Osisko Gold Royalties Ltd - Corporate Presentation, April 23, 2024
Ā
Procedures
1. Updated December 2004
The TRAUMA
Audit & Research
NETWORK
DEVELOPING EFFECTIVE CARE
FOR INJURED PATIENTS THROUGH
PROCESS AND OUTCOME
ANALYSIS AND DISSEMINATION
TARN
PROCEDURES
3. 3
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Section 1:
Before you begin
Page
No.
How to set up TARN at your hospital 5
Which patients to include 6
Which form to use 8
Setting up a system of data capture 9
The path of a data collection form 10
Section 2:
You are now ready to begin
Page
No.
Important points to remember 12
How to complete a TARN form 13
Pre-existing conditions 18
Anatomical description of injuries 20
Section 3:
Now youāre up & running ā Further Information
Page
No.
Abbreviated Injury Scale (AIS) 22
Injury Scoring Systems
- ISS 23
- Ps04 24
Group comparisons 25
Local trauma audit 27
Improving trauma care
5. 5
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COMPLETE AND RETURN THE RELEVANT PAPERWORK
Membership Authorisation
Site Identification
Hospital Contacts
STARTUP Training form
LOCATE THE PERSON, THE PLACE AND THE FACILITIES
Identify the staff who will collect the data & arrange STARTUP training for
them, they should be:
Organised Proactive
Confident Enthusiastic
Identify a working area with:
Filing space A desk
A phone Access to a photocopier & Fax
A computer
WORK OUT A SYSTEM
Create a logging number system for your cases
Keep it simple: 1,2,3 is fine
Use a book or computer
Create a filing system for photocopies of the completed forms
It is vital to keep copies of forms, so you can identify
individual patients in the TARN reports
A data collection route should be identified
This is unique to each site because different systems are available
Please refer to āSetting Up a system of Data captureā for ideas
INTRODUCE TARN AND YOURSELF
The data collector should introduce themselves to all levels of staff with
whom they will liase
Donāt forget the Ambulance service & Coroners office
A Clinician or data collector should introduce TARN to the trauma
staff at a relevant meeting
Use the overheads and notes available from TARN
It is vital that the lead Consultant be present in order to drive this
forward
You should consider inviting staff from Clinical Audit, ITU, Orthopaedics,
Paediatrics & Ambulance services, in order to ensure that the message gets
across to all trauma receiving departments ā that this important & useful data
is being collected
THE REPORTS
Decide who should receive the TARN reports
Customised reports are available at any time, to support
audit & research
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INCLUSION CRITERIA
The decision to include a patient should be based on the following 3 points:
1 All trauma patients IRRESPECTIVE OF AGE
Who fulfil one or more of the following:2
YELLOW DATA COLLECTION FORM
Trauma admissions whose length of stay is 72
hours or more
OR
Trauma patients admitted to a High
Dependency Area regardless of length of stay
OR
Deaths of trauma patients occurring in the
hospital including the Emergency Department
(even if the cause of death is medical)
OR
Trauma patients transferred to
another hospital:
- for further care
- or who are admitted to a High Dependency
Area
- or who die from their injuries
BLUE DATA COLLECTION FORM
Trauma patients transferred to your hospital
for continuing trauma care whose
combined hospital stay on any site is 72
hours or more.
OR
Trauma admissions to a High Dependency
Area regardless
of length of stay.
OR
Trauma patients who die from
their injuries
(even if the cause of death is medical).
3 And whose injuries fulfil the injury criteria.
Common injury exclusions:
Isolated fractures of the femoral neck or single pubic rami aged 65 years or more
or uncomplicated spinal sprains
or closed facial injuries
and/or simple skin injuries including uncomplicated penetrating injuries
and/or less than 10% superficial or partial thickness burns
(all full thickness burns are included)
for more exceptions please see next page
7. 7
More Injury exclusions and inclusions
The following examples are shown for clarity and apply to injuries in isolation or where
accompanied by skin injuries only.
ARTERIES & VEINS
Intimal tears & superficial lacerations/perforations of arteries or veins with < 20% blood
loss are EXCLUDED.
(with the following exceptions: Femoral, Neck, Facial, Cranial ā all of which are INCLUDED)
NERVES
Injuries to the sciatic, face, femoral or cranial nerves are INCLUDED.
All other injuries to nerves, alone or in combination are EXCLUDED.
MUSCLES, TENDONS & LIGAMENTS
All patients with injuries to muscles, tendons & ligaments, alone or in combination with
other muscles, tendons, ligaments are EXCLUDED.
FOOT, TOES JOINTS & BONES
Any combination of the following are EXCLUDED:
Foot fracture
Any number of fractured toes, metatarsals &/or tarsals
Dislocated phalanges or inter-phalangeal joints, subtalar, transtarsal or
transmetatarsal joints.
Massive destruction or crushed limb is INCLUDED.
HAND & FINGERS JOINTS & BONES
Any combination of the following are EXCLUDED:
Fractured hand
Any number of fractured fingers, carpus or metacarpus
Carpel-metacarpal, metacarpal-phalangeal or interphalangeal dislocation.
Massive destruction or crushed limb is INCLUDED.
FRACTURE/DISLOCATIONS TO: ANKLE/WRIST/ELBOW/SHOULDER
Are INCLUDED.
