procedures manual

procedures manual

PROCEDURES MANUAL

UPDATED MAY 2015

CONTACTS

The TRAUMA Audit & Research NETWORK, 3 rd

Floor, The Mayo Building, Salford Royal NHS Foundation Trust,

Salford, England, M6 8HD

Telephone:

Email:

00 44 (0) 161 206 4397 [email protected]

Website:

Executive Director:

[email protected]

https://www.tarn.ac.uk

Director of Operations, Deputy to the Executive Director:

Chair:

Research Director:

Audit Committee Director:

Maralyn Woodford

Antoinette Edwards

Professor Tim Coats

University Hospital of Leicester

Professor Fiona Lecky,

University of Sheffield

Salford Royal NHS Foundation Trust

Administration and PA:

Coding Supervisor:

Coding & Validation Officers:

Finance & Coding Officer:

Program Developer and Registry Manager:

Projects Manager

Systems Analysts:

Statistician:

Training & Audit Manager:

Dr Dhushy Kumar

University Hospitals Coventry and

Warwickshire NHS Trust

Gemma Reed

Phil Hammond

Naomi Brook

Paul Gembarski

Victoria Zagrodnik

Laura Blakeley

Corinne Tilley

Tom Jenks

Victoria Phillipson

Tom Lawrence

Sophie Jones

Marisol Fragoso Iniguez

Mike Young

Omar Bouamra

Laura White

CONTENTS

2.3

2.4

2.5

SECTION

1

1.1

SECTION

2

2.1

2.2

INFORMATION PRIOR TO JOINING

Systems of data capture

STANDARDS OF PRACTICE

Inclusion Criteria

Pre-existing conditions

Anatomical injury descriptions

Abbreviated Injury Scale (AIS)

The path of a TARN submission

4.14

4.15

4.16

4.17

4.9

4.10

4.11

4.12

4.13

4.4

4.5

4.6

4.7

4.8

4.1

4.2

4.3

SECTION

3

STATISTICS

,

INFORMATION AND REPORTING

3.1

3.2

3.3

ISS

Ps

Survival Rate and Ws graph

3.4

SECTION

4

TARN reports

EDCR

(Electronic Data Collection & Reporting system) USER GUIDE

Getting started

Data entry system aids

Standard entry types

Printing

Submissions

Creating a Submission

Which Dataset: Core or Extended

The Core Dataset

The Extended Dataset

General Submission Details

Searching for Submissions

EDCR Reporting

Analysing your own data using the PRI report

TARN Home page

Locating a field in EDCR

CORE data entry exercise

Major Trauma Best Practice Tariff

2

1. S

YSTEMS OF DATA CAPTURE

Identifying patients using ICD10 codes

Most sites use their Hospital coding system (ICD10) to identify their TARN patients.

An ICD10 code is given to every patient seen at a hospital and there are 2 sections that refer to Trauma: S OR T codes.

Ask the I.T. Department to produce a regular spreadsheet listing all patients with an S or T code that fulfil the following:

Stayed for >3 days

Died

Transferred out

Transferred in

Admitted to Critical care

The spreadsheet should include:

Discharge destination

ICD10 code/s

Name

Age/DOB

Admission date

Discharge Date/Date of Death

LOS

TARN has a list of all included ICD10 Trauma codes on www.tarn.ac.uk/Resources

You can then quickly identify which injuries can be excluded from your spreadsheet (elderly Neck of Femurs, Closed limb fractures, superficial injuries etc).

Also exclude any patient admitted to a rehabilitation ward only or whose LOS <3 days (unless they died, were transferred out or spent time in Critical care).

Patients who die from their injuries in the Emergency Department are included in TARN.

Clarifying inclusion

When you have your remaining list of potential TARN patients, you must request the case notes and firstly check to ensure the injuries fulfil the TARN Injury criteria (see 2.1):

If they do: Complete a submission

If they do not: Do not complete a submission, regardless of LOS or Outcome

NEVER COMPLETE A SUBMISSION USING THE EMERGENCY DEPARTMENT CARD ONLY.

.

3

2. Standards of practice

2.1

I

NCLUSION CRITERIA

:

The decision to include a patient should be based on the following 3 points:

A.

A

LL TRAUMA PATIENTS IRRESPECTIVE OF AGE

B.

W

HO FULFIL ONE OF THE FOLLOWING LENGTH OF STAY CRITERIA

D

IRECT ADMISSIONS

Trauma admissions whose length of stay is 3 days 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 other hospital for specialist care or for an ICU/HDU bed.

P

ATIENTS TRANSFERRED IN

Trauma patients transferred into your hospital for specialist care or ICU/HDU bed whose combined hospital stay at both sites is 3 days or more

OR

Trauma admissions to a ICU/HDU area regardless of length of stay

OR

Trauma patients who die from their injuries (even if the cause of death is medical)

Patients transferred in for rehabilitation only should not be submitted to TARN.

C. A

ND WHOSE ISOLATED INJURIES MEET THE FOLLOWING CRITERIA

B

ODY

R

EGION

I

NCLUDED

IN ISOLATION

OR

SPECIFIC INJURY

HEAD

T

HORAX

A

BDOMEN

SPINE

F

ACE

FEMORAL FRACTURE

F

OOT OR HAND

:

JOINT OR BONE

(

EXCEPT WHERE SPECIFIED

)

All brain or skull injuries

All internal injuries

All internal injuries

Cord injury, fracture, dislocation or nerve root injury.

Fractures documented as: Significantly

Displaced, open, compound or comminuted.

All Lefort fractures

All panfacial fractures.

All Orbital Blowout fractures

All Shaft, Distal, Head or Subtrochanteric fractures, regardless of Age.

Isolated Neck of Femur or

Inter/ Greater trochanteric fractures <65

years old

Crush or amputation only.

E

XCLUDED

IN ISOLATION

(

EXCEPT WHERE SPECIFIED

)

LOC or injuries to scalp

Spinal strain or sprain.

Fractures documented as Closed and simple or stable.

Isolated Neck of femur or

Inter/Greater trochanteric fractures > 65

years.

Any fractures &/or dislocations, even if

Open &/or multiple

4

I

FINGER OR TOE

LIMB

HANDS

N

F

UPPER

(

EXCEPT

ERVE

/

FINGERS

)

NHALATION

A

D

ROSTBITE

SPHYXIA

EXPLOSION

ELECTRICAL

ROWNING

HYPOTHERMIA

LIMB

BELOW KNEE

(

EXCEPT

FEET

/

TOES

)

PELVIS

V

S

B

ESSEL

KIN

URN

None

Any Open injury.

Any 2 limb fractures &/or dislocations.

Any Open injury.

Any 2 limb fractures &/or dislocations.

All injuries to digits, even if Open fractures, amputation or crush &/or multiple injuries.

Any Closed unilateral injury

(including multiple closed fractures &/or dislocations or the same limb)

Any Closed unilateral injury

(including multiple closed fractures &/or dislocations or the same limb)

Single pubic rami fracture >65 years old. All isolated fractures to Ischium, Sacrum,

Coccyx, Ileum, acetabulum.

Multiple pubic rami fractures.

Single pubic rami fracture <65 years old.

Any fracture involving SIJ or Symphysis pubis.

Any injury to sciatic, facial, femoral or cranial nerve.

All injuries to femoral, neck, facial, cranial, thoracic or abdominal vessels.

Transection or major disruption of any other vessel.

Laceration or penetrating skin injuries with blood loss >20% (1000mls)

Major degloving injury.

All other nerve injuries, single or multiple.

Intimal tear or superficial laceration or perforation to any limb vessel.

Simple skin lacerations or penetrating injuries with blood loss < 20% (1000mls); single or multiple.

Contusions or abrasions: single or multiple.

Any full thickness burn or

Partial/superficial burn >10% body surface area

NOT referred to a Burns unit

Minor degloving injury.

Partial or superficial burn <10% body surface area.

Or any burn referred to a Burns unit.

All included - if not referred to Burns unit If referred to Burns unit.

Severe frostbite Superficial frostbite

All

All

All

Accompanied by another TARN eligible injury

All

None

None

None

Hypothermia in isolation

None

5

2.2

P

RE

-

EXISTING CONDITIONS

Where applicable, all of the following should be recorded in a TARN submission:

E

NDOCRINE

N

UTRITIONAL

, M

ETABOLIC

& GU

D

ISEASES

ICD Chapters IV, XI, XIV

GU Diseases NFS

Upper GI

Lower GI

Ulcer

Liver disease

Previous splenectomy

Renal disease

Crohn’s disease,

Colitis

Diverticular disease

Other GU Diseases

Metabolic NFS

Diabetes mellitus

Diabetes insipidus

Adrenal disease

Thyroid disease

Pituitary disease

Other Metabolic Diseases

Other ENM and GU Diseases

NEOPLASMS

& B

LOOD

/I

MMUNE

D

ISEASES

ICD Chapters II, III

Cancer of GI Tract

Cancer of Lung

Cancer of Breast

Cancer of Kidney

Cancer of GU Tract

Cancer of Bone

Cancer of Skin

Cancer of Brain

Other Neoplasms

Thrombocytopenia

Thrombocytosis

Coagulopathy

Haemophilia

Anaemia

Lymphoma

Multiple Myeloma

Leukaemia

Other Blood/immune Diseases

Other

M

ENTAL

& B

EHAVIOURAL

D

ISORDERS

ICD Chapter V

Psychosis

Schizophrenia

Depression

Deliberate self-harm

Neurosis

Personality Disorder

Alcohol abuse

Drug addiction

Anorexia/Bulimia

Obesity

Other

D

ISEASES OF THE

N

ERVOUS

S

YSTEM

ICD Chapter VI

Stroke/CVA/TIA

Subarachnoid bleed

Vertebrobasilar disease

Migraine

Epilepsy

Cerebral palsy

Spina Bifida/Previous spinal cord injury

Mental handicap

Dementia

Parkinson’s Disease

Multiple Sclerosis

Other

6

C

IRCULATORY

&

RESPIRATORY

S

YSTEMS

ICD Chapters IX and X

Heart NFS

IHD

Myocardial Infarction

Carditis NFS

Valvular heart disease

Cardiomyopathy

Other Circulatory

Hypertension

Peripheral vascular Disease

DVT

PE

Vasculitis

Asthma

COPD

Fibrosis NFS

Bronchiectasis

Cystic Fibrosis

Other Respiratory

G

ENERAL

I

NFECTIONS

&

PARASITIC DISEASES

ICD Chapter I

HIV/AIDS

TB

MRSA

STD

Other

M

USCULO

-S

KELETAL

& C

ONNECTIVE

T

ISSUE

ICD Chapter XIII

Arthritis

Osteoarthritis

Rhumatoid arthritis

Connective Tissue Disease

Major joint replacement

Brittle bone disease

Generalised osteoporosis

Paget’s Disease

Degenerative Spinal disease

Other

S

KIN

&

SUBCUTANEOUS TISSUE

, D

ISEASES OF THE EYE

&

EAR AND

P

REGNANCY

ICD Chapters XII, VII, VIII, XV

Pre-existing skin conditions

Diseases of the Eye

Diseases of the Ear

Pregnancy at time of injury

Other

N

O

P

RE

-

EXISTING

D

ISEASE

M

ISSING

A full list of PED and how to record them in EDCR can be located by clicking on the hyperlinked “Pre-existing medical conditions” field in the OUTCOME section.

7

2.3

A

NATOMICAL INJURY DESCRIPTIONS

Injury detail

Injury detail is of

paramount importance to any TARN submission

, therefore all injuries sustained by a patient must be recorded on every submission.

Information relating to injuries should be obtained from the following sources: clinician’s notes, nursing notes, radiology reports, operative notes, discharge summaries and post mortem reports.

Guidelines to help with injury documentation, record:

 Length, depth or Grade of lacerations (especially to internal organs)

 Depth, size and location of haemorrhages and contusions (especially in the brain)

 Open or Closed fractures

 Stability & site of Fractures (e.g. Comminuted/Displaced Shaft/Proximal/Distal fracture)

 Articular (joint) involvement (e.g. Intra-articular, extra-articular)

 Blood loss

 Vessel damage

 Location & number of rib fractures

 Compression or effacement of ventricles/brain stem cisterns

 Neurology associated with spinal cord injuries

 Instability, Blood loss, Joint involvement or Vascular damage associated with Pelvic Fractures

 Cardiac arrest associated with asphyxia or drowning

Unconfirmed injuries

Injuries should only be recorded when the diagnosis is confirmed.

