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First Hospital
Number! Time of Arrival to First Hospital% Date of Departure from First
Hospital% Time of Departure from First Hospital
Element Name
Definition
Answer Options& Emergency Department Stay Over 2 HoursI Reason why
the patient remained in the emergency department over 2 hours.
Transfer
to Lower Level FacilityS Was the patient transferred to a non-designated
or lower level designated facility?
EMS Run Report8 Is an EMS run report present in the patient care
record?
Prehospital Essential DataI Are the prehospital essential data
items completed on the EMS run report?' Documentation of Trauma Team
ActivationV Is documentation of trauma team activation present for
severe or major trauma patient?Q Were trauma team member response times
within designated time for those in-house?$ Trauma Team Response Time On call Q Were trauma team member response times within designated time
for those off-site?M Were trauma surgeon response times within
designated time for those in-house?+ Documentation of Trauma Team
Response Times7 Is documentation of trauma team response times
present?
Trauma Flow Sheet
Is a trauma flow sheet utilized?
Assessments( Is documentation of assessments present?
Interventions* Is documentation of interventions present?
Responses
to Interventions7 Is documentation of responses to interventions
present?C Yes
No
Not applicable (patient was not transported by EMS)
UnknownË No ICU beds
Surgeon unavailable
Staffing
Receiving facility on divert
Delay in arrival of transfer EMS
Operating room at saturation
Not applicable (patient did not stay in ED over 2 hours)
Other
UnknownY Yes
No
Not applicable (patient was not transported by EMS or report not present)
Unknown> Yes
No
Not applicable (trauma team was not activated)
UnknownV Yes
No
Not applicable (trauma team was not activated or members not off-site)
Unknown: Yes
No
Not applicable (trauma surgeon not needed)
Unknown
Yes
No
Unknown Hourly Recording of Vital Signs
Is documentation present for
at least hourly sequential recording of vital signs (blood pressure,
pulse, respirations, and temperature) for the patient beginning with
arrival in the emergency department, including time spent in radiology,
up to the time of admission, death, or transfer? & Hourly Recording of
Glasgow Coma Scoreü Is documentation present for at least hourly
determination and recording of Glasgow Coma Score (GCS) for the patient
beginning with arrival in the emergency department, including time spent
in radiology, up to the time of admission, death, or transfer?# Hourly
Recording of Intake & Outputõ Is documentation present for at least
hourly determination and recording of intake and output for the patient
beginning with arrival in the emergency department, including time spent
in radiology, up to the time of admission, death, or
transfer?
Resuscitation Protocols& Were resuscitation protocols
followed?
Treatment Protocols" Were treatment protocols
followed?
Standards of Care
Were standards of care
followed?
Required Equipment Availablee Was required equipment, which
is shared with other departments, immediately available when
requested?$ Are All Required Chart Notes Present7 Are physician notes
present in the patient care record?
Delays of Injury0 Were there
delays in identification of injuries?
Transferring EMS Provider
NumberJ Yes
No
Not applicable (i.e. patient expired in less than an hour)
Unknown- Yes
No
Not applicable
UnknownF Yes
No
Not applicable (i.e. required equipment not requested)
Unknown Yes
No
Not applicable
Unknown¶ Y e s
N o
( C h o o s e
a l l
t h a t
a p p l y )
D a i l y
P r o g r e s s
N o t e s
M i s s i n g
P r i m a r y
P h y s i c i a n
N o t e s
M i s s i n g
S p e c i a l t y
o r
o t h e r
N o t e s
M i s s i n g
O t h e r
S p e c i f y
N o t
A p p l i c a b l e
• The six-digit numeric code for the EMS
agency that transported the patient from another acute care facility to
your facility.
Transferring EMS Activation Date
EMS Activation
Time? The time of day of EMS activation if transferring patient out.
C Date of EMS arrival at your hospital if transferring patient out.
EMS Arrival Date
EMS Arrival TimeM The time of day of EMS arrival
at your hospital if transferring patient out.
EMS Provider
Number` Date the EMS agency transported the patient from another acute
care facility to your facility. 6 List of EMS facility numbers. Options
for null values.