LIMB FRACTURES (EXCLUDING FEMUR)
Are INCLUDED if: displaced, open, compound or comminuted, otherwise are:
EXCLUDED
FACE FRACTURES:
Are INCLUDED if: displaced, open, compound or comminuted, otherwise are:
EXCLUDED
DISLOCATED HIPS
Dislocated hips are INCLUDED
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USE YELLOW FORM IF:
YOUR SITE IS THE FIRST HOSPITAL THAT THE PATIENT ATTENDED
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USE BLUE FORM IF:
THE PATIENT HAS BEEN TRANSFERRED INTO YOUR SITE FOR
CONTINUING TRAUMA CARE.
REMEMBER
The following 10 fields are Obligatory and the form will
be returned to you if any of these values are incomplete!
Hospital identification number
Trauma Network Number
Date of Birth
Sex
Type of injury
Cause of injury
Date of arrival at hospital
Outcome - Alive / Dead
Date of Death or Discharge
At least one injury description
THE FUTURE:
TARN is currently in the processing of transferring from a paper based
system to a Web based system of data collecting and reporting.
The aim is to have National implementation by the end of 2005.
For more information see the website: www.tarn.ac.uk
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Yellow Forms
1. Casualty cards should have tick boxes that look something like this:
Accident 4 DOA
Fall 4 DID
Asthma
Admitted 4
Ask the I.T. department to print regular reports (using the tick boxes), that select out:
Admissions, Falls, Accidents, Died in Department (DID) and Transfers.
The report should contain the following information:
Hosp No. Age/D.O.B. Destination/Ward No. Initial complaint
Patients who die from their injuries in the Emergency Department can
easily be missed; therefore it may be necessary to set up another method
of identifying these patients.
2. Regularly check the PAS system for Discharge Dates and disregard any patient whose
length of stay is less than 72 hours (unless they died, spent time on ICU or were
transferred).
3. When the remaining patients are discharged, request the notes and if the injuries fulfil our
Inclusion Criteria:
COMPLETE A YELLOW FORM
Blue Forms
1. Where applicable in your hospital, check:
HDU/ICU, Neurosurgery, Orthopaedics, Paediatrics, Burns & Plastics and General
Surgical wards approximately once a month for Trauma patients who were transferred in.
There are 3 suggested ways to do this:
i) Check the relevant computer system or (if they do not have one)
ii) Check through the ward log book or
iii) Ask a helpful nurse to keep a record of all Trauma admissions
The information you require is:
Hosp No. Age/D.O.B. Destination after leaving ICU/NSU/Ward
2. Once you have identified a Trauma patient, check that the patient died, was transferred or
had a length of stay of more than 72 hours (including time spent at the initial hospital)
then, if the injuries fulfil our Inclusion Criteria:
COMPLETE A BLUE FORM
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Hospital Information Systems Lists
SPECIFIC TO YOUR SITE
Remember in addition to the Emergency Department, also include patients admitted directly to:
HDU/ICU, Neurosurgery, Orthopaedics, Paediatrics, Burns / Plastics, General Surgery and
all Specialist Units
Data Collector decides if Inclusion Criteria is fulfilled ā if YES
Complete a form, remembering to keep a photocopy and a record of all Trauma numbers issued
Data should be gathered from: Ambulance Logs, Radiology reports, Post Mortems, Hospital notes,
Trauma sheets, Op notes & Discharge summaries
Once a month - Send all forms to TARN
Number of forms logged in at TARN, including date arrived
The following month:
Data Checked, Coded, Validated
& Non Transfers are:
Transferrals are scanned
into a separate āholding
databaseā
Database interrogated
REPORTS PRODUCED
Electronic search for
corresponding transfer
form done every month,
once matched & validated
Scanned onto the National
Database
Monthly Clinical Reports
Incorporates data received i
previous month.
Report includes
probability survival and
actual outcome
Themed Quarterly Reports
Comparative process and outcome
analyses
Regular schedule of analyses to
enable year on year comparison
Customised Analyses
(as requested)
Regional or Specialist Unit
Comparison
(where agreed)
Compare changes in practice
acrossRegions
Neurosurgical Units,
Paediatric services etc
Trauma Research
Informing the research
agenda
If rejected for either:
Inclusion Criteria or
Missing Obligatory Data
Forms are returned to Site
Monthly Transfer Reports
Aids the capture of TARN to
TARN transfer cases.
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A PHOTOCOPY OF EACH DATA COLLECTION FORM SHOULD BE KEPT
FOR YOUR OWN RECORDS.
PLEASE ONLY SEND ORIGINAL FORMS TO US.
SINCE ACCURATE ANALYSES IS BASED ON ACCURATE NFORMATION,
IT IS IMPORTANT THAT NEGATIVE RESPONSES ARE RECORDED.
Blank fields will be recorded on the database as 'missing data'
ALL DATES SHOULD BE 8 DIGITS LONG e.g. 01/01/2005 not 1/1/02.
ALL TIMES SHOULD BE RECORDED USING THE 24 HOUR CLOCK.
NEVER RECORD A TIME AS 00.00 OR 24.00 - IT HAS TO BE 23.59 OR
00.01.
YES/NO BOXES SHOULD BE CROSSED NOT TICKED.
DO NOT PUT LINES THROUGH INAPPLICABLE FIELDS.
NEVER WRITE N/K OR N/A IN A FIELD.
IT IS VITAL TO RECORD YOUR 4 DIGIT SITE ID CODE AND TRAUMA
NUMBER ON EVERY FORM, INCLUDING CONTINUATION SHEETS.
