Handbook for Collection and Review of TARN Data in Ireland

Transcription

1 Major Trauma Audit Handbook for Collection and Review of TARN Data in Ireland NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 1 of 36

2 Title NOCA - Major Trauma Audit Handbook for collection and review of TARN Data in Ireland Document Reference Number; NOCA MTA-HB 01 Version Number 05 Developed by National Office of Clinical Audit Approval Date February 2015 Revision Date February 2017 Change Log Page Heading Change 7 National Office of Clinical Audit Updated to reflect current activity of NOCA (February 2015) 20 Types of TARN Reports Text changes and additions 23 Contacts Update of contact details for NOCA Contact National Office of Clinical Audit. Tel: [email protected] NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 2 of 36

3 Foreword Major Trauma Audit is a milestone development for the National Office of Clinical Audit and for the evolution of trauma care in Ireland. Measuring performance is vital to managing and improving it. We want Irish trauma victims to have the best possible outcomes to ensure their journey from injury to recovery is optimal. Quality data is required so we can understand better the trauma patient journey and when problems are identified intervene to fix them. Benchmarking our hospitals against national and international comparators creates a culture of competition which drives performance and should ultimately benefit the patient. As data co-ordinators you are the eyes and ears of trauma at your hospital; your work will link the care provided to patients by the Ambulance Services, Emergency Medicine, Neurosurgery, Orthopaedics, ICU, Rehabilitation Medicine, General and Cardiothoracic Surgery and more. The future direction of trauma care in Ireland will be defined by the data you collect. I wish you every success in your role. Dr. Conor Deasy Clinical Lead Major Trauma Audit Chair Major Trauma Audit Governance Committee National Office of Clinical Audit NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 3 of 36

4 Table of Contents Introduction... 5 Major Trauma Audit A Short Literature Review... 6 The Trauma Audit and Research Network... 7 The National Office of Clinical Audit... 7 Data capture in hospitals What, How Where?... 8 Data confidentiality for hospital based MTA data coordinators Data Quality Data Entry in TARN edcr for MTA Data Coordinators from Ireland Information on post mortems (autopsy) Reviewing TARN reports The Clinical Governance /Quality and Safety Committee Contacts References Appendix 1: Sample of a HIPE extract from one Hospital Appendix 2: Sample Look-Up list Appendix 3: Guidance for TARN Data Collection in Ireland on Pre- Hospital Data Fields Appendix 4: Identifying first GCS for patients in hospitals Collecting this data for TARN Appendix 5: Rehabilitation Prescription Appendix 6: On-line Resources providing support for clinical audit including major trauma audit NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 4 of 36

5 Introduction The National Office of Clinical Audit (NOCA) commenced the first phase of national data collection for Major Trauma Audit (MTA) in October This audit uses international best practice and trauma audit methodology of the Trauma Audit and Research Network (TARN ) to benchmark hospitals, groups and our overall health systems performance in trauma care against national and international norms. NOCA will utilise the outputs of this audit to help drive quality improvement to achieve the best possible clinical outcomes for our trauma patients. The role of the MTA Data Coordinator in hospitals includes; Identification and submission of relevant trauma cases to the TARN Electronic Data Collection and Reporting (edcr) portal; Working with the local Clinical lead to review and disseminate hospital TARN reports; Membership of the hospital Clinical Governance Committee. The purpose of this Handbook is to provide guidance for data collection and review of audit findings in Ireland. This Handbook will provide you with background information on major trauma audit in Ireland, sources of hospital data and highlight data protection requirements for MTA in Ireland, review of audit findings and reports, and the hospital clinical governance committee. It should be used in conjunction with the current TARN Procedures Manual, which is the primary source of information for TARN and the edcr portal. We hope this handbook will assist your role, and welcome continuous feedback to NOCA. We look forward to working with you to sustain MTA across all trauma receiving hospitals to support excellence in trauma care. Marina Cronin Hospital Relations Manager National Office of Clinical Audit NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 5 of 36

6 Major Trauma Audit A Short Literature Review Traumatic injury remains a global public health problem. Each year, 5.8 million people die from injury, and many more are disabled. It is the leading cause of death of men and women under the age of 45 years. More productive years of life are lost to traumatic injury than heart disease and cancer combined (World Health Organisation (WHO), 2009). Trauma registries have been in existence for more than three decades facilitating local, national and international benchmarking and performance improvement, and are now considered to be an essential component of mature trauma systems (O Reilly et al, 2012). Trauma registries are databases designed to record the acute phase of hospital care delivered to trauma victims. Patients fulfilling specific inclusion criteria usually based on a definition using the international classification of diseases (ICD) are included in the database. Trauma registries generally include information on patient demographics, the circumstances surrounding injury, pre-hospital care and transport, emergency department and in-hospital interventions received, anatomic injury description, physiological measurements, complications, outcomes and patient destinations. They also increasingly include information on pre-existing diseases, recognised as an important determinant of outcome, independent of age and injury severity (Moore and Clarke, 2008). Trauma registries support the performance improvement process through monitoring trauma system trends, supplying benchmarking data, and identifying injury trends including distribution by age, geographic location, and cause of injury (Nwomeh et al, 2006). International research and education has resulted in improved outcomes for injured patients and has transformed the delivery of modern trauma care of which MTA is a crucial component (Victoria State Trauma System, 2009; London Trauma Office, 2011). MTA provides the necessary intelligence to support trauma systems and severely injured patients are 15-20% less likely to die if admitted to a Trauma Centre within an organised trauma system than if admitted to other hospitals (Celso et al, 2006). Trauma registries have a global presence. A recent literature review and web-search identified active trauma registries by publications emanating from the registries in (O Reilly et al, 2012). Most articles sourced registries from the US (288(50%)), followed by Australia (45(8%)), Germany (32(6%)), Canada (27(5%)), UK (13(2%)), China (13(2%)) and Israel (12(2%)). The Americas produced most trauma registry articles and South East Asia the least. The majority of trauma registry articles originated from very highly developed countries 467(82%). Least developed countries had the fewest (5(1%)), (O Reilly et al, 2012) highlighting the global spread of trauma audit. NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 6 of 36

