APPENDIX A: EAST MCT Outcomes after acute care surgery and trauma care in incarcerated individuals Trauma Diagnoses: (select all that apply) Neurologic Injuries Traumatic Brain Injury Epidural Subdural Subarachnoid Diffuse axonal injury Concussion Other Spine injuries Cervical spine Thoracic spine Lumbar spine Other Paralysis (circle) Yes No Orthopedic injuries Fracture Location(s) Dislocation Location(s) Other Location(s) Intra-abdominal injuries (check all) Liver laceration Grade: Spleen laceration Grade: Kidney laceration Grade: Large bowel injury Small bowel injury Bladder injury Other organ injury Other Thoracic Injuries (check all) Rib fractures Hemothorax Pneumothorax Sternal fracture Cardiac injury Other Acute Surgical Diagnoses: (select all that apply) General Surgery Acute appendicitis (circle) Perforated Non-perforated Cholecystitis (circle) acute chronic Symptomatic cholelithiasis Choledocholithiasis Cholangitis Gallstone pancreatitis Alcoholic pancreatitis Diverticulitis (circle) With abscess With peritonitis Esophageal Perforation GI Bleed(circle): Upper Lower Bowel obstruction(circle): Large Small Volvulus (circle) Sigmoid Cecal Small bowel Gastric/duodenal ulcer(circle): Bleeding Perforation Intestinal perforation (circle): Large Small Hernia (circle) Ventral Inguinal Femoral Other : (circle) Reducible Incarcerated Strangulated Unknown Soft tissue infections Abscess Necrotizing infection Location Perianal disease Acute limb ischemia Aneurysmal disease Other Other Injuries (check all) Vascular injuries Location Laceration Location Facial fracture Other
TITLE: Outcomes after acute care surgery and trauma care in incarcerated individuals: a prospective observational trial Data Element Definition / Instructions Demographics: Case Number Age Biological sex Race Height Weight Payor Assigned number by institution, Ordered chronologically from oldest (1) to newest Free text entry of patient s age, age 16 and older at time of admission Select patient s biological sex from the following: Male Female Select patient s race from the following: White Black Hispanic Asian Other Free text entry of patient s height in cm Free text entry of patient s weight in kg Primary payor identified for the individual patient. Usually identified by business manager of surgery department. Medical History: Comorbidities Recorded (Yes, No, NR = Not Recorded) for all of the following: Obesity Hypertension Diabetes mellitus (includes type I and type II) Drug use disorder, including alcohol use disorder Mental health condition COPD
CHF Dementia Anticoagulant use HIV Hep C History of Tobacco use Cancer o Type (free text) Other (free text) Pre-hospital data: Treatment location prior to presentation Duration of symptoms prior to arrival Similar presentation Record location of patient prior to presentation to definitive hospital Prison Jail Outside emergency department Outside inpatient hospital Other (free text) Record approximate time elapsed since injury or symptom onset to presentation to initial health facility outside correctional facility. Circle <12 hours, 12-24 hours, >24 hours, or unknown. Was the patient previously evaluated for same injury or for same problem/symptoms? Yes, No, NR = Not Recorded. Incarceration Data: State of incarceration Location of incarceration - arrival Location of incarceration - discharge Specifies in which state patient is currently incarcerated in order to classify by structure/model of correctional healthcare. Information on state of incarceration will only be used to classify by model of care. Use two letter abbreviation Record location of incarceration prior to presentation. Prison Jail Unspecified Record location of incarceration at discharge from hospital or ED Prison Jail Unspecified
Injury Data (if applicable): ISS ED GCS AIS by body region Mechanism of Injury (MOI) Intent of Injury Free text entry of Patient s calculated ISS (ISS = Injury severity score, range 1-75) Free text entry of patient s initial or first recorded GCS (Glasgow Comas Scale; range 3 to 15; composed of three parts: eye, verbal, motor). 3 is the worst. Free text entry for head, spine, chest, abdomen, extremity upon presentation (0=no injury, 1=minor, 2=moderate, 3=serious, 4=severe, 5=critical, 6=unsurvivable) Select mechanism of injury from the following: Fall MVC (Motor Vehicle Collision) Pedestrian Gunshot wound Machine Assault o Weapon - Choose: hand/foot blunt object free text Other (free text) Record intent of injury, if known Intentional (yes/no) o Self-harm o Not self-harm Unintentional (yes/no) o Occupational injury o Not occupational injury Unspecified Admission Data (if applicable): Admitting Service Select admitting service: Trauma Orthopedic Surgery Neurosurgery Cardiothoracic surgery Medicine ENT Plastic surgery