AS WE ENDEAVOUR TO SCAN ALL DATA COLLECTION FORMS ONTO
THE DATABASE, PLEASE DO NOT USE ANY OF THE FOLLOWING:
STAPLES
CORRECTION FLUID
SELLOTAPE
HOLE PUNCHES
LASTLY, ALWAYS REMEMBER THERE IS A FULL SUPPORT SERVICE
AVAILABLE FROM TARN!
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Obligatory fields are highlighted in Red
PATIENT INFORMATION
Family Name:
First Name:
Date of Birth:
A & E Record No:
Hospital Record Number:
The following details should be recorded (on the front page of the tear off
section) so that statistical returns can be linked to patient records.
However they must be retained at the Hospital.
Hospital Identification No. The four-digit code (beginning with 8) that is specific to your Hospital and is
issued on receipt of your Membership Authorisation form.
This must be written on all data collection forms and continuation sheets.
Trauma Network No. A number up to 8 digits long, which is assigned to each qualifying patient. The
data coordinator in the hospital submitting the data form should assign this
number and keep a record with the patient's details. This number is used as
an index to identify the patient, so must never be duplicated!
PLEASE USE SIMPLE NUMBERS! e.g. 1, 2, 3.
Incident Postcode: The postcode where the incident occurred.
You only need to document the first part and the first digit of the second half of
the postcode.
Patient's Postcode: Record the postcode of the patient's normal residence.
You only need to document the first part and the first digit of the second half of
the postcode.
Sex: Indicate by an X in the appropriate box.
Date of Birth: Record the date of birth of the patient.
Weight: Record the weight in kg. of the patient if aged under 15 years
INCIDENT DETAIL
Date of Injury: Record the date that the incident occurred
Time of Injury: Record the time of injury determined by pre-hospital
personnel or police.
Type of Injury: Blunt:
Injury resulting from the application of a diffuse force is recorded as 'blunt'.
Penetrating:
Injury resulting from tissue penetration or punction by an object e.g. bullet,
knife, glass shards.
NOTE:
If there are 2 types of injury, choose that which caused the
most severe injury. i.e. patient was assaulted with fists (BLUNT)
resulting in concussion and stabbed (PENETRATING) resulting in a
ruptured liver. Record as penetrating.
Burn/Inhalation:
Indicate by an X in addition to 'Type of Injury' ā Burns are recorded as blunt.
Please also indicate the cause of the burn or inhalation injury.
Cause: Indicate by an X in the appropriate box, a description of the cause of the
injuries. If using the āOtherā field, please indicate what happened to the patient
in the box provided.
Trapped at Scene: This field relates to all trappings, not just this involving RTAs.
Position in RTA: Indicate by entering an X in the appropriate box.
14. 14
AT SCENE / EN ROUTE (relating to Ambulance & Helicopter)
No Details: Cross this box only if you cannot find any detail of the pre hospital care.
Date: Record the date that the Ambulance/Helicopter was called.
Ambulance Service: Record the Ambulance/Helicopter Service that attended the patient.
Do not fill in the four boxes on the right hand side, they are for TARN use only.
Call Ambulance: Record the time that the Ambulance/Helicopter was called.
Despatch to Scene: Record the time that the Ambulance/Helicopter was sent to the scene by
Control.
Arrive at Scene: Record the time that the Ambulance/Helicopter arrived at the scene.
Departure Scene: Record the time that the ambulance left the scene.
Ambulance staff: Indicate by entering an X in the appropriate box.
Please complete both 'Y' and 'N' boxes where relevant.
Measurement/Procedures
commenced at:
Record the time that the following physiology was measured at scene/enroute.
Glasgow Coma Scale
Score:
Record the Eye Opening, Verbal Response and Motor Response at
scene/enroute (see page 10&11 for guidelines).
Pulse per min: 1st
recording of Pulse rate/minute taken at scene/enroute.
Unassisted resp.
rate/min:
1st
recording of number of respirations by the patient in 15 seconds,
multiplied by 4 taken at scene/enroute.
Record actual (unassisted) Resp Rate ONLY in this space.
This is an unassisted measurement only, if patient is ventilated please
leave blank.
Systolic BP: 1st
recording of Systolic Blood pressure in either arm by auscultation
or palpation taken at scene/enroute.
Pulse Oximeter:
Use an X in the appropriate box to indicate if the Pulse Oximeter was used
& then record the actual value.
Emergency Procedures: Indicate by an X in the appropriate box to indicate any procedures that were
carried out.
Please record negative responses.
ON ARRIVAL AT HOSPITAL
Date of Arrival: Record the date that the patient is admitted to the Emergency Department.
Time of Arrival: Record the time that the patient is admitted to the Emergency Department.
Mode of Arrival: Indicate by an X in the box, the type of transport used to bring the patient to the
Emergency Department.
Minor/Major/Other Area: Indicate by an X in the box, the area of the Emergency Department to which the
patient was first admitted. 'Other Area' applies to other departments in the
hospital. Resus should be recorded as Major.
Was the patient intubated
before arrival?
Indicate by an X in the 'Y' box if the patient was intubated prior to arrival in the
Emergency Department.
Was the patient paralysed
before arrival?
Indicate by an X in the 'Y' box if the patient received any paralysing drugs prior
to arrival in the Emergency Department.
Was the patient ventilated
before arrival?