Never record possible, probable or suspected injuries.

Radiology reports and post mortems

The user should paste a radiology report into the relevant imaging section of any EDCR submission.

When a Report is pasted into an EDCR submission, it will automatically appear on the AIS coding section, thus ensuring that the TARN coder has all the information in front of them before assigning AIS codes.

Post mortem results should be used whenever available even if this results in a delay in dispatching your submission.

All injury coding using AIS is done centrally at TARN, but users can see every AIS code issued by TARN by clicking into the

AIS coding section once a submission has been Approved.

Accurate and detailed injury descriptions will enable a more precise Injury Severity Score (see 3.1) and therefore a more accurate Probability of Survival calculation (see 3.2).

8

2.4

A

BBREVIATED INJURY SCALE

(

AIS

)

Background information

A.I.S. was first published in 1969 by the Association for the Advancement of Automotive Medicine (A.A.A.M.). The latest edition (AIS2005) is now available from the AAAM website: www.AAAM..org

at cost of $250 per dictionary.

Structure

Based on anatomical injury.

A single AIS score for each injury.

More than 1500 injuries 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.

Example AIS codes

I

NJURY

Fracture 1 rib

N

UMERICAL IDENTIFIER

450201

AIS

1

S

EVERITY

Minor

Fractured 2 ribs 450202 2 Moderate

Haemopneumothorax 442205 3 Serious

Bilateral lung lacerations

Bilateral flail chest

441450

450214

4

5

Severe

Critical

Massive chest crush 413000 6 Maximum

Coding structure explained

Body Region Type of

Anatomical

Structure

Specific

Anatomical

Structure

Specific

Anatomical

Structure

Level Level AIS

4 5 0 2 0 2 . 2

All existing codes on the TARN database that were coded with AIS98 (previous version of dictionary) were successfully mapped to corresponding AIS2005 codes, so continuing comparisons can be made.

9

2.5

T

HE PATH OF A TARN SUBMISSION

POTENTIAL

CONFIRM

CREATE

DIARY

VALIDATE

DISPATCH

APPROVE

REJECT

RETURN

REDISPATCH

TRANSFER

CASE

REPORT

I.T. system report produced or ICD 10 codes are used to highlight potential TARN patients.

Data Collector/EDCR user checks if TARN Inclusion Criteria is fulfilled – if YES

Using the EDCR system a user then creates a submission for each TARN patient and enters data gathered from ambulance sheets, radiology reports, post mortems, hospital notes, trauma sheets, operative notes and discharge summaries, a unique submission number will appear at the top of each submission screen. Further detail can be added at any time and in any order whilst a submission remains in the created status.

These submissions can be accessed again using the EDCR submission summary screen, which lists their STATUS as CREATED.

Any additional information the user wishes TARN to have (e.g. radiology reports) can be added to the

DIARY SECTION prior to dispatch. Diary section is also used by TARN post dispatch to inform user of any rejection or return of a submission.

Once all available patient data is entered, the user electronically VALIDATES the submission. The validation procedure checks to ensure no mandatory fields have been missed and if so, will not allow dispatch until all are completed.

The user then DISPATCHES all validated submissions to TARN. All dispatched submissions are then assigned to an individual TARN coder. No further detail can then be added by user, however further detail can be added by TARN post dispatch.

These submissions can be viewed using the EDCR submission summary screen, which lists their

STATUS as DISPATCHED .

Within one week all standard submissions (excluding transfers out-see below) are coded, assigned an

ISS and APPROVED by TARN. These submissions can be viewed using the EDCR submission summary screen, which lists their STATUS as APPROVED .

If the submission does not meet TARN inclusion criteria, the TARN coder will electronically REJECT it, informing the user of the reason in the DIARY section.

These submissions can be viewed using the EDCR submission summary screen, which lists their

STATUS as REJECTED.

If the submission requires additional information prior to approval, the TARN coder will electronically RETURN it informing the user of the reason in the DIARY section.

These submissions can be viewed using the EDCR submission summary screen, which lists their

STATUS as RETURNED.

When user has the additional detail required, they must RE-DISPATCH the submission.

These submissions can be viewed using the EDCR submission summary screen, which lists their

STATUS as REDISPATCHED and then when coded and approved by TARN as APPROVED .

Transfers out for further care to another TARN site are coded and FLAGGED whilst awaiting the second site’s submission. These submissions can be viewed using the EDCR submission summary screen, which lists their STATUS as DISPATCHED with a FLAG attached. Once the second site’s submission is received, TARN matches and approves both submissions.

A case is a complete picture of patient care and final outcome. A case can involve one or multiple sites. When a submission is approved or a transfer out is matched and approved, a case number will appear at the top of the submission screen.

O

NLY APPROVED SUBMISSIONS ARE USED IN

TARN

REPORTS AND ANALYSES

.

10

3. Statistics, information and reporting

3.1

T

HE INJURY SEVERITY SCORE

(

ISS

)

Background

Increased injury severity scores are associated with increased rates of mortality.

ISS is based on the AIS and is calculated at discharge or death.

Only 10% of patients with an ISS of <8 die compared with 95% of patients with an ISS of >50.

Calculating the ISS

a) Code all injuries using the AIS dictionary b) Assign to one of the following body regions:

Head, neck, or cervical spine

Face

Chest or thoracic spine

Abdomen, pelvic contents or lumbar spine

Extremities or bony pelvis

External injuries or burns c) Square the highest score in each body region d) Add the sum of the squares of the highest AIS scores in each of the three most severely injured body regions.

Example

Body region

Head

Head

Chest

Abdomen

Extremities

External

Injury

Temporal fracture

Small Subdural haematoma

3 rib fractures

Liver laceration (major)

Tibia fracture(displaced)

Abrasions

ISS = 16 +16 + 9 = 41

ISS scores range from 1 to 75, a score of 75 results in one of two ways:

Three AIS 5 injuries (5

2

+ 5

2

+ 5

2

= 75)

Code

150400

140652

450220

541826

853405

910200

4

3

1

AIS

2

4

2

AIS

2

4

16

4

16

9

1

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

11

3.2

P

ROBABILITY OF SURVIVAL

(P

S

)

Further Improvements in the Probability of Survival Model: November 2014

Probability of survival

A probability of survival (PS) is calculated for each injured patient and retained on the TARN database. This allows comparative outcome analyses for hospitals and for other groups of patients to be performed.

Early Outcome Prediction Models using TRISS

In 1984 the Probability of Survival (PS) of each patient was originally calculated from the Revised Trauma Score,

Injury Severity Score, age and method of injury (blunt or penetrating). This was known as the TRISS model. There were a number of reasons to develop a European model from this early method:

1. The Revised Trauma Score incurred a high number of cases with unrecorded data (respiratory rate, systolic blood pressure and Glasgow Coma Scale).

2. The way that the Injury Severity Score was incorporated into the calculation contradicted some statistical reasoning.

3. Patients who were transferred to another hospital for further care were excluded.

4. Patients who were intubated at scene were excluded.

5. Children were included but not in a statistically acceptable fashion.

The first TARN PS model

In 2004 a new PS logistic regression model based on age, gender, Injury Severity Score (ISS) and Glasgow Coma Score

(GCS) was launched by TARN. Where GCS was missing, intubation was used instead. Each element in the model carried a weighting derived from retrospective analysis of the TARN database. As the nature of the trauma population changes over time, we recalculated these weightings in 2009 and 2012.

During 2014 we have recalculated the coefficients once more and, at the same time updated the model by adding measures to include the comorbidities of patients and a “true 30 day” outcome. This has resulted in 2 case mix standardised outcome (Ws) charts for your hospital.

Why have we added comorbidities?

For PS to work effectively we must include all characteristics of the injured patients so that we are comparing like with like. In addition to the patient’s age, gender, injuries and level of consciousness, we also need to consider the patient’s state of health. A patient with a severe pre-existing medical condition is different to a patient who was in good health at the time of injury. We have handled this comorbidity using a modified version of the Charlson

Comorbidity Index, which assigns weightings to certain medical conditions (mCCI). Twenty one groups of comorbidity were created and a weight was allocated to each of these groups. The weights were derived according to the strength of the relationship between the disease group and outcome.

Why have we added outcome at 30 days?

Outcome (alive or dead) at 30 days from injury has historically been used in the calculation for Ws. However many patients are discharged before this 30 day point. In order to include these patients we need to know whether patients died at or before the 30 day point after leaving hospital. To do this, we now receive information about postdischarge deaths from the Office of National Statistics (ONS) and use this information in one of the calculations of

Ws for your hospital. In the future you will receive two Ws charts – one using outcome in hospital and one using the

“true 30 day” outcome.

The case mix standardised outcome measure Ws Case mix standardisation uses bands of probability of survival. The bands have been revised using an increasingly robust methodology so that there are an equal number of deaths in each band. You will see these changes in the PS Breakdown table on the TARN website and in your Clinical Reports.

Detailed PS14 Model

The Probability of Survival for each patient is calculated using the information in the table below which shows the logistic regression coefficients for patient characteristics (PS14). log e is the natural logarithm.

ISS is transformed using fractional polynomial technique for a better fit of the model. mCCI represents the categorised modified Charlson Comorbidity Index.

12

b = is defined as the linear combination of the regression coefficients and the values of the corresponding patient’s characteristics (ISS, GCS, modified CCI, age and gender).

Outcome at 30 days or at discharge Outcome at “true 30 days” using ONS data linkage

Predictors Coefficient Predictors Coefficient

-2.79052 -2.69482

-2.57574 -2.45931

GCS=3

GCS 4 - 5

GCS 6 - 8

GCS 9 - 12

GCS 13 - 14

GCS 15 (reference)

GCS "Intubated" mCCI Not Known mCCI 0 (reference) mCCI 1 - 5 mCCI 6 - 10 mCCI > 10

Age 0 - 5

Age 6 - 10

Age 11 - 15

Age 16 - 44 (reference)

Age 45 - 54

Age 55 - 64

Age 65 - 74

Age >=75

Gender Male

(reference)

Gender Female

Age 0 - 5 x Female

Age 6 - 10 x Female

Age 11 - 15 x Female

Age 45 - 54 x Female

Age 55 - 64 x Female

Age 65 - 74 x Female

Age >=75+ x Female

Constant

0.00000

-0.17252

-0.13805

0.43973

0.21675

-0.06972

0.17164

0.25829

0.34770

5.28621

-3.79637

-2.73865

-1.87664

-1.29443

-0.46062

0.00000

-2.62397

-0.44900

0.00000

-0.49572

-0.96308

-1.59703

-0.00483

0.25323

-0.08435

0.00000

-0.41388

-0.93229

-1.58082

-2.67520

GCS=3

GCS 4 - 5

GCS 6 - 8

GCS 9 - 12

GCS 13 - 14

GCS 15 (reference)

GCS "Intubated" mCCI Not Known mCCI 0 (reference) mCCI 1 - 5 mCCI 6 - 10 mCCI > 10

Age 0 - 5

Age 6 - 10

Age 11 - 15

Age 16 - 44 (reference)

Age 45 - 54

Age 55 - 64

Age 65 - 74

Age >=75

Gender Male (reference)

Gender Female

Age 0 - 5 x Female

Age 6 - 10 x Female

Age 11 - 15 x Female

Age 45 - 54 x Female

Age 55 - 64 x Female

Age 65 - 74 x Female

Age >=75+ x Female

Constant

-3.76650

-2.71299

-1.86781

-1.30580

-0.47979

0.00000

-2.60120

-0.46578

0.00000

-0.55263

-0.97536

-1.59290

-0.00183

0.26395

-0.07315

0.00000

-0.40554

-0.96322

-1.57605

-2.70957

0.00000

-0.17699

-0.11076

0.43701

0.22544

-0.07948

0.15534

0.19627

0.33205

5.21655

13

3.3

S

URVIVAL

R

ATE

& W

S COMPARISONS

Survival Rate

The Ps of each individual patient (admitted during the previous 4 years) are combined into the overall

Hospital Survival Rate.

Survival Rate represents Actual versus Predicted Survivors, per 100 patients.

A high positive value is desirable this indicates that your hospital has more survivors than expected

Conversely a negative value indicates that your hospital has fewer survivors than expected.

Survival Rate is updated every 4 months and shown under the Performance Comparisons section of the

TARN website for each member Hospital (once 50 cases are submitted).

The 95% Confidence Interval (CI) is shown as a blue line and 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 CI range (such as below) would show that there is a good deal of confidence in the value of Ws.

