Download National Trauma Registry Comprehensive Data Set—Data

National Trauma Registry Comprehensive
Data Set—Data Dictionary
Standards and Data Submission
Our Vision
Better data. Better decisions.
Healthier Canadians.
Our Mandate
To lead the development and
maintenance of comprehensive
and integrated health information
that enables sound policy and
effective health system management
that improve health and health care.
Our Values
Respect, Integrity, Collaboration,
Excellence, Innovation
Table of Contents
Revision History ............................................................................................................................ v
Acknowledgements ..................................................................................................................... vii
Section 1—Introduction................................................................................................................. 1
History ....................................................................................................................................... 2
Participating Facilities and Provinces ........................................................................................ 4
Data Dictionary Layout .............................................................................................................. 5
Trauma Defined ......................................................................................................................... 5
Null Values ................................................................................................................................ 6
Section 2—Data Elements ............................................................................................................ 7
Section 2A—Demographic Data ................................................................................................... 7
Institution Number ..................................................................................................................... 7
Trauma Number ........................................................................................................................ 8
Fiscal Year of Patient Discharge ............................................................................................... 9
Province .................................................................................................................................. 10
Unique Personal Identifier ....................................................................................................... 11
Age .......................................................................................................................................... 12
Sex .......................................................................................................................................... 13
Postal Code ............................................................................................................................. 14
Section 2B—Injury Data .............................................................................................................. 15
Date of Injury ........................................................................................................................... 15
Time of Injury ........................................................................................................................... 16
Place of Incident (ICD-9-CM) .................................................................................................. 17
Place of Incident (ICD-10-CA) ................................................................................................. 18
Injury Etiology (ICD-9-CM) ...................................................................................................... 19
Injury Etiology (ICD-10-CA) ..................................................................................................... 20
Injury Type ............................................................................................................................... 21
Nature of Injury Codes (ICD-9-CM) ......................................................................................... 22
Nature of Injury Codes (ICD-10-CA)........................................................................................ 23
Sports/Recreational Activity Code ........................................................................................... 24
Work-Related Code ................................................................................................................. 25
Protective Devices ................................................................................................................... 26
Section 2C—Scene Data ............................................................................................................ 27
Modes of Transport to Trauma Centre .................................................................................... 27
Systolic Blood Pressure on Arrival at Scene ........................................................................... 28
National Trauma Registry Comprehensive Data Set—Data Dictionary
Unassisted Respiratory Rate on Arrival at Scene ................................................................... 29
Heart Rate on Arrival at Scene ................................................................................................ 30
Glasgow Coma Scale—Eye at Scene ..................................................................................... 31
Glasgow Coma Scale—Verbal at Scene ................................................................................. 32
Glasgow Coma Scale—Motor at Scene .................................................................................. 33
Total Glasgow Coma Scale at Scene ...................................................................................... 34
Section 2D—Lead/Trauma Hospital: Pre-Admission Data ......................................................... 35
Inter-Facility Transfer............................................................................................................... 35
Transferring Institution ............................................................................................................. 36
ED Bypass ............................................................................................................................... 37
Date of Arrival .......................................................................................................................... 38
Time of Arrival ......................................................................................................................... 39
Temperature on Arrival ............................................................................................................ 40
Systolic Blood Pressure on Arrival .......................................................................................... 41
Intubation Code on Arrival ....................................................................................................... 42
Unassisted Respiratory Rate on Arrival................................................................................... 43
Heart Rate on Arrival ............................................................................................................... 44
Paralytic Agents ...................................................................................................................... 45
Glasgow Coma Scale—Eye .................................................................................................... 46
Glasgow Coma Scale—Verbal ................................................................................................ 47
Glasgow Coma Scale—Motor ................................................................................................. 48
Total Glasgow Coma Scale ..................................................................................................... 49
Total Revised Trauma Score on Arrival................................................................................... 50
Blood Alcohol Concentration ................................................................................................... 51
Post-ED/-Arrival Destination .................................................................................................... 52
Section 2E—Lead/Trauma Hospital: Post-Admission Data ........................................................ 53
Date of Admission ................................................................................................................... 53
Length of Stay ......................................................................................................................... 54
Intensive Care Unit Days ......................................................................................................... 55
Predot Injury Codes (AIS 1990) .............................................................................................. 56
Predot Injury Codes (AIS 2005, Update 2008) ........................................................................ 57
Severity Codes and ISS Body Regions (AIS 1990) ................................................................. 58
Severity Codes and ISS Body Regions (AIS 2005, Update 2008) .......................................... 59
MAIS Code by ISS Body Region (AIS 1990) ........................................................................... 60
MAIS Code by ISS Body Region (AIS 2005, Update 2008) .................................................... 61
Injury Severity Score (AIS 1990) ............................................................................................. 62
Injury Severity Score (AIS 2005, Update 2008)....................................................................... 63
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Number of Ventilator Days ...................................................................................................... 64
OR Procedures (ICD-9-CM) .................................................................................................... 65
OR Procedures (ICD-10-CA) ................................................................................................... 66
Date of OR Procedures (ICD-10-CA) ...................................................................................... 67
Comorbidities .......................................................................................................................... 68
Comorbidities (ICD-10-CA)...................................................................................................... 69
Complications .......................................................................................................................... 70
Complications (ICD-10-CA) ..................................................................................................... 71
Date of Discharge .................................................................................................................... 72
Separation Status .................................................................................................................... 73
Discharge Disposition .............................................................................................................. 74
Section 3—Appendices ............................................................................................................... 75
Appendix A: Sports/Recreational Activity Codes ..................................................................... 75
Appendix B: Inclusion Lists—ICD-10-CA ................................................................................ 79
Appendix C: Exclusion Lists—ICD-10-CA ............................................................................... 81
Appendix D: Injury Types ........................................................................................................ 83
Appendix E: List of Comorbidities and Accompanying Definitions .......................................... 85
Appendix F: List of Complications and Accompanying Definitions .......................................