Indicate by an X in the 'Y' box if the patient was ventilated prior to arrival in the
Emergency Department.
Seen by Doctor Time: Record all the times that each doctor sees the patient.
Seen by Doctor
Grade:
Record the grade of every doctor by referring to the codes on the tear off
section of the form.
Seen by Doctor
Speciality:
Record the speciality of every doctor by referring to the codes on the tear off
section of the form.
If your patient has been seen by >6 Doctors; please ensure all the
specialities are recorded and highest grades should be documented first.
15. 15
ON ARRIVAL AT HOSPITAL cont
ATLS/APLS: Indicate by an X in the appropriate box if the doctor has/has not completed an
Advanced Trauma &/or Advanced Paediatric Life Support Course.
Trauma Team Present: Indicate by an X in the appropriate box if the Trauma Team was present.
The definition of a Trauma team varies from hospital to hospital, so it is
important to also record individual grades/specialties.
Measurement/Procedur
es commenced at:
Record the time when the initial assessment was made in the
Emergency Department.
Capillary Refill: Indicate capillary refill of < or > 2 seconds, by an X in the appropriate box.
Pulse per minute: The 1st
recording of Pulse rate/ minute taken in the Emergency Department.
Unassisted
Resp. rate/min:
1st
recording of number of respirations by the patient in 15 seconds x by 4,
taken in the Emergency Department.
Record actual (unassisted) Resp Rate ONLY in this space.
This is an unassisted measurement only, if patient is ventilated please leave
blank.
Systolic BP: The 1st
recording of Systolic blood pressure in either arm by auscultation or
palpation taken in the Emergency Department.
Pulse Oximeter: Put an X in the appropriate box to indicate if the Pulse Oximeter was used and
then record the actual value.
Procedures carried out
in the EmergencyDept:
Record any investigations or treatments carried out in the E.D.
Record negative responses if known.
X-ray: Indicate whether the patient had an X-ray within 24 hrs of arrival. If yes record
the time & indicate the body area/s X-rayed.
CT: Indicate whether the patient had an CT scan within 24 hrs of arrival. If yes
record the time & indicate the body area/s scanned.
Ultrasound: Indicate whether the patient had an Ultrasound within 24 hrs of arrival. If yes
record the time & indicate the body area/s scanned.
Date of Discharge
from E.D.:
Record the date that the patient leaves the E.D.
Time of Discharge: Record the time that the patient leaves the E. D. (If transferred directly to
another site, this time should = Time of Transfer).
Discharged from: Record the E.D. area from which the patient is admitted, transferred to another
hospital or sent to the mortuary.
Discharged to: Use an X in the appropriate box to indicate where the patient was transferred to,
following Discharge from E.D.
GLASGOW COMA SCALE
EYE OPENING:
4 = Spontaneous:
3 = To Voice:
2 = To Pain:
1 = None
Assessment of the stimulus required to induce eye opening:-
At this point, with no further stimulation, patientā' eyes are open.
If a patient's eyes are unopened, a request to "open your eyes" should be
spoken, and if necessary, shouted. If the eyes are then opened, the action is
considered a response to voice stimulation.
If verbal stimulation does not elicit eye opening, the standard painful stimulus is
applied (firm pressure to the nailbed or sternum for 5-10 seconds). If eyes are
open it is considered a response to pain.
No eye opening, despite pain stimulus.
If total GCS is 15 then: Eye = 4 Verbal = 5 Motor =6
If both eyes are closed due to swelling -facial injuries & eye opening can not be assessed,
record as 9.
16. 16
GLASGOW COMA SCALE cont
VERBAL RESPONSE:
5 = Orientated:
4 = Confused:
3 = Inappropriate Words:
2 =Incomprehensible Soun
1 = No Verbal Response:
After the patient is aroused, he is asked who he is, where he is, and what the
year and month are. If accurate answers are obtained to ALL questions, the
patient is recorded as orientated.
Although the patient is unable to give the correct answers to the previous
questions, he is capable of producing phrases, sentences, and even
conversational exchanges.
The patient speaks or exclaims only a few words (often curses). Such a
response is usually obtained only by physical stimulation rather than a verbal
stimulus, although occasionally a patient will shout obscenities or call 'relatives'
names for no apparent reason.
The patient's response consists of groans, or indistinct mumbling and does not
contain intelligible words.
Prolonged and, if necessary, repeated stimulation does not produce any
phonation.
5 =
4 =
3 =
2 =
1 =
VERBAL RESPONSE -CHILDREN:
The child smiles, is orientated to sounds, follows objects & interacts
appropriately.
The child is consolable and interacts appropriately.
The child is occasionally consolable and/or moans.
The child is inconsolable and irritable.
No verbal response.
MOTOR RESPONSE:
6 = Obeys Commands:
5 = Localizes Pain:
4 = Withdraws:
3 = Flexion Response:
2 = Extension Responses:
1 = No Motor Response:
This requires an ability to comprehend instruction, usually in some form of verbal
command, but sometimes by gestures and writing. The patient is required to
perform the specific movements requested. The command is given to hold up 2
fingers (if physically feasible), the patient should respond appropriately.
If the patient does not obey commands, a painful stimulus is applied as firm
pressure to the nail bed or sternum for 5-10 seconds. The patient reaches to
and/or removes the source of pain.