Comparative Outcome Analysis (Ws graph)

Comparative Outcome Analysis (Ws) is used to assess a group of patients; in this way a comparison graph can be compiled containing all sites that submit data to TARN.

Sites are displayed by ascending Survival Rate but must always be viewed in conjunction with Data completeness

Comparative Outcome Analysis (Funnel plot)

Sites are displayed by Precision (number of cases) but must always be viewed in conjunction with Data completeness.

14

3.4

T

ARN REPORTS

Self produced reports

Users with relevant rights to the EDCR system can produce these at any time, covering any time period.

Themed Tri-annual Network Reports

Published by TARN every four months and uploaded into EDCR.

Tri-annual reports cover the following themes:

 Traumatic brain injury & spinal injury

 Orthopaedic injuries – pelvic injury and open lower limb fractures

 Shocked patients, timeliness of transfers

Performance Comparisons

Published by TARN every 4 months onto the website, showing:

 Standards of care performance for injuries to:

 Brain, Spine, Chest and Limbs.

 Hospital Survival Rate

 Trust Data Accreditation %.

 Trust Data Completeness %

Data Accreditation: Updated November 2014 (added fields shown in blue below)

A measure of how often CORE fields are completed in every submission, including:

GCS/Intubation Incident or Call

999 date & time

Arrival time Transfer Reason and hospital

CT Time Operation Times, grades, specialty

Doctors in the

ED: Times,

Grades,

Specialities

Data Completeness

Injuries

(%of NFS codes)

Transfer request date and time

Shown as a percentage

Measure of no. of cases submitted versus Expected no. of cases

Expected no. of cases is based on HES data.

Pre-existing medical conditions

Pupils reactivity for AIS3+ head injury

15

Activity

Real time data

An Activity Summary for each Hospital’s submissions approved during last 90 days or current calendar year. Includes:

 Submission Summary

 ISS Breakdown

 MOI breakdown

Ad hoc analyses

Ad hoc analyses can be requested by any member site and produced by TARN at any time.

16

4. EDCR: User guide

4.1

G

ETTING STARTED

The system is designed to run from Microsoft’s Windows Internet Explorer.

Open internet explorer on your PC, and select the address: www.tarn.ac.uk

The TARN Home Login page will then be displayed.

To save the address as a favourite, select the favourites option in the browser Toolbar, then select Add to Favourites .

Logging in to TARN

The Login is shown at the right of the Home page.

This requires you to enter the username and password supplied by TARN.

If you wish to change your supplied password, you can do this after log in on the Home page.

If the system has no activity for a period it will log the user out, a re-login will then be required. (There is a warning given when the session is reaching its timeout, and if timed out then a message is shown at the bottom of this panel)

NOTE: Any work in progress but not saved may be lost.

If the user does not have a login or there is a problem with the login then the TARN administration staff should be contacted, selection of “Contact Us” will show the details.

If the user cannot remember the password, then selection of the “Forgotten password” option will allow the entry of the username, and will send an email of instructions to the registered email address.

Changing password

This allows a logged in user to change their password; it does not allow the old one to be viewed or edited. (The password entered will be shown as  on entry). If the Login fails then, then it should be tried again, in case of a miss-type, the entry is case independent so entry of user name or password “BILL” or “bill” or “Bill” are all treated alike.

If the user still cannot login, then they should contact TARN Administration who has the option of resetting the current password to something else (again they cannot view or edit the old password).

Logging off

While the user is logged into the system the top of the screen will always have the option to log off the current user at the right end of the bar; selection of this will log the current user out of the system with no further prompt.

17

4.2

D

ATA ENTRY SYSTEM AIDS

Field types

When entering submissions there are three types of entry fields these are:-

MANDATORY ENTRIES: The entry MUST be made in order to dispatch the submission to TARN and are marked with a

RED * to the left of the entry field.

PREFERRED ENTRIES: These entries should be entered (if data available), but are not enforced and are marked with a

GREEN # to the left of the entry fields.

Any entry not marked is optional and entry is not enforced.

Tool tips

Tool tips tell you what information should be recorded in that field e.g. Respiratory Rate Tool tip.

Simply hover the mouse over the field name to get the Tool tip.

Help prompts

For most fields Help Prompts are available; these can be viewed by holding the mouse over a field name and clicking the left mouse button.

Help prompts give information about what the field name means, how it is recorded in the Notes and which Location it is usually recorded in, see below.

18

4.3 S

TANDARD ENTRY TYPES

These may be in any section, and come in any order.

TEXT (LIMITED ENTRY)

This entry type will accept text and numbers up to a preset length, e.g. Patient Post Code (first part); this example entry takes letters and numbers up to a preset total of five (5) characters.

In this particular field the entry is validated later.

The length of the entry is preset and may be different from one field to another.

FREE TEXT ENTRY

This entry type will accept a limited (but very large) entry, e.g. the entry may be larger than the visible panel (see injury details section on EDCR).

The scroll bar at the right of the panel allows the other text to be read.

DATE

The Date entry type requires entries in each part of the field set. The <TAB> key or completing all the digits required will move to the next part of the field.

The entries must be numbers only.

Date of Incident: 12/10/2010 (DD/MM/YYYY)

Each part is validated and a warning will be displayed at the end of the line if the entry is incorrect.

Invalid Day - If the Day is 0 or more than the number of days in the month

Month – If the Month is 0 or more than 12

Year – If the year is less than 1800

Date in Future – If the entry is for a future date

Invalid Entry - If the entry is invalid in other ways, e.g. “/” is not allowed.

The date is checked for leap years so an entry of 29/02/2010 would be invalid.

Dates are allowed from 1/1/1800 to “NOW”. The date entered cannot be in the future.

Auto-population

In some fields this button (represented as two pieces of paper one on top of other, see below) this button is shown at the end of the field indicates that the selection can be auto filled.

This happens when the entry may have been entered onto a previous screen or can be inferred from a preceding entry, selection of the button will fill in this entry with that made previously.

If the entry cannot be auto-populated it will be left blank i.e. there has been no other entry made to

duplicate.

Time

The time type entry requires an entry in each part of the field set, the <TAB> key or completing all the digits required will move onto the part of the field.

The entries must be numbers only, in the 24 hour clock format .

Time of Arrival at the Hospital: 15: 35 (HH:MM)

Each part is validated and a warning will be displayed at the end of the line if the entry is incorrect.

Time cannot be 00:00 – The entered time is not allowed to be exactly midnight, if the actual time was 00:00 then the entry of 00:01 should be made.

Invalid Hours – If the hours are more than 23

19

Invalid Minutes – If the minutes are more than 59

Invalid Entry - If the entry is invalid in other ways, e.g. “/” is not allowed

Drop list

This type of entry is the choice of a preset entry from a list.

Usually there is the option at the top of the list for a “nothing” entry to clear the choice made.

Select the down arrow button to “drop” the list then select the choice required.

Once a choice has been made the list is hidden and the choice selected is shown.

The choices available are usually controlled by TARN Admin, if an entry required is not listed then contact your administrator.

Radio buttons

This entry is the choice of a single selection from a multiple choice list.

It is usually used where only one answer can be correct at any one time.

E.g. Sex

The selection of any choice will remove any previously marked choice and make the current selection the choice.

The - button will clear the choices made to this option.

Tick selection boxes

These entries allow the choice of one or more selections from a preset list.

It is used where multiple choices/selections are valid.

E.g. the selection of Vehicle Collision as an Injury Mechanism will open up sub choices of “Position” and “Protection”.

Selection of the box will mark the choice, reselection will unset the choice.

Extra information entry

In places there may be the option of adding additional data to the section; this is shown by the additional of a + symbol next to the entry that can be repeated.

By selecting + an extra drop list is created so another entry can be added.

E.g. Pre-existing conditions or complications

20

4.4

P

RINTING

Printer friendly versions of pages

On each page the option for a printer friendly version of the screen is presented at the bottom of the left side bar menu.

This will reshow the current page details, without the top and side menus, so it is ready for printing.

Print

This option will generate a printed copy of the submission entry form with details as entered; the printout is several pages long, and is previewed on screen before being optionally printed.

There are printed blank entry lines for questions that may not need to be answered in this case or for options to a question answered that did not need that option (i.e. Grade & Speciality of the Attendant 2, who as an Ambulance

Paramedic does not need those entries); these should be ignored.

There will also be blank entry lines for any question left unanswered that should have an entry.

Note that the extra sections (Attendant, etc) are indented and included in the section to which they were added.

In the cases where multiple sections have been added they are numbered.

4.5

S

UBMISSION S

A submission is an entry of a hospital admission trauma event relating to the care and outcome of a patient.

On selection of the submission section the screen shows a summary of all submissions.

Selection of one of the underlined numbers in the summary categories, or a selection of a status in the drop list will show all submissions in that category.

4.6

C

REATING A NEW SUBMISSION

The submission data can be entered from a pre-printed blank form or entered directly from the case notes.

Choosing a hospital

This determines which hospital you are about to view or enter data for, if you only enter data for one hospital, only one option will be available.

Once a hospital site has been chosen and saved, the rest of the submission screens are available.

This will also automatically assign the next 12 digit sequential submission number for the new submission, and give it a

TARN case number.

You will see the submission number at the top of the screen, followed by (Created) in brackets; you are now ready to enter data.

21

4.7

W

HICH DATASET

: C

ORE OR

E

XTENDED

The Electronic Data Collection & Reporting (eDCR) system allows users to choose which dataset best suits the type of submission they need to enter: Core or Extended Dataset.

C

ORE

D

ATASET

: For standard submissions

The Core screens contain only the Key Performance fields that are routinely used in the Clinical Reports, the

Network Reports (where applicable) and the website Performance Comparison results.

These screens were developed to enable data entry into these key fields to be quicker and more efficient.

As soon as a submission is created, a user automatically enters the ‘Core Dataset’ format.

There are 10 screens that a user can enter data into: Opening Section, Incident, Pre Hospital, ED, ED

Attendants, Imaging, Operations, Critical Care, Ward and At Discharge.

There are options to bypass locations if no information is recorded.

There are a reduced number of Observations, Interventions and Investigations to enter data into.

Most fields are Mandatory with the option for: Yes, No or Not Recorded available where applicable.

Times are classed as preferred fields to allow the user to enter data when times are simply not available.

E

XTENDED DATASET

: For more complex/severe submissions

For the more complex or severe cases, we suggest that users continue to use the EDCR system as before, this is now called the “Extended Dataset.”

The Extended dataset allows users to more easily enter multiple interventions, observations, Investigations and attendants into every location.

To enter the Extended Dataset simply create a submission and click on the link which can be found at the top and bottom of every screen, or choose the option from the left hand side navigation hyperlinks.

Once a user enters and saves data in the Extended Dataset, they can no longer revert back to the Core dataset.

The Extended Dataset allows users to enter data as before.

22

4.8 C

ORE DATASET

O

PENING

S

ECTION

The Opening section of the Core Dataset is a combination of the Opening section, Patient Details and

Transfer screens with only the Core fields from each displayed.

The Patient’s NHS number is an increasingly important Core field and users should aim to complete this wherever possible, the option for Not know is: 9999999999.

Patient’s postcode should also be completed wherever possible, with the following options also available:

No fixed abode: ZZ99 3VZ

Unknown postcode or Foreign national: ZZ99 3WZ

The Core Dataset has no dedicated Transfer screen, but a user can still enter Transferred patients by selecting: Transfer In, Out or In & out on the Opening screen.

If one of these options are chosen then additional Transfer questions appear.

BEST PRACTICE TARIFF:

Patient GP Details and Presence of Rehabilitation Prescription – these are predominantly used by Major

Trauma Centres – see section 4.17 for further details.

OTHER AUDITS:

The question “Does the patient have severe open lower limb fracture/s?” relates to BOAST4 criteria patients only and when answered YES prompts a new BOAST4 screen to appear.

BOAST4 patients are: High Energy Open Tibia or Tibia/Fibular fractures only that are further categorised as

Gustilo Grade IIIB or IIIC or undgraded

I

NCIDENT

The Incident screen is identical in both the Core and Extended datasets.

The Incident location (free text) box has been removed, but any free text information about the incident location can still be entered using the Description of incident box.

A new question called “Length of time trapped” appears when the Trapped at scene box is confirmed.

P

RE

H

OSPITAL

The Pre Hospital screen is a combination of At Scene and En-route with only the Core fields from each displayed.

The user has the following 4 options for Pre-Hospital data:

1. If no pre hospital details are available:

Enter No for Pre Hospital Stay.

