2024 Data Dictionary Frequently Asked Questions

Q: Do in-house traumas meet the NTDS Patient Inclusion Criteria?

A: Patients who had a traumatic event that resulted in an injury while being treated at your hospital do not meet the NTDS Patient Inclusion Criteria and must not be reported.

Q: A patient was transferred to my facility after falling off the toilet and sustaining a head injury while being treated for a medical condition at the transferring hospital. Does this patient meet the NTDS Patient Inclusion Criteria?

A: Yes. If the patient sustained a qualifying traumatic injury within 14 days of their encounter at your hospital and are transferred to your facility, then they meet the NTDS Patient Inclusion Criteria and must be reported to TQIP.

Q: Do isolated hip fractures meet the NTDS Patient Inclusion Criteria?

A: The NTDS Patient Inclusion Criteria does not exclude patients who sustained a traumatic isolated hip fracture (IHF). If the patient sustained a traumatic isolated hip fracture within 14 days of their initial hospital encounter and meet at least one criterion from "Step 2", they must be reported. 

Q: Is the NTDS Patient Inclusion Criteria the same as the TQIP Inclusion Criteria?

A: No. Centers submitting data to the Trauma Quality Programs must follow the NTDS Patient Inclusion Criteria as stated in the TQIP Participation Agreement. Then, TQIP determines which patients are included in the TQIP Benchmark Report using the internally defined TQIP Patient Inclusion Criteria. The TQIP Patient Inclusion Criteria is included for each TQIP Benchmark Report in the References section and can change over time. 

Q: "Patient transferred from one acute care hospital to another acute care hospital." Does this include patients who were transported by a private vehicle (POV)?

A: Yes. If the patient sustained a qualifying traumatic injury within 14 days of their initial hospital encounter and was transferred from one acute care hospital to another acute care hospital, regardless of the mode of transport, then they meet the NTDS Patient Inclusion Criteria and must be reported to TQIP.

Q: Are stand-alone/free-standing emergency departments considered acute care hospitals?

A: It depends on the individual facility and how they are recognized by CMS. Click here for more information.

Q: If a patient is transferred to our hospital, must they have sustained their injury within 14 days of presenting to the referring hospital? Or within 14 days of arriving at our hospital?

A: The patient must have sustained a traumatic injury within 14 days of their initial hospital encounter. If the patient was transferred to your hospital, then they must have been injured within 14 days of arriving at the referring hospital. If their first hospital encounter was at your hospital, then they must have been injured within 14 days of arriving at your hospital.

Q: Should patients with isolated burns be reported to the NTDB/TQIP?

A: No. Starting with the 2021 patient admission year, the “T20-T28 with 7th character modifier of A ONLY” and  “T30-T32 (burn by TBSA percentages)” codes were removed from the NTDS Patient Inclusion Criteria. However, if a patient has a qualifying traumatic injury AND a burn, then they must be considered for NTDS inclusion.

Q: Are trauma patients admitted for medical or non-trauma reasons excluded from the NTDS Patient Inclusion Criteria?

A: No. If the patient sustained a traumatic injury within 14 days of initial encounter, the injury meets “Step 1” criteria, and the patient was admitted to your hospital, they meet the NTDS Patient Inclusion Criteria.

Q: What is GCS 40 and why are we reporting this?

A: The GCS 40 assessment is a new approach to assessing the patient’s level of consciousness in response to specific stimuli. The NTDS does not require that your center start using the GCS 40 assessment for your patients, and you should report what is documented in the patient’s medical record.

For more information regarding the specifics of the GCS at 40 assessment, you may consider reviewing the Glasgow Coma Score website: https://www.glasgowcomascale.org/.

Q: Is it true that the NTDS allows for either the standard GCS or GCS 40, but not both?

A: Yes. The Initial Field GCS 40, Initial ED/Hospital GCS 40, and Highest GCS 40 Motor data elements are reflective of the GCS 40 assessment criteria. If the providers at your hospital have not transitioned to using the GCS 40 criteria to assess your patients, and are using the standard GCS criteria, then report the null value "Not Known/Not Recorded" for the Initial ED/Hospital GCS 40-Eye/Verbal/Motor data elements.

Q: Will the NTDS still be accepting standard GCS if our facility is not using GCS 40?

A: Yes. Centers should report either the standard GCS or GCS 40, but not both.

Q: I have a suggestion to add, remove, and or change an NTDS data element definition. How can I communicate this?

A: Suggestions to add, improve, or remove an NTDS data element definition should be submitted at the Data Dictionary Revision Site.

Q: For patients that we report to the NTDB/TQP, do we report information after the trauma service has signed off on their care and they are still admitted at our hospital?

A: Yes. The NTDS does not consider the hospital service treating the patient. Therefore, all information must be reported up until the patient is ordered to be discharged from the hospital, regardless of the attending service.

Q: If a patient experienced multiple episodes of the same hospital event, do we report each time the event happened?

A: The NTDS only collects data one time for each hospital event; only report the first time the event occurred.

Q: How should the Protective Devices data element be reported on a patient who was walking and tripped and fell? "Not Applicable"? or "1. None"?

A: The Protective Devices data element does not consider the mechanism of injury. If no protective device or safety equipment was being used by the patient at the time of injury, regardless of the mechanism, you should report the Element Value "1. None".

Q: Are things like a walker, wheelchair, etc., considered protective devices or equipment?

