for including NTDS complications on trauma patients? Do we submit complications that occur post discharge? The only timeframes listed for Hospital Complications are located in the specific complication definitions, located in Appendix 3: Glossary of Terms that begin on page A3.4. At this time, we are only asking for complications that occurred during the initial hospital stay for the traumatic event.

27 Process Measure Collection Criterion (pages ) Are isolated concussions to be included in the TQIP data? Collection Criterion: Collect on patients with at least one injury in AIS head region Yes, concussive head injuries are coded in the AIS head region.

28 Venous Thromboembolism Prophylaxis Type (page 117) If an anticoagulant is documented in the progress notes as given for therapeutic reasons and not prophylactic; would we still complete the field VTE prophylaxis type? The collection criterion for this TQIP process measure is Collect on all patients. So, if your patient is not receiving medications for VTE prophylaxis, report the field value 5. None, even if the patient is receiving a medication listed in the definition for other therapeutic reasons.

29 Transfusion Blood Conversion (page 123) My hospital records blood product values by CC's. When our MTP is used, should we average the conversion rate or use a set AMT? Collection Criterion: Collect on all patients with transfused packed red blood cells within first 4 hours after ED/hospital arrival If you are reporting your blood products in CCs, use the null value Not Applicable for this field.

30 Angiography (p. 137) Angiography with or without embolization excludes CTA s. Can you provide further clarification on what exactly you are looking for? All data fields with the collection criterion Collect on all patients with transfused packed red blood cells within first 4 hours after ED/hospital arrival are used to study hemorrhage control. So, it is important to know the amount of blood given, what procedures were performed, as well as, time to procedure. Does it matter whether it is done in CT Radiology vs. Interventional Radiology? No.

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