2. If the patient was transferred in or injured in Hospital, therefore pre hospital data isn’t appropriate:

Enter Not Appropriate for Pre Hospital stay.

Answering No or Not Appropriate allows the user to bypass this screen completely.

3. If the patient was brought in by Ambulance or Helicopter but the full Patient Report Form (PRF) isn’t available or readable.

Enter Yes for Pre Hospital stay and No for Patient Report Form issued.

23

The user is still prompted to answer Observations, Interventions and Attendants but is not prompted to answer Date/Time of Departing scene or asked for PRF, Vehicle Call Sign or CAD

(Computer Aided Dispatch) numbers.

4. If the patient was brought in by Ambulance/Helicopter and the PRF is available/readable.

Enter Yes for Pre Hospital stay” and Yes for Patient Report Form issued.

The user is then prompted to enter the following fields:

Patient Report Form, Vehicle Call sign and CAD (computer aided dispatch) numbers are all important fields and should be found on the PRF (when available). The option for not known is: 9999 for all 3 fields.

Date and Time of Arrival Pre Hospital relate to the date and time the Ambulance or Helicopter arrived at scene.

P

RE

H

OSPITAL

A

TTENDANTS

Answering Yes to the question “Attendants at this location” will prompt the following additional fields to appear:

Save refreshes the screen and stores the Attendant information in the crumb trail on the left hand side allowing another attendant to be entered.

P

RE

H

OSPITAL

I

NTERVENTIONS

Interventions are limited to the following questions: Airway Support, Breathing Support, Spinal Protection,

Chest Drain, Blood Products within first 24 hours, Fluid and Tranexamic Acid.

If Yes is selected for any intervention, further questions about date/time/type will appear.

P

RE

H

OSPITAL

O

BSERVATIONS

Observations remain batched in the sections: Respiration, Circulation and Nervous System, but are restricted to the following Core fields:

 Respiratory: Airway status, Breathing status, Oxygen saturation, Respiratory rate.

 Circulation: Pulse rate, Blood pressure.

 Nervous system: GCS, Pupil size and Reactivity.

Each section shares a date and time that apply to all the observations.

Where available, users should aim to enter the first set of observations taken Pre Hospital.

Multiple recordings of Observations, Interventions and Attendants can also be added simply by pressing the Save button.

ED

Users are prompted to answer

ED Stay

: Yes, No or Not Recorded.

If a patient is seen in ED, the user should answer Yes.

If the patient is transferred in or injured in hospital and therefore bypasses ED, the user should answer No.

If there is absolutely no information about whether or not a patient was seen in ED, the user should answer

Not Recorded.

Answering No or Not Recorded allows the user to bypass this screen completely.

ED O

BSERVATIONS

Observations remain batched in sections: Respiration, Circulation and Nervous System, but are restricted to the following Core fields:

24

 Respiratory: Airway status, Breathing status, Oxygen saturation, Respiratory rate.

 Circulation: Pulse rate, Blood pressure.

 Nervous system: GCS, Pupil size and Reactivity.

Each section shares a date and time that apply to all the observations.

Where available, users should aim to enter the first set of observations taken in ED.

ED I

NTERVENTIONS

ED Interventions are structured in the same way as in Pre Hospital, with the additional of the following 3 questions: Extubation, Spinal Protection Removed and Embolisation (Interventional Radiology).

If Yes is selected for any intervention, further questions about date/time/type of intervention will appear.

ED Attendants

ED Attendants are now recorded on a separate screen.

Multiple Attendants can easily be recorded simply by clicking on the save button.

Save refreshes the screen and stores the Attendant information in the crumb trail on the left hand side, allowing another attendant to be entered.

I

MAGING

Core imaging fields are limited to just: X-ray, CT, Ultrasound, Fast Scan and Other Imaging which includes:

AP and Judet Oblique Radiograph and MRI scan.

A user must answer Yes, No or N/R to each question.

If Yes is chosen, the user is then prompted to complete: Date, Time and Body region scanned, Method of

Image transfer to specialist centre and whether or not the image was Reported by Senior Radiologist.

Users also have the ability to copy and paste reports directly into the relevant imaging section. It is recommended that users copy in reports that show any injuries.

TARN injury coders can see copies of all pasted reports on the AIS coding screen, which helps ensure accurate injury coding.

Dates and Times of Imaging are Core fields and users should aim to record these for every applicable submission.

Time of CT should be recorded as time CT began (referred to as Scout View)

25

O

PERATIONS

Users are prompted to answer

Operations:

Yes, No or Not Recorded.

If a patient has an Operation, the user should answer Yes.

If the patient does not have an Operation, the user should answer No.

If there is no information about an Operation that was performed, the user should answer Not Recorded.

Answering No or Not Recorded allows the user to bypass this screen completely.

Answering Yes prompts further questions:

Total number of Operations should include the operation you are entering data for, i.e. if a patient has only one operation in total, put 1 into this field.

If a patient has 2 Operations, put 2 in this field, then enter the data relating to the first Operation, Save and the information is stored in the crumb trail to the left, the screen then refreshes to allow you to enter in your second Operation.

Supervisor Present should be recorded when a Consultant is present in the Operating room, but not actually performing the Operation.

Grade and Speciality of the most senior surgeon from each speciality and the Anaesthetist are Core fields and should be recorded wherever possible

Only the first Grade/Speciality is Mandatory in case only 1 speciality is involved.

An option for Not Known exists for both Grade and Speciality.

Procedures are now batched by Body region, to make it easier for users to find the most relevant one

(example showing Abdomen and Face Procedures below).

Procedure names are now based on OPCS classifications.

C

RITICAL

C

ARE

Users are prompted to answer

Critical Care Stay:

Yes, No or Not Recorded.

If a patient is taken to Critical Care for any length of time, the user should answer Yes.

If the patient isn’t taken to Critical Care, the user should answer No.

If there is no information about the Critical care stay, the user should answer Not Recorded.

Answering No or Not Recorded allows the user to bypass this screen completely.

Answering Yes prompts the user to answer questions relating to Date/Time, Observations and Interventions.

In Critical Care the Observations and Interventions are the same as those requested in ED.

Where applicable, users should complete the first set of observations taken in Critical Care.

Attendants are not required in the Core Dataset.

Length of Stay in Critical Care should be completed as days, with anything up to 24 hours being classed as 1 day, when a user completes this field the system will copy the data over onto the At Discharge screen.

Date and Time of Departure from Critical Care are new fields, as is Readmission to ICU.

C

RITICAL

C

ARE

A

TTENDANTS

CC Attendants are now recorded on a separate screen.

26

Multiple Attendants can easily be recorded simply by clicking on the save button.

Save refreshes the screen and stores the Attendant information in the crumb trail on the left hand side allowing another attendant to be entered.

W

ARD

The Ward section core questions are limited to just Date & Time of arrival/departure and type of ward.

Observations, Interventions and Attendants are no required in the Core Dataset.

BOAST4

This screen only appears if a user answers Yes to the question on the Opening section “Does this patient have severe open lower limb fracture/s”.

Questions on this screen have come directly from the British Orthopaedic Association standard of care.

Users are prompted if Surgical Stabilisation or Soft tissue cover has been selected but no relevant Operation has been recorded.

It is important that users record the Operations and Gustilo grade

A

T

D

ISCHARGE

The At Discharge screen is a combination of the Outcome and Injuries screens with only the Core fields from each displayed.

Is a user answers Yes to Complications they are then prompted to answer Yes, No or Not Recorded to the following: Deep Vein Thrombosis, Duodenal Ulcer, Pulmonary Embolism and Multi Organ Failure.

All other complications should be entered using the drop down box.

Length of Stay in Critical care is a Core field and if completed on the Critical care screen will automatically populate onto the At Discharge screen.

If the patient doesn’t go to Critical Care, Users should put 0 into this field .

Number of Days intubated is also a Core field and should be completed in days, with anything up to 24 hours being classed as 1 day.

If the patient is not intubated, users should record as 0.

If a patient’s Outcome at Discharge is recorded as Alive, the user is prompted to answer:

Did the patient self discharge

Date/Time of Discharge

Discharged to

Glasgow Outcome Scale (disability status, normally found on the discharge letter)

Readmission

With options for Not Recorded or Not Known available where applicable.

If a patient’s Outcome is recorded as Dead, the user is prompted to answer:

 Date/Time of Death

 Cause of Death

 Post Mortem done

 Mode of death

 Organ donation

The “Glasgow Outcome Scale” field will auto-populate with Death and the “Discharged to” field with Mortuary.

O

UTCOME

M

EASUREMENTS

The outcome measurements screen is automatically populated once a submission has been coded and

Approved by TARN, therefore the User does not enter data into this section. The Outcome Measurements screen contains the Patient’s:

27

AIS C

ODING

 Injury Severity Score (ISS)

 Probability of Survival (Ps)

 New Injury Severity Score (NISS)

 ICD10 codes mapped from AIS codes

 Age

 Gender

 Earliest recorded GCS

 Intubation status

The AIS coding screen is used by TARN coders to assign Abbreviated Injury Codes (AIS) to all injuries documented on the At Discharge screen.

The AIS coding screen also shows any CT, X-ray, US or Fast scan reports copied and pasted into the Imaging screen by the user.

D

ISPATCH AND

V

ALIDATION

Dispatch and Validation work the same as before:

Missing Mandatory fields highlighted in red

Missing Preferred fields highlighted in green.

A user can not dispatch a submission without completing all the Mandatory Core fields.

R

EHABILITATION SCREEN

This screen relates to the Best Practice Tariff questions that now appear on the Opening Section and is therefore predominantly for Major Trauma Centres.

To quality for Best Practice Tariff payment, MTC users must answer the 4 key Rehabilitation Prescription questions seen below:

If they answer Yes to the question on the Opening section:

“Rehabilitation Prescription Details”

the additional

Rehabilitation screen will appear, the questions shown on this additional screen do not affect Best Practice Tariff.

There is now a separate London Rehabilitation Prescription for London Major Trauma Centres which is accessed in exactly the same way as the Standard RP.

Please refer to section 4.17 for further details about Best Practice Tariff and the Rehabilitation Prescription.

4.9

E

XTENDED DATASET

A location is any place where observations can be taken or procedures can be carried out.

At the top of each location screen, there is a space to enter the date and time that the patient entered that location.

Data can be entered in any order; you may enter the Ward details prior to the At Scene details and the system will allow it.

28

Related sections

In each of the system Locations, there are options to record procedures carried out and staff in attendance. These are called RELATED SECTIONS and there are five of them in the Extended Dataset:-

 OBSERVATIONS

 INVESTIGATIONS

 INTERVENTIONS

 ATTENDANTS

 OPERATIONS

These can be accessed using the buttons at the bottom of each location screen.

Clicking a button will bring up another screen where details can be entered.

There is a space at the top of each section to record the date and time, this date and time will be used for all procedures in this section unless you tell the system otherwise.

The pre-populate button can be used to copy the date from the main location screen. Alternatively, you can type in the date.

As details are entered and saved at a location, the side bar menu will change. It will give details of how many procedures have been carried out at each location.

Clicking on a location will bring up more details about the data entered. Clicking on an individual field will bring up details of an observation, procedure or attendant.

OBSERVATIONS, INVESTIGATIONS AND INTERVENTIONS are further split into the following subsections:

OBSERVATIONS INVESTIGATIONS INTERVENTIONS

Respiration

Circulation

Nervous system

Metabolism

Host Defence

Respiration

Circulation

Nervous system

Metabolism

Host defence

Imaging

Blood sampling

Urine sampling

Signal

Other

Clicking on the ATTENDANTS button in a location will bring up a screen that will allow you to record attendants at that location, including ambulance staff and nurses.

Information is entered using drop down lists. Use this button to record attendants at all locations except theatre (see below).

Clicking on the OPERATIONS button in a location will bring up a screen where surgical and other procedures can be recorded.

Data entry is via drop down boxes and text entry.

The Operations section asks for details of Grade of Surgeon and Anaesthetist performing the operation, therefore there is no need to go into the Attendants subsection at this location.

Data entry in related sections

Data is entered using drop down boxes or by keyboard entry according to the field.

Some fields only require a “Yes” or “No” response.

All that is needed is to record that the procedure was carried out. To do this, use the radio buttons.

29

A procedure may be marked as not performed by selection of the “No” option. A selection can be cleared using the “-” option.

Additional recordings in related sections

Extra sections can be added from the same category if required. If, for example the patient had two GCS observations in the Emergency Department, you would enter them as below:

Click E.D, Observations, Circulation and enter date, time and recording of 1 st

GCS – then Save Changes.

