Alaska Trauma Registry Training PI Section

1. Alaska Trauma
Registry Training
TRAUMA PROGRAM
RURAL AND COMMUNITY HEALTH SYSTEMS
STATE OF ALASKA, DIVISION OF PUBLIC HEALTH

2. PI

3. ACS Filters

4. Three tabs under
PI:
Filters
PI Tracking
Notes

5. Three tabs under
PI:
Filters
ACS
EMS
Alaska-Defined
Complications
PI Tracking
Notes

6. Let’s look at the registry

7. PI: Filters
• ACS Filters – Mandatory
• Was there at least hourly documentation and recording of vitals?
• Was there at least hourly determination of GCS for any trauma patient while in the ED with skull
fracture and GCS < 12 or spinal cord injury?
• Did patient require reintubation of airway within 48 hours of extubation?
• Was abdominal, thoracic, vascular or cranial surgery performed more than 24 hours after arrival?
• Was burn patient with an inhalation injury not intubated?
• Did burn patient have an initial escharotomy performed more than 8 hours after arrival?
• Did this patient have an unplanned return to the operating room?
• Was this an unplanned visit for the same injury for which patient was seen in the facility’s ED and
discharge home within the last 72 hours?
• Was the patient’s cervical spine injury/fracture identified in the ED?
• Did this patient require reintubation > 24 hours after extubation?

8. PI: Filters
• ACS Filters Additional Information
• Apply to care at your facility
• Each PI filter applies to specific patient population (a subset of all the trauma
patients)
• These are not simple yes and no questions; the Field Value may have a
different definition for each PI Filter
• Have your Data Dictionary with you until you know these ACS filters
• Full definition of each filter is in the Data Dictionary
• Any “unknown” responses will not fall out for review on Standard ACS
Filter Report

9. PI: ACS Filters
• Was there at least hourly documentation and recording of vitals?
• Patient Population
• Emergency department patients who are unstable or critical
• Critical patients are those that are a critical care admission, transfers or deaths
• Trauma Activation for “prehospital unstable”, “ED unstable” or “potentially unstable”
• If patient determined to be stable, the hourly vital signs may no longer apply,
and filter can still be a “yes”
• This would be a facility criterion
• Applies to ED documentation only (including time in radiology or special
procedure lab)
• Answer
• Yes - Vitals obtained hourly
• No - Vitals not obtained hourly
• NA - Not treated in the emergency department

10. PI: ACS Filters
• Was there at least hourly determination of GCS for any trauma patient while in
the ED with skull fracture and GCS < 12 or spinal cord injury?
• Patient Population
• Only applies to patients with a skull fracture with a Glasgow Coma scale < 12;
or has a spinal cord injury (regardless of GCS)
• GCS or neurological checks may meet filter intent
• Applies to ED documentation only (including time in radiology or special
procedure lab)
• Answer:
• Yes - GCS (or neurological checks) obtained hourly
• No - GCS (or neurological checks) not obtained hourly
• NA - Not Treated in ED or does not have Skull Fracture with GCS of <12, or
spinal cord injury

11. PI: ACS Filters
• Did patient require reintubation of airway within 48 hours of extubation?
• Patient Population
• Applies to all patients that are extubated at your facility
• Answer:
• Yes - Required reintubation within 48 hours of extubation
• No - Did not require reintubation within 48 hours of extubation, or
Electively reintubated for surgical or diagnostic procedure, or
Reintubation occurring greater than 48 hours after extubation
• NA - Not intubation or not extubated

12. PI: ACS Filters
• Was abdominal, thoracic, vascular or cranial surgery performed more
than 24 hours after arrival?
• Patient Population
• Applies to patients who have an unanticipated operation more than 24 hours
after patient arrival in ED
• May enter up to 4 selections
• Abdominal Unanticipated abdominal operation performed
• Thoracic Unanticipated thoracic operation performed
• Vascular Unanticipated vascular operation performed
• Cranial Unanticipated cranial operation performed
• Review physician H&P, op notes, progress notes to determine if surgery was
planned/anticipated

