1. GEORGIA TQIP State collaborative data validation project
Amy Svestka, BA, EMT, CSTR
Program Manager, TQIP Data Quality
American College of Surgeons, Committee on Trauma

2. GA Collaborative Data Validation…

3. Site Selection Random selection
Excluded centers who had already undergone a data validation visit within the last 3-years.

4. What is a Data Validation Site Visit?
Patient List
All Deaths with a length of stay of 15 days or fewer.
Patients with an ISS greater than 24, no major complications, and a length of stay of at least 1, but not more than 30 days
Patients with a length of stay between 15 and 30 days with no major complications or death
Patients 64 years of age or more, no co-morbidities, and a length of stay of 15 or fewer days
Patients on the mechanical ventilator for more than 7 days who had a length of stay of 30 or fewer days and no pneumonia
Patients who survived with a GCS motor score of 1, no major complications, and a length of stay between 3 and 30 days.
TQIP Data Abstraction
Comparison Review
The comparison review is for educational purposes.
Recommendations

5. Agenda…

6. TQIP Data Validation Tool…

11. Data validation findings

12. Results… Average scores Submission Frequency Report Education Staffing
90-100% overall average
80-89% overall average
Below 80% overall average
Submission Frequency Report
Education
Staffing

13. 90-100% Overall Average Date of Birth Gender Race
ICD-10 Primary External Cause Code
Inter-Facility Transfer
Pre-Hospital Cardiac Arrest
Initial ED/Hospital SBP
Initial ED/Hospital Pulse
Initial ED/Hospital GCS Motor
ED Discharge Disposition
Hospital Discharge Disposition
Cerebral Monitor Date
Cerebral Monitor Time
VTE Prophylaxis Type
VTE Prophylaxis Date
Transfusion Blood (4 Hours)
Transfusion Blood (24 Hours)
Transfusion Blood Measurement
Transfusion Blood Conversion
Transfusion Plasma (4 Hours)
Transfusion Plasma Measurement
Transfusion Plasma Conversion
Transfusion Platelets (4 Hours)
Transfusion Platelets (24 Hours)
Transfusion Platelets Measurement
Transfusion Platelets Conversion
Cryoprecipitate (4 Hours)
Cryoprecipitate (24 Hours)
Angiography
Embolization Site
Angiography Date
Angiography Time
Surgery for Hemorrhage Control Type
Surgery for Hemorrhage Control Date
Surgery for Hemorrhage Control Time
Withdrawal of Care
Withdrawal of Care Date
Withdrawal of Care Time

14. 80-89% Overall Average Highest GCS Motor
GCS Assessment Qualifier of Highest GCS Total
Midline Shift
Cerebral Monitor
Transfusion Plasma (24 Hours)
Cryoprecipitate Conversion

15. Below 80% overall Average
Co-Morbid Conditions
AIS Injury Codes
Hospital Complications
Highest GCS Total
Initial ED/Hospital Pupillary Response
VTE Prophylaxis Time
Lowest ED/Hospital SBP

17. Co-Morbid Conditions 62.96%
Provides a baseline heath status of the patient
Risk-adjusted benchmarking
Average Score
62.96%

18. Co-Morbid Conditions Findings…
“Not Applicable” was reported when patient’s past medical history was unknown
“Not Known/Not Recorded” was reported when patient’s had no NTDS comorbidities
Definitions were not being followed
Co-Morbid Condition were reported when the criteria was not met
Co-Morbid Conditions were not reported when the criteria was met

19. AIS Injury Codes 53.44% TQIP Patient Inclusion Criteria
Risk-Adjusted Cohorts
Severe TBI
Isolated Hip Fracture
Non Risk-Adjusted Cohorts
Fracture
Mid-shaft Femur Fracture
Open Tibia Shaft Fracture
Blunt Splenic Injury
Important for modeling
Highest AIS by body region
Survival Risk Ratio
Average Score
53.44%

20. Abbreviated injury Scale 2005
AIS 2005
Abbreviated injury Scale 2005
Update 2008

21. AIS Findings… Missed injuries Injuries coded incorrectly
External Injuries
Cerebral Concussion
Lung laceration
Pericardium hemopericardium
Torn “Vein of Labbe”
Injuries coded incorrectly
Large SDH reported (25). Documentation supported SDH NFS (9)
Minor concussion reported (3). Documentation supported DAI (12)
Single SDH NFS reported (9). Documentation supported small bilateral SDH (12)
Simple open radius fracture reported (6). Documentation supported comminuted open radius shaft fracture (9)