Save Changes will clear the E.D. Observations screen (storing the information in the crumb trail – see below) but keep you on the same screen so you can simply enter another date, time and GCS recording without moving between screens.

You may know that a particular procedure has been carried out a second time, but not have any data to enter, for example, you may know a second blood pressure reading has been taken, but not have the actual reading.

In this case, you would tick the Add New Section box. This would create a section containing the date and time and nothing else.

Crumb trail

Whenever you SAVE information in a Related Section, the screen is cleared and the information is stored under the relevant Location to the left of main screen; this is called a “crumb trail” and you can review or change any information by clicking on the relevant location, then into the data you wish to change.

You will see a number to the right of any Location you have entered Related Section data into, this number represents the number of data fields you have added, e.g. if you add GCS, Bp,

Pulse and Attendant to E.D. you will see E.D. (4).

Hospital questions

T

HE ENTRY OF ANSWERS TO HOSPITAL QUESTIONS IS OPTIONAL AND DEPENDANT ON WHETHER SPECIFIC QUESTIONS HAVE BEEN SET BY THE

HOSPITAL

.

This section will display any additional questions that the hospital has requested, the questions in this section are not requested by TARN.

These are specific to the hospital selected, and may have a specified format for entry.

For details on where these are created contact TARN.

30

4.10 G

ENERAL SUBMISSION DETAIL

Applicable to both Core and Extended Datasets.

In all sections any changes made MUST be saved by the user.

Moving away from the entry screen will not save the entered/changed details automatically.

A submission can be saved at almost any point, and returned to later for editing, there is a warning given if a save is not possible, usually due to “Live” validation in an entry.

The top side bar menu shows all the submission sections, allowing for quick access as required.

If extra details or extra sections have been added to a section, e.g. Attendants then they will also be shown here (as below).

The lower side bar menu shows options available for the submission being edited.

Saving

On most screens any changes made to the section will NOT be saved or prompted to be saved when the section is exited or moved away from.

If the screen is timed out, due to inactivity the entries made will not be saved, if you are leaving the screen for a while and want to save your entered work, then save before you leave.

If the changes are to be saved then they should be explicitly saved.

If there are any errors on screen due to checking of the entered data they will have to be corrected before the screen can be saved, e.g. If the entry is out of bounds i.e. an age of 120 (limited to 1 - 110) there will be an on screen message shown, and the error must be corrected or cleared before the page can be saved.

Saving options

On screen at both top and bottom of the section is a choice of options for that section.

On entry to a section open for editing the choice may be:-

SAVE CHANGES:

This allows the saving of changes made to the section and remains in that section.

SAVE AND NEXT:

Allows saving of the changes and moving to the next Location on the list.

SAVE AND BACK:

Allows saving of changes and moving back to the main page of that section e.g. If in Attendants in Emergency

Department section, you will be taken back to the Emergency Department opening screen.

Edit

When a submission is recalled, it is shown as a read only set, the edit option re-enables the editing of the sheet allowing entries to be made and saved.

You can not edit a submission after it has been dispatched to TARN.

View

If a submission has been made editable, the view option will return it to being read only, preventing any inadvertent changes from being saved.

Anybody with rights to “view data and produce reports”, will only ever see data in the View state.

Any data dispatched or approved will only be viewable not editable.

Add new section

Multiple sections can be recorded by selection of this option; this will repeat the section allowing multiple entries for the patient. E.g. If a patient has multiple visits to Imaging suite on different dates – use this option.

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Delete section

Will delete all the data entered for that section.

If a section has been visited and saved with no entries, then any mandatory or preferred entries due for that section will be requested before the submission can be dispatched.

If a section has been saved in error, then the section should be deleted, this will remove it from the validation.

Validate

Selecting this option will validate that the submission selected is ready for dispatch, it does not dispatch it.

The submission is checked for entries in the mandatory and preferred fields , and any incorrect entries that would prevent the submission being dispatched.

If there is no missing data, then the validation warning screen is not shown, and the opening section is displayed.

If there is any missing data, then the screen will show a list of warnings and errors in the submission; each warning is listed with the section, question and warning.

All missing mandatory fields are highlighted in Red.

All missing preferred fields are highlighted in Green.

Selection of the underlined section name will take the user back to that section for editing.

Once all mandatory fields are completed, an option to Dispatch this submission to TARN appears underscored at the top of the page.

Dispatch

The simplest way to dispatch a submission is to validate, then use the dispatch statement (see above).

Alternatively a user can bypass the Validate option and choose the Dispatch button to the bottom left of the screen, this will also check for missing mandatory and preferred fields.

Once a submission has been dispatched the user will see the submission number at the top of the screen with

(Dispatched) in brackets.

Approve

This is the Status of a dispatched submission that a TARN qualified coder has checked and coded.

The user can see all approved submissions by looking on the Submission Summary page and choosing the Approved status in the drop down list.

Once a submission has been approved the user can click into it and will see the submission number at the top of the screen with (Approved) in brackets.

Only when a submission has been approved by TARN can it be used in any reports.

Flag

A TARN coder will flag a submission if it is a transfer out to another TARN site and is awaiting the corresponding submission to match and approve.

Flagged submissions will remain in the Dispatched in-tray until un-flagged and approved by TARN.

Reject

This is the Status of a dispatched submission that a TARN coder has checked but it doesn’t fulfil the Inclusion Criteria.

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The submission is rejected and a message will be entered section explaining why it has been rejected.

The user can see all rejected submissions by looking on the Submission Summary page and choosing the Rejected status in the drop down list, or by clicking on the number to the side of the Rejected in-tray (also on the Submission Summary page).

Once a submission has been rejected the user can click into it and will see the submission number at the top of the screen with (Rejected) in brackets.

No further action is necessary unless user disagrees with reject reason or has further information.

Return

This is the Status of a dispatched submission that a TARN coder has checked, but needs further detail from the user before APPROVING.

The submission is returned and a message will be entered explaining why it has been returned.

Once the additional data is added, a hospital user should REDISPATCH the submission to TARN.

The user can see all returned submissions by looking on the Submission Summary page and choosing the Returned status in the drop down list, or by clicking on the number to the side of the Returned in-tray (also on the Submission

Summary page).

Once a submission has been returned the user can click into it and will see the submission number at the top of the screen with (Returned) in brackets.

View diary

This shows any diary notes associated with this submission and can be added to by TARN and user.

Diary notes are used to communicate with others who are collaborating with the submission.

Diary notes can be added by user (before dispatch) or by TARN (post dispatch).

Once a diary note has been saved it is not editable

If the submission is only being viewed, then the user cannot add to the diary notes.

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4.11

S

EARCHING FOR SUBMISSIONS

The submission search screen allows the user to find any existing submission (regardless of status) based on numerous fields.

The search options can be entered either singularly or multiply, but the result is restrictive when multiple i.e. where family name and postcode have entries only those that match for both will be shown.

The search options are not case sensitive on entry, i.e. Family Name search for Ford, ford and FORD will all return the same entries.

Standard searches

The simplest field to search on is the submission number, but if this is not known try using the Hospital Arrival Date fields, this will then list all submissions that arrived at your hospital within that time period.

Enter the field/s and select “Find” option.

This will produce a list of all submissions matching your criteria and you can access them simply by clicking the underlined submission number.

Wild card searches

The search can include symbols for wild card searching if unsure of exact spelling or detail, the symbols used are:-

% {percent}: to indicate a wild card where required, this symbol can represent none, one or many characters.

_ {underscore}: to indicate any single character. Note that the character must be present.

Examples below:

Fred_ would find Fredi & Freda, but not Fred or Frederick.

If the family name (m) is searched for then nothing may be found, if however the search was for m% then this would find any submissions that start with the letter m.

If the family name %man is searched for, then this will find any name ending in man, i.e. Seaman, Hillman, etc.

If the search is for a segment of the name that could be anywhere in the name then the % should be added to both ends, i.e. %man% this will then return both Seaman and Manfield and also Hunmanton.

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4.12 EDCR

REPORTING

In addition to entering data, you can also produce reports to summarise and analyse data for your hospital(s). The

EDCR system allows you to produce different types of reports.

Detailed explanations of these reports and instructions about how to produce them can be found below.

To create any EDCR data report, follow these steps:

1. Click on REPORTS on the menu bar at the top of the screen.

2. Click the CREATE REPORT link

3. Choose the report you wish to create (see below for details of all reports)

4. Where applicable, choose your Hospital

5. Enter your START DATE and END DATE. Remember to enter them in dd/mm/yyyy format; the dates are inclusive

6. Where applicable choose DATE FOR SELECTION OR RANGE . Dependant on the report this could be Arrival,

Discharge, Incident or Approval date.

7. When you have finished setting up your report, click GENERATE REPORT.

8. View GENERATED REPORT.

Performance Review Indicators

This report highlights the fields that underpin the analysis used to monitor Standards of Care in both the

Performance Comparison section of the TARN website and in the Clinical reports.

As it is produced in excel format, users can filter or produce breakdowns. Instructions on how to do this are contained in section 4.13

Submission ID

NHS number

Age

Gender

Injury Mechanism

ISS & ISS band

Intubation

GCS

Probability of Survival

Outcome

Incident date/time

Arrival date/time

Discharge date

LOS

ICU LOS

Transfer from/to

Mode of arrival

ED visit

Trauma Team

Senior Dr in ED Date/Time

First Dr in ED Date/Time

No of Operations

Date/time 1st Operation st

Time to 1 Operation st

Date/Time 1 st

CT

Time to 1 CT

Incident & Home postcodes

Triage Tool

Pre Alert

PRF

Wards visited (first 3)

NICE criteria

Shocked Patient

Rehab Prescription

GOS

Case for Review

Most severely injured body region

Maximum AIS

All Injuries

Cases for review are based on one or more of the following criteria:

Died

Went to Critical Care

Low Ps deaths (<75%)

ISS > 12

GCS < 8

Demographic and Clinical Frequencies

The Demographic and Clinical Frequencies report allow you to analyse the data for your hospital(s). They show how two or more questions interrelate and the patterns of interaction between them. If, for example, you wanted to know how many people had been admitted to your hospital as the result of a vehicle collision and look at the pattern of age or gender, you could use the Demographic and Clinical Frequencies report. To create a Demographic and Clinical Frequencies report, follow these steps.

EXAMPLE reports below:

If you wanted to report on first 6 months of 2014, your start date would be 01/01/2014 and your end date would be

30/06/2014.

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1. Choose the type of DATE TO USE FOR RANGE you want. You have a choice of incident date or admission date. Admission date is the date that the patient arrived at hospital.

2. If you wish, you can, produce a report for a particular body region using the BODY REGION drop down if your want to produce a report on a particular type of injury. The body regions are:

THORAX

ABDOMEN

HEAD

UPPER LIMB

LOWER LIMB

SPINE

If you want all injury types in your report, leave this option blank.

1. You can also use the ISOLATED INJURIES option to say whether you want to produce a report on just one particular body region, or injuries in that body region with injuries to other body regions.

2. SELECTION CRITERIA: You can further filter your report by Age, Gender, Outcome, Injury Type or Injury

Mechanism. If you leave these fields blank, all patients within the date range selected will be included.

3. CHOOSE YOUR ROW AND COLUMN (see next page for examples of how to do this); there are a range of criteria available for use in your report. You must choose one row and one column.

4. Observations are available under the Row and column options, but if chosen one of these you must then choose whether you want HIGHEST OR LOWEST (use the Process Measure Options buttons for this).

5. When you have finished setting up your report, click GENERATE REPORT .

6. View GENERATED REPORT.

EXAMPLE I: ISOLATED THORACIC PATIENTS ONLY

To produce this report, you would choose Thoracic from the Injury Type drop down and choose Isolated from the

Isolated Injuries drop down.

EXAMPLE II: THORACIC PATIENTS WITH OTHER INJURIES

To produce this report, you would choose With Other Injuries from the Isolated Injuries drop down.

EXAMPLE III: VEHICLE COLLISION BY AGE

After entering your hospital and date information at the top of the report, you would select Age (all) and Mechanism of injury (vehicle collision) as your variables. This would create a report breaking down submissions relating to vehicle collisions by age.

EXAMPLE IV: AGE (16 – 25) BY INJURY MECHANISM

Using the same variables in another way would produce a different report. To produce this report, you would select

Age (16-25) and Injury Mechanism (all) as your variables. This would produce a report breaking down submissions relating to 16 – 25 year olds by mechanism of injury.

