ACS - PRQ Pre-Review Questionnaire

AOTR

August 3, 2018

Ellen Fitzenrider, BA, RHIT

University Hospitals Cleveland Medical Center

Disclaimer

• All information provided at any specific time is as accurate as possible.

• The ACS changes definitions and information frequently. Use the following link to obtain the most current information:

https://www.facs.org/quality-programs/trauma/vrc/resources

You are encouraged to share corrected information with the AOTR membership.

Remember to collect the registry information the way YOURfacility wants the information.

Put on your thinking cap!

•What verifying agency has “glitches” in their system and only sent out PART of a PRQ to a reviewing hospital?

ACS

Pre-Review Questionnaire (PRQ)

• 12 different PRQs.

Make sure you pick the CORRECT ONE!!

3 – Level 1 3-Level 2 4-Level 3

1-Level 1 Adult/Level 2 Pediatrics

1 Level 2 Adult/Level 2 Pediatrics

• All state “interim” because document is constantly changing/updated

• Attachments/Appendices – additional requirements

• Alternate Pathway Overflow

PRQ Submission

•Must be completed 30 days prior to visit

•When application completed, online access is provided with password.

Is it the RIGHT PRQ?????

• BE BRIEF, CONCISE AND ORGANIZED

•Make sure YOUR information is ACCURATE

• Numbers MUST add up correctly!!!!!!

PRQ Problems

•Doesn’t flow well

•What TPM SEES and what reviewers GET aren’t always the same thing

•Questions are not well defined

• Tables don’t always make sense – you figure it out!

•Only see questions related to your Level – doesn’t work

ACS Review Timeframe

•Reporting period is defined as 12 months

•2 month lag to date of visit

•Data cannot be older than 14 months prior to the site visit

•Should you pull charts from ADMIT date or DISCHARGE date?

Example - ACS Review Timeline

•ACS review date November 1, 2018

•PRQ due in ACS office October 2, 2018 (30 days)

•ACS review chart year – September 1, 2017 to September 30, 2018 (12 months)

•Data cannot be older than 14 months from review date.

Another difficult question!

•What verifying agency has “glitches” in their system and sent a different PRQ to their reviewers than the one submitted by the facility??

ACS

Disclaimer

•Not all of the following slides will apply to ALL facilities

Adult/Pediatrics Level 1 -2-3

•Not all of the following slides will contain data collected by YOUR facility

•Apply this information appropriately to YOUR facility

Reports

• Check with your vendor to see if they have ACS reports built into your system

• Check the reports to make sure they present your data appropriately

• You may have to tweak them

• Save the tweaked reports to use again next time

Crosstab Example

Crosstab Graph Report Example

15

35

50

100

50

10

25

60

5

75

10

20

60

25

10

25

0

20

40

60

80

100

120

Yes No Maybe Undecided

Which type of Perfume would you buy?

Cat Breath Perfume Puppy Breath Perfume Horse Perfume Baby Bath Perfume

Payor Mix (Table B)

Payer All Patients %

Trauma Patients %

Commercial

Medicare

Medicaid

HMP/PPO

Uncompensated/Indigent

Other

Total

Hospital Beds (Table C) (do not include neonatal beds)

Hospital Beds Adult Pediatric TotalLicensed

Staffed

Average Census

Total ED Trauma Visits for the reporting year following NTDS Trauma Inclusion Criteria

Table #5 Total

Admitted ED Trauma visits (regardless of service)

1286

Blunt trauma percentage

Penetrating trauma percentage

Thermal percentage

ED Disposition Trauma Visits

Table #6 TotalDischargedTransferred OutAdmitted 1286Died in ED, excluding DOAsDOAsTotal

Total ED Visits vs ED Disposition Visits

Table #6 Total

Discharged

Transferred Out

Admitted 1286

Died in ED, excluding DOAs

DOAs

Total

Table #5 Total

Admitted ED Trauma visits (regardless of service)

1286

Blunt trauma percentage

Penetrating trauma percentage

Thermal percentage

Total Trauma Admissions by Service(Table 7)

Service Admissions

Trauma 200

Orthopaedic

Neurosurgery

Other Surgical

Burn

Non-surgical 682

Total Admissions 1438

Nonsurgical Admits (NSA) – A(Table 8 N=682)

Nonsurgical admissions (NSA) 0-9 ISS

10-15 ISS

16-24 ISS

>= 25 ISS

# of patients admitted to NSA 645 25 10 2% of total NSA

%of total NSA w/trauma consult

% of total NSA w/any surgical consult (including trauma)

% of total NSA secondary to single level falls% of mortality (for each ISS category

Nonsurgical Admits (NSA) – B (Table 8 N=682)

0-9 10-15

16-24 >=25

# of patients admitted to a nonsurgical service (from Table 7)

645 25 10 2

Percent of total NSATotal NSA w/trauma consult 75 35 0 0

Total NSA w/any surgical consult (including trauma)

125 55 5 5

Total NSA secondary to single level falls (how is this defined at your facility????)Total mortality (for each ISS category)

Nonsurgical Admissions >10%

•Total admission = 1892

•Total NSA admission = 682

•10% of total admissions = 189

•Total NSA admissions (682) = 36% of total admissions

Nonsurgical Admission Follow-up Question

•Were ALL patients in above table REVIEWED by the TPM/TDM for appropriateness of admission and other opportunities for improvement?