23. Importance of Hospital Complications…
TQIP Benchmark Report
Highlights areas of opportunity, as well as areas of excellence
Excessive missingness could lead to exclusion from risk-adjusted complications models
Under reporting will lead to inappropriate labeling of high performance
Over reporting will lead to inappropriate labeling of low performance
Average Score
70%

24. Hospital Complications Findings…
Missing Hospital Complications
Not Applicable was reported when there was documentation of reportable complications in the patient’s medical record
Cardiac arrest with CPR
Unplanned return to the OR
Definitions were not being followed
Hospital Complications were reported when the criteria was not met
Hospital Complications were not reported when the criteria was met

25. Importance of Highest GCS – Total…
Used in the Severe TBI Cohort
Average Score
65%

26. Highest GCS – Total Findings…
Collection Criterion
Missed injuries
Concussion
The definition was not followed
Highest documented score within 24 hours

27. Importance of Initial ED/Hospital Pupillary Response
Future - Severe TBI Cohort
Average Score
65%

28. Initial ED/Hospital Pupillary Response Findings
Collection Criterion
Missed injuries
Concussion
The definition was not followed
Physiological response of the pupil size within 30 minutes or less of ED/hospital arrival

29. Importance of VTE Prophylaxis Time
TQIP Benchmark Report VTE Prophylaxis cohort
Average Score
75%

30. VTE Prophylaxis Time Findings
The time reported was the time ordered, not the time administered

31. Importance of Lowest ED/Hospital SBP
TQIP Benchmark Report “Shock” cohort
Initial ED/Hospital SBP between 0 and 90 mmHg
Average Score
75%

32. Lowest ED/Hospital SBP Findings
Definition was not being followed
Lowest sustained (>5 min) systolic blood pressure measured within the first hour of ED/hospital arrival
Incorrect values were reported

33. Submission frequency report findings

34. Submission Frequency Report…
Provides frequency tables for each NTDB data variable
Provides an opportunity for centers to see what their data looks like when it is received by the NTDB
Catches mapping problems
Data Validation

35. Submission Frequency Report Findings
“Not Applicable” was reported in data fields where ALL patients apply.
Weight
Initial ED/Hospital SBP
Inconsistencies between related data variables
Surgery for Hemorrhage Control Type vs. Surgery for Hemorrhage Control Date/Time
Clinical sense of associated Co-Morbid Conditions
120 patients reported with “COPD” vs. 16 patients reported with “Steroid Use”

36. Causes of data discrepancies
Human error
Documentation issues
Mapping problems
Abstractor not following or understanding a data field definitions

37. staffing

38. Staffing… 75% understaffed 97 NTDS variables vs. 310 average variables
Resources for Optimal Care of the Injured Patient aka.
The Orange Book, Chapter 15
75% understaffed
One full-time equivalent employee dedicated to the registry must be available to process the data capturing the NTDS data set for each 500–750 admitted patients annually (CD 15–9).
This staffing need increases if additional data elements are collected.
Hospitals must also take into account the additional tasks, above the abstraction and entry of patient data, that are assigned to the registrar. Processes such as report generation, data analysis, research assistance, and meeting various submission requirements will decrease the time dedicated to the meticulous collection of patient data.
Electronic downloads into the trauma registry also create additional tasks, as does ongoing data validation prior to data acceptance.
Additional staff will be required to perform these tasks to ensure the integrity and quality of registry data that are used for prevention, PIPS, and other essential aspects of the trauma program.

39. education

40. Education… The trauma registrar is a vital member of the trauma team.
Ideally, the trauma registrar works directly with the trauma team and reports to the trauma program manager.
Trauma registrars should receive initial training when they start the job.
They must attend or have previously attended two courses within 12 months of being hired: (1) the American Trauma Society’s Trauma Registrar Course or equivalent provided by a state trauma program and (2) the Association of the Advancement of Automotive Medicine’s Injury Scaling Course (CD 15–7).
Resources for Optimal Care of the Injured Patient aka.
The Orange Book, Chapter 15

41. Education…
A certifying examination is available through the sponsorship of the American Trauma Society’s Registrar Certification Board, leading to the designation of certified specialist in trauma registries (CSTR) or equivalent.
Registrars should complete a minimum of 8 hours of registry-specific continuing education per year.
The trauma registrar must demonstrate proficiency with the NTDS.
Centers are encouraged to support trauma registrar training by providing educational offerings within the facility. For example, a lecture regarding organ injuries is appropriate training for registrars, because they are expected to code organ injuries, as well as the procedures performed to treat the injuries.

42. TQIP Education… Monthly Educational Experiences Monthly Webinars
One center has not participated
Monthly Webinars
TQIP Online Course
50% completed the 2017 course

43. ??? QUESTIONS ???