7 The Trauma Audit and Research Network TARN has been at the forefront of quality and research initiatives in trauma care, most recently supporting the development of Major Trauma Networks in the UK. TARN is based on web-enabled collection of a standardised dataset for patients who are admitted to hospital or die in the Emergency Department (ED). This includes injury severity scoring and benchmarking of data which is undertaken at the TARN base in Manchester, UK. Hospital MTA co-ordinators and clinicians will have direct access to their own hospital s data and will be able to compare their performance against aggregated data for similar hospitals. This data includes mechanism of injury, incident and pre-hospital data including ambulance data, observations, investigations and interventions in the emergency department, theatre, critical care and the ward, times to treatment, length of stay, and patient outcomes. TARN uses a model to calculate the probability of survival for particular injuries or combinations of injuries, taking into account the patients age, gender and level of consciousness (GCS) on presentation to the ED. The database then compares the number of expected survivors against the number of actual survivors to produce a rate of survival for each hospital adjusted by the complexity of the major trauma case mix. The National Office of Clinical Audit The National Office of Clinical Audit (NOCA) was established in 2012, through a collaborative agreement between the HSE Quality Improvement Division and the Royal College of Surgeons in Ireland. The primary purpose of NOCA is to establish sustainable clinical audit programmes at national level which will ultimately improve outcomes for Irish patients. NOCA works with multidisciplinary stakeholders from both public and independent providers, to encourage participation and engagement with its audit processes. Recommendations arising from the audits will be returned to hospitals via structured governance systems, and changes applied either through the actions of individual clinicians or through more general systems improvements to the care of patients. NOCA is currently responsible for the national commissioning of the Irish National Orthopaedic Register (INOR), National ICU Audit, Major Trauma Audit (MTA), Comparative Audit of Hospital Mortality, Irish Audit of Surgical Mortality (IASM), and National Emergency Medicine Clinical Audit and provides governance to the Irish Hip Fracture Database (IHFD and the National Perinatal Epidemiology Centre (NPEC). NOCA has facilitated the establishment of a multidisciplinary Major Trauma Audit Governance Committee, with clinical leadership from Emergency Medicine and Trauma Specialists to support the delivery of MTA. NOCA through this Governance Committee will review TARN reports, contextualise them for Ireland, and ultimately propose national aggregate reports for publication through the NOCA Governance Board. NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 7 of 36

8 Data capture in hospitals What, How Where? What? To identify what data you must collect, access the current TARN Audit Proforma, available on the membership area of the TARN site. Alternately, use a data capture device (e.g. laptop/ tablet) to access the edcr on a realtime basis to collect data. How? You need to identify and build key relationships for effective working. Familiarise yourself with all trauma care that is managed in your hospital and in particular, the patient pathway following major trauma. Talking to colleagues in the Emergency Medicine Department, ICU, theatres, HIPE, surgical wards etc. is a good way of finding out where the data you need to access is available from. Introduce yourself and make friends with the key personal in your hospital s IT Department, the Medical Records Department, The HIPE (Hospital In Patient Inquiry) Department, the Medical Administration / Human Resources Department and your local Coroner s Office. In order to facilitate your identification of Major Trauma patients, you will need to request a regular extract from your hospital HIPE department. Appendix 1 is a sample of a HIPE extract. Alternately, you may seek direct access to the HIPE records. For further information on HIPE, visit the Healthcare Pricing Office website; Working with the nominated MTA Clinical Lead in your hospital, create awareness around major trauma audit. Introduce yourself and your role at all relevant department and multidisciplinary meetings. Consider a short submission for your hospital newsletter. Where? The information you require for major trauma audit is readily available as it has been collected as part of routine care or practice. There are very many sources for this information, from the ambulance patient care report (PCR), EM clinical notes, admission records, theatre records, to your hospital patient information system and X Ray system (PACS). You will cross-reference information between sources to ensure that your data is accurate e.g. checking the grade of the doctor attending the patient against the staff list from the medical Administration Department. Figure 1 illustrates the MTA work flow process, illustrating common data sources. This is not exhaustive, so it is important that you familiarise yourself with processes in your hospital. NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 8 of 36

9 Figure 1: MTA work flow process Data Collection and Submission Data Sources MTA Coordinator retrieves list of potential patients HIPE data - S & T Codes ED Register (Manual ) -Transfers out, Deaths Admissions MTA Coordinator reviews data Data accepted Data NOT accepted TARN ICD10 coding for inclusion/exclusion, Query to TARN MTA Coordinator retrieves clinical data MTA Coordinator reviews clinial data No further review Patient Care Report (PCR) (Ambulance) EM Department Chart / Notes EM Department Information System In -patient chart Discharge Letter Hospital Information System (HIS) Discharge letter Data accepted Data NOT accepted No further review Medical Administration Medical Staff List, EM Dept Nursing Staff list Intensive Care Unit (ICU) Clinical Notes Picture Archiving and Communication System - X Ray (PACS) Post Mortem Reports MTA Coordinator collates data Pre- hospital EM Dept, Radiology Theatre Ward Intensive Care Complications Discharge Readmission Death PCR stored in EM Dept Chart (usually) or scanned in ED IS EM Dept chart and ED IS, Staff Lists, HIS PACS, Medical staff list In-patient notes, Theatre IS, Medical staff list In patient notes, HIS ICU notes Discharge Letter, In -patient notes (Medical & nursing notes, drug kardex, PACS) Discharge Letter, In patient notes, HIS Post Mortem Reports MTA Coordinator enters data to TARN MTA Coordinator feedbacks to Clinical Lead and Hospital Trauma Committee NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 9 of 36