General surgery (non-trauma) Other (free text) Post ED Disposition Consulting Service(s) Select patient s hospital destination following emergency department consultation: Floor Intensive Care Unit (ICU) Operating Room Step-down Unit Discharge Other (free text) Record if any of the following were consulted during the patient s primary admission (Yes, No, NR = Not Recorded. Trauma surgery Orthopedic surgery Neurosurgery Cardiothoracic surgery Medicine ENT Plastic surgery General surgery (non-trauma) Psychiatry Diagnoses: Trauma Diagnoses Acute Surgical Diagnoses Appendix I - Select all that apply. If unknown, leave blank. Specify grade of solid organ injury if known. Spine injuries include compression, herniation, spinal cord injury, or fracture of any part of the vertebrae including spinous, transverse, or articular process(es). Paralysis defined as loss of motor function of any limb due to spinal injury, may be temporary or permanent. Appendix I - Select all that apply. If unknown, leave blank. Select diagnosis whether or not surgery was performed. Procedures (if applicable): Need for Operation (Need OR) Time to first operation from admission Record if patient sent to operating room for any procedure. Yes, No, NR = Not Recorded. Free text number of hours from the time of presentation to the ED to entry into an operating room suite. Round to the nearest whole hour.
Number of Operations (NumOps) CPT of Procedure 1 CPT of Procedure 2 CPT of Procedure 3 CPT of Procedure 4 Time to fixation Other interventions Admission Data: Hospital length of stay ICU length of stay Transfusion Number of operations during length of stay. Free text entry of number up to 12 patient procedures. CPT code of initial procedure performed (if applicable) CPT code of 2nd procedure performed (if applicable) CPT code of 3rd procedure performed (if applicable) CPT code of 4th procedure performed (if applicable) If patient sustained orthopedic fracture requiring surgical intervention, record free text number of hours from the time of presentation to the ED to entry into an operating room suite for fixation (either definitive or temporary). Report the first procedure only. Round to the nearest whole hour. Recorded (Yes, No, NR = Not Recorded) for the following: Chest tube insertion Check indication(s) Central line insertion Tracheostomy Traction (orthopedic injury) Casting (orthopedic injury) Laceration repair record only if sutured/stapled Nasogastric decompression record if within initial 24 hours of presentation Other (free text) Free text entry for number of consecutive days patient hospitalized at index admission (Day of admission = hospital day #0. Include any portion of a day that patient was in the hospital) LOS = Length of Stay. Recorded in days. Free text entry of number of days patient required ICU admission (ICU = Intensive Care Unit, LOS = Length of Stay). Day of admission = hospital day #0. Include any portion of a day that patient was in the ICU. Recorded in days. Number of separate units of packed red blood cells transfused in the first 24 hours after presentation
Ventilator Days Free text entry of the number of days the patient was on mechanical ventilation. Include any portion of a day that patient was ventilated. Recorded in days. Discharge data: Discharge to AMA Select patient s discharge destination: Home Self Care Home with Services Rehab Skilled Nursing Facility Long-term Care Psychiatric facility Hospice Morgue Correctional Facility Other Did the patient leave the hospital against medical advice? Yes/No Complications: Hospital Mortality Complications during admission Death during index hospitalization (yes or no) Recorded for all of the following: Sepsis Septic shock Acute renal injury Deep vein thrombosis Stroke Pulmonary embolism Myocardial infarction Cardiac arrest Central line-associated blood stream infection (CLABSI) Acute respiratory distress syndrome Post-operative hemorrhage Mechanical wound failure Ileus or other post-operative gastrointestinal complication Wound infection o Superficial o Deep Pneumonia (includes ventilator associated)