A: No. Wheelchairs, walkers, etc. are durable medical equipment that are prescribed for medical use and not as protective equipment or devices.

Q: What should be reported when documentation states that there was no airbag deployment but did not state that airbags were present in the vehicle?

A: While most vehicles today are equipped with airbags, we cannot assume that all vehicles are equipped with airbags. Therefore, if you do not have documentation to support that the vehicle was equipped with airbags, then you should not report Element Value "8. Airbag Present" for the Protective Devices data element. Since you did not report Element Value "8. Airbag Present", you would then report the null value "Not Applicable" for the Airbag Deployment data element.

Q: What is the UUID and why is it included in the NTDS?

A: The Universally Unique Identifier (UUID) is a HIPAA complaint method that will be assigned by EMS services to link data from NEMSIS to other reporting entities, like the TQP.

Q: EMS providers in my state are not using NEMSIS v3.5.0. If a patient is transported from the scene of injury to my hospital, what should be reported for the UUID element?

A: Report the null value “Not Known/Not Recorded.”

Q: A patient arrived by EMS from an urgent care clinic. Does the NTDS consider this to be an inter-facility transfer?

A: The NTDS defines an inter-facility transfer as a patient who was transferred to your facility from another acute care facility. Ultimately, it depends on your state. If the urgent care facility is licensed as an acute care facility, then yes. If not, then no.

Q: What should be reported when a patient is transferred from one center to another center but travels by private car, rather than EMS transport?

A: If the patient was transferred from one acute care facility to another acute care facility and traveled by private auto, then Element Value "1. Yes" should be reported for the Inter-facility Transfer data element.

Q: What if EMS calls the highest level of activation, but the activation is cancelled or downgraded prior to arrival at our center? How is this reported?

A: If the highest level of trauma activation was called by EMS prior to arrival and then cancelled or downgraded prior to arrival, the Element Value "1. Yes" must be reported for the Highest Activation Level data element. The definition does not exclude cancelled or downgraded activations prior to arrival.

Q: Is this data element strictly for patients that come from the scene? If a patient is transferred from an outside hospital and activated as the highest level of activation, how is this reported?

A: This data element applies to all patients. If the patient was transferred from an outside hospital and received the highest level of trauma activation at your hospital, then the Element Value "1. Yes" must be reported.

Q: What date/time should be reported if the trauma surgeon arrives before the patient arrives at the ED/hospital? The patient hospital arrival date/time or the date/time the surgeon arrived?

A: Report the date and time the trauma surgeon arrived even if it was before the patient arrived.

Q: What if the patient received a lower-level or no trauma activation, what do we report for the Trauma Surgeon Arrival Date and Trauma Surgeon Arrival Time data elements?

A: Report the null value “Not Applicable.” The Trauma Surgeon Arrival Date and Trauma Surgeon Arrival Time data elements are only reported for patients who meet the Highest Activation data element criteria.

Q: Patient arrives to ED with CPR in progress. The physician describes in their narrative that the patient had no respirations, no pulse and declares the patient as expired.  Can we report a "0" value for the Initial ED/Hospital Pulse Rate and Initial ED/Hospital Respiratory Rate if there is no numerical value documented in the medical records?

A: If it is standard practice at your center to document zero respirations per minute and a zero-pulse rate using the descriptors such as “no respirations”, “respirations absent”, or “no pulse” then “0” may be reported for the Initial ED Hospital Pulse Rate or Initial ED/Hospital Respiratory Rate, given that the documentation reflects the first recorded respiratory rate within 30 minutes or less of ED hospital arrival.

Q: Is it necessary to report the patient's temperature?

A: Yes.  It is the expectation that all centers report all data defined in the NTDS data dictionary.  The patient's initial ED/hospital temperature is an important predictor of their outcome.

Q: A patient came into the ED with a documented "0" for their pulse and blood pressure and expired within a few minutes of arrival at the ED. There was no documentation of respiratory rate. What should we report for the Initial ED/Hospital Respiratory Rate?

A: If a respiratory rate was not documented within 30 minutes or less of the patient’s arrival to your ED, then the appropriate null value to report for the Initial ED/Hospital Respiratory Rate data element is “Not Known/Not Recorded”. 

Q: If there is no drug screen done at our hospital, but the autopsy report shows a positive drug result for THC and Cocaine, can we report these results?

A: No. While the patient’s autopsy report included a positive drug screen result, you should only report positive drug screen results within 24 hours after the patient’s first hospital encounter. The NTDS does not collect post-discharge data for this element, so using an autopsy report for this data element would not be accurate.

Q: A trauma patient tested positive on the drug screen for barbiturates but is prescribed them. How is this reported?  

A: If the patient was not administered a barbiturate during the patient care event, but the patient’s first recorded drug screen results within 24 hours after the first hospital encounter was positive for barbiturates, then you should report Element Value “2. BAR”.

Q: Now that marijuana is legalized in many states, do we report this if the patient has tested positive?

A: Yes. The NTDS definition does not consider the legality of a drug. Therefore, if a patient were to test positive on a drug screen for marijuana (if it was not administered by a facility during the treatment for this injury event), then you should report the Element Value "12. THC (Cannabinoid)".

Q: We have a flexible ICU that admits ICU status patients and stepdown level patients.  If the admission order states, "admit to stepdown", and the admission plan is documented as "observe in stepdown" but the room /unit is titled ICU what should we report for the ED Discharge Disposition?