10 Data confidentiality for hospital based MTA data coordinators The Data Protection Acts 1988 & 2003 provide the legislative basis for the approach of the Office of the Data Protection Commissioner with regard to personal data in the health service, including clinical audit. The key issue is respect for the patient s reasonable expectation that their health information will be kept confidential (Data Protection Commissioner, 2007). To ensure confidentiality to service users and to enable access to third parties such as NOCA and TARN in this case, all personal data will be pseudonmysed (allocation of unique, reference numbers or codes to identifying data) at hospital level and will not be entered on the TARN edcr. What is Pseudonymisation? Pseudonymisation (or reversible anonymisation ) involves the use of a coding system, i.e. allocating individuals unique reference numbers. The lookup list from which the true identities may be obtained is then held securely and only accessed by authorised persons at that hospital for specific, pre-defined purposes i.e. the MTA data coordinator and the Hospital Clinical Lead. NOCA recommends the look-up list maps the TARN Submission No. to the patient identifiers i.e. Full Name, Date of Birth, Hospital Medical Record Number. This is to facilitate the hospital identifying and re-assessing the data of patients whose care metrics may have fallen outside normal standards identified by anonymised audit by TARN. See Appendix 2 for an example of a look up list. Ensuring data confidentiality practical issues Specific guidance is contained in A practical guide to clinical audit QPSD-D (HSE, 2013) and this includes the following; Data Management Data is only accessible by appropriately authorised staff on a need-to-know basis. At hospital level, this should include the MTA Data Coordinator, Hospital Clinical Lead, Members of the Clinical Governance Committee. Data is checked to ensure confidentiality and accuracy. Data collection sheets and the lookup list should only be kept for the length of time they are absolutely required (for the purposes of the audit). Once they are no longer required, they should be destroyed immediately. Infrastructure Additionally to maintain general security and data protection, MTA coordinators should: Ensure passwords to the computers and specifically to the TARN edcr portal are kept secure at all times and to change passwords as prompted NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 10 of 36

11 Ensure that reports within the edcr are not visible to unauthorised personnel. Lock their workstation if leaving their desk unattended Ensure office is kept secure and always locked when unoccupied Retain all paperwork associated with MTA reports in a locked filing cabinet Use appropriate facilities for disposal of confidential waste Ensure computers are password protected All devices used to store data are encrypted (for example, laptops and USB devices). If laptops / tablets are removed from the work location, the person responsible for that laptop must ensure that it is secure at all times. The hospital should have a central location for the storage of final audit reports (both in hard and soft copy). Archived clinical audits should be stored on a secure computer. Report directly to local hospital management, TARN and NOCA if there has been any breach of security Traceability It is recommended that each hospital maintains a log of all reports generated locally and their status. All reports should be anonymised by MTA data coordinators before being made available for review and consideration by others. Data Quality Major trauma audit relies on capturing all eligible patients; a selection bias whereby only the best outcomes were entered on TARN at a hospital would result in that hospital not improving care to the patients most in need; TARN reports are presented with measures of data capture and completeness. Data can be considered to be of good quality when the correct reliable data is available in a timely manner. Data quality is described through the following dimensions; accuracy, validity, reliability, timeliness and, relevance, legibility and completeness (HIQA, 2013). MTA via TARN, data must be accurate, valid, complete and reliable. For NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 11 of 36

12 Table 1: Ensuring Data Quality for MTA Dimension What is it How? Accurate Data Valid Data Data Completeness It describes or measures what it was designed to describe or measure. It is collected in accordance with any rules / definitions applicable for that information, which benchmarking over time. These rules check for correctness, meaningfulness, and security before the data is processed. It has all those items required to describe or measure the intended activity or event. TARN issue a report of called Data Accreditation. For Accurate Injury Severity Scoring; Particular attention to injury descriptions. For Accurate Probability of Survival (Ps): Particular attention to injury descriptions, age, gender and Glasgow coma scoring in the ED. Use the help text on the TARN edcr portal Use the TARN procedure manual. Use the Handbook for Major Trauma Audit to see data for specific fields. Data is validated on the TARN edcr portal prior to dispatch. This is a measure of frequency of CORE field completion. Pay particular attention to the Core fields are as follows; Glasgow Coma Score or Intubation/ventilation Incident Date/time Arrival time in ED Transfer reason, previous/next hospital/ time of transfer request (2014) CT time Operation time, grade, speciality of surgeon, grade of anaesthetist ED doctors: time, grade & speciality Injury detail proportion of NFS (not further specified) codes Pupil reactivity for patients with Head NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 12 of 36

13 Dimension What is it How? Injuries (2014) Pre-existing conditions (2014) Data Reliability It is collected consistently over time. When reporting findings, use direct NOT TARN issues a Data Completeness secondary reports to ensure accurate report, which is a measure of the and reliable information e.g. X ray report expected verses the submitted reports. from PACS system as opposed to a documented note of this report in the patient record. Ensure all cases meeting TARN inclusion criteria are captured. Data Entry in TARN edcr for MTA Data Coordinators from Ireland. This predominantly includes guidance regarding personal data and data variables contextualised for the Irish Health care Service. This table only focuses on these specific fields in the edcr portal and does not cover all data fields. This should be used in conjunction with the current TARN procedures manual. NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 13 of 36