Accreditation report

This report provides a breakdown of all fields used in the Data Accreditation % shown on the TARN website:

Accreditation is shown as a score ( Green ) and an expected value (Black). The score is a fraction of the expected value.

Any score of <100% will be highlighted in red. These are the fields to review.

ISS for CDS report

With effect from 1 st

April 2013, Major Trauma Centres are required to make a full data submission to TARN within

25 days following a Patient’s discharge, thus enabling their contractors to have an Injury Severity Score (ISS) to feed into the Commissioning Data set (CDS) within the relevant timeframe for patients with an ISS >8. TARN has created a specific report that MTC users can produce to show days to dispatch for these patients.

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Unmatched Transfers

Lists any unmatched transfers into or out of each Hospital.

Includes: Corresponding site Submission ID, Age, Gender, NHS number, Corresponding Hospital, Transfer date

Postcode report

This report provides detailed information on postcodes – both incident and patient - arrival date, age and outcome listed by Submission ID. To create a Postcode report, follow these steps:

CQUIN A Report: BOAST4 patients

Number of BOAST4 patients who have stabilisation within 24 hours & soft tissue cover within 72 hours of injury.

Clarification: Open tibia fracture, graded as Gustilo Grades IIIB and IIIC or ungraded

CQUIN B Report: Long bone fractures

Number of patients who have one or more long bones stabilised within 24 hours of injury.

Clarification: TARN eligible patients who have one or more long bone fractures to the shaft of the femur and/or

tibia.

Submission Summary report

The Submission Summary report will enable TARN users to summarise submissions over a specified time period. The report includes the following fields:

Submission number

Patient’s first name

Patient’s surname

Date of Birth

Gender

Age

ED number

Hospital Number

NHS Number

Patient Postcode

Date of Arrival

Discharge Date

Date of Death (if applicable)

Discharge status

ISS

As the reports contain sensitive patient data, they can only be produced by a hospital user with rights to a specific hospital

. For this reason staff at TARN can produce these reports but can’t see the fields highlighted above in red.

To create a Submission Summary Report on the eDCR system, follow the steps below:

1. Click on SUBMISSION, then SEARCH and select your hospital.

2. Choose the DATE PERIOD – the options are:

Incident date

Admission date

Discharge date

Submission Creation date

Submission Approval date

Submission Return date

Re-submission date

The most useful dates will be Admission date, Discharge date and Submission Approval date.

3. Choose the date range using the FROM and TO date cells.

4. Chose the Submission Status:

CREATED: The report will contain submission you are currently working on.

APPROVED: The report will contain submissions sent to TARN that have been coded and approved.

If you leave the Submission Status blank, the report will contain every submission (Created, Dispatched,

Approved etc) entered during the time period selected.

5. Click FIND – the results will appear at the bottom of the screen.

6. Click on REPORT (top left) - the list will be converted into an excel spreadsheet.

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S

UBMISSION SUMMARY REPORT EXAMPLES

This will generate a report showing all cases Approved by TARN during June 2012

This will generate a report showing all cases Created during June 2012

38

4.13 A

NALYSING YOUR OWN DATA USING THE

PRI

REPORT

________________________________________________________________________________

39

40

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4.14

HOME PAGE

This is the starter page for the TARN system, the screen has links to various public details of the TARN project, with the option to login to the members only.

From the top menu the following options can be accessed:-

A

BOUT US

This section contains basic information about Trauma.

How TARN evolved.

R

ESOURCES

This section lists some of the resources available.

PS12 calculator

INCLUSION CRITERIA

Fracture definition list

Anatomy guide

Procedures manual

List of ICD10 Trauma codes and inclusion rules for TARN.

Where the Adobe icon appears this indicates a PDF document, the other options will open further pages.

T

RAINING

This section contains information about TARN training courses, held regularly in central Manchester and London

R

ESEARCH

A collated list of applicable research papers for reference.

Past publications

List of current research

Collaborative projects

C

ONTACT

U

S

Directions to TARN offices

Map of TARN offices

Address of TARN

Job title and Email address for all TARN staff

Executive Board members listed

P

ERFORMANCE

C

OMPARISONS

This part of the website provides, for the first time, important information about the rates of survival for patients who have been injured and treated at different hospitals across England and Wales. It also provides information about the benefits of certain kinds of treatment.

This information is freely available without a username and password .

This section contains data relating to every Network/region of England and Wales, including:

Data completeness %

Data accreditation %

Survival rates

Standards of care results relating to: Brain, Spinal, Chest and Limb injuries

,

Detailed information on how each of these is calculated is also included.

This part of the TARN website was designed with the help of The Healthcare Commission and modelled on the Heart

Surgery Website.

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4.15 L

OCATING A FIELD

FIELD NAME

CORE

DATASET

Airway status Yes

Airway support

Analgesia

Angiography

Antibiotics

Anticonvulsant

AP and Judet oblique radiograph

Biochemistry

Bladder catheter

Blood gases

Blood pressure

Blood products

Bp mean

Bp mean (calculated)

Breathing status

Breathing support

Cannulation

Capillary refill

Cardiac enzymes

Cardio respiratory resuscitation

Chest drain

Yes

Yes

BOAST4

Yes

Yes

Yes

Yes

Yes

Yes

EXTENDED DATASET

SUBSECTION

Observations/

Respiration

Interventions/

Respiration

Interventions/

Nervous System

Investigations/

Other Imaging

Interventions/

Host Defence

Interventions/

Nervous System

Investigations/

Other Imaging

Investigations/

Blood Sampling

Interventions/

Metabolism

Investigations/

Blood Sampling

Observations/

Circulation

Interventions/

Circulation

Observations/

Circulation

Observations/

Circulation

Observations/

Respiration

HELP TEXT

The patient’s airway status ON ARRIVAL in a location. Choose from: patent (normal breathing), obstructed (airway blocked), supported

(breathing with mask), intubated (breathing through tube inserted into airway) or annulated (breathing through thin tube inserted through cricothyroid membrane). Use ‘missing’ option if status not known.

Procedures carried out to support or maintain the airway in this location.

Choose from Airway positioning, Pharyngeal tube, Intubation,

Cricothyroidotomy, Tracheostomy Or Extubation

Drugs administered to relieve pain. Details usually found in drugs section of notes.

An x-ray procedure where dye is injected into arteries so that blood circulation can be studied.

Anti-infection drugs. Details usually found in drugs section of notes.

Drugs administered to prevent muscle convulsions. Details usually found in drugs section of notes.

Takes oblique views of injury site to give 3 dimensional images. Primarily for pelvic injuries.

Tests on the chemical composition of blood, such as levels of sodium, potassium or glucose.

A tube that is placed in the bladder to help with urination.

Range of tests (pH, pCO2, Bicarb, BXS) used when patient has symptoms of an oxygen/carbon dioxide imbalance.

Enter systolic and diastolic values if known.

Blood and related products. Choose from blood, FPP or platelets and give quantity in units

Mean arterial blood pressure read directly from machine.

Interventions/

Respiration

Interventions/

Circulation

Observations/

Circulation

Observations/

Circulation

Mean arterial blood pressure calculated using systolic and diastolic values.

The patient’s breathing status ON ARRIVAL in a location. Choose from: air (breathing room air), added oxygen (oxygen administered via nasal tubes), compromised (breathing impaired by injury), manual ventilation

(breathing supported by ‘bag’ operated by hand), non-invasive ventilation (mechanical ventilation via mask) or invasive ventilation

(mechanical ventilation via tube inserted into airway. Use ‘missing’ option if status not known.

Interventions to assist breathing. Choose from: oxygen, manual ventilation (breathing supported by ‘bag’ operated by hand), mechanical ventilation (via tube), CPAP (Continuous Positive Airway Pressure) or

BiPAP (Bi-level Positive Airway Pressure). Choose ‘missing’ if not known.

The insertion of a tube for drainage. Can be written as cannule, IV or peripheral line.

Measured in seconds. Reading is normal if less than 2 seconds.

Tests to check for enzymes released into blood when heart is damaged.

Record presence of troponin, troponin T or creatinine using selection buttons.

May also be noted as Cardio Pulmonary Resuscitation (CPR).

Interventions/

Circulation

Interventions/

Respiration

Drainage of fluid, air or pus from the inthoracic space.

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Circulatory status

Cooling

Creatinine (urine)

EEG

Embolisation

End tidal co

2

Escarotomy

Fluid

Gastric tube

GCS

Cricothyroidotomy

CT scan

CT with contrast

Cystogram

Defibrillation

Diagnostic peritoneal lavage

Diastolic blood pressure

Direct compression of external haemorrhage

Doppler probe

ECG

ECG (12 lead)

Echocardiogram

Yes

Yes

Yes

Observations/

Circulation

Interventions/

Host Defence

Investigations/

Urine Sampling

Interventions/

Respiration

Investigations/

CT

Investigations/

Other Imaging

Investigations/

Other Imaging

Interventions/

Circulation

Investigations/

Diagnostic peritoneal lavage

Observations/

Circulation

Interventions/

Circulation

Observations/

Circulation

Investigations/

Cardiography/Neuro physiology

Investigations/

Cardiography/Neuro physiology

Investigations/

Cardiography/Neuro physiology

Investigations/

Cardiography/Neuro physiology

Interventions/

Circulation

Observations/

Respiration

Interventions/

Respiration

Interventions/

Circulation

Interventions/

Metabolism

Observations/

Nervous System

The patient’s circulatory status ON ARRIVAL in location. Choose from: unsupported (normal circulation), inotrope/vasopressor dependent

(assisted by drugs), balloon pump (mechanical device attached to catheter to assist circulation), on-going CPR (cardio pulmonary resuscitation continued after arrival at hospital. Use ‘missing’ option if status not known.

Reducing temperature of body area in cases of burns/scalds.

Measured in millilitres per minute (ml/min). For a 24-hour urine collection, normal results are 90-139 ml/min for adult males less than 40 years old, and 80-125 ml/min for adult females less than 40 years old.

For people > 40, values decrease by 6.5 ml/min for each decade of life.

Creation of temporary hole in cricothyroid membrane to assist breathing in case of severe facial injury.

Computed Tomography scan. Shows the internal structure of organs.

A Computed Tomography scan using dye to show vascular structures.

An x-ray of the bladder using dye.

An electrical device used to restore normal heartbeat by applying a brief electric shock.

Procedure to check for bleeding in cases of abdominal injury. Now little used.

Blood pressure in arteries when heart is at rest. Measured in millimetres of mercury (mmHg).

Stopping bleeding using a pressure bandage or stitches, or a tourniquet in the case of vascular injury.

A portable ultrasound device used to measure blood pressure in suspected cases of vascular injury.

Standard ECG used for routine heartbeat monitoring.

Electrocardiogram using different permutations of twelve leads to measure electrical activity of heart. 6 leads on chest (VI - 6) and 1 on each limb (I - IV).

Checks for damage to heart and checks functionality of chambers.

Written in radiology report, often shown as LVF + RVF.

Electroencephalogram. A brain scan.

A non-surgical procedure performed by an interventional radiologist. It involves the deliberate blocking of a bleeding artery (using coagulants) to stop blood flow.

A dynamic reading of how much carbon dioxide a patient is breathing out. Usually found in anaesthetist’s notes.

Burns procedure. Cutting through burnt tissue to assist breathing/circulation.

Fluids administered to regulate sugar levels in blood. Choose from dextrose, colloid, crystalloid, polygelatine, starch or hypertonic saline/hyperOsmolar fluid and record units administered.

A tube inserted into the stomach for drainage or feeding.

Assesses eye, verbal and motor response. A number is recorded for each, giving the patient a total score from 15. 3 – 5 = serious brain impairment. 15 =normal functioning. Total will be automatically calculated on saving or can be input using drop down list if scores are missing.

44

Glucose administration

(hypo)

Gut status

Haematology

Inotropes/vasopressors

Intra cranial pressure monitoring (ICP)

Limb splint

Lung function tests

Mannitol

MRI scan

Muscle chart recording

Near patient blood test

(glucose)

Needle thoracocentesis

Neurophysiology

Oxygen

Oxygen saturation

Paralysis

Pelvic sling

Pericardiocentesis

X ray

Power status

Yes

Yes

Yes

Pulse rate

Renal status

Respiratory rate

Sedation status

Yes

Yes

Yes

Interventions/

Metabolism

Observations/

Metabolism

Investigations/

Blood Sampling

Interventions/

Circulation

Observations/

Nervous System

Interventions/

Host Defence

Observations/

Respiration

Interventions/

Nervous System

Investigations/

Other Imaging

Observations/

Nervous System

Observations/

Metabolism

Interventions/

Respiration

Observations/

Nervous System

Interventions/

Respiration

Observations/

Respiration

Interventions/

Nervous System

Interventions/

Host Defence

Interventions/

Circulation

Investigations/

Plain X-Ray

Observations/

Nervous System

Observations/

Circulation

Observations/

Metabolism

Observations/

Respiration

Observations/

Nervous System

The administration of glucose to prevent diabetic coma.