A: If the ED discharge disposition order was to admit the patient to stepdown, report Element Value “3. Telemetry/step-down unit.”

Q: For the ED Discharge Disposition Element Values, what is the difference between "4. Home with services" and "9. Home without services"?

A: The Element Value "4. Home with services" is reported for patients with a discharge order from the ED to their home that includes some type of ordered service such as home health. The Element Value "9. Home without services" is reported for patients with a discharge order for home without any additional services.

Q: What should be reported for the ED Discharge Disposition if the discharge order instructed the patient to be discharged from the ED to the floor and the patient went to the telemetry floor?

A: Report the Element Value "1. Floor bed" because the disposition order was written for the patient to be discharged to the floor from the ED.

Q: For trauma patients discharged from the ED to hospice (who did not come from hospice), which Element Value should be reported?

A: For patients whose ED discharge disposition order was home with hospice care, you should report Element Value "4. Home with services" because the patient is returning home, now with hospice services.

For patients whose ED discharge disposition order to a hospice care facility, you should report Element Value "6. Other (jail, institutional care, mental health, etc.)" because the patient is going to another institution that provides hospice care, instead of home.

Q: What ED Discharge Disposition do we report for an ED patient who has admission orders but leaves AMA prior to being physically moved to an inpatient room?

A: If the plan was for the patient to be admitted and the patient was waiting for a bed when they decided to leave AMA, you must report the unit the order was written for.

Q: We are experiencing a high volume of admissions to our hospital and patients are often being held in the ED. What ED Discharge Disposition do we report for an ED patient who has discharge orders for the floor, but due to a shortage of beds, the patient stays in the ED?

A: The NTDS is not asking for the physical location of the patient, but more their phase of care. If the patient was NOT in their ED phase of care, say they were housed in the ED area waiting on a bed, then you must report what the ED Discharge Disposition was at the time the ED phase of care ceased, along with the ED Discharge Date and Time accordingly.

Q: What date and time do I report if the patient has a final discharge order, but the patient physically remains in the ED for a longer period?

A: You must report the date and time the final discharge order was written. The time the patient is waiting for a bed is not considered.

Q: My center is a TQIP center so if transfusion data is being reported for the TQIP Measures for Processes of Care, why are they also reported for the ICD-10 Hospital Procedures?

A: The ICD-10 Hospital Procedures data element is reported by all hospitals and it is the ICD-10 PCS code of the first transfusion of packed red blood cells, platelets, and plasma within the first 24 hours. Whereas, TQIP centers who report the Measures for Processes of Care data elements must report the total amount of CCs of whole blood, packed red blood cells, plasma, platelets, and cryoprecipitate transfused on all patients within 4 hours of ED/hospital arrival.

Q: Sometimes a patient may have a procedure done that starts after their discharge order was written. Should we report these procedures?

A: No. Anything that occurred after the patient was ordered to be discharged from your hospital is post-discharge data, which is not reported.

Q: If the patient is intubated for surgery, remains intubated after surgery, and returns to the unit intubated, do we report the ICD-10 procedure code for the intubation?

A: If the only occurrence of the patient being intubated was in the operating room (OR), you should not report the intubation as an ICD-10 Hospital Procedure. This applies even if the patient remains intubated in the unit for several days following the surgery.

Q: If a procedure is denoted in the NTDS definition with an asterisk and is performed multiple times in the operating room, should the procedure code only be reported once?

A: No. All procedures performed in the OR must be reported regardless of if they have an asterisk or not. You should only report the first event for procedures with asterisks that were done in the ED, ICU, ward, or radiology department.

Q: I have a question about an ICD-10 PCS code and/or ICD-10 PCS coding rule. Can NTDS/TQIP staff help with this?

A: No. For questions regarding ICD-10 PCS coding rules or guidelines, consider contacting the ICD-10 coding champion at your center as they are the experts in that area or an expert external source.

Q: Can I report other pre-existing conditions or comorbidities that are not defined in the NTDS Data Dictionary?

A: No. Centers may collect other pre-existing conditions in their registry per their data collection needs, but the only pre-existing conditions included in your TQP data submission file are those defined in the NTDS Data Dictionary.

Q: If on arrival to your hospital the patient states that they are a DNR and the family will bring the paperwork later, what should we report for the Advance Directive Limiting Care data element?

A: It depends. If life-sustaining treatments were limited due to the directive, you must report Element Value “1. Yes.” If the directive did not limit life-sustaining treatment, you must report Element Value 2. No.

Q: Can the advanced directive limiting care be taken from past admissions? 

A: Yes. The only requirements are the directive must have been signed/dated prior to arrival AND life-sustaining treatment was limited during this patient care event because of the advance directive.

Q: Where can I find more information about the descriptors that are consistent with the DSM 5, 2013 diagnostic criteria of alcohol use disorder?

A: Consider reaching out to the American Psychological Association (APA) or the Behavioral Health department at your center for descriptors that are consistent with the DSM 5, 2013 diagnostic criteria of alcohol use disorder.

Q: A diagnosis of alcohol use disorder was not documented but descriptors consistent with the diagnostic criteria of alcohol use disorder were documented. How do I report this?

A: Report the Element Value "1. Yes." The NTDS definition requires that descriptors documented in the medical record consistent with the diagnostic criteria of alcohol use disorder OR a diagnosis of alcohol use disorder documented in the patient’s medical record.

Q: What should be reported for patients who were prescribed a medication that interferes with blood clotting, but were noncompliant in taking it?