Readmission and Follow-up: Follow-up appointment completed Readmit Readmitdays Urinary tract infection Unplanned ICU admission Unplanned re-operation Unplanned intubation Other Was this patient seen in follow-up in an outpatient clinic setting with surgical team/primary care provider or documented follow-up (phone call, letter, etc) within 90 days of discharge date? (Yes, No, NR = Not Recorded) Patient readmitted for similar problem or complication from index hospitalization within 90 days of discharge. (Yes, No, NR = Not Recorded) Record number of days since discharge to first readmission. Round to nearest whole day. Site Information (only record once per site): Level of Trauma Center ACS admissions Record Level 1-4. If not designated as a trauma center, enter N/A. Record the number of acute care surgery admissions in the calendar year preceding the current year of the study
EAST Multi-Center Study Data Collection Tool Outcomes after acute care surgery and trauma care in incarcerated individuals: a prospective observational trial Enrolling Center: Case Number: Demographics: Age Sex: Race: Height (cm): Weight (kg): Primary payor: Comorbidities (check all that apply): Obesity Hypertension Diabetes mellitus Drug use disorder (including alcoholism) Mental health condition COPD CHF Dementia Anticoagulant use HIV Hepatitis C History of tobacco use Cancer: Type: Other: Pre-hospital Information: Location prior to presentation (circle): Prison Jail Outside ED Outside inpatient hospital Other: Duration of symptoms prior to arrival (circle): <12 hours 12-24 hours >24 hours Unknown Has patient presented for evaluation for same injury or same problem: Yes No NR Incarceration Information: State of incarceration: Location of incarceration Prior to Arrival (circle): Prison Jail Unspecified Location of incarceration at Discharge (circle): Prison Jail Unspecified Diagnoses Was the patient admitted for trauma? (circle) Yes No Unknown Injury Information (if applicable):
ISS ED GCS: AIS: Head Spine Chest Abdomen Extremity Mechanism of Injury (check one): Fall MVC Pedestrian vs GSW Machine injury Assault Weapon: Hand/foot Blunt object Other Other: Intent of Injury (check if applicable): Intentional If yes: Self-harm Not self-harm Unintentional If yes: Occupational injury Not occupational injury Unspecified Admission: Admitting Service (check one): Trauma Orthopedic Surgery Neurosurgery Cardiothoracic Surgery General Surgery (non-trauma) Post ED Disposition (check one): Floor ICU Other - Consulting Service(s) (check all consulted): Trauma Orthopedic Surgery Neurosurgery Cardiothoracic Surgery General Surgery (non-trauma) Medicine ENT Plastic Surgery Other Step-down unit Discharge Medicine ENT Plastic Surgery Psychiatry Other Trauma Diagnoses (see appendix): Acute Surgical Diagnoses(see appendix):
Procedures: Need for operation (circle): Yes No NR Time to first operation: hours (Use decimals if needed) Number of Operations: CPT Procedure 1: CPT Procedure 3: CPT Procedure 2: CPT Procedure 4: Time to fixation (ortho injuries only): hours Other interventions (check all performed): Chest tube insertion Indication: Pneumothorax Hemothorax Other: Central line insertion Tracheostomy Traction Casting Laceration repair (with suture or staples only) Nasogastric decompression (in first 24 hours) Other: Admission Information: Hospital LOS: days ICU LOS: days Discharge Information: Discharged to: Home self-care Home with services Rehab Skilled Nursing Facility Long-term care Ventilator days: days Transfusion: /units prbcs in first 24 hours of admission Psychiatric facility Hospice Morgue Correctional Facility Other: Did the patient leave AMA (circle): Yes No Complications:
Did patient die during hospital stay: Yes No Complications during admission (check all that apply): Sepsis Wound infection Septic shock superficial Acute renal injury deep Deep vein thrombosis Pneumonia (including ventilator Stroke associated) Pulmonary embolism Urinary tract infection Myocardial infarction Unplanned ICU admission Cardiac arrest Unplanned reoperation Central line-associated blood stream Unplanned intubation infection Other: Acute respiratory distress syndrome Other: Post-operative hemorrhage Other: Mechanical wound failure Ileus or other GI complication Readmission and Follow-up: Readmit within 90 days: Yes No NR Number of days from discharge to readmission: days Follow-up appointment completed within 90 days: Yes No NR With (circle): Primary care Surgical Team