APPENDIX A: EAST MCT – Outcomes after acute care surgery and trauma care in incarcerated individuals

Trauma Diagnoses: (select all that apply) Neurologic Injuries

Traumatic Brain Injury

Epidural

Subdural

Subarachnoid

Diffuse axonal injury

Concussion

Other______________

Spine injuries

Cervical spine

Thoracic spine

Lumbar spine

Other______________

Paralysis (circle) Yes No Orthopedic injuries

Fracture Location(s)___________

Dislocation Location(s)___________

Other______________ Location(s)___________ Intra-abdominal injuries (check all)

Liver laceration Grade:

Spleen laceration Grade:

Kidney laceration Grade:

Large bowel injury

Small bowel injury

Bladder injury

Other organ injury

Other______________ Thoracic Injuries (check all)

Rib fractures

Hemothorax

Pneumothorax

Sternal fracture

Cardiac injury

Other _________________ Other Injuries (check all)

Vascular injuries Location__________

Laceration Location__________

Facial fracture

Other _________________

Acute Surgical Diagnoses: (select all that apply) General Surgery

Acute appendicitis (circle) Perforated Non-perforated

Cholecystitis (circle) acute chronic

Symptomatic cholelithiasis

Choledocholithiasis

Cholangitis

Gallstone pancreatitis

Alcoholic pancreatitis

Diverticulitis (circle) With abscess With peritonitis

Esophageal Perforation

GI Bleed(circle): Upper Lower

Bowel obstruction(circle): Large Small

Volvulus (circle) Sigmoid Cecal Small bowel

Gastric/duodenal ulcer(circle): Bleeding Perforation

Intestinal perforation (circle): Large Small

Hernia (circle) Ventral Inguinal Femoral Other : (circle) Reducible Incarcerated

Strangulated Unknown

Soft tissue infections

Abscess

Necrotizing infection

Location ______________

Perianal disease

Acute limb ischemia

Aneurysmal disease

Other______________

TITLE: Outcomes after acute care surgery and trauma care in incarcerated individuals: a prospective

observational trial

Data Element Definition / Instructions Demographics: Case Number Assigned number by institution, Ordered chronologically from oldest (1) to newest Age Free text entry of patient’s age, age 16 and older at

time of admission Biological sex Select patient’s biological sex from the following:

• Male

• Female Race Select patient’s race from the following:

• White

• Black

• Hispanic

• Asian

• Other Height Free text entry of patient’s height in cm Weight Free text entry of patient’s weight in kg Payor Primary payor identified for the individual patient.

Usually identified by business manager of surgery department.

Medical History: Comorbidities Recorded (Yes, No, NR = Not Recorded) for all of the

following:

• Obesity

• Hypertension

• Diabetes mellitus (includes type I and type II)

• Drug use disorder, including alcohol use disorder

• Mental health condition

• COPD

• CHF

• Dementia

• Anticoagulant use

• HIV

• Hep C

• History of Tobacco use

• Cancer

o Type (free text)

• Other (free text)

Pre-hospital data: Treatment location prior to presentation Record location of patient prior to presentation to

definitive hospital

• Prison

• Jail

• Outside emergency department

• Outside inpatient hospital

• Other (free text) Duration of symptoms prior Record approximate time elapsed since injury or to arrival symptom onset to presentation to initial health facility

outside correctional facility. Circle <12 hours, 12-24 hours, >24 hours, or unknown.

Similar presentation Was the patient previously evaluated for same injury or

for same problem/symptoms? Yes, No, NR = Not Recorded.

Incarceration Data: State of incarceration Specifies in which state patient is currently incarcerated

in order to classify by structure/model of correctional healthcare. Information on state of incarceration will only be used to classify by model of care. Use two letter abbreviation

Location of incarceration - arrival Record location of incarceration prior to presentation.

• Prison

• Jail

• Unspecified

Location of incarceration - discharge Record location of incarceration at discharge from hospital or ED

• Prison

• Jail

• Unspecified

Injury Data (if applicable): ISS Free text entry of Patient’s calculated ISS (ISS = Injury

severity score, range 1-75) ED GCS Free text entry of patient’s initial or first recorded GCS

(Glasgow Comas Scale; range 3 to 15; composed of three parts: eye, verbal, motor). 3 is the worst.