A: Report Element Value “1. Yes” if the patient was prescribed a medication that interferes with blood clotting but were noncompliant in taking it.

Q: In the Additional Information section of the definition, what is meant by “Anticoagulant must be part of the patient’s active medication”?

A: It means the patient must have been prescribed the medication when they were injured.

Q: Should I report the Element Value “1. Yes” for the Bleeding Disorder data element if the patient has a diagnosis sickle cell anemia?

A: No. The NTDS definition only considers conditions where the blood does not clot properly. Sickle cell anemia is not a clotting disorder so if that is their only bleeding disorder then the Element Value "2. No" must be reported.

Q: Should I report the Element Value “1. Yes” for the Bleeding Disorder data element if the patient has a diagnosis of thrombocytopenia?

A: Yes. Thrombocytopenia is a condition in which the patient's blood cannot clot properly, so if there is documentation in the patient's medical record that the patient's thrombocytopenia was present prior to their injury, then it meets the NTDS definition criteria.

Q: Should I report the Element Value “1. Yes” for the Bleeding Disorder data element if “bleeding disorder” is documented but doesn't specify what kind of bleeding disorder the patient has?

A: No. There are many types of bleeding disorders, but the qualifying disorders that meet the NTDS definition are the disorders in which the blood cannot clot properly. Consider investigating to see what type of bleeding disorder the patient has and whether it meets the NTDS definition criteria.

Q: Is there a comprehensive list available of the congenital anomalies that meet the NTDS definition criteria?

A: No. There are many different types of cardiac, pulmonary, body wall, CNS/spinal, GI, renal, orthopedic, or metabolic congenital anomalies and it would not be possible to list them all in the definition. We suggest that centers review discrete cases with their TPM or TMD if they have questions about specific conditions.

Q: Do e-cigarettes or vape pens meet the definition criteria to report the Element Value "1. Yes" for Current Smoker?

A: No. The NTDS definition excludes patients who report smoking cigars, pipes, or smokeless tobacco. E-cigarettes and vape pens are considered smokeless tobacco.

Q: Does dependency on an oxygen tank meet the definition criteria to report Element Value "1. Yes" for the Functionally Dependent Health Status data element?

A: No. A patient on chronic oxygen therapy does not meet the NTDS definition criteria. The patient must be partially or completely dependent on a device or person to perform their ADLs due to a cognitive or physical limitation, not a physiological limitation.

Q: I am not sure if my patient is functionally dependent. Who is a good contact to find out more information about activities of daily living (ADLs)?

A: Consider reaching out to the occupational therapy or physical therapy department at your center for more information about ADLs and functional dependency.

Q: A patient has a diagnosis of pre-injury hypertension, and it is managed by diet and exercise. Does this meet the Hypertension data element definition criteria?

A: No. If a patient has a diagnosis of hypertension, their treatment must include antihypertensive medication to report Element Value “1. Yes.”

Q: A patient was prescribed and administered antihypertensive medication during their initial stay at the hospital, but a diagnosis of "hypertension" was not documented. For this patient, should I report Element Value "1. Yes" for the Hypertension data element?

A: No. A diagnosis of hypertension must be documented in the patient's medical record and the patient's hypertension must have been present prior to the injury.

Q: Does a diagnosis of peripheral vascular disease (PVD) meet the Peripheral Arterial Disease (PAD) definition criteria?

A: Yes. PAD and PVD are used interchangeably in documentation because PAD is a type of PVD.

Q: How should this be reported for males? For patients not of childbearing ages?

A: The Pregnancy data element applies to all patients. If the patient did not have a diagnosis or confirmed pregnancy prior to arrival at your hospital, report the Element Value "2. No".

Q: Does the term "disorder" need to be documented or does documentation of "substance abuse" meet the Substance Use Disorder data element definition criteria?

A: Not necessarily. The NTDS definition includes a list of the substance use disorder diagnoses that meet the definition criteria. Descriptors documented in the patient’s medical record consistent with the diagnostic criteria of substance use disorders specifically cannabis, hallucinogens, inhalants, opioids, sedative/hypnotics, and stimulants also meet the definition criteria.

Q: Where can I find more information about the descriptors that are consistent with the DSM 5, 2013 diagnostic criteria of substance use disorders?

A: If you would like further information in regard to the substance use disorder diagnosis criteria as indicated in the DSM 5, 2013, you may consider reaching out to the American Psychological Association (APA) or the Behavioral Health Department liaison at your center, as this is their area of expertise.

Q: I have a question about an ICD-10-CM code and/or ICD-10-CM coding rule. Can NTDS/TQIP staff help with this?

A: No. For questions regarding ICD-10-CM coding rules or guidelines, consider contacting the ICD-10 coding champion at your center, as they are the experts in this area or an external expert source.

Q: I have a question about an AIS code and/or AIS coding rule. Can NTDS/TQIP staff help with this?

A: No. For questions regarding AIS coding rules and guidelines, please contact the AIS coding experts at the AAAM: info@aaam.org.

Q: When will AIS 2015 be required and AIS 2005, Update 2008 no longer be accepted?

A: Starting with the 2025 patient admission year, the NTDS will retire AIS 05, update 08 and AIS 2015 will be the only acceptable version of AIS defined in the NTDS and accepted by the Data Center.

The TQP validator will still allow the submission of either AIS 05, Update 08 or AIS 2015 for patient records with a hospital arrival on or before December 31, 2024.