14 Table 2: Data entry for specific fields in the EDCR (Ireland). Section Question Answer Ireland (See Help Text in the TARN edcr) Hospital Patient Number ED Patient Number Leave both fields blank NHS Patient Number Foreign nationals including those from Ireland should be recorded as: Patient Surname/Family Name X Opening section Patient first name X Full date of birth Answer No to this field Short date of birth Answer No to this field Age Patient Post Code (first part) Enter age in years Use following codes ZZ99 *Patient Post Code (second part) 3WZ Best Practice Tariff Does the patient have a GP? Enter Not Appropriate Presence of a Rehabilitation Prescription? Presence of Physical Factors? Presence of Cognitive / Mood Factors? Answer Yes, No or Not appropriate NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 14 of 36

15 Section Question Answer Ireland (See Help Text in the TARN edcr) Opening section Presence of Psychosocial Factors? Rehabilitation Prescription details? Refer to Appendix 5 for further information on Rehabilitation Prescription Incident Other audits Penetrating Injury Study? Incident Date Incident Time Leave blank This information can be retrieved from the PCR under Clinical Information Time of Onset, Date of Onset. Pre Hospital Pre Hospital Incident Post Code (first part) Incident Post Code (second part) Incident Post Code (1st numeric of second part) Major Trauma Triage Tool Method of transport Leave this blank Not applicable To identify pre-hospital transport by helicopter, look for the following annotation in the Station Code section of the PCR. MV National Ambulance Service Rescue 116- Irish Coast Guard Service (Dublin) Rescue Irish Coast Guard Service (Shannon) Rescue 117- Irish Coast Guard Service (Waterford) Rescue 118- Irish Coast Guard Service (Sligo) Attendants Data variables contextualised from an Irish health care setting have been added. Select from following: Emergency Medical Technician Paramedic Advanced Paramedic To find out the grade of ambulance personnel, go to the Register page of the NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 15 of 36

16 Section Question Answer Ireland (See Help Text in the TARN edcr) following website, and enter the Practitioner PIN into Check the Register Ambulance Service Patient Report Form Number Vehicle Call Sign No Data variables contextualised from an Irish health care setting have been added. Select from following: National Ambulance Service Dublin Fire Brigade Auxiliary / Voluntary Ambulance Providers Private Ambulance Providers Do not enter this number. Refer to Appendix 3 for further information on Pre Hospital / Ambulance Numbers This can be found in the PCR and can be entered onto TARN. Refer to Appendix 3 for further information on Pre Hospital / Ambulance Numbers CAD No Enter 9999 Refer to Appendix 3 for further information on Pre Hospital / Ambulance Numbers Pre- Hospital interventions Blood products Data variables contextualised from an Irish health care setting have been added. In Ireland predominantly Solvent Detergent Plasma is used instead of Fresh Frozen Plasma, Fibrinogen Concentrate is used instead of Cryoprecipitate Octaplex Prothrombin Complex Concentrate and not Beriplex is issued to hospitals. NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 16 of 36

17 Section Question Answer Ireland (See Help Text in the TARN edcr) ED attendants Nursing Medical(Same grades throughout all clinical specialties) Training If Nursing is selected the following drop down list will PG Dip Emergency Nursing Data variables contextualised from an Irish health care setting have been added. Select from following: Nursing Staff Nurse Clinical Nurse Manager I Clinical Nurse Manager II Clinical Nurse Manager III Assistant Director of Nursing Advanced Nurse Practitioner Medical Intern Senior House Officer Registrar Staff Grade Registrar (Usually on Registrar staff rota) Specialist Register Associate Specialist (Usually on Consultant staff rota) Consultant Data variables contextualised from an Irish health care setting have been added. The following have been included: PG Dip Emergency Nursing Post Graduate Diploma in Emergency Nursing Select the appropriate training course at the highest level which the nurse has attended NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 17 of 36

18 Section Question Answer Ireland (See Help Text in the TARN edcr) Training If Doctor (including Advanced Nurse Practitioner) is selected the following drop down list will appear. ATLS, APLS Select the appropriate training course at the highest level which the Doctor (Advanced Nurse Practitioner) has attended Outcome Post Mortem (PM) Where a PM results are awaited from the Coroner, complete the submission, and in the "Outcome" screen, for the PM drop-down box, select "Awaiting Post Mortem". Whilst it will not be possible or feasible for TARN to code all submission, some can be coded and closed. For further information, please contact TARN Support. Submitting PM reports on TARN TARN prefer that the PM report is scanned. If you are faxing a copy of a report, please inform TARN by telephone. It is imperative that reports are fully de-identified; patients, pathologist and coroner details must be fully redacted. Inclusion of injury detail is critical for TARN coding of injuries, as well as cause of death. If you cannot submit the PM, submit the injury detail obtained from the PM at the AT DISCHARGE screen PM Done injuries obtained direct from Pathologist for cases such as this. NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 18 of 36

19 Information on post mortems (autopsy) There are many reasons under which an autopsy is mandatory by law and is referred to the local coroner refer to the coroners service website or seek this information from your own hospital pathology department. Where the autopsy is carried out governs from where the final report is issued. It may be several weeks in some cases months before the post mortem report is available. If toxicology tests (testing for, e.g., alcohol, medications) are required, it could be longer. Queries relating to post mortem results should be made to the relevant Coroner s office. A final post mortem report is returned to the patient s medical chart. In cases where an inquest is to be held, these results will only be released at the discretion of the Coroner. NOCA has engaged with both the Coroners Society and Coroners service implementation team to inform them of MTA and explore the feasibility of expediting Coroners' post mortem reports. The Coroners Society is the professional group representing Irish Coroners. The Coroners Service have advised us that delays will likely be experienced. In these cases, you are advised to complete the submission, and in the "Outcome" screen, for the Post Mortem drop-down box, select "Awaiting Post Mortem". Setting up a local process to access Coroner s reports. TARN may be able to close some submissions. Hospitals participating in the major trauma audit are required to engage directly with their local Coroner. 1.1 For up-to-date contact details for your local Coroner and for further information, refer to the Coroners service website The hospital MTA Clinical Lead and Data Coordinator should meet with their local Coroner to introduce MTA and Trauma Audit Research Network (TARN). 1.3 Inform local Coroner that Coroner s Society are aware and supportive of MTA. 1.4 Where appropriate, identify a liaison person in the Coroner s office to liaise with hospital MTA Data Coordinator 1.5 Agree mechanism required to gain access to reports to include; Mechanism of contact for reports telephone, Process for call down of multiple reports or single reports Mechanism for receipt and acknowledgement of reports Review and feedback process NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 19 of 36