AIS by body region Free text entry for head, spine, chest, abdomen,

extremity upon presentation (0=no injury, 1=minor, 2=moderate, 3=serious, 4=severe, 5=critical, 6=unsurvivable)

Mechanism of Injury (MOI) Select mechanism of injury from the following:

• Fall

• MVC (Motor Vehicle Collision)

• Pedestrian

• Gunshot wound

• Machine

• Assault

o Weapon - Choose:

▪ hand/foot

▪ blunt object

▪ free text

• Other (free text)

Intent of Injury Record intent of injury, if known

• Intentional (yes/no)

o Self-harm

o Not self-harm

• Unintentional (yes/no)

o Occupational injury

o Not occupational injury

• Unspecified Admission Data (if applicable): Admitting Service Select admitting service:

• Trauma

• Orthopedic Surgery

• Neurosurgery

• Cardiothoracic surgery

• Medicine

• ENT

• Plastic surgery

• General surgery (non-trauma)

• Other (free text) Post ED Disposition Select patient’s hospital destination following

emergency department consultation:

• Floor

• Intensive Care Unit (ICU)

• Operating Room

• Step-down Unit

• Discharge

• Other (free text) Consulting Service(s) Record if any of the following were consulted during the

patient’s primary admission (Yes, No, NR = Not Recorded.

• Trauma surgery

• Orthopedic surgery

• Neurosurgery

• Cardiothoracic surgery

• Medicine

• ENT

• Plastic surgery

• General surgery (non-trauma)

• Psychiatry Diagnoses: Trauma Diagnoses Appendix I - Select all that apply. If unknown, leave

blank. Specify grade of solid organ injury if known. Spine injuries include compression, herniation, spinal cord injury, or fracture of any part of the vertebrae including spinous, transverse, or articular process(es). Paralysis defined as loss of motor function of any limb due to spinal injury, may be temporary or permanent.

Acute Surgical Diagnoses Appendix I - Select all that apply. If unknown, leave

blank. Select diagnosis whether or not surgery was performed.

Procedures (if applicable): Need for Operation (Need OR) Record if patient sent to operating room for any

procedure. Yes, No, NR = Not Recorded. Time to first operation from admission Free text number of hours from the time of

presentation to the ED to entry into an operating room suite. Round to the nearest whole hour.

Number of Operations (NumOps) Number of operations during length of stay. Free text

entry of number up to 12 patient procedures. CPT of Procedure 1 CPT code of initial procedure performed (if applicable) CPT of Procedure 2 CPT code of 2nd procedure performed (if applicable) CPT of Procedure 3 CPT code of 3rd procedure performed (if applicable) CPT of Procedure 4 CPT code of 4th procedure performed (if applicable) Time to fixation If patient sustained orthopedic fracture requiring

surgical intervention, record free text number of hours from the time of presentation to the ED to entry into an operating room suite for fixation (either definitive or temporary). Report the first procedure only. Round to the nearest whole hour.

Other interventions Recorded (Yes, No, NR = Not Recorded) for the

following:

• Chest tube insertion – Check indication(s)

• Central line insertion

• Tracheostomy

• Traction (orthopedic injury)

• Casting (orthopedic injury)

• Laceration repair – record only if sutured/stapled

• Nasogastric decompression – record if within initial 24 hours of presentation

• Other (free text) Admission Data: Hospital length of stay Free text entry for number of consecutive days patient

hospitalized at index admission (Day of admission = hospital day #0. Include any portion of a day that patient was in the hospital) LOS = Length of Stay. Recorded in days.

ICU length of stay Free text entry of number of days patient required ICU

admission (ICU = Intensive Care Unit, LOS = Length of Stay). Day of admission = hospital day #0. Include any portion of a day that patient was in the ICU. Recorded in days.

Transfusion Number of separate units of packed red blood cells

transfused in the first 24 hours after presentation

Ventilator Days Free text entry of the number of days the patient was

on mechanical ventilation. Include any portion of a day that patient was ventilated. Recorded in days.

Discharge data: Discharge to Select patient’s discharge destination:

• Home Self Care

• Home with Services

• Rehab

• Skilled Nursing Facility

• Long-term Care

• Psychiatric facility

• Hospice

• Morgue

• Correctional Facility

• Other

AMA Did the patient leave the hospital against medical advice? Yes/No

Complications: Hospital Mortality Death during index hospitalization (yes or no) Complications during admission Recorded for all of the following:

• Sepsis

• Septic shock

• Acute renal injury

• Deep vein thrombosis

• Stroke

• Pulmonary embolism

• Myocardial infarction

• Cardiac arrest

• Central line-associated blood stream infection (CLABSI)

• Acute respiratory distress syndrome

• Post-operative hemorrhage

• Mechanical wound failure

• Ileus or other post-operative gastrointestinal complication

• Wound infection

o Superficial

o Deep

• Pneumonia (includes ventilator associated)

• Urinary tract infection

• Unplanned ICU admission

• Unplanned re-operation

• Unplanned intubation

• Other Readmission and Follow-up: Follow-up appointment completed Was this patient seen in follow-up in an outpatient clinic

setting with surgical team/primary care provider or documented follow-up (phone call, letter, etc) within 90 days of discharge date? (Yes, No, NR = Not Recorded)