13. PI: ACS Filters
• Was burn patient with an inhalation injury not intubated?
• Patient Population
• Applies to all trauma burn patients
• Inhalation injury
• Damage to the pulmonary parenchyma caused by inhalation of substances
• Very hot air
• Toxic gas
• Asbestos
• Chemical products
• Answer:
• Yes - Has inhalation injury but NOT intubated
• No - Has inhalation injury and WAS intubated
• NA - Did not have inhalation injury

14. PI: ACS Filters
• Did burn patient have an initial escharotomy performed more than 8
hours after arrival?
• Patient Population
• Applies to all trauma burn patients
• Answer:
• Yes - Had escharotomy performed more than 8 hours after arrival
• No - Had escharotomy performed less than 8 hours after arrival
• NA - Did not have escharotomy performed

15. PI: ACS Filters
• Did this patient have an unplanned return to the operating room?
• Patient Population
• Applies to all trauma patients
• Answer:
• Yes - Unplanned return to operating room
• No - Returned to operating room but planned, or went to surgery only once
• NA - Never went to operating room

16. PI: ACS Filters
• Was this an unplanned visit for the same injury for which patient was seen in the
facility’s ED and discharge home within the last 72 hours?
• Patient Population
• Applies to the patients treated in your ED and returns to your facility for previously
unplanned admission (thru ED or DA) within 72 hours of the previous ED visit for
the same injury.
• Answer:
• Yes - Patient seen for this injury and discharged home from your ED and returns for
admission within 72 hours of an ED visit at your facility
• No - Patient seen for this injury and either left AMA or was transferred to another
facility and returns for admission within 72 hours of an ED visit to your facility
• NA - Patient not seen for this injury in your ED within the last 72 hours; patient does
not meet patient population

17. PI: ACS Filters
• Was the patient’s cervical spine injury/fracture identified in the ED?
• Patient Population
• Applies to all patients with a final diagnosis of cervical spine (cord) injury
and/or fracture
• Answer:
• Yes - Cervical spine injury/fracture was identified in the ED
• No – Cervical spine injury/fracture NOT identified in the ED
• NA - The patient did not have a cervical spine injury/fracture

18. PI: ACS Filters
• Did this patient require reintubation > 24 hours after extubation?
• Patient Population
• Applies to all patients that are extubated at your facility
• Answer:
• Yes – Required reintubation greater than 24 hours after extubation
• No – Did not require reintubation greater than 24 hours after extubation, or
Electively reintubated for surgical or diagnostic procedure, or Reintubation
occurring in less than 24 hours after extubation
• NA - Not intubation or not extubated

19. PI: EMS Filters

20. Three tabs under
PI:
Filters
ACS
EMS
Alaska-Defined
Complications
PI Tracking
Notes

21. Let’s look at the registry

22. PI: Filters
• EMS Filters
• Unstable patient on scene greater than 10 minutes?
• EMS activated trauma alert on unstable prehospital patients?
• EMS activated trauma alert on patient with ISS greater than 15?
• Was tourniquet applied prehospital?
• Was cervical spine immobilization applied in ED?
• EMS administered oxygen to patient when O2 saturation less than 94 percent?
• Definitive airway applied prehospital?
• Definitive airway applied in ED?

23. PI: EMS Filters
• EMS Filters Additional Information
• Applied to prehospital EMS agency delivering patient to your facility
• Skipped if no prehospital EMS agency
• Skipped if a Transfer In
• If does not auto-fill manually then answer
• Can’t auto-fill with yes and no
• Place curser over filter box to see if it is open for data entry
• Full definition in Alaska Data Dictionary

24. PI: EMS Filters
• Unstable patient on scene greater than 10 minutes?
• Patient Population
• Applies to prehospital unstable patients
• Auto-fills with Yes if Prehospital Departs Location minus Prehospital
Arrived at Patient is greater than 10 minutes
• Field opens for Patient Status: 1, Prehospital Unstable and not a Transfer In.
• Blank if either Prehospital Arrival at Patient or Prehospital Departs Location are
unknown.
• Answer:
• Yes – Scene time > 10 minutes
• No – Scene time < 10 minutes
• NA - Not an unstable patient or not transported by EMS