20 Reviewing TARN reports Types of TARN Reports There are two standard reports available via the Trauma Audit and Research Network (TARN) edcr portal. 1. User Generated Reports generated at hospital level usually run on a specified timeline parameters 2. TARN Clinical Working Reports prepared for the National Office of Clinical Audit - issued to hospitals in March, July and November each year, which incorporate information on specified clinical themes : Shocked patients, timeliness of transfers Orthopaedic injuries Traumatic brain injury & spinal injury. Hospitals can request individual reports from TARN. Accessing TARN reports MTA Clinical Leads and Data Coordinators can access these standard reports on their edcr portal. Training for accessing and generating all reports is available to both MTA Clinical Leads and Data Coordinators. NOCA facilitates delivery of this training by TARN representatives at the Royal College of Surgeons in Ireland. Complete information on accessing and generating reports is available in the TARN Procedures Manual. User Generated Reports Once a cohort of submissions are approved by TARN,, local hospital users can generate reports These reports require initial review by the MTA Data Coordinator and Clinical Lead. Generate the initial baseline reports (on current approved submissions). Once the initial baseline report has been developed, NOCA recommends reports are generated on a monthly basis. Monthly reports should be downloaded and trended to clearly illustrate changes. The findings in the User Generated reports should be reviewed by MTA Clinical Leads and Data Coordinators to ensure accuracy and monitor audit findings. Any data inconsistencies identified should be addressed directly with TARN and NOCA. Reviewing TARN Reports 1. An initial review of both the User Generated Reports and TARN Clinical Working Reports prepared for the National Office of Clinical Audit should be carried out by MTA Clinical Lead and Data Coordinator. 2. This initial review may identify issues relating to data quality or potential audit findings for review. 3. Data quality should be addressed with TARN and notified to the Hospital Quality and Safety Committee as well as NOCA. 3.1 An initial review of TARN User Generated Reports may raise an enquiry relating to individual TARN submission such as incorrect or incomplete data. It is possible (though rare) for an ISS coder at NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 20 of 36

21 TARN to make an error. Should individual submissions require review, the Data Coordinator will link the submissions to the patient records to allow in-depth review of the record. It is important that these issues are addressed in your regular review of your hospital s data and then immediately corrected. Following review of the TARN reports, MTA Clinical Lead and/or Data Coordinator should engage directly with TARN and copy to NOCA if there are inaccuracies in data or queries regarding this analysis or any aspect of the findings. Early review will ensure accuracy and validation is achieved in advance of any Clinical Working Reports. 4. Should either the TARN User Generated Reports and the TARN Clinical Working Reports prepared for the National Office of Clinical Audit reports identify significant audit findings or audit outliers, these should be presented to and actioned by the Clinical governance/ Quality and Safety committee. 4.1 Significant audit findings: TARN guidance on review of audit findings and individual case studies is included in the TARN Procedures Manual. The MTA Governance Committee recommends review of following submissions patients with a high Ps score who die and patients with a low Ps score who survive. 4.2 Audit outliers- These will be identified in the TARN Clinical Working Reports prepared for the National Office of Clinical Audit. 4.3 Aspects of clinical practice of particular interest to the hospital e.g. Time to CT scan, Time to surgery for a specific cohort of patients. 5. Report findings and results from these reviews should be presented to the hospital/group clinical governance and Quality and Safety Committee. 5.1: Reporting when things go wrong is essential. If during the course of reviewing the MTA audit findings, a patent safety incident which led to or potentially could lead to unintended and/or unnecessary harm is identified, this should be managed and reported in line with Local and National Safety Incident Management Policies. 6. Where a mechanism exists, knowledge gained from both reports and from reviews should be shared with both local clinical governance leaders and front line staff, facilitating learning from major trauma audit. NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 21 of 36

22 The Clinical Governance /Quality and Safety Committee NOCA works with established Clinical Governance Committees / Quality and Patient Safety Committees in individual Hospitals. It will endeavour to ensure all audit reports and feedback is received by Audit Clinical Leads, Data Coordinators and Hospital Management / Governance / Quality and Safety Committees. Refer to the recent publications from the Quality and Patient Safety Division of the Health Services Directorate (HSE) on Quality and Safety Committees (HSE, 2013; HSE, 2014). Generic Responsibilities of a Hospital Audit Clinical Governance Committee The Governance Committee provides guidance to the audit and lends support to clinical audit staff in achieving overall aims and objectives. It provides both clinical and professional expertise when required, and works closely with the Executive/ Group Clinical Governance Board. Governance Committee responsibilities include: Support the Clinical Lead and Data Coordinator in operational management of the audit; Active review and management of audit findings and reports; Identifying clinical expertise for case review where required; Ensuring that the audit complies with appropriate hospital and national policies. Membership of the Hospital Governance Committee members Relevant specialities and groups representative of local trauma care should be included to ensure objective contribution to decision making and review of audit outputs is adequately achieved. These may include; Local Ambulance Service Representative, Emergency Medicine, Surgery, Paediatrics, Anaesthetics, Radiology, Nursing, Therapy, Hospital Management. NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 22 of 36