Readmit Patient readmitted for similar problem or complication

from index hospitalization within 90 days of discharge. (Yes, No, NR = Not Recorded)

Readmitdays Record number of days since discharge to first

readmission. Round to nearest whole day. _________________________________________________________________________________ Site Information (only record once per site): Level of Trauma Center Record Level 1-4. If not designated as a trauma center,

enter N/A. ACS admissions Record the number of acute care surgery admissions in

the calendar year preceding the current year of the study

EAST Multi-Center Study Data Collection Tool

Outcomes after acute care surgery and trauma care in incarcerated individuals: a prospective

observational trial

Enrolling Center: ___________________________ Case Number: ________ Demographics: Age _____ Sex: ______ Race: _____________ Height (cm): _________ Weight (kg): _________ Primary payor: ____________________________ Comorbidities (check all that apply):

Obesity

Hypertension

Diabetes mellitus

Drug use disorder (including alcoholism)

Mental health condition

COPD

CHF

Dementia

Anticoagulant use

HIV

Hepatitis C

History of tobacco use

Cancer: Type: ___________

Other: _________________ Pre-hospital Information: Location prior to presentation (circle): Prison Jail Outside ED Outside inpatient hospital Other:____________ Duration of symptoms prior to arrival (circle): <12 hours 12-24 hours >24 hours Unknown Has patient presented for evaluation for same injury or same problem:

Yes No NR Incarceration Information: State of incarceration: ___________ Location of incarceration Prior to Arrival (circle): Prison Jail Unspecified Location of incarceration at Discharge (circle): Prison Jail Unspecified Diagnoses Was the patient admitted for trauma? (circle) Yes No Unknown Injury Information (if applicable):

ISS ______ ED GCS: ______ AIS: Head ______ Spine______ Chest______ Abdomen______ Extremity______ Mechanism of Injury (check one):

Fall

MVC

Pedestrian vs _________

GSW

Machine injury

Assault

Weapon: Hand/foot Blunt object

Other _________

Other: _____________

Intent of Injury (check if applicable):

Intentional If yes: Self-harm Not self-harm

Unintentional If yes: Occupational injury Not occupational injury

Unspecified Admission: Admitting Service (check one):

Trauma

Orthopedic Surgery

Neurosurgery

Cardiothoracic Surgery

General Surgery (non-trauma)

Medicine

ENT

Plastic Surgery

Other _______________

Post ED Disposition (check one):

Floor

ICU

Other ____________-

Step-down unit

Discharge

Consulting Service(s) (check all consulted):

Trauma

Orthopedic Surgery

Neurosurgery

Cardiothoracic Surgery

General Surgery (non-trauma)

Medicine

ENT

Plastic Surgery

Psychiatry

Other _________________ Trauma Diagnoses (see appendix): Acute Surgical Diagnoses(see appendix):

Procedures: Need for operation (circle): Yes No NR Time to first operation: _____________ hours (Use decimals if needed) Number of Operations: ___________________ CPT Procedure 1: ___________ CPT Procedure 2: ___________ CPT Procedure 3: ___________ CPT Procedure 4: ___________ Time to fixation (ortho injuries only): ______________ hours Other interventions (check all performed):

Chest tube insertion Indication: Pneumothorax Hemothorax Other:__________

Central line insertion

Tracheostomy

Traction

Casting

Laceration repair (with suture or staples only)

Nasogastric decompression (in first 24 hours)

Other: ________________ Admission Information: Hospital LOS: _______ days ICU LOS: ___________ days

Ventilator days: ___________ days Transfusion: _______/units pRBCs in first 24 hours of admission

Discharge Information: Discharged to:

Home self-care

Home with services

Rehab

Skilled Nursing Facility

Long-term care

Psychiatric facility

Hospice

Morgue

Correctional Facility

Other: _____________ Did the patient leave AMA (circle): Yes No Complications:

Did patient die during hospital stay: Yes No Complications during admission (check all that apply):

Sepsis

Septic shock

Acute renal injury

Deep vein thrombosis

Stroke

Pulmonary embolism

Myocardial infarction

Cardiac arrest

Central line-associated blood stream infection

Acute respiratory distress syndrome

Post-operative hemorrhage

Mechanical wound failure

Ileus or other GI complication

Wound infection

superficial

deep

Pneumonia (including ventilator associated)

Urinary tract infection

Unplanned ICU admission

Unplanned reoperation

Unplanned intubation

Other: _______________

Other:________________

Other:________________

Readmission and Follow-up: Readmit within 90 days: Yes No NR Number of days from discharge to readmission: ________ days Follow-up appointment completed within 90 days: Yes No NR With (circle): Primary care Surgical Team