After the painful stimulus the following occurs:
- Elbow flexes
- Rapid movement
- No muscle stiffness
- Arm is withdrawn away from the trunk
After the painful stimulation the following occur:
- Elbow flexes
- Slow movement
- Accompanied by stiffness
- Forearm and hand held against the body
- Limbs assume hemiplegic position
After the painful stimulation the following occur:
- Legs and arms extend
- Accompanied by stiffness
- Internal rotation of shoulder and forearm
TRANSFER TO or FROM ANOTHER HOSPITAL (where applicable)
Date of transfer: Record the date that the patient was transferred from/to your hospital.
Time of transfer: Record the time that the patient was transferred from/to your hospital.
17. 17
Reason for transfer: Use an X to indicate the reason that the patient was transferred.
Accompanying Patient: Use an X to indicate who accompanied the patient during the transfer.
Transfer To/From: Record the receiving/transferring Hospital's name
Via: Indicate by an X in the appropriate box, the mode of the transfer used.
Please ignore the area that is shaded. This is for Trauma Network office use only.
SUBSEQUENT CARE
Operation/Procedure: Indicate by an X in the appropriate box, if the patient had an operation/procedure or
not. CARRIED OUT AT YOUR HOSPITAL ONLY
Date of Arrival in
Theatre:
Record the date that the patient arrived in theatre (Using the anaesthetic record)
Time of Arrival: Record the time that the patient arrived in theatre (Using the anaesthetic record).
Time of departure: Record the time that the patient leaves theatre (Using the anaesthetic record).
SHOULD NOT INCLUDE TIME SPENT IN RECOVERY
Grade of Surgeon: Record the grade of Surgeon who performed the operation - refer to the codes on
the inner page of the tear off section of the form.
Grade of Anaesthetist: Record the grade of the Anaesthetist - refer to the codes on the inner page of the
tear off section of the form.
Number of further Ops: Record the number of further operations performed (at your hospital). Do not
include the initial one.
Operation/Procedures: Briefly record details of the 1st
operation/procedure.
Use the continuation sheet if more space is needed.
Complications: Record any complications that occur whilst the patient is still in hospital. Use the
continuation sheet if more space is needed.
Pre-Existing Diseases: VERY IMPORTANT - Indicate any Pre-existing diseases/conditions.
A referral list is included on the following 3 pages.
OUTCOME
The patient's outcome should be recorded at discharge, transfer or death (up to a maximum
of 93 days stay).
However, analysis is performed on using Outcome at 30 days.
Alive / Dead:
If alive:
If dead:
Indicate, by an X in the appropriate box, whether the patient died or survived.
Record the date the patient was discharged from your hospital
If a patient is transferred out the Discharge date should = the Transfer date.
If they return, the Discharge date should be the final date they were
discharged /transferred from your hospital. (Please also record the date the
patient returned on the comments section of the form).
The cut off point is 93 days ā if a patient is an inpatient longer, then the
discharge date should be the 93rd
day.
Record the date and time of death (if occurring at your site).
Total Length of
stay:
Indicate total number of days the patient spent at your hospital. If the patient is
Transferred - do not include any time spent at a 1st
or 2nd
Hospital
If the length of stay is 3 days then the patient is only included if the admission
time is before 12.00 midday
For patients who arrive in hospital and die on the same day, the length of stay is
equal to 1 day.
Length of stay of ICU:
(An ICU is defined as a unit
with an average patient to
nurse ratio not larger than 2:1)
Enter the total number of days the patient spent in the ICU/ HDU.
Enter patients who spent <24 hours in ICU as 1 day.
No ICU days = 0 (please do not leave blank).
18. 18
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All of the following should be documented!
(Including no pre-existing disease)
ENDOCRINE NUTRITIONAL, METABOLIC &
GU DISEASES
ICD Chapters IV,XI,XIV
ā¦ GU Diseases NFS
ā¦ Upper GI
ā¦ Lower GI
ā¦ Ulcer
ā¦ Liver disease
ā¦ Previous splenectomy
ā¦ Renal disease
ā¦ Crohnās disease,
ā¦ Colitis
ā¦ Diverticular disease
ā¦ Other GU Diseases
ā¦ Metabolic NFS
ā¦ Diabetes mellitus
ā¦ Diabetes insipidus
ā¦ Adrenal disease
ā¦ Thyroid disease
ā¦ Pituitary disease
ā¦ Other Metabolic Diseases