Initial EMS Responderj List of EMS agency numbers.
Can have more than one entry for multiple responders. Options for null
values.‡ The six-digit numeric code for the EMS agency that was the
initial responder at the scene. Use if this is a transfer to your
facility.
Initial EMS Response Date
Initial EMS Activation
Time
Initial EMS Arrival TimeG Date EMS arrived at the scene. Use if
this a transfer to your facility.Q Time EMS was dispatched to the scene.
Use if this is a transfer to your facility.J Time EMS arrived at the
scene. Use if this is a transfer to your facility.m Numeric code
assigned to the facility. Use if patient was a transfer from another
hospital to your hospital. " Date of Arrival to First Hospital 6 List
of Hospital facilities. Options for null values. 6 List of EMS agency
numbers. Options for null values.
Additional Hospital Number' Date of Arrival to Additional Hospital
& Time of Arrival to Additional Hospital* Date of Departure from
Additional Hospital* Time of Departure from Additional Hospital—
Numeric code assigned to the facility. Use if patient was a transfer
from the first hospital to another hospital before they arrived at your
hospital. r Date the patient arrived at the first hospital. Use if
patient was a transfer from one hospital to your hospital. r Time the
patient arrived at the first hospital. Use if patient was a transfer from
one hospital to your hospital. a The six-digit numeric code for the EMS
agency that transported the patient out of your facility.
CT of Head
ReceivedR Did the patient with a head injury and GCS less than 14
receive a CT of the head?# Comatose Patient Airway Establishedm Was a
definitive airway established for a comatose patient (GCS < 9) before
leaving the
emergency department?" Admitted Under Care of Non-Surgeonu Was the
patient admitted to the hospital under the care of an admitting or
attending physician
who was NOT a surgeon? Gunshot Managed Non-OperativelyP Was a patient
sustaining a gunshot wound to the abdomen managed nonoperatively?
Laparotomy Over 1 Hour
Craniotomy Over 4 Hours± Did a
patient with epidural or subdural brain hematoma receive a craniotomy
over 4 hours after
arrival in the emergency department, excluding those performed for ICP
monitoring?
Debridement Over 8 Hours Abdominal Surgery Over 24
Hours< Was abdominal surgery performed over 24 hours after
arrival?- Thoracic Surgery Over 24 Hours; Was thoracic surgery
performed over 24 hours after arrival?- Vascular Surgery Over 24
Hours; Was vascular surgery performed over 24 hours after
arrival?
Cranial Surgery Over 24 Hours: Was cranial surgery performed
over 24 hours after arrival?+ Non-fixation of Femoral Diaphyseal
FractureT Was there non-fixaction of a femoral diaphyseal fracture in an
adult trauma patient?
Re-intubation Within 48 HoursFOR LEVEL III &
IV HOSPITALS
Yes
No
Not applicable 2 Yes
No (free text box to clarify)
Not applicable w Did the patient require re-intubation of the airway
within 48 hours of extubation, excluding operating room extubation?{ Was
there an interval of more than 8 hours between arrival and the initiation
of debridement of
an open long bone fracture?‘ Did a patient with abdominal injuries and
hypotension (systolic BP < 90) undergo
laparotomy within 1 hour of arrival in the emergency department?N Were
trauma surgeon response times with in designated time for those offsite?e Date the patient physically left the referring hospital to go to
a second hospital or your hospital. e Time the patient physicall<
y
left the referring hospital to go to a second hospital or your hospital.
Q Date the patient physically left the second or additional transferring
hospital. N Time the patient physically left the second or additional
referring hospital.
System can auto-calculate. › Date the patient
arrived at second hospital.Use if patient was a transfer from the first
hospital to another hospital before they arrived at your hospital.œ Time
the patient arrived at second hospital. Use if patient was a transfer
from the first hospital to another hospital before they arrived at your
hospital.- Trauma Team Response In- House
Yes
No
Not applicable: RSWG Recommended Hospital Performance Improvement
Elements% Trauma Surgeon Response Time- On call& Trauma Surgeon
Response Time- In Houseÿ ’
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