Q: I have a patient who arrived at our hospital with a SCr level three times their baseline and they were diagnosed with an AKI. Does this meet the AKI data element definition criteria?

A: No. The patient's AKI was present on arrival.

Q: In the AKI data element definition, how is the patient's baseline serum creatinine (SCr) defined?

A: The NTDS definition of AKI is consistent with the March 2012 KDIGO Guideline. A patient's baseline SCr is their normal SCr level given the patient's age, race, and gender.

Q: Where can I find more information about the March 2012 KDIGO Guideline?

A: You can find more information about the March 2012 KDIGO Guideline.

Q: If a patient arrives with an elevated Creatinine/kidney infarction/Stage I or II AKI/etc., are the symptoms considered present on arrival?

A: No. If a patient’s condition progresses to Stage 3 AKI after arrival, you must report Element Value “1. Yes.” The only patients who are excluded are those with renal failure that were requiring chronic renal replacement therapy prior to their injury.

Q: If a patient is admitted with a known alcohol use disorder and is started on alcohol detox initiatives, should I report Element Value "1. Yes" for the Alcohol Withdrawal Syndrome data element?

A: No. The patient must have experienced the onset signs and symptoms of alcohol withdrawal after arrival to your hospital.

Q: We have a patient who had the signs and symptoms of alcohol withdrawal upon arrival. Should I report Element Value "1. Yes" for the Alcohol Withdrawal Syndrome data element?

A: No. The patient's alcohol withdrawal was present on arrival.

Q: Does the term "alcohol withdrawal syndrome" need to be documented to meet the Alcohol Withdrawal Syndrome data element definition criteria?

A: No. Only the signs and symptoms of alcohol withdrawal that began after arrival to your hospital must be documented in the patient's medical record.

Q: A patient arrived with CPR in progress, and then had return of spontaneous circulation (ROSC). It was documented that the patient went into cardiac arrest again 4 minutes later and received CPR. Is this patient excluded from the Cardiac Arrest with CPR data element definition?

A: No. In this instance, report the Element Value "1. Yes" for the Cardiac Arrest with CPR data element. Patients receiving CPR on arrival are excluded, however, if another episode of cardiac arrest with CPR happens at any time during their stay, then the second episode meets the NTDS definition criteria.

Q: A patient meets the criteria for the Cardiac Arrest with CPR data element on three different days during their hospital stay. Do we report each event or just the first occurrence of cardiac arrest with CPR?

A: No. Only report the first occurrence of Cardiac Arrest with CPR. The same is true of all Hospital Events defined in the NTDS Data Dictionary.

Q: After arriving at the trauma center, if a patient had documented loss of heart rate and had compressions started, but "cardiac arrest" was not documented in the chart, what should be reported for the Cardiac Arrest with CPR data element?

A: In this instance, report the Element Value "1. Yes" for the Cardiac Arrest with CPR data element because there is documentation of the cessation of cardiac activity after hospital arrival and the patient received compressions.

Q: On hospital day 11, a patient was transferred off the trauma service to a medical service for further medical management and developed a CAUTI on hospital day 12. The patient meets all the definition criteria of the CAUTI data element.  Since trauma was no longer following this patient, which Element Value must be reported?

A: If a patient meets the criteria of the CAUTI data element definition and the UTI occurred during the patient’s initial stay at your hospital, then Element Value "1. Yes" must be reported, regardless of the attending service. The NTDS definition does not consider the hospital service that was treating the patient at the time of the event, just that the event occurred after arrival to your hospital and before the hospital discharge order was written.

Q: Should patients who are transferred to our hospital from another facility with an indwelling catheter already in place be considered for the CAUTI data element?

A: Yes. The NTDS definition of CAUTI is consistent with the January 2019 CDC definition of CAUTI including the CDC transfer rule.

Q: A patient had an ultrasound that showed an acute deep vein thrombosis (DVT) in the right gastrocnemius vein that was NOT treated with anticoagulation, an IVC filter, nor clipping of the vena cava. What should be reported for the DVT data element?

A: Since the patient's DVT was not treated, you must report Element Value "2. No."

Q: A patient scored positive for delirium, but it was due to alcohol withdrawal. How should I report this?

A: Report the Element Value "2. No" for the Delirium data element if the patient's delirium was due to alcohol withdrawal.

Q: Does my center have to use the Confusion Assessment Method (CAM) or the Intensive Care Delirium Screening Checklist (ICDSC) to screen for delirium?

A: No. Any objective screening tool used to test for delirium may be used. The CAM and ICDSC are just examples provided in the NTDS definition.

Q: Is there a timeframe associated with the "Hospital Event" Delirium?

A: The only timeframe that applies to the Delirium data element is that the onset of symptoms began after arrival at your hospital.

Q: If the "acute onset of behaviors" is directly related to the injury, should that still be counted as a hospital event?

A: The only patients that are excluded are those whose delirium was due to alcohol withdrawal. 

Q: A patient was diagnosed with hepatic encephalopathy during their initial stay at our hospital. Later that same visit, they had increased agitation and needed sedation for it. If someone is diagnosed with encephalopathy during their admission and does not have alcohol withdrawal, how should I report this?

A: Delirium and acute encephalopathy are different terms that describe the same thing. If your hospital documents acute encephalopathy instead of delirium as a diagnosis, if the acute encephalopathy was not alcohol-related, you must report Element Value “1. Yes” for the Delirium data element.