ā¦ Other ENM and GU Diseases
MENTAL & BEHAVIOURAL DISORDERS
ICD Chapter V
ā¦ Psychosis
ā¦ Schizophrenia
ā¦ Depression
ā¦ Deliberate self-harm
ā¦ Neurosis
ā¦ Personality Disorder
ā¦ Alcohol abuse
ā¦ Drug addiction
ā¦ Anorexia/Bulimia
ā¦ Obesity
ā¦ Other
NEOPLASMS & BLOOD/IMMUNE DISEASES
ICD Chapters II, III
ā¦ Cancer of GI Tract
ā¦ Cancer of Lung
ā¦ Cancer of Breast
ā¦ Cancer of Kidney
ā¦ Cancer of GU Tract
ā¦ Cancer of Bone
ā¦ Cancer of Skin
ā¦ Cancer of Brain
ā¦ Other Neoplasms
ā¦ Thrombocytopenia
ā¦ Thrombocytosis
ā¦ Coagulopathy
ā¦ Haemophilia
ā¦ Anaemia
ā¦ Lymphoma
ā¦ Multiple Myeloma
ā¦ Leukaemia
ā¦ Other Blood/immune Diseases
ā¦ Other
DISEASES OF THE NERVOUS SYSTEM
ICD Chapter VI
ā¦ Stroke/CVA/TIA
ā¦ Subarachnoid bleed
ā¦ Vertebrobasilar disease
ā¦ Migraine
ā¦ Epilepsy
ā¦ Cerebral palsy
ā¦ Spina Bifida/Previous spinal cord injury
ā¦ Mental handicap
ā¦ Dementia
ā¦ Parkinsonās Disease
ā¦ Multiple Sclerosis
ā¦ Other
19. 19
MUSCULO-SKELETAL & CONNECTIVE TISSUE
ICD ChapterXIII
ā¦ Arthritis
ā¦ Osteoarthritis
ā¦ Rhumatoid arthritis
ā¦ Connective Tissue Disease
ā¦ Major joint replacement
ā¦ Brittle bone disease
ā¦ Generalised osteoporosis
ā¦ Pagetās Disease
ā¦ Degenerative Spinal disease
ā¦ Other
GENERAL INFECTIONS & PARASITIC
DISEASES
ICD Chapter I
ā¦ HIV/AIDS
ā¦ TB
ā¦ MRSA
ā¦ STD
ā¦ Other
NO PRE-EXISTING DISEASE
MISSING
CIRCULATORY & RESPIRATORY SYSTEMS
ICD Chapters IX and X
ā¦ Heart NFS
ā¦ IHD
ā¦ Myocardial Infarction
ā¦ Carditis NFS
ā¦ Valvular heart disease
ā¦ Cardiomyopathy
ā¦ Other Circulatory
ā¦ Hypertension
ā¦ Peripheral vascular Disease
ā¦ DVT
ā¦ PE
ā¦ Vasculitis
ā¦ Asthma
ā¦ COPD
ā¦ Fibrosis NFS
ā¦ Bronchiectasis
ā¦ Cystic Fibrosis
ā¦ Other Respiratory
SKIN & SUBCUTANEOUS TISSUE
DISEASES OF THE EYE & EAR
PREGNANCY
ICD Chapters XII, VII, VIII, XV
ā¦ Pre-existing skin conditions
ā¦ Diseases of the Eye
ā¦ Diseases of the Ear
ā¦ Pregnancy at time of injury
ā¦ Other
20. 20
AAANNNAAATTTOOOMMMIIICCCAAALLL DDDEEESSSCCCRRRIIIPPPTTTIIIOOONNN OOOFFF IIINNNJJJUUURRRIIIEEESSS
List all injuries documented by the:
Physician's examination
X-rays
CT scans
MRI/NMR reports
Operative findings
Autopsy/Post Mortem reports
Injuries should only be recorded when the diagnosis is certain.
NEVER RECORD POSSIBLE, PROBABLE OR SUSPECTED INJURIES!
Photocopies of X-ray reports/CT Scans/Autopsy reports can be attached to
the form via a paperclip (You must ensure all patient identifiers have been
removed). Autopsy results should be used whenever available even if a
delay in submission of the form is required.
You have space to document up to 6 injuries on the Data Collection form and
up to 28 injuries if you use the continuation sheet provided if necessary
(Remember to write your hospital identification code and the patient's Trauma
Network number at the top of the sheet).
All your injury coding using AIS-98 will be done centrally at TARN
Guidelines to help with the accurate documentation of injuries
ACCURATE AND DETAILED INJURY DESCRIPTIONS WILL
ENABLE A MORE PRECISE CHARACTERIZATION OF
INJURY SEVERITY.
Record the length of all lacerations/penetrating injuries, whether external or inte
Record the depth if laceration to vessels.
Record the size and site of all cerebral contusions.
Locate all entrance and exit wounds on penetrating injuries.
Record the amount of blood loss from internal organs.
Record the part of the bone that is fractured and the extent of that fracture.
All fractures must be defined as Open or Closed.
Record all injuries (no matter how insignificant they may appear).
22. 22
TTTHHHEEE AAABBBBBBRRREEEVVVIIIAAATTTEEEDDD IIINNNJJJUUURRRYYY SSSCCCAAALLLEEE (((AAAIIISSS)))
BACKGROUND INFORMATION
First published in 1969 by the Association for the Advancement of
Automotive Medicine (AAAM)
Latest edition is now available from the AAAM:
Website: Carcrash.org
Email: AAAM1@aol.com
It is based on anatomical injury
There is a single AIS score for each injury a patient may sustain
In the present edition more than 1200 injuries are listed
Scores range from 1 to 6 - the higher the score the more severe the injury
The intervals between the scores are not always consistent e.g. the
difference between AIS3 and AIS4 is not necessarily the same as the
difference between AIS1 and AIS2.
EXAMPLES OF AIS SCORES
Injury Score Severity
Fracture 1 rib 1 MINOR
Fractured 2-3 ribs 2 MODERATE
Haemo/pneumothorax 3 SERIOUS
Flail chest 4 SEVERE
Bilateral flail chest 5 CRITICAL
Massive chest crush 6 INCOMPATIBLE WITH LIFE
WHAT THE CODES MEAN!