25. PI: EMS Filters
• EMS activated trauma alert on unstable prehospital patients?
• Patient Population
• Prehospital unstable patients transport by EMS
• Auto-fills with Yes if Trauma Alert Called by EMS date/time entered for a Prehospital
Unstable patient
• Field opens for Patient Status: 1, Prehospital Unstable and not a Transfer In.
• Blank if either Patient Status or Trauma Alert Called by EMS date/time are unknown.
• Answer:
• Yes – Prehospital EMS DID activate (notify) hospital for unstable prehospital patient
• No – Prehospital EMS DID NOT activate (notify) hospital for unstable
prehospital patient
• NA - Not an unstable prehospital EMS trauma patient

26. PI: EMS Filters
• EMS activated trauma alert on patient with ISS greater than 15?
• Patient Population
• Trauma patients with ISS >15 transported by prehospital EMS
• Auto-fills with yes if Trauma Alert Called in by EMS date/time entered for a trauma
patient with ISS greater than 15
• Field open for prehospital EMS transport patient with ISS > 15 and not a Transfer In
• Answer:
• Yes – Prehospital EMS DID activate (notify) hospital for trauma patient with ISS > 15
• No – Prehospital EMS DID NOT activate (notify) hospital for trauma patient with ISS
> 15
• NA - Not a trauma patient with ISS > 15

27. PI: EMS Filters
• Was tourniquet applied prehospital?
• Patient Population
• All trauma patients transported by EMS
• Auto-fills with yes if Prehospital Treatment “tourniquet” checked off
• Field opens for patient transported prehospital by EMS and not a Transfer In
• Blank if Prehospital Treatment “tourniquet” NOT checked off.
• Answer:
• Yes – Prehospital EMS applied tourniquet prehospital
• No – Prehospital EMS DID NOT apply a tourniquet prehospital
• NA - Not transported by prehospital EMS

28. PI: EMS Filters
• Was cervical spine immobilization applied in ED?
• Patient Population
• All trauma patients transported by EMS
• Auto-fills with Yes if prehospital transfer and ED applied cervical collar
• Field opens for patient transported prehospital by EMS and not a Transfer In
• Blank if Prehospital Treatment “cervical immobilization” checked off
• Answer:
• Yes – ED applied cervical spine immobilization
• No – ED did not apply cervical spine immobilization or EMS had applied
cervical spine immobilization
• NA - Not transported by prehospital EMS

29. PI: EMS Filters
• EMS administered oxygen to patient when O2 saturation less than 94 percent?
• Patient Population
• All trauma patients transported by EMS
• Auto-fills with Yes if Prehospital Treatment “oxygen” checked off and prehospital
Oxygen Saturation is < 94%.
• Field opens for patient transported prehospital by EMS, prehospital O2 Saturation <
94%
• Blank if Prehospital Treatment “oxygen” NOT checked off and Prehospital
O2Saturation < 94%
• Answer:
• Yes – Oxygen administered by EMS for patient is oxygen saturation < 94%.
• No – Oxygen not administered by EMS for patient is oxygen saturation < 94%
• NA - Trauma patient oxygen saturation > 94% or not transported by EMS

30. PI: EMS Filters
• Definitive airway applied prehospital?
• Patient Population
• All trauma patients transported by EMS
• Auto-fills with Yes if one of the following Prehospital Treatments “intubation, EOA,
LMA or cricothyroidotomy” checked off
• Field opens for data entry for patient transported prehospital by EMS and not a Transfer
In
• Blank if one of the following Prehospital Treatments “intubation, EOA, LMA or
cricothyroidotomy” NOT checked off
• Answer:
• Yes – EMS placed definitive airway prehospital
• No – EMS DID NOT place definitive airway prehospital
• NA - Not transported by prehospital EMS

31. PI: EMS Filters
• Definitive airway applied in ED?
• Patient Population
• All trauma patients transported by EMS
• Auto-fills with Yes if an ICD-10-PCS code is entered for a definitive airway on
Procedure screen with Location of ED.
• Field opens for patient transported prehospital by EMS and not a Transfer In.
• Blank if Prehospital EMS transport trauma patient and NO ICD-10-PCS code
entered for a definitive airway listed on Procedure screen with Location of ED
• Answer:
• Yes – ED placed definitive airway
• No – ED DID NOT place definitive airway
• NA - Not transported by prehospital EMS