Q: To meet the definition criteria of the Pressure Ulcer data element, does the wound have to be "staged" and documented in the medical record?

A: No. The definition does not require the wound must be "staged,” however, the definition does require documentation that the pressure ulcer is consistent with the NPUAP 2014 criteria for either a stage II-IV pressure ulcer, unstageable/unclassified, or suspected deep tissue injury.

Q: In the event a patient has clear documentation of deep tissue injury where a specialized wound care team is treating the patient but there is no diagnosis of "pressure ulcer" in the record, will deep tissue injury meet the definition criteria?

A: In lieu of a documented diagnosis, this definition only requires the signs and symptoms be documented in the patient’s medical record. If there is documentation of a “deep tissue injury” that meets the NPUAP 2014 criteria, you must report Element Value "1. Yes" for the Pressure Ulcer data element.

Q: If a patient arrives with a Stage I pressure ulcer, are the symptoms considered present on arrival?

A: No. If the pressure ulcer progresses to Stage II—IV after arrival, you must report Element Value “1. Yes.”

Q: Does “surgical site infection” need to be documented word-for-word in the medical record for SSI inclusion?

A: The exact words “surgical site infection” are not necessarily required to meet the definitional criteria. What is required is a diagnosis of a surgical site infection; all centers document differently, but some examples include “wound infection” and “surgical abscess.” Note that there are additional definitional criteria that must also be met for the SSI data elements.

Q: A patient was discharged home and then readmitted on day 40 with a surgical site infection. What do I report for SSI?

A: The NTDS does not collect data on re-admitted patients. Nothing that occurred after the patient was originally discharged is reported to TQP. 

Q: For the Unplanned Admission to ICU data element definition, what is meant by "EXCLUDE: Patients with a planned post-operative ICU stay"? 

A: Excluded patients are those in which it was determined prior to their surgery that they would require ICU care post-operatively.

Q: Does the Unplanned Admission to ICU data element only apply to patients moving between floor level and ICU level of care or should the move from an intermediate care/step-down/telemetry unit to ICU also be included?

A: The Unplanned Admission to ICU data element does not exclude patients that had an unplanned admission or return to the ICU from the intermediate care/step-down/telemetry unit. If the patient was on the intermediate care/step-down/telemetry unit and transferred to the ICU, report the Element Value "1. Yes" for the Unplanned Admission to ICU data element.

Q: A patient went from the floor to the OR for an open reduction internal fixation of a fractured femur.  While in the PACU, the patient had severe hypoxia and was then transferred to the ICU for closer monitoring. The following day the patient was transferred back to the floor. What should be reported for the Unplanned Admission to ICU data element in this instance? 

A: Report Element Value "1. Yes" for the Unplanned Admission to ICU data element because it was not known prior to going to the OR that the patient would require ICU care after surgery.

Q: What should be reported for the Unplanned Admission to ICU data element if a COVID-positive trauma patient has an unplanned admission to the ICU due to COVID? If a patient has an unplanned admission to the ICU for a medical reason?

A: The NTDS definition does not exclude unplanned ICU admissions due to medical reasons. All patients that meet the Unplanned Admission to ICU criteria must have Element Value “1. Yes” reported.

Q: What should be reported for the Unplanned Intubation data element if a patient was intubated in the operating room, crashes, and is unable to be extubated from surgery?

A: In this instance, report the Element Value "2. No" for the Unplanned Intubation data element. Patients who are intubated for surgery do not meet the definition criteria unless they are reintubated more than 24 hours after being extubated.

Q: What should be reported for the Unplanned Intubation data element when a patient is at high-risk for intubation gets admitted to the ICU with the known possibility that they may require intubation. The patient is given a trial of respiratory therapy but ends up being intubated due to hypoxia/distress.

A: In this instance, report Element Value "1. Yes" for the Unplanned Intubation data element. The decision to intubate a patient isn’t always an immediate one. The patient’s respiratory status was being closely monitored, however, the patient developed hypoxia and respiratory distress, which required the patient to be intubated.

Q: What should be reported for the Unplanned Intubation data element for patients who were intubated to protect their airway?

A: In this instance, report Element Value "2. No" for the Unplanned Intubation data element because the definition requires the patient be intubated due to severe respiratory distress. Patients are sometimes intubated due to a change in mental status or are combative to protect their airway from potential compromise not due to respiratory failure.

Q: A patient was taken to the operating room for damage control laparotomy. Knowing that the subsequent stage of the damage control surgery is going to be based on the patient's physiology and response to the first stage, what should be reported for the Unplanned Visit to the Operating Room data element?

A: If it was known that the patient would require subsequent or staged procedures after initial management of a similar or related procedure, then they do not meet the Unplanned Visit to the Operating Room definition criteria, and Element Value "2. No" should be reported because the second surgery was planned.

Q: How should iatrogenic events occurring in the ED or ICU that prompt an unplanned trip to the OR be reported for the Unplanned Visit to the Operating Room data element?

A: The Unplanned Visit to the Operating Room data element definition does not exclude iatrogenic events from operative procedures performed in the emergency department (ED) or intensive care unit (ICU).

Q: For patients who arrive with a solid organ injury and stable vital signs, our standard practice is to attempt conservative management with serial exams and plan for operative treatment upon deterioration if needed.  If the patient deteriorates and requires surgery, what should be reported for the Unplanned Visit to the Operating Room data element?