Body
Region
Type of
Anatomical
Structure
Specific
Anatomical
Structure
Specific
Anatomical
Structure
Level Level AIS
4 5 0 2 6 4 . 4
450264.4 = Flail chest with lung contusion
23. 23
IIINNNJJJUUURRRYYY SSSCCCOOORRRIIINNNGGG SSSYYYSSSTTTEEEMMMSSS
The Injury Severity Scale (ISS)
ISS is based on the AIS and is calculated at discharge or death
The injuries have been documented by Operative notes, Radiology reports or Autopsy
Increased injury severity scores are associated with increased rates of mortality
Only 10% of patients with an ISS of <8 die compared with 95% of patients with an ISS
of >50
The ISS is calculated as follows:
A. Code all injuries using the AIS dictionary
B. Assign to one of the following body regions:
1) HEAD, NECK, OR CERVICAL SPINE
2) FACE
3) CHEST OR THORACIC SPINE
4) ABDOMEN, PELVIC CONTENTS OR LUMBAR SPINE
5) EXTREMITIES OR BONY PELVIS
6) EXTERNAL INJURIES OR BURNS
C. Add the sum of the squares of the highest AIS scores in each of the three most
severely injured body regions
EXAMPLE
ISS scores range from 1 to 75
A score of 75 results in one of two ways:
Three AIS 5 injuries (52
+ 52
+ 52
= 75)
Injuries coded as AIS6 are, by convention, given an ISS of 75
There is variation in the frequency of different scores:
9 & 16 are common,
14 & 22 are unusual
7 & 15 are unobtainable
Injury Scaling Courses are held regularly by TARN. They teach clinical & non-clinical
staff how to use the AIS dictionary & assign ISS scores.
Region Injury Code AIS AIS2
Head Temporal fracture 1504002 4
Small Subdural haematoma 1406524 16
Chest 3 rib fractures 4502202 4
Abdomen Liver laceration (major) 5418264 16
Extremities Tibia fracture(displaced) 8534053 9
External Abrasions 9102001 1
ISS = 16 (head) + 16 (Abdomen) + 9 (Extremities) = 41
24. 24
IIINNNJJJUUURRRYYY SSSCCCOOORRRIIINNNGGG SSSYYYSSSTTTEEEMMMSSS
Probability of Survival (Ps04)
An Improved Approach To Outcome Predictions
The Probability of Survival (Ps) of each patient has previously been calculated form the Revised
Trauma Score, Injury Severity Score, age and method of injury (blunt or penetrating).
Additionally, the outcome of the patient (survival or death) has been taken at discharge or 3
months.
The Problem
ā¢ Most acute care audits use outcome at 30 days
ā¢ The Revised Trauma Score incurs a high number of cases with unrecorded data
(respiratory rate, systolic blood pressure and Glasgow Coma Scale)
ā¢ The way that the Injury Severity Score is incorporated into the calculation
contradicts some statistical reasoning
ā¢ Patients who are transferred to another hospital for further care are excluded
ā¢ Patients who are intubated at scene are excluded
ā¢ Children are included but not in a statistically acceptable fashion
ā¢ Patients with burns injuries are excluded
ā¢ Patients with penetrating injuries currently have their Ps calculated using North
American model figures
The Solution
ā¢ Outcome (survival or death) at 30 days
ā¢ The Glasgow Coma Scale score only
ā¢ The Injury Severity Score in an improved format
ā¢ Patients transferred for further care
ā¢ Patients intubated at scene with a GCS already recorded
ā¢ Children with a better weighting for their age
ā¢ Patients with burn injury
ā¢ Patients with penetrating injury
ā¢ A relationship between gender and age
Further details of the outcome predictor model can be found on the TARN
website: www.tarn.ac.uk
Therefore the Probability of Survival (Ps04) of each injured patient will now be
more accurately calculated using:
ā¢ Age ā¢ Gender ā¢ Glasgow Coma Scale ā¢ Injury Severity Score
We have highlighted areas for improvement with this TRISS
Therefore we are now introducing an improved, more predictive,
model that includes:
25. 25
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TTThhheee CCCooommmpppaaarrraaatttiiivvveee OOOuuutttcccooommmeee AAAnnnaaalllyyysssiiisss (((WWWsss gggrrraaappphhh)))
The following statistics are commonly known as DEF statistics & are used
internationally
These statistics are used to make comparisons of hospital performance
Comparison of the Ps of all patients (seen at a particular hospital with observed
outcome) can be used as an index of overall performance
Probabilities of survival are combined in the `Standardised W statistic' (Ws) to
assess a group of patients, in this way a national `league table' can be compiled
COMPARATIVE OUTCOME ANALYSES
-9
-7
-5
-3
-1
1
3
5
7
9
Ws&95%CI
Hospital 'XX' is highlighted
More
survivors
More
deaths
10-30%
Grouped according to the number of patients admitted to each hospital from November 2002 as a percentage of their
admissions 2000/04 *
<10% >30%
The Ws provides a measure of excess survivors or deaths per 100 patients treated at each hospital
This new format is an interim measure between the earlier groupings based on RTS
(now obsolete due to our improved Prediction Model) and our longer term objective. This will
group hospitals according to the actual versus predicted data returns - the latter to be based on
data obtained from the Office of National Statistics.
26. 26
A HIGH POSITIVE WS value is desirable - This indicates that your hospital has MORE
SURVIVORS than expected.
Conversely a NEGATIVE WS value indicates that your hospital has LESS SURVIVORS
than expected.
The Ws can be shown graphically (with 95% confidence intervals) to illustrate
clinical differences between hospitals relative to the UK norm (SEE GRAPH
BELOW).