Yes No

•Provide documentation at visit

Direct Admissions

•Do you have a way to flag this type of patient in your registry?

•Total Direct Admits = 152

•Remember this number for future reference

Classic ACS Reviewer Responses

•Well you’ll just have to figure it out

•Why DON’T you know?

•Explain these numbers to me.

Injury Severity/Mortality (Table 11)

ISS (A)Total number of Admissions

(B) Total number of Deaths from Admissions

% Mortality(B over A)

Number of Admitted to Trauma Service

0-910-1516-24>=25

Total 1438 (1286+152)

ADMITTEDdeaths ONLY

200

Transfers OUT of your Facility (IV Table 5)

Transfer Category # of Transfers <24 hrs # of Transfers > 24 hrsPediatricsHandSpineOrthopaedics Other disciplines:

Pelvic ringAcetabular fx

Vascular/AorticCardiac bypass

Soft tissue coverage Facial traumaOther ortho Burns

Neurosurgery Other – Specify Replantation Health Plan Repatriation (send back to own Total Transfers Country)

Team Activations (Table 26)

Level # of Activations % of Total Activation

Highest Red, 1, MD, Full

Intermediate Yellow, 2, ED, Limited

Lowest (Consult) Green, 3, Resident, Don’t use/everyone else

Total Must equal total ADMISSIONS = 1438

Team Members Responding (Table 27)

Activation Level

Responder Highest Intermediate Lowest

Trauma Surgeon

X X

ED Attending

X X

Anesthesia X X

Neurosurgery

Neurosurgery Questions

• # of craniotomies for TBI within 24 hrs of admissions

• # of severe TBI (GCS<9) on admission for the reporting year

•% of severe TBI (GCS<9) who had ICP within 48 hrs

• If no ICP placed, is the patient PI’d for appropriateness?

Questions

•Are burr holes counted as a craniotomy?

•How do you define TBI patients?

•Traumatic Brain Injury (TBI) is damaged brain tissue w/LOC or amnesia w/resulting brain dysfunction.

Orthopedics

Orthopaedic Questions

• ****There is NO ICD10 code for wash outs!***

• Average/range time to wash out for open tib fx w/blunt mechanism

Use time to OR for open tib fx repair (S82. and 7th digit B or C)

• Average time to 1st antibiotic for open tib fx w/blunt mechanism

•What constitutes an “open tibia” fx?

Pelvic Ring Questions

• The number of operations performed at this institution during the reporting year for pelvic ring and acetabular fractures secondary to a trauma mechanism, excluding isolated hip fractures:

• A. Pelvic ring injuries (S32.81__/S82.82__)

• B. All acetabular fracture patterns (S32.4___)

• C. How many of these patients had neurological deficits?

Orthopaedic Questions

•Pelvic ring and acetabular fractures

•How do you distinguish between the two????

What’s an acetabular fracture pattern???

•What is a neurological deficit?

•PRQ Note: Do not include hip fractures or injuries that result from a trip/fall.

Orthopaedic Questions

•% of femoral shaft fractures stabilized within 24 hrs of admission – (taken to OR for IM rod, x-fix or ORIF)

•Do you include SLF??

•Do you only pick “shaft” or do you go proximal/distal?

Palliative Care

Palliative Care Questions

•Total # of ICU deaths: (Died in ICU ONLY) = 35

•MUST be a smaller number than total

Deaths = 120

•Of total ICU deaths, # of withdrawal of care = 20

•Of total ICU deaths, # transferred to

hospice care = 0

ACS December 2017 Webinar

•Hospice Patients

• “Are patients dispo’d to hospice reviewed/counted as a death for peer review and PI purposes?” (Level I)

• For verification purposes, a living patient discharged to hospice should not be counted as a death. This should be captured in your transfer numbers and reviewed with all other transfers. Information concerning the patient after their passing can be captured in your registry.

Burn Questions

•# of ADMITTED burn patients for reporting year

•# of burn patients transferred for acute care during reporting year

•Transferred in: Transferred out:

•DO NOT include ED burn transfers in this number. ADMITTED burns only!

Registry

Registry Questions

•What registry program does the hospital use?