23 Contacts National Office of Clinical Audit 4th Floor, 121 St Stephen s Green, Dublin 2 Hospital Relations Manager: Marina Cronin Direct: [email protected] MTA Clinical Lead: Dr. Conor Deasy [email protected] NOCA Manager: Fiona Cahill Direct: [email protected] Trauma Audit and Research Network TRAUMA Audit & Research NETWORK, 3rd Floor, The Mayo Building, Salford Royal NHS Foundation Trust, Salford, England, M6 8HD Telephone: (0) EDCR helpdesk: (0) /5909 Fax: (0) [email protected] NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 23 of 36

24 References British Society of Rehabilitation Medicine (2013) Specialist Rehabilitation in the Trauma pathway: BSRM core standards Version 1.3 October Available at: (Accessed on: 12/02/2014). Celso B., Tepas J., Langland-Orban B., Pracht E,. Papa L., Lottenberg L., and Flint L., (2006) A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centres following the establishment of trauma systems. The Journal of Trauma, 60(2), Data Protection Commissioner (2007) Data Protection Guidelines on research in the Health Sector,(Data Protection Commissioner: Mr. Billy Hawkes). Available at: (Accessed on: 17/06/2013). Economic and Social Research Institute (ESRI) (2013) Hospital In-Patient Inquiry Scheme Data Dictionary 2013, version 5. Available at: (Accessed on: 06/11/2013). Egan, J. (2011) STN003-PCR Information Standard-V2 (Approved by: Council). Available at: ical_resources/information_management/pcr_information_standard.aspx?hkey= ab6-470b-b054- f5bd (Accessed on 07/01/2014). Health Services Executive (2013) A practical guide to clinical audit QPSD-D (Chair: Dr Ian Callanan) Available at: (Accessed on; 17/01/2014) Health Services Executive (2013) Quality and Safety Committees, Guidance and Sample Terms of Reference. Available at: (Accessed on: 20/08/2014). Health Services Executive (2014) Report of the Quality and Safety Clinical Governance Development Initiative, Sharing our Learning. Available at: (Accessed on: 20/08/2014). Health Information and Quality Authority (2013) Guidance on information governance for health and social care in Ireland. Available at: (Accessed on 09/07/2013) London Trauma Office (2011) Mid-Year Report for the period April-September NHS. Available at: (Accessed on; 17/06/2013). Moore L, Clark DE. (2008) The value of trauma registries. Injury 39(6), National Trauma Audit Committee of the Royal College of Surgeons of Ireland (2010) The Implementation of a National Trauma Audit (Chair: Miss Patricia Houlihan), Personal communication. Nwomeh, BC., Lowell, W., Kable, R., Haley, K., and Ameh, EA. (2006) History and development of trauma registry: lessons from developed to developing countries. World Journal of Emergency Surgery, Avaliable at: (Accessed on; 17/06/2013). NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 24 of 36

25 O'Reilly GM, Cameron PA, and Joshipura M. (2012) Global trauma registry mapping: a scoping review. Injury. 43(7), Victoria State Trauma System (2009) Trauma towards Review and future directions of the Victorian State Trauma System. Available at: -Review-and-futuredirections-of-the-Victorian-State-Trauma-System (Accessed on; 17/06/2013). World Health Organisation, (2009) Guidelines for trauma quality improvement programmes. Available at: (Accessed on; 17/06/2013). NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 25 of 36

26 Appendix 1: Sample of a HIPE extract from one Hospital. REPORT NAME Total Time Period -Date HIPE Extract for MTA Number of reports returned based on request Set a discharge date, consider weekly or monthly basis. DIAG CODE The Principal Diagnosis is between S00 and S99. The Principal Diagnosis is between T00 and T14. The Principal Diagnosis is between T20 and T31. Request for Data Variable DIAG CODE MRN FULLNAME EMADM ADMDATE DISDATE DOB AGE GENDER Explanation (ERSI, 2013) HIPE Codes Comment This can be divided into "principle " and "additional diagnosis" codes. A PRINCIPLE DIAGNOSIS is one which is chiefly responsible for the current episode of care. An ADDITIONAL DIAGNOSIS is one which co-exists with a principle diagnosis or occurs during episode of care. Patient Medical Record No Patient Name Type of admission- This indicates the priority of the admission Admission date to hospital Discharge date from hospital Date of Birth - This will be useful for retrieving patient chart and results. age Male / Female This is the filter for your list i.e. all patients with based on S and T Codes. TARN suggest include upto diagnostic 5 codes 1 Elective For MTA-This will help 2 Elective Readmission you to identify "emergency" admissions, 4 Emergency as well as "Elective and 5 Emergency Readmission Emergency Readmissions" 6 Maternity 7 New born (0-27 days) NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 26 of 36

27 Request for Data Explanation (ERSI, 2013) HIPE Codes Comment Variable ADMTYPE Source of Admission - 1 Home Useful to identify Where the patient was prior to admission. 2 Transfer from nursing home/convalescent home or other long stay accommodation transfers in 3 Transfer from Hospital in Hospital code list or transfer from any Acute Hospital not specified in Hospital Code Listing 4 Transfer from Non-Acute Hospital not in Hospital Code Listing DISCHARGE CODE Identifies the discharge destination 5 Transfer from hospice not in Hospital Code Listing 6 Transfer from psychiatric hospital/unit 7 New born 8 Temporary place of residence (e.g. hotel) 9 Prison 0 Other 00 - Self discharge Also useful to identify 01 - Home transfers out, deaths 02 - Nursing home, convalescent home or long stay accommodation 03 - Emergency Transfer to Hospital in Hospital Code Listing or transfer to any Acute Hospital not specified in Hospital Code Listing 04 - Non Emergency Transfer to Hospital in Hospital Code Listing or transfer to any Acute Hospital not specified in Hospital Code Listing 05 - Transfer to psychiatric hospital/unit 06 - Died with post mortem 07 - Died no post mortem 08 - Emergency Transfer to Non- Acute hospital not in Hospital Code Listing 09 - Non Emergency Transfer to Non-Acute hospital not in Hospital Code Listing 10 - Transfer to external rehabilitation facility (not in Hospital Code Listing) 11 - Hospice (not in Hospital Code Listing) NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 27 of 36