32. PI: Alaska Defined Filters

33. Three tabs under
PI:
Filters
ACS
EMS
Alaska-Defined
Complications
PI Tracking
Notes

34. Let’s look at the registry

35. PI: Filters
• Alaska Defined Filters
• Tools to track patient care issues at your facility
• Work with your Trauma Committee to select which to monitor
• Determine time period to monitor
• Do not monitor them all – unless decided by committee
• Facility to determine definition for these filters
• Data Dictionary has suggested the definition
• When Tracking a Filter:
• Filter MUST be answered for every patient that meets the defined patient population
• If you have a patient that does not meet the patient population then you can select
NA
• Filters cover all phases of care (e.g., EMS, ED, radiology, inpatient)

36. PI: Alaska-Defined Filters
• EMS adequately splinted extremity fracture
• ED Trauma Team activated per protocol
• ED measure O2 saturation measured upon admission
• ED administered oxygen to patient with O2 < 94 percent
• ED started IV in less than 4 attempts
• ED appropriately splinted extremity fracture
• ED successfully Intubated in less than 4 attempts
• ED reduced dislocated joint reduced prior to transfer or admission
• ED inserted chest tube for pneumothorax (> 25 prior to transfer or admission

37. PI: Alaska-Defined Filters
• ED applied circumferential pelvic compression for complex pelvic fracture prior to
transfer or admission
• ED obtained fetal heart tones for pregnant patient
• ED initiated fetal monitoring for pregnant patient
• ED weighed pediatric patient
• Hypothermic patient (T < 90 F) actively warmed
• Open fracture treated with IV antibiotic in 3 hours of patient’s arrival
• Moderate/deep sedated patient did NOT require assisted respirations or reversal agent
• Cat scan started within 1 hour of being ordered
• Radiology readings free of discrepancies

38. PI: Alaska-Defined Filters
• Radiology services available within 30 minutes of patient’s arrival
• Screening, Brief Intervention and Referral to Treatment (SBIRT) completed
• General surgeon consulted on trauma patient admitted to medicine service
• EMS adequately splinted extremity fracture
• Pediatric patient (<15) intubated with 1 attempt
• Pediatric patient (< 15) extubated within 24 hours of rapid sequence intubation
(excluding operative procedure)
• Pediatric patient (< 15) was appropriately ventilated during the first 12 hours
for a child with normal initial vital signs
• Pediatric patient (<15) received appropriate fluid resuscitation during the first
12 hours for a child with normal initial vital signs

39. PI: Alaska-Defined Filters
• Laparotomy was therapeutic
• Antiplatelet medication administered
• Antiplatelet reversal medication administered
• Sequential compressions devices (SCDs) initiated
• TBI monitoring equipment (Licox, Ventriculostomy drain, etc.) utilized for TBI
• Patients < 15: Imaging guidelines for head injury were followed (PECARN guidelines
• Patients <= 2 injured in home received a non-accidental trauma evaluation
• Patients <= 2 Patient’s temperature was less than 35 C for greater than 2 hours
• Patients <= 15: Fluid administration of >50 ml/kg crystalloid in the first 2 hours

40. PI: Alaska-Defined Filters
• Suggested Patient Population
Cat scan started within 1 hour of being ordered
Suggested Patient Population: All pregnant trauma patients
Yes Cat scan started within 1 hour of being ordered
No Cat scan started > 1 hour of being ordered

41. Complications

42. Three tabs under PI:
Filters
ACS
EMS
Alaska-Defined
Complications
NTDB Complications
System Filters
PI Tracking
Notes

43. Let’s look at the registry

44. PI: Alaska-Defined Filters
• Complications
• Complications that occur during hospital stay
• Alaska Data Dictionary includes definition
• NTDB Complications
• NTDB definition
• Changes each year
• Complication = hospital event
• System Filters (Complications)

45. PI: NTDB Complications
• Acute Kidney Injury
• Acute Respiratory Distress Syndrome
• Alcohol Withdrawal Syndrome
• Cardiac Arrest with CPR
• Catheter-Associated Urinary Tract Infection
• Central Line-Associated Bloodstream Infection
• Deep Surgical Site Infection
• Deep Vein Thrombosis
• Delirium
• Extremity Compartment Syndrome
• Myocardial Infarction