• Is data collected and analyzed? YES

•Data submitted to NTDS/TQIP yearly in a TIMELY fashion? YES, have proof ready for reviewers

•Does the registry support the PIPS process? YES – How

• Risk-adjusted benchmarking participation? YES

TQIP (only option currently) – have reports available

Registry Questions (con’t)

• 80% of charts ENTERED into registry within 60 days of discharge? YES

• Registrars education (12 months of hire date) – ATS Registry course/OTRC/AAAM? –YES

• Confidentiality measures in place? –YES –Explain

• 1 FTE per 500-750 ADMITTED patients? –YES

• Data validation process in place –YES

HAVE PROOF READY FOR THESE QUESTIONS

ACS Webinar Registry Question

• Confusion – 1200 admissions for a Level 1 requirement vs 500-750 patients = 1 FTE for registry data collection.

• Staffing - The current standard is one full time employee for every 500-750 admitted trauma patient into the registry based on the time needed to code and capture NTDB/TQIP data points.

• Registrars have other duties such as, generate reports, perform data analysis, act as research assistance, and meet various submission requirements that will decrease the time dedicated to the collection of patient data. More detailed information can be found in Chapter 15 page 112.

• There are discussions and plans to revise this standard. 11-17

Autopsy

Autopsy Question

•What % of patients that died have an autopsy? (need total death number here)

•How are findings reported to the trauma program?

Death Questions

•# of total trauma deaths in reporting year = 120

•# of DOA - 24

•# of ED (Died) - 36

• In-hospital (including OR) – 60 (20 ICU)

•Total = 120

Death Questions (con’t)

• # of deaths in each category

•Mortality without opportunity for improvement – 24

•Mortality with opportunity for improvement – 36

•Unanticipated mortality with opportunity for improvement – 60

• TOTAL DEATHS = 120 (same as previous slide) Numbers must add up correctly.

MORE Reviewer Responses

•GRRRRRRRR! Mumble, mumble, mumble

•Shouting, Flirting, Patronizing

•Racism

•Weakness based on their personal bias OR

whatever burr is under their saddle today!

Geriatrics

Geriatric Questions (Table E-1)

• Age 65 or greater, ADMITTED patients

ISS # of ADMITS (A)

# OF DEATHS (B)

% Mortality(B /A X 100)

# admitted to Trauma Service

# admitted to Other Surgical Services

# admitted to NSA

0-9 323 4 1.2 (4 / 323 X100)

100 50 173

10-18

16-24

>=25

Total 450 125 75 250

Geriatric Questions

•Does the trauma program ADMIT more than 10% of patients to a NSA? – NO hopefully!

• If YES – provided proof of PI review of these patients for appropriateness of admissions or other PI issues

•This usually affects Level 3s more than other facilities.

Geriatric Questions (con’t)

•# number of geriatric patients ADMITTED from column A (table above) with SLF/standing height fall. (EXCLUDE isolated hip fractures) - 222

•Are ISOLATED HIP FRACTURES included in your registry?

Injury Prevention

Injury Prevention Questions

•What are the 3 leading causes of injury in your community?

•MVC

•Falls

•Assault – GSW, stab, battering

Organ Donation

Organ Donation Questions

•Does the facility of an organ donation program? YES

•How many donors in the reporting year?

•# of donations meeting brain death criteria after cardiac death (excluding eyes/skin)

•# of deaths vs # of donation referrals vs # of successful donations

Maybe???????

Appendix #1 – Trauma Medical Director

•Trauma admissions per year?

•# of admissions with ISS>15 per year?

•# of trauma operative cases per year (Limited to spinal or general anesthesia in the OR)

Appendix #2 – Trauma Surgeons

Name Residence Board ATLSStatus

# of trauma calls per month

# of trauma patients ADMITTED per year

CME # of OR cases per year

% of PI attendance

TraumaOther

Appendix #3 – Trauma Bypass Occurrences

• Total # of bypass occurrences

• Total # of hours on bypass

• #% of time on bypass

Date of Occurrence

Time of Bypass Time Bypass Ended

Reason for Bypass

Appendix #5 – Neuro/Ortho/ED

Name Residency Boarded ATLSStatus

# of trauma calls per month

# of trauma craniotomies

CME

Things to Remember•Use the correct PRQ

•Numbers MUST add up

• Verify your numbers

•No ICD10 code for WASH OUT

• Clarify confusing questions with TPM/MD so you’re on the same page

THANKS for Your Input!

•Lita Holdeman

•Erika Joos

•Sandy Daly-Crossley

•Deanah Moore

References

• American College of Surgeons Committee on Trauma FACS.org

• Resources for Optimal Care of the Injured Patient

• The Ideal Site Visit, Dr. Todd Maxson and

Amy Kessler, RNs

• PRQ

• Clarification Document

www.facs.org/quality-programs/trauma/vrc/resources