data entry: system structure the trauma audit & research network (tarn) data collection session...
TRANSCRIPT
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Data Entry: System structure
The Trauma Audit & Research Network (TARN)
Data Collection session
Log into: https://www.tarn.ac.uk/Training
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Electronic Data Collecting & Reporting system(EDCR) overview
Process of care & outcome data relating to eligible Trauma patients
Secure on-line system (www.tarn.ac.uk):
Username & password required
Patient confidentiality paramount:
Names, Hospital Numbers, Full Postcodes not seen by TARN
Location based system, following patient pathway: From scene to Discharge
Choice of datasets: Core or Extended
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Submission Contains all the data relating to a Patient’s incident:
Patient
Incident
Location
Outcome
Injuries
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Submission Summary screen
Screen showing current STATUS of all your Hospitals’ submissions
You can access any submission by clicking on number adjacent to Status
You can see all submissions created by any User linked to your Hospital
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Submission Status CREATED
DISPATCHED
APPROVED
REJECTED*
RETURNED*
REDISPATCHED*
DISPATCHED & FLAGGED
AWAITING POST
MORTEM**
Incomplete submission, data being entered
Complete submission, TARN to check
Checked & coded by TARN (part of Hospital dataset)
Does not fulfil inclusion criteria
Additional information requested by TARN
Additional information supplied by User
Flagged awaiting matching Transfer or PM PM to be sent to TARN at later date
(reminder email sent regularly)
Only Approved cases are used in Reports
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Searching for submissions
Use any fields on SEARCH screen. FIND Results appear at bottom of screen Access relevant submission by clicking on (12 digit) Submission ID Click REPORT to convert to Excel
Example: Hospital: St Elsewhere3 Admission Dates: 01/05/15-02/05/15 Status: All
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Transfer notification system TRANSFER NOTIFICATION: Submission Summary screen
Shows Missing transfers into/from your Hospital
Hover over Hospital name to show corresponding site coordinator details
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The submission processUser:Create New Submission: Example: Hospital HolbyaNHS Number: 9999999999Date of Arrival: 10/01/2015 Time of Arrival: 10.00
Check for duplicationUnique Submission ID generated Choose Dataset: Core or ExtendedEnter & Save dataValidate dataDispatch
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Standard Screens
Core dataset Extended dataset
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Core Dataset For standard cases
Most fields Mandatory
Contains: ALL Fields used in routine analysis and reporting
Generic screens: Pre Hospital, ED, Critical Care
Limited Observations & Interventions
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Generic Questions
Dates Times Observations (Patient’s observed status on arrival in location)
Requested: Pre Hospital, ED and Critical Care
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Generic QuestionsRequested: Pre Hospital, ED and Critical Care
Interventions (non surgical procedures given to patient in that location)
Attendants (Doctors who treated patient in that location)
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Core Dataset: Observations & InterventionsPre-hospital, ED and Critical Care locations
•Respiratory rate•Oxygen saturation•Blood pressure•Capillary refill
•Pulse rate•Glasgow Coma Score*•Pupil reactivity**
•Pupil size•Airway status•Breathing status
•Airway support•Breathing support•Blood products in 24hrs•Tranexamic Acid
•Chest drain•Spinal protection•Fluid
•Extubation•Spinal Protection Removal •Embolisation
Observations: 1st taken
Interventions:
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*GCS: Glasgow Coma Score: GCS
Measure of a patient’s level of consciousness, taken by assessing: Eye, Verbal and Motor responses.
Ranges from 15 (normal functioning) to 3 (no responses).
Reduced GCS is an indication of a possible brain injury.
Used in the Probability of Survival model
Record: Pre Hospital, ED & at 1st hospital (Transfers in)
One of most important fields in EDCR: Part of the Data Accreditation %
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Rapid Sequence Intubation (RSI) sometimes performed Pre Hospital
RSI: sedation & paralysis of a pt prior to Intubation
GCS3 often documented in ED: THIS SHOULD NOT BE RECORDED
Users should record in ED: Airway Status: Intubated Breathing Status: Ventilated GCS: No Resp Rate: No
Documentation of GCS & Intubation
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**Pupil Reactivity Record: Pre Hospital, ED & Critical Care
Particularly important: When GCS is <15 or Head injury
Included in future Probability of Survival model
One of most important fields in EDCR: Part of the Data Accreditation %
Note: PEARL (Pupils Equal & Reacting to light) Record as BRISK
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Specialist screens
BOAST4Rehabilitation prescriptions
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BOAST 4Guideline derived from BOA & BAPRAS
Severe Open fractures of Tibia
TARN specialist screen used to collect data
Guideline requires: 1. Early identification of severe open fractures of the tibia 2. Joint care from orthopaedic & plastic surgeons 3. Surgical wound debridement & operative fracture stabilisation within 24
hours 4. Definitive soft-tissue cover within 72 hours of injury
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Gustilo Anderson Open fracture Classification
Severe Open Tibial fracture: Gustilo Anderson grade IIIB or IIIC
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Specialist screen – BOAST 4BOAST4 screen appears if User answers “Yes” to question on the Opening section:
“Does this patient have severe open lower limb fractures”?
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BOAST4
“Did the fracture have surgical stabilisation” &
“Was definitive soft tissue cover of injury achieved”
Only answer YES if procedures performed at your Hospital.
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Rehabilitation Prescription
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Core Dataset: Outcome Measures screen
Note: This screen auto-populates post Injury Coding by TARNUsers do not enter data into this screen
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Validating VALIDATE Missing Mandatory (red) & Preferred fields (green) Mandatory fields must be corrected Click here to Dispatch to TARN
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View Diary* Rejected submissions: Reason for rejection noted by TARN in Diary Returned submissions: Additional information requested by TARN in Diary Re-dispatched submissions: User should respond to TARN request in Diary &
then Re-dispatch the submission
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Awaiting Post Mortem** Where selected: User should send Post Mortem to TARN when available Particularly important: Deaths in ED
When sending PMs: Annonymise Include 12 digit submission ID Email to: [email protected] or [email protected] Post Mortems shredded by TARN after coding
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Extended Dataset1. Complex cases
a. Multiple ICU visits
b. Transfers in: bypass ED
2. Or ADDITIONAL data points e.g. Haematology, Blood Gases, Pelvic binder
All Observations, Interventions & Investigations shown
Core fields remain Mandatory
Extended dataset only fields: Not routinely analysed