Gut (digestive) status of patient ON ARRIVAL in location. Choose from: nil by mouth (receiving no food either normally or with assistance), eating

(eating normally), naso/oro gastric tube (feeding via tube in nose/mouth), percutaneous enteric feed (feeding via tube inserted into intestine through skin), parental feed (fed via large bag). Choose

‘missing’ option if status not known.

Tests to determine levels of haemoglobin in blood and/or number of white blood cells.

Drugs to assist circulation.

Intra cranial pressure. Arterial blood pressure inside the skull in millimetres of mercury (mmHg). Sometimes referred to as ICP bolt.

Restraint fitted to injured limb

Tests used to measure lung capacity in cases of spinal injury (cervical or thoracic cord). Can record whether spirometry and/or peak flow tests carried out.

Osmotic diuretic used to reduce pressure in cranium by reducing brain swelling. Details usually in drug chart.

Magneto Resonance Imaging scan. A computerised scan producing detailed images of the internal organs of the body. More detailed than

CT scan and used mostly for spine, brain and limb injuries.

An assessment of muscle response. More detailed than limb muscle power assessment.

Level of glucose in blood.

45

Used to determine the cause of abnormal accumulation of fluid in the pleural space, usually in cases of tension pneumothorax.

Tests to check the functioning of the nervous system.

Administered to assist breathing.

Oxygen saturation of arterial blood as %.

Drugs administered to reduce or suppress muscle response. Details usually found in drugs section of notes.

Also referred to as pelvic sheet. Used to keep pelvis stable after injury.

Procedure to relieve pressure in heart area.

Standard X-ray.

The patient’s muscle power status ON ARRIVAL in a location. Choose from: normal, lateralised weakness (weakness on one side of body), segmental weakness (weakness in defined area of body, e.g. Upper arm, forearm, thigh), other focal weakness (weakness in single muscle or muscle group), general weakness or paralysis. Use ‘missing’ option if status not known.

Number of heartbeats per minute. Details usually written in notes.

Renal (kidney function) status of patient ON ARRIVAL in a location.

Choose from: normal, catheterised (catheter fitted to bladder to assist urine extraction) or dialysis/filtration dependent (assisted by machine).

Number of breaths per minute. Ranges from 0 – 70. Normal range 16 –

24.

The patient’s sedation status ON ARRIVAL in a location.

Sedation/ anaesthesia

Sensation deficit recording

Septic status

Simple airway manoeuvre

Simple reduction of fracture/dislocation

Simple suture/glue

Simple wound dressing

Simple wound irrigation/debridement

Spinal Protection

Steroids

Synacthen tests

Systolic blood pressure

Temperature

Tetanus prophylaxis

Toxicology screen

Thoracostomy

Tracheostomy

Tranexamic Acid

Ultrasound

Urea (urine)

Urethography

Urine output

Urogram

Warming

Waterlow score

Yes

Yes

Yes

Yes

Interventions/

Nervous System

Observations/

Nervous System

Observations/

Host Defence

Drugs administered to render patient unconscious or reduce consciousness. Details usually found in drugs section of notes.

Tests patient’s response to stimuli. Four possible states: normal, abnormal, reduced or absent.

Interventions/

Respiration

Interventions/

Host Defence

Interventions/

Host Defence

Interventions/

Host Defence

Interventions/

Host Defence

Interventions/

Host Defence

Interventions/

Host Defence

Observations/

Metabolism

Observations/

Circulation

Observations/

Host Defence

Interventions/

Host Defence

Observations/

Host Defence

Interventions/Respira tion

Interventions/

Respiration

Interventions/

Circulation

Blood pressure in arteries when heart contracts. Measured in millimetres of mercury (mm/Hg). Normal readings vary according to age and general health, but are generally considered high if above 140 in an adult.

7 possible reading points: ear/tympanic, oral, naso-paharnageal, rectal, intravascular, oesophageal or rectal.

Injection given to immunise patient against tetanus when a wound has occurred.

Checks blood and/or urine for presence of drugs, particularly paracetamol and salicylate levels.

An incision made into the chest wall to provide an opening for the purpose of drainage.

Surgical construction of an opening in the trachea for the insertion of a catheter or tube to facilitate breathing. Usually found in notes.

An antifbrionolytic drug that prevents the breakdown of blood clot and so helps stop bleeding. It is given as an intravenous infusion which is started as soon as possible after injury. It may be given by ambulance paramedics or in the resuscitation room. It should not be given more than 3 hours after injury.

Imaging test that uses high-frequency sound waves.

Investigations/

Ultrasound

Investigations/

Urine Sampling

Investigations/

Other Imaging

Investigations/

Urine Sampling

Investigations/

Other Imaging

Interventions/

Host Defence

Observations/

Host Defence

Septic (blood poisoning) status of patient ON ARRIVAL in location.

Choose from: not septic, suspected infection, proven infection or inflammatory response (redness or swelling). Choose ‘missing’ if status not known.

Procedure to remove obstructions from airway.

Re-aligning bones/joints after dislocation or fracture. Usually performed as operative procedure.

A skin suture. Details usually written in notes.

Bandages and other dressings.

Cleaning a wound.

Used to keep spine stable after injury. Usually referred to as spinal board, collar, blocks or full spinal protection.

Drugs to improve muscle strength. Details usually found in drugs section of notes.

Measures levels of cortisone in blood.

Urea clearance time. Measured in millilitres per minute (ml/min).

Normal range 64 - 99 ml/min.

A scan of the urethra.

Millilitres (mls) of urine per hour. For catheterised patients.

A scan of the urinary system involving dye in the veins and kidneys.

Increasing body temperature, e.g. in cases of hypothermia.

Numerical assessment of risk of developing a pressure sore. 0 – 9 is low risk. 20 + is very high risk.

46

4.16

5.

6.

7.

1.

2.

3.

4.

CORE DATA ENTRY EXERCSE

Click onto Submissions (top grey bar)

New Submission (top left of screen)

Choose your Hospital

Enter date of Arrival: 01/05/14

Time of Arrival: 12.00

NHS Number (9999999999)

If no duplicate submission found – you’re taken into the Core dataset.

O

PENING SECTION

A

GE WILL AUTO

-

CALCULATE ON SAVING

HELP TEXT:

CLICK ON THE FIELD NAME FOR GUIDANCE

47

O

PENING SECTION

F

IND

GP PRACTICE

CODE

, E

NTER POSTCODE

: M44

H

IGHLIGHT CHOSEN PRACTICE

USE THIS CODE

48

I

NCIDENT

PRE-POPULATION BUTTON: Auto-populates date/time fields

MULTIPLE RESPONSES: press the + button

49

P

RE HOSPITAL

50

P

RE HOSPITAL

MULTIPLE ENTRIES: E

NTER

& SAVE CHANGES,

DATA SAVED IN

C

RUMB

T

RAIL

&

SCREEN REFRESHED

51

P

RE HOSPITAL

O

BSERVATIONS

52

P

RE HOSPITAL

O

BSERVATIONS

53

P

RE HOSPITAL

I

NTERVENTIONS

54

ED

55

ED O

BSERVATIONS

56

ED O

BSERVATIONS

P

T ARRIVES IN

ED I

NTUBATED AND VENTILATED

A

IRWAY

S

TATUS

=I

NTUBATED

B

REATHING

S

TATUS

=M

ECHANICALLY VENTILATED

R

ESPIRATORY

R

ATE

= NOT R

ECORDED

57

ED I

NTERVENTIONS

58

ED A

TTENDANTS

Enter first and most senior doctor from each specialism

59

I

MAGING

Copy and paste imaging reports directly into submission

Note: Senior Radiologist = Consultant

60

I

MAGING

61

O

PERATION

Choose Body area, Procedure and (V) to select

1. BOAST4 (Surgical stabilisation):

Primary Open reduction & External Fixation

2. BOAST4 (Soft tissue cover): Skin Graft – unspecified

3. SKIN: Skin Debridement

62

C

RITICAL

C

ARE

C

RITICAL

C

ARE

A

TTENDANTS

W

ARD

Observations, Interventions, Attendants not required on Ward

63

A

T

D

ISCHARGE

64

BOAST4

Only record Operations performed at your Hospital

65

4.17

MAJOR TRAUMA BEST PRACTICE TARIFF

The Major Trauma Best Practice Tariff (BPT) was launched by the Department of Health on 1st April 2012 and is relevant to Major Trauma Centres (MTCs). Although funding is attached to individual patients, it is an enhancement of the trauma system or network to improve care. There are certain elements of care which will need to be delivered for the BPT to be paid to MTCs, which will need to be captured in the TARN data set in order for payment to be approved.

The Major Trauma Best Practice Tariff uses the Injury Severity Score (ISS) to assign one of two levels of tariff based on either ISS>8 or ISS>15.

The criteria for 2014-15 have been modified and for either of these levels

, this document addresses key questions relevant to the Major Trauma Best Practice Tariff and to assist TARN Data Coordinators in completing submissions & creating reports.

Background

Commissioners will issue the tariff if the following criteria are met:

Level 1 is payable for all patients with an ISS>8 providing that the following criteria are met:

The patient is treated in an MTC

Trauma Audit and Research Network (TARN) data is completed and submitted within 25 days of discharge or death.

Any coroners’ cases are flagged within TARN as being subject to delay to allow later payment

A rehabilitation prescription is completed for each patient and recorded on TARN

Tranexamic acid (TXA) administered within 3 hours of injury for any patient receiving blood within 6 hours of injury: Exclusions: Isolated AIS3+ Head injuries

Non-emergency transfers: Patient must be admitted to MTC within 2 calendar days of referral from Trauma

Unit

Level 2 is payable for all patients with an ISS>15 or more providing that the Level 1 criteria are met, plus:

Direct admissions or emergency (<12 hour) transfers: Patient must be seen by Consultant within 5 minutes of arrival

Direct admissions: Head CT performed within 1 hour of arrival for patients with AIS1+ Head injury & GCS

<13 in ED (or intubated pre-hospital)

Exclusions: patients requiring emergency surgery or interventional radiology within 1 hour of admission

Process

All trauma submissions that are TARN eligible should be completed and dispatched to TARN within 25 days of patient discharge/death. Once the submission has been dispatched to TARN, coding and approval will be completed.

The TARN Data Coordinator will be able to produce a Best Practice Tariff Report on the patients.

Any amendments to the submissions will need to be sent to TARN for completion.

BPT Reports are available for both provider and commissioners to create. Usernames and passwords will be assigned once requested through [email protected]

Validation

Only minor modifications should be made as it is expected that for a Major Trauma Centre, all key information has been accurately documented in the patient notes.

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The validation period should not be used to provide answers to the 4 key questions from the Rehabilitation

Prescription. Since the RP should be available in the patient notes prior to submission dispatch it is suggested that if the RP be missing from the patient notes, then you should inform your senior clinician/rehabilitation specialist. It is also recommended that this is discussed with your Network Manager(s) for resolution. Any remaining concerns should be raised with the Department of Health.

The Rehabilitation Prescription

The Rehabilitation Prescription should be completed for every patient identified as having rehabilitation needs due to major trauma. If the RP is not required, this will need to be recorded in the TARN eDCR.

Where can the Rehabilitation Prescription be found?

The Rehabilitation Prescription should be easily identified in the patient’s clinical records that are used to complete a

TARN submission.

Who will complete the Rehabilitation Prescription?

The document - Rehabilitation Prescription- should be completed by Health Care Professionals after a multidisciplinary team (MDT) assessment and signed off by senior staff members, at a minimum:

Specialist registrar in Rehabilitation Medicine or

Band 7 specialist rehabilitation clinician

What information from the Rehabilitation Prescription will I need to enter on the eDCR?

To qualify for tariff payment, there are 4 key questions that need to be completed by the Healthcare Professionals.