A: The definition does not exclude patients who failed conservative and/or non-operative management. If the patient fails conservative management of a solid organ injury, Element Value “1. Yes” must be reported.

Q: A patient fell and was admitted with rib fractures. During their stay, it was discovered that the patient also had a femur fracture that was missed on initial evaluation. Would the trip to the operating room for their femur fixation count as an Unplanned Visit to OR?

A: Yes. Missed injuries are not excluded from the Unplanned Visit to the OR definition. If this trip to the operating room was not indicated in the patient’s original plan of care, you must report Element Value “1. Yes.”

Q: A patient has a hemothorax on admit and a chest tube is placed. On follow-up CT, a retained hemothorax is diagnosed and the surgeon documents per trauma guideline, the patient will be taken to the OR for VATS. Would the OR trip for VATS count as an Unplanned Visit to OR?

A: Yes. VATS are not excluded from the Unplanned Visit to the OR definition, therefore Element Value “1. Yes” must be reported.

Q: We have instances where a patient goes for a craniectomy a day or more into the in-patient stay due to blossoming bleed, failure of Tier 2 therapy, or worsening neurologic status. Do these trips to the OR meet the definitional criteria if they occur outside of the initial neurosurgery evaluation/plan of care?

A: There are no exclusions for delayed craniectomies. If the patient’s condition changes such that an OR trip occurs, this is considered unplanned, and you must report Element Value “1. Yes.”

Q: Our infection control department collects VAE and not VAP. Why does the NTDS still define VAP and not VAE?

A: The CDC’s revision cycle is on a much different schedule than the NTDS revision cycle, and the NTDS Workgroup does not have access to the updated CDC definitions until after they have completed and released the NTDS Data Dictionary for the corresponding year of the CDC update. Also, in the past, we received many complaints from centers that found it confusing to frequently revise the NTDS definitions that are consistent with the CDC definitions. This was brought the NTDS Workgroup’s attention, and they decided that the best course of action would be to keep the NTDS definitions consistent for a minimum of three revision cycles (or three data dictionaries in a row) to maintain the integrity of the data.

Q: Should the Total ICU Length of Stay be reported based on the time the patient was physically in the ICU or the time the patient received ICU level of care?

A: The cumulative amount of time the patient is physically in the ICU must be reported for the Total ICU Length of Stay data element. The definition does not consider the date and time the order to cease ICU care was placed just the cumulative amount of time the patient was in the ICU.

Q: How should we report time if there is an order for the patient to be admitted to the ICU, but due to lack of beds, the patient remains in another area of your hospital?

A: ICU Length of Stay is based on the physical time the patient was in the ICU. Therefore, you must report the total days the patient was physically in the ICU [any partial days are equal to 1 day].

Q: When reporting the Total Ventilator Days data element, should patients with tracheostomies that require ventilator support be included post trach placement?

A: Patients who have a tracheostomy and on mechanical ventilation are not excluded from the definition. If the patient remained on a mechanical ventilator (via endotracheal tube or tracheostomy), then that time must be calculated towards the cumulative amount of time to report for the Total Ventilator Days data element.

Q: Would bag valve mask ventilation performed through an i-gel, King airway or other adjunct be included when reporting the Total Ventilator Days data element?

A: A bag valve mask (BVM) is a non-invasive means of ventilator support; therefore, you should not include the use of a BVM when calculating the total ventilator days.

Q: A patient is intubated and, on the ventilator, but the ventilator is on CPAP mode. Does this meet the Total Ventilator Days definition criteria?

A: No. CPAP and BiPAP are not included in the calculation of ventilator days. If the patient was on either CPAP or BiPAP (even CPAP and BIPAP modes on the ventilator) the entire 24 hours of any calendar day, you should not include that time in your total vent time calculation.

Q: What should be reported for the Total Ventilator Days data element if a patient was taken to the OR at 22:42 on 01-01-2023, and then went from the PACU to the ICU at 02:06 on 01-02-2023 and remained intubated in the ICU until 17:00 on 01-04-2023, when he was extubated?

A: For this scenario, the Element Value "3" must be reported for the Total Ventilator Days data element. You start counting the vent time when the patient leaves the PACU.

Q: If a patient is transferred to inpatient hospice within our facility, what should be reported for the Hospital Discharge Date and Hospital Discharge Time data elements?  They are not “discharged” from the facility, but their care is transferred to the hospice provider.

A: Although the patient was transitioned to inpatient hospice care, they were not discharged from the hospital. The Hospital Discharge Date and Hospital Discharge Time data elements must be reported as the date the final discharge order was written for the patient to be discharged from the hospital. If the patient expires, you must report the date/time of death as written on the death certificate.

Q: When there is brain death, should we report the time that the brain death occurred, or the time physician pronounced the patient dead for the Hospital Discharge Date and Hospital Discharge Time data elements?

A: Report the time of death as it's documented on the patient's death certificate for the Hospital Discharge Date and Hospital Discharge Time data elements.

Q: If a patient comes in from a hospice facility and is discharged back to the same hospice facility, what should be reported for the Hospital Discharge Disposition data element?

A: If the patient’s current residence is at the hospice facility, and the patient was discharged back to the same hospice facility, then the Hospital Discharge Disposition must be reported as Element Value “6. Discharge to home of self-care.”

Q: If a patient comes in from a hospice facility and is discharged back to a different hospice facility, what should be reported for the Hospital Discharge Disposition data element?