28 Request for Data Variable LOS ITU/ICU days TRANS -IN-HOSP Explanation (ERSI, 2013) HIPE Codes Comment Length of stay in hospital This identifies the number of days, or part thereof, the patient spent in an intensive care environment e.g. ICU/ITU/CCU/HDU/NITU etc. Name of Hospital where patient was transferred in 12 - Prison 13 - Absconded 14 - Other (e.g. Foster care) 15 - Temporary place of residence (e.g. hotel) Dublin and Mid Leinster Region 0100 St. Mary s Hospital, Phoenix Park 0101 St. Columcille s Hospital, Loughlinstown 0102 Naas General Hospital 0106 Cherry Orchard Hospital, Ballyfermot 0201 Midland Regional Hospital, Portlaoise 0202 Midland Regional Hospital, Mullingar 0203 Midland Regional Hospital,Tullamore Dublin and North East Region 0400 Louth County Hospital, Dundalk 0402 Cavan General Hospital 0403 Our Lady s Hospital, Navan 0404 Monaghan General Hospital 0922 Our Lady of Lourdes Hospital, Drogheda 0108 Connolly Hospital Blanchardstown Useful for TARN data re ICU List of Hospitals for Transfers-In and Out Western Region 0300 Midwestern Regional Hospital, Dooradoyle 0301 Midwestern Regional Maternity Hospital Limerick 0302 Midwestern Regional Orthopaedic Hospital, Croom NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 28 of 36

29 Request for Data Variable TRANS -IN-HOSP Explanation (ERSI, 2013) HIPE Codes Comment Name of Hospital where patient was transferred in 0304 Midwestern Regional Hospital, Nenagh 0305 Midwestern Regional Hospital, Ennis 0500 Letterkenny General Hospital List of Hospitals for Transfers-In and Out TRANS-OUT-HOSP Name of Hospital where patient was transferred out to 0501 Sligo General Hospital 0502 Our Lady s Hospital, Manorhamilton 0800 Galway University Hospitals 0801 Merlin Park University Hospital, Galway 0802 Mayo General Hospital 0803 Roscommon County Hospital 0805 Ballina District Hospital 0919 Portiuncula Hospital, Ballinasloe Southern Region 0600 Waterford Regional Hospital (Ardkeen) 0601 St. Luke s General Hospital, Kilkenny 0602 Lourdes Orthopaedic Hospital, Kilcreene 0605 Wexford General Hospital 0607 South Tipperary General Hospital, Clonmel 0608 Our Lady s Hospital, Cashel 0701 St. Mary s Orthopaedic Hospital, Gurranabraher 0703 Mallow General Hospital 0704 Bantry General Hospital 0705 St. Finbarr s Hospital, Cork 0724 Cork University Hospital (Includes Cork University Maternity Hospital) 0725 Erinville Hospital, Cork (Closed March 2007) 0726 Kerry General Hospital Voluntary Hospitals 0901 Adelaide Hospital, Dublin 0903 Meath Hospital, Dublin 0904 St. James s Hospital, Dublin 0908 Mater Misericordiae University Hospital, Dublin NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 29 of 36

30 Request for Data Variable TRANS-OUT-HOSP Explanation (ERSI, 2013) HIPE Codes Comment Name of Hospital where patient was transferred out to 0910 St. Vincent s University Hospital, Elm park 0912 St. Michael s Hospital, Dun Laoghaire 0913 Mercy University Hospital, Cork South Infirmary/Victoria, Cork 0918 St. John s Hospital, Limerick 0923 Beaumont Hospital, Dublin 0925 Peamount Hospital, Newcastle 0930 Coombe Women and Infants University Hospital, Dublin 0931 National Maternity Hospital, Holles St, Dublin 0932 Rotunda Hospital, Dublin 0934 Waterford Maternity Hospital 0940 The Children s University Hospital, Temple St, Dublin 0941 Our Lady s Children s Hospital, Crumlin 0943 National Children s Hospital, Harcourt St 0945 St. Anne s Hospital, Dublin 0946 Hume St. Hospital, Dublin 0947 St. Luke s Hospital, Rathgar 0948 St Luke's Radiation Oncology Network - St James's Centre 0949 St Luke's Radiation Oncology Network - Beaumont Centre 0950 Royal Victoria Eye & Ear Hospital, Dublin List of Hospitals for Transfers-In and Out 0954 Incorporated Orthopaedic Hospital, Clontarf 0955 National Orthopaedic Hospital, Cappagh 0956 St. Mary s Auxiliary Hospital, Baldoyle 0960 National Rehabilitation Hospital, (NHR), Dun Laoghaire 0978 Our Lady s Hospice, Harold s Cross, Dublin 1225 St. Joseph's Unit, Harold s Cross NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 30 of 36

31 Request for Data Variable TRANS-OUT-HOSP Explanation (ERSI, 2013) HIPE Codes Comment Name of Hospital where patient was transferred out to 1270 Adelaide, Meath Incorporating National Children s Hospital (AMNCH), Tallaght 1762 St. Joseph s Hospital, Raheny 1001 Blackrock Hospice Other Acute Hospitals (not in Hospital Code List above) 9030 Acute Hospital in Northern Ireland 9031 Acute Hospital in England 9032 Acute Hospital in Scotland 9033 Acute Hospital in Wales 9040 Acute Hospital in France 9041 Acute Hospital in Germany 9050 Acute Hospital in the United States of America 9060 Private Hospital 9099 Other Acute Hospital List of Hospitals for Transfers-In and Out NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 31 of 36