These 4 key questions can be easily found at the top of the Rehabilitation Prescription and will be present on the

Opening Section of the eDCR:

(a) Rehabilitation Prescription (completed or not required) No □ Yes □ Not required □

(b) Presence of physical factors affecting activities or participation No □ Yes □ Not indicated □

(c) Presence of cognitive/mood factors affecting activities or participation No □ Yes □ Not indicated □

(d) Presence of psychosocial factors affecting activities or participation No □ Yes □ Not indicated □

If any of these questions have not been completed on the form, then we suggest that you contact the senior staff member that signed off the Rehabilitation Prescription.

Do I have the option to enter the full Rehabilitation Prescription onto the eDCR?

Should your Trust wish to have the full prescription entered onto the eDCR for future analysis, we have built in this option. Details on how to enter these details can be found below.

Data Collection

All questions required for the Major Trauma Best Practice Tariff will be in both the Core and Extended versions of the eDCR. Questions relevant to the tariff will be in the ‘Opening Section’, ‘Incident’, ‘Pre Hospital/At Scene’, ‘ED’, ‘ED

Attendants’ ‘Critical Care Attendants’ and ‘At Discharge’

NOTE: It is important that you record the patient NHS Number. If it is not possible to access the NHS Number from any part of the clinical notes/electronic records, please use the default number for ‘missing’: 9999999999.

Opening Section

Within the Opening Section there will be the following 3 new questions:

1. GP Search Facility

2. Rehabilitation Prescription

3. Transfer in – Date & time of arrival at 1st hospital

4. Date and Time of transfer request

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GP Search Facility

It is important that you tell us about the Patient’s GP so we can identify the GP Practice Code. The GP Practice code will then allow us to match the patient to their Commissioning Group. This will help Commissioners to issue a tariff payment.

1. If the patient notes identify that the patient has a GP, click on ‘Yes’.

2. Clicking ‘Yes’ will generate a new question prompting the user to enter the GP Practice Code. This can be entered in the text box. The GP Practice Code may not be readily available in the patient notes so alternatively, click on ‘Find GP Practice’

3. Clicking on ‘Find GP Practice’ will generate a pop up box. To search for the GP Practice, enter at least 3 characters from either one of the following:

Post code

GP Name

GP Practice Name

Line of address

Town/county

This will identify a list of potential GP practices. Select the correct GP Practice from the drop down menu and click on ‘Select code’. This will auto populate the pop up menu and also the GP Practice code on the opening section.

Rehabilitation Prescription

The 4 key questions required for the Major Trauma Best Practice Tariff will be set as mandatory.

NOTE: the order of some answer options have changed their regular format to match the order of the Rehabilitation

Prescription. Some answer options may begin with ‘No’

1. If there is a prescription available in the patient’s clinical notes, click on ‘Yes’.

2. By clicking ‘Yes’, this will activate the other 3 key questions along with the option to enter the full

Rehabilitation Prescription Details.

68

3. If you wish to enter the full Rehabilitation Prescription, click ‘Yes’ for ‘Rehabilitation Prescription Details’.

On clicking ‘Save’ this will activate a new ‘Rehabilitation’ location in the left hand side navigation.

4. By clicking the ‘Rehabilitation’ location, all questions present on the Rehabilitation Prescription are available on screen for data entry in a series of drop down and radio button options.

5. There is now a separate London Rehabilitation Prescription for London Major Trauma Centres which is accessed in exactly the same way as the Standard RP.

Patients that are transferred into a Major Trauma Centre

If you have the information accessible from the patient notes, it is important to tell us the date and time of arrival at the 1st receiving hospital and the date and the time of the Referral request. This will assist in calculating whether the patient was transferred within 2 calendar days of the referral request.

1. If a patient has been transferred in, Select ‘Transfer In’ from the ‘Was the patient transferred?’

2. If details are available, complete ‘Date arrived at 1 st

hospital’ and ‘Time arrived at 1 st

hospital’

3. Complete the date of Referral request and, if available, the time.

ED & ED Attendants

To measure whether a patient was seen by a Consultant led trauma team within 5 minutes of arrival, the following mandatory questions will need to be completed:

1. In ‘ED Attendants’, complete the date and time the patient was seen

2. Select ‘Doctor’ from ‘Type of Attendant’ to record that the patient was seen by a Doctor

3. Complete ‘Grade’ and Speciality’ of the Doctor.

Critical Care Attendants

Patients that are transferred as an Emergency (i.e within 12 hours), in to the Major Trauma Centre will also need to been seen by a Consultant within 5 minutes of arrival, however, these patients may bypass the Emergency

Department and go straight to Critical Care. A new location has been created in the ‘Core’ to record critical care attendants that works in exactly the same way as ‘ED Attendants’.

1. If a patient has been transferred in directly to critical care, click on ‘Critical Care Attendants’ from the left hand side navigation. If you are in the ‘Extended Dataset’ click on ‘Critical Care’ and then enter the attendants by clicking on ‘Attendants’

2. Complete date and time the patient was seen.

69

3. Select ‘Doctor’ from ‘Type of Attendant’ to record that the patient was seen by a Doctor

4. Complete ‘Grade’, Speciality’ and ‘Training’ of the Doctor

Tranexamic Acid & Blood Products

In the Core version of the eDCR, Blood, Blood Products and Tranexamic Acid can be recorded as an ‘Intervention’.

Please ensure that you record both the date and time that tranexamic acid was administered. Please also check whether blood products were given to the patient and record date, time and blood product type. If dates and times aren’t recorded, then this will affect tariff payment.

Tranexamic Acid

Tranexamic Acid can be recorded in the following locations:

Pre-Hospital

ED

It can also be recorded in any location within the Extended system.

Blood Products

Blood product type and volume can be entered within any location in the extended system and can also be entered in the following sections within the core:

Pre-Hospital

ED

Critical Care

CT scan within 1 hour

It is important to record the date and time of the first CT scan to each body region and any subsequent scans that showed injuries.

These can be recorded in the imaging section of the CORE dataset or under investigations in the Extended dataset.

At Discharge/Outcome: Patients awaiting Post Mortem

To ensure that all patients receive the Major Trauma Best Practice Tariff, an option is available on the Post Mortem drop down list called ‘Awaiting Post Mortem’ and allows a user to dispatch a submission without injury details if

the patient outcome is ‘Death’ and ‘Awaiting Post Mortem’ is selected.

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Reporting

It is important to produce the following reports to validate the information on patients that have been submitted to

TARN. This will assist in ensuring that all information required for the Major Trauma Best Practice Tariff is fully completed and correct. There will be 10 working days from ‘TARN submission approval’ to validate the information.

After 10 working days, Commissioners from Specialised Commissioning Groups can access the eDCR to produce the above reports to identify the patients that qualify for tariff payment.

All reports for the Major Trauma Best Practice Tariff are in an Excel format. If you are responsible for producing

these reports, please ensure that you have Excel User Rights assigned to your account. If not, please contact

TARN on [email protected]

Report Types

1.

BPT 14/15

This report highlights ALL approved submissions that were dispatched to TARN with an ISS>8

The report will allow you to cross check the following fields:

General details

Admission Date

Discharge Date

Outcome

Dispatch Date

Outcome

Approval date

Key Fields for Best Practice Tariff

Days to Dispatch (including those dispatched >25 days)

Consultant led trauma team within 5 minutes

Tranexamic Acid for those patients receiving blood products

within 3 hours of injury

Rehabilitation Prescription completed

Transferred within 2 calendar days (non emergency transfer)

ISS

CT scan within 1 hour of arrival

Current BPT level if applicable

Demographics

Patient’s CCG

Hospital treating the patient

Fields highlighted in RED will alert a user of information that currently results in no BPT payment, this may include cases dispatched >25 days who are ineligible for BPT.

Fields highlighted in YELLOW alert a user to information that is currently affecting the BPT payment level.

These provide the user with advance warning that the submission may need to be checked to ensure that the correct details have been entered.

Making amendments to submissions highlighted in the report

Users will have 10 working days to validate submissions. If a user is required to make any amendments, please email [email protected] along with the TARN submission ID. Please ensure that you allow sufficient time for TARN to make any amendments to the submissions.

2. BPT post mortem pending

This report will list submissions where the post mortem is still outstanding.

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How to produce the reports

1. To produce the reports, log on to the eDCR at https://www.tarn.ac.uk/

2. Once logged in, click on ‘Reports’ in the top navigation bar.

3. Click on CREATE REPORTS to access all the available reports.

4. From the list, there will be the following reports for Best Practice Tariff:

BPT 2013/14: eligible

BPT 2013/14: ineligible

BPT 2014/15

BPT Awaiting Post Mortem

5. Select the time frame that you require by completing the ‘Start Date’ and ‘End Date’ fields. The dates must be entered in dd/mm/yyyy format. Ensure you use the correct financial years’ report.

6. When you have finished setting up your report, click GENERATE REPORT.

7. You will receive a message saying that your report is being generated. Click on OK

8. Choose VIEW GENERATED REPORTS

9. If you wish to view a previously generated reports, simply Click on VIEW REPORTS

10. Should you wish to Sort or Filter information, click within the table, and click on DATA (top margin in Excel).

You can then Sort or Filter by clicking on the field you wish to use..

Commonly asked questions

How will I know that the patient has been seen by a consultant within 5 minutes?

A consultant of ANY specialty should be present within 5 minutes of patient arrival and be ‘part of’ the team seeing the patient.

If the patient is given tranexamic acid and blood products, does there have to be a minimum blood volume given to qualify for tariff payment?

No, the criteria are not dependent on the amount of blood given but details of the date and time of both any blood, blood products and Tranexamic acid is essential.

What if the patient is seen by a consultant but no indication that a trauma team was present?

If no trauma team is indicated in the notes, but states that a consultant has seen the patient within 5 minutes of arrival (where applicable), then this will still qualify for the tariff this year.

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What is the difference between an ‘Emergency Transfer’ and an ‘Urgent’ Transfer?

An Emergency Transfer is a patient that has been transferred within 12 hours.

An ‘Urgent’ Transfer (non-emergency) is a transfer within 2 calendar days of Referral request.

For Level 1 patient it states that ‘If the patient is transferred as an urgent transfer (non-emergency), then the transfer should take place within 2 calendar days of referral from the Trauma Unit.’ How will this be calculated?

If you have the date and time of Referral request from the Trauma Unit, then this should be entered on screen in the opening section as described above. This will enable us to calculate if the patient has been transferred within 2 calendar days of the request. There would be no financial loss to the Major Trauma Centre unless the patient was not transferred within 2 calendar days if it was an ‘urgent’ (non emergency) transfer.

What if the patient is transferred in? Do they still need to be seen by a consultant within 5 minutes?

Only if they are an Emergency transfer. If the patient is an ‘emergency’ transfer (defined as being transferred within

12 hours of arrival at 1 st

hospital), then they may be transferred in and seen in the ED or sent straight to theatres or critical care.

What if the patient is awaiting a Post Mortem? Will this affect payment of the Best Practice Tariff?

No, it won’t affect payment of the Best Practice Tariff. As highlighted in this document, TARN has modified the system so it allows trusts to dispatch a submission of a patient who has died without injury details. We understand that there can be a delay in receiving a post mortem, and in some cases, can result in a delay of many months. We have therefore amended the ‘Post Mortem’ question to include an option ‘Awaiting Post Mortem Report’ to monitor these patients. The report is accessible to both the Trust and the PCT so any outstanding patients can be reconciled by the PCT. The tariff for these patients will apply if the submission is dispatched within 25 days of death and the deceased patient mets either the level 1 or level 2 criteria.

Will a Trauma Unit also be paid the Best Practice Tariff?

The Tariff is only applicable to Major Trauma Centres, but Trauma Networks will be encouraging Trauma units to submit data so the full patient care can be matched between both Trusts and the overall level of care can be completely assessed.

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Questions Related to the Major Trauma Best Practice Tariff – use this as a ‘check sheet’

Question

NHS Number

Important Data to Record Question Location

If Transfer IN

GP Details

Rehabilitation Prescription

Tranexamic Acid

Blood Products

Consultant within 5 minutes

CT within 1 hour

Outcome (if Dead)

Date / Time of Arrival at 1st

Hospital

Arrival Date/Time

Date/Time of Referral Request

4 key questions: a) Rehabilitation prescription b) Presence of physical factors c) Presence of cognitive/mood factors d) Presence of psychosocial factors

Date

Time

Date

Time

Blood Product Type

Date/ Time

Grade

Speciality

Trauma Team

Time

Date

Body region scanned

Awaiting Post Mortem

Pre-hospital

ED

Pre-hospital

ED

Critical Care

ED Attendants (CORE)

Critical Care Attendants (CORE)

ED

Opening Screen

Imaging (CORE)

Investigations (EXTENDED)

At Discharge

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