A: The patient must return to the exact same place to be considered returning to their current place of residence or home. In all other cases, follow UB-04 codes as defined by the Centers for Medicare and Medicaid Services (CMS).

Q: In the Additional Information section of the Hospital Discharge Disposition, it references UB-04 codes. Who at my center would be a good resource for more information about these codes?

A: The UB-04 codes are defined by the Centers for Medicare and Medicaid Services (CMS) and your hospital's billing department is a good resource for more information about these codes. The only NTDS instruction that may differ from CMS is the information in the third bullet that states Element value "6. Home" refers to the patient's current place of residence (e.g., Prison, Child Protective Services, etc.)."

Q: When reporting the Highest GCS Total data element, is this to be reported as the highest documented "on" the next calendar day or "through" the next calendar day?

A: For patients that meet this Reporting Criterion, report the patient’s highest total GCS on the calendar day after they arrived at your ED or hospital. For example, a trauma patient with a subdural hematoma arrived and was admitted to your hospital on 01-05-2023. Report the highest total GCS documented on 01-06-2023.

Q: What Element Value is reported for Highest GCS Total if the patient was no longer admitted to my center on the calendar day after ED/hospital arrival?

A: Report the null value “Not Applicable.”

Q: For patients who meet this Reporting Criterion, what should be reported for the Initial ED/Hospital Pupillary Response data element when the patient experiences trauma to one eye, but the other eye was documented as reactive within 30 minutes of ED/hospital arrival?

A: Report the null value “Not Known/Not Recorded.”

Q: For patients that meet this Reporting Criterion, what should be reported for the Initial ED/Hospital Pupillary Response data element if the patient is blind in both eyes?

A: If the patient is blind in one or both eyes, then you should report the appropriate Element Value ("1. Both Reactive", "2. One Reactive", "3. Neither Reactive") that was documented within 30 minutes of the patient's arrival to your ED or Hospital, because, depending on the etiology of their blindness, a patient may still have a pupillary response.

Q: Which Element Value should be reported for the Venous Thromboembolism Prophylaxis Type data element if the patient's first dose of VTE prophylaxis administered was Plavix?

A: Element Value “10. Other” must be reported for patients whose first dose of VTE prophylaxis medication was not a LMWH, direct thrombin inhibitor, Xa inhibitor, or unfractionated heparin.

Q: If a patient was on an anticoagulant at home (e.g., Eliquis) and they were started on the same medication while in the hospital, should we report this for the Venous Thromboembolism Prophylaxis Type data element?

A: If the patient was started back on their routine anticoagulant while in the hospital, and it was specifically for VTE prophylaxis, then you must report the type of VTE prophylaxis administered to the patient.

Q: What if the patient refuses the first dose of VTE Prophylaxis but then agrees to take it two days later?

A: If the patient initially refuses, but later agrees, report the type of first VTE prophylaxis, along with the date/time that first dose was administered.

Q: My center documents blood products in units. Do I need to convert each unit to CCs when reporting these?

A: Yes. The Packed Red Blood Cells (PRBCs), Whole Blood, Plasma, Platelets, and Cryoprecipitate data elements must be reported for all patients and in CCs (mLs).

Q: A patient was transferred to hospice. How should the Withdrawal of Life Supporting Treatment data element be reported?

A: Administering comfort care measures and/or transferring a patient to hospice is different from withdrawing or withholding life-supporting treatment. If the patient was placed in hospice and then expired, then the patient simply died, and Element Value "2. No" must be reported for the Withdrawal of Life Supporting Treatment data element.

Q: What is an example of when the Element Value "1. Yes" should be reported for the Withdrawal of Life Supporting Treatment data element?

A: An example of a patient meeting this definition is: An intubated patient that physicians determined had a very poor prognosis. They discussed this with the patient's family, and they decided to extubate the patient once all the patient's family were able to arrive at the hospital. The patient expired soon after being extubated.

Q: How should this element be reported for patients that meet the Reporting Criterion and had surgery within 24 hours, but it was not documented that the procedure was for hemorrhage control?

A: To report one of the listed procedures, the surgery must have been for hemorrhage control. If this is unclear or missing from the documentation, you may consider checking with your Trauma Medical Director or relevant surgeon to get clarification as to whether the surgery was for hemorrhage control or not.

Q: A patient meets the Reporting Criterion, had surgery for hemorrhage control, but there isn't an Element Value for the type of surgery. How is this reported?

A: Element Value "1. None" is reported if Surgery for Hemorrhage Control Type is not a listed Element Value option.

Q: Does this Reporting Criterion apply to all open fractures or just long-bone fractures?

A: The Reporting Criterion "Report on all patients with any open fracture(s)", applies to ALL AIS code descriptors that contain “open” and all AIS extremity/limb codes that contain “amputation.”

Q: How should the Antibiotic Therapy data element be reported when the patient doesn't have an open fracture, but the AIS code descriptor includes "open" in addition to other descriptors? For example, a patient with a closed, displaced, comminuted nasal fracture assigned an AIS code "251002.2".

A: If the AIS code meets the Reporting Criterion "Collect on all patients with any fracture(s)" and the patient did not receive IV antibiotic therapy within 24 hours after the first hospital encounter, then report the Element Value "2. No" for the Antibiotic Therapy data element.

Q: Can we report antibiotics administered by EMS?

A: Yes. Report Antibiotic Therapy administered to the patient within 24 hours after injury, regardless of where the antibiotics were administered.