32 Appendix 2: Sample Look-Up list TARN Submission no Patient Name Medical Record Number Date of birth Mary Smith /09/ John Smith /12/ NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 32 of 36

33 Appendix 3: Guidance for TARN Data Collection in Ireland on Pre- Hospital Data Fields Data field Definition Patient Report Form Number In Ireland, the Patient Report Form is called the Patient Care Report (PCR). The PCR No number comprises of 4 elements as follows; EMS Control Centre code, Incident number, Vehicle call sign, The fourth elements indicate first, second or third patient, A, B or C in a possible multiple person incident travelling in the same ambulance (1). This is a sequential number of report forms completed by EMS staff. It is linked to the patient (1).. The Entry Format on the PCR is Alphanumeric. All PCR Forms are electronically stored. Guidance for Data Entry Ireland Do not enter this number. Vehicle Call Sign No CAD No This is the call sign or number allocated to specific vehicles within the service providers. This number is specific to each Vehicle, and allows ambulance control centres to track each vehicle and alert them to calls in their area (1). The Entry Format on the PCR is Alphanumeric. This is a sequential Incident number generated for each incident by the individual service providers. This number can be linked to one patient or to multiple patients for example in cases where multiple patients are involved in a multi vehicle road traffic collision. This is recorded in the Incident Number section (1). The Entry Format on the PCR is Alphanumeric. This can be found in the PCR and can be entered onto TARN. Enter 9999 Reference (1). Egan, J. (2011) STN003-PCR Information Standard-V2 (Approved by: Council). Available at: ndard/phecc/clinical_resources/information_management/pcr_information_standard.aspx?hke y= ab6-470b-b054-f5bd (Accessed on 07/01/2014). NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 33 of 36

34 Appendix 4: Identifying first GCS for patients in hospitals Collecting this data for TARN The first Glasgow Coma Score in hospital (mostly in the Emergency Department) is critical data requirement to TARN methodology. It is essential to the Probability of Survival score of each individual patient. While all patients are assessed on admission, recommended practice is that all multiple trauma patients and any patient with an altered level of consciousness should have a baseline Glasgow Coma Scale (GCS) Score recorded. However, if it is clear that the patient has not had any loss of consciousness, this may not always be documented in a Neurological Observation Chart. However, this information may be located in the patient notes. Where there is doubt, please consult with your clinical lead. Identifying first GCS for patients in hospitals Where is this information found? Neurological Observation Charts Early Warning score chart How is this information recorded? Eye Score (1-4) Verbal Score (1-5) Motor Score (1-6) The patients level of consciousness may also be initially checked using the AVPU scale. A Alert Record GCS in TARN Total GCS score -15 This may also be documented in the medical notes. Record as missing, assumed normal Where a GCS is not recorded the patient and the patient is fully awake and talking, they are alert (A). V Responds to Voice Record as missing, assumed abnormal P Responds to Pain U Unresponsive Where a GCS is not recorded the patient and the patient responds only to voice (V), pain (P) or is unresponsive (U). Medical Notes / Nursing Notes / Triage notes OTPP / OTTPP this means Orientated to Time, Place and Person. If there is no score, record as missing, assumed normal Impact on TARN Where the option of missing, assumed normal is entered: This is counted as GCS 15 in the individual Ps calculation This is classed as `missing data` and will impact slightly in the submission accreditation score (%) for the hospital. NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 34 of 36

35 Appendix 5: Rehabilitation Prescription The Rehabilitation prescription (RP) is used to document the rehabilitation needs of severely injured patients (ISS score 9) and identify how they will be addressed. The RP should be initiated within 1 working week of admission to the trauma service (Ireland, Rehabilitation Medicine Clinical Care Programme, 2014) The RP may be completed by any suitably qualified member of staff, including a Senior (Band 7) Allied Health professional (AHP) or therapist. In Ireland, this will usually be carried out by a Rehabilitation Medicine Specialist. The RP encompasses several different components, including: A description of the injuries, relevant psycho-social background, risks and treatment to date An individualized (text-based) description of rehabilitation needs/recommendations in sufficient detail to inform planning and delivery of on-going rehabilitation/care. Four essential data items for reporting to TARN 1. Confirmation that a RP was completed or not required 2. Presence of physical disability affecting activities or participation 3. Presence of cognitive/mood factors affecting activities or participation 4. Presence of psychosocial factors affecting activities or participation. Examples of Physical, Cognitive /Mood, Psychosocial Factors Example of physical factors Example of Cognitive / Mood Example of psychosocial factors Factors Complex musculoskeletal management Complex neuro-rehabilitation Complex amputee rehabilitation needs Re-conditioning / cardiopulmonary rehab Complex pain rehabilitation Profound disability / neuropalliative rehabilitation Complex communication support Cognitive assessment/management Complex mood evaluation / support Challenging Behaviour management Evaluation of Low Awareness state Complex discharge planning eg Housing / placement issues, Major financial issues Uncertain immigration status Major family distress / support Emotional load on staff Specialist Rehabilitation in the Trauma pathway: BSRM core standards Version 1.3 October 2013 (British Society of Rehabilitation Medicine 2013) NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 35 of 36

36 Appendix 6: On-line Resources providing support for clinical audit including major trauma audit This dedicated website includes information on coroner s service including post mortem. This website has information for citizens but also provides guidance to organisations. This website has the current version of the clinical audit guidelines. This website outlines includes information on clinical governance from the HSE Quality and Patient safety Division. This website provides information on all NOCA audits including the current major trauma audit. This website outlines on-going patient safety initiatives and activities in Ireland including progress of the project groups which are driving the implementation of recommendations from the Commission on Patient Safety and Quality Assurance. The website of the Trauma Audit and Research network with a dedicated membership area. NOCA MTA-HB 01 v5. Effective Date: Feburary,2015 Page 36 of 36