The 95% Confidence Interval indicates that we can be 95% certain the true Ws
lies somewhere along the line Accounting for different injury severity mixes and
the `standardised Z statistic' (Zs) provides a measure of its statistical significance.
A narrow range would show that there is a good deal of confidence in the value
of Ws.
The Zs value is often misquoted when comparisons of trauma care are made
between hospitals.
The Zs statistic is purely a measure of the STATISTICAL SIGNIFICANCE of Ws
statistic.
It is often said that:
Zs scores >1.96 indicate the hospital is SIGNIFICANTLY BETTER than the UK
average
Zs scores <1.96 indicate that the hospital is SIGNIFICANTLY WORSE than the
UK average
Comparisons have become more relevant to Clinicians after extensive work was
undertaken to base the regression analyses on statistics derived from the AIS
dictionary.
As statistical methods become more refined we can be a little more confident that
these inter-hospital comparisons really do reflect variations in Clinical practice.
27. 27
LLLOOOCCCAAALLL TTTRRRAAAUUUMMMAAA AAAUUUDDDIIITTT
"Closing the audit loop" involves re-analysis of performance after appropriate changes
have been introduced, this can only occur if all those involved in the management of the
major trauma patient are consulted and co-operate.
TARN reports should be shared with Audit departments, Purchasers &
Clinical colleagues
CENTRAL TO THIS PROCESS IS THE MULTIDISCIPLINARY AUDIT
The Quarterly report is an extremely useful tool to inform multidisciplinary audit
meetings, to use to your best advantage we recommend these steps:
1) Schedule a regular Audit meeting of representatives from Trauma receiving
Departments
2) Theme the meetings with additional data from TARN e.g. Head Injury
3) Always discuss a patient who survived after serious injury and optimum care
4) Present your hospital status in relation to the other TARN sites
5) Invite speakers from TARN or other participating hospitals
AIM TO IMPROVE YOUR TRAUMA SERVICES AS A RESULT
OF THESE MEETINGS
Identifying National standards, deriving local guidelines, discussing them at
multidisciplinary meetings & acting on those discussions
IS CENTRAL TO CHANGE IN PRACTICE & IMPROVING TRAUMA CARE
28. 28
IIIMMMPPPRRROOOVVVIIINNNGGG TTTRRRAAAUUUMMMAAA CCCAAARRREEE
Why?
ā¢ 33% of death after injury thought to be preventable
ā¢ The initial management of major trauma was unsatisfactory
ā¢ The treatment and mortality rate of injured patients varied inexplicably between
hospitals.
ā¢ There were delays in providing experienced staff and timely operations
A retrospective study of 1000 trauma deaths from injury in England and Wales.
Brit.Med.J 1988: 296;1305.
Preliminary analysis of the care of injured patients in 33 British Hospitals: first report of the United Kingdom
Major Trauma Outcome Study. Brit.Med.J 1992: 305;737-740.
When?
ā¢ Overall hospital care has made a valuable but variable contribution to reductions
in case fatality after injury between 1989 and 1997.
ā¢ However there was significant variability in the proportion of survivors between
the highest and lowest 10% of hospitals in England and Wales.
ā¢ The proportion of severely injured seen first by senior doctors increased
Trends in trauma care in England and Wales 1989-1997. Lancet 2000: 355;1771-75
How?
Example 1: Management of major trauma: changes required for improvement.
Quality in Health Care 1999:8;78-85
ā¢ The reduction in trauma mortality in Leeds between 1988 and 1995 was due to a
strategic mixture of change:
Context: Common goals for improving trauma care
NHS Executive
Royal College of Surgeons report
Content: Targets for treatment times
Specific protocols
Trauma team membership
Process: Complex
No formal model of change management
29. 29
TARN provided a nationally driven framework for the collection, submission and
scrutiny of trauma survival data by hospitals, and crucially, comparison with other
hospitals. The existence of such a framework allowed common ground to be
established between different centres and laid the foundation for a systematic
process for clinical audit, which was also replicated in each centre.
Key benefits of TARN:
Common understanding about actual meaning of the data and
standardisation of collection and definition of terms likely to achieve
credibility among clinicians
Useful and reliable data
Gaining acceptance and the use of audit data
Drives quality improvements
Example 2: Trauma audit ā closing the loop. Injury 1994;25: 511-514
The Salford Trauma Audit Group evolved over a period of 3 years and learnt the
following lessons:
Close inter-disciplinary cooperation
Continuity of care from the scene to
rehabilitation
Frequent statistical analyses of
performance
Senior clinical involvement
Application of protocols
Multidisciplinary audit
Improvements in Care
Shown by increasingly more actual survivors than predicted survivors
30. 30
CCCOOOMMMMMMOOONNNLLLYYY UUUSSSEEEDDD SSSYYYMMMBBBOOOLLLSSS
Symbol Meaning
Ī Female
Ī Male
0 (after number) Degree744
0 (after word) Not Present, None
Ī Increase, Or Upgoing
ĪØ Decrease, Or Downgoing
Ļ No Change
< Less Than
ā¤ Equal To Or Less Than
> Greater Than
ā Not Equal To
SS Half
+, ++, +++, ++++ Four Point Scale Of Severity
O No, None
āā Differential Diagnosis
ā Diagnosis
6 (or) 7 Position Of Tooth
# Fracture
Īø Operating Theatre