46. PI: NTDB Complications
• Organ/Space Surgical Site Infection
• Osteomyelitis
• Pulmonary Embolism
• Pressure Ulcer
• Severe Sepsis
• Stroke/CVA
• Superficial Incisional Surgical Site Infection
• Unplanned Admission to ICU
• Unplanned Intubation
• Unplanned Visit to the Operating Room
• Ventilator-Associated Pneumonia

47. PI: NTDB Complications
• Alaska Data Dictionary Includes
• NTDB Definition
• Additional Information
• Occurred during initial stay at your hospital
• Diagnosis in medical records
• Excluded patients
• Registrar not a nurse
• May need nursing help determine definition meet
• Ask for help

48. PI: NTDB Complications
• Acute Kidney Injury
• Definition
• Acute Kidney Injury, AKI (stage 3), is an abrupt decrease in kidney function.
KDIGO (Stage 3) Table:
• (SCr) 3 times baseline; OR
• Increase in SCr to ≥ 4.0 mg/dl (≥ 353.6 μmol/l) ; OR
• Initiation of renal replacement therapy OR, in patients < 18 years, decrease in eGFR to <35
ml/min per 1.73 m²; OR
• Urine output <0.3 ml/kg/h for > 24 hours; OR
• Anuria for > 12 hours; OR

49. PI: NTDB Complications
• Acute Kidney Injury
• Additional Information
• Must have occurred during the patient's initial stay at your hospital.
• A diagnosis of AKI must be documented in the patient's medical record.
• If the patient or family refuses treatment (e.g., dialysis,) the condition is still
considered to be present if a combination of oliguria and creatinine are present.
• EXCLUDE patients with renal failure that were requiring chronic renal
replacement therapy such as periodic peritoneal dialysis, hemodialysis,
hemofiltration, or hemodiafiltration prior to injury.
• Consistent with the March 2012 Kidney Disease Improving Global Outcome
(KDIGO) Guideline.

50. PI: System Filters (Complications)
• Prehospital – Airway
• Aspiration, Prehospital
• Esophageal Intubation
• Extubation, Unintentional
• Mainstem Intubation
• Unable to Intubate
• Other airway complication

51. PI: System Filters (Complications)
• Prehospital – Fluids
• Prehospital – Miscellaneous
• Hospital – Airway
• Hospital – Pulmonary
• Hospital – Cardiovascular
• Hospital – Gastrointestinal
• Hospital – Hepatic, Pancreatic, Biliary, Splenic
• Hospital – Hematologic

52. PI: System Filters (Complications)
• Hospital – Infection (Nonpulmonary, Nonorthopedic)
• Hospital – Renal/Genitourinary
• Hospital – Musculoskeletal/Integumentary
• Hospital – Neurologic
• Hospital – Vascular
• Hospital – Psychiatric
• Hospital – Miscellaneous
• Hospital – Provider Errors/Delays

53. PI: System Filters (Complications)
• Complications
• Use Alaska Data Dictionary
• Definitions
• Full list of complications
• Select NTDB complication, checks complication off in system filters
• If mark complication in system filter, checks NTDB complication

54. PI: PI Tracking

55. Three tabs
under PI:
PI
PI Tracking
Notes

56. Let’s look at the registry

57. PI: PI Tracking
• PI Tracking
• Tracking tool available in Web Registry
• Includes all PI steps identified by ACS
• All trauma information stored in one secure location

58. PI: PI Tracking
• Activate PI Tracking
• Quick Review
• High-lite PI filter to be tracked on “Filter” screen
• Select Edit
• Check activate tracking box “yes”
• Close edit box with “ok”
• Go to PI Tracking screen
• Select Auto-trigger filter
• Moves all filters identified for tracking to the PI tracking screen

61. PI: PI Tracking
• PI Tracking
• Tracking tool available in Web Registry
• Includes all PI steps identified by ACS
• All trauma information stored in one secure location

63. PI: PI Tracking
• PI Tracking
• Includes all PI steps identified by ACS
• Issue Identification
• Levels of Review
• Conclusions/evaluation
• Action Plan
• Implementation
• Evaluation / “Loop Closure”

64. PI: PI Tracking
• PI Tracking
• An optional lesson available trauma PI program
• Required components
• How to use the registry
• Step-by-step instruction on the PI Tracking screen
• Report Runner PI reports
• How to track PI
• Case Reviews
• System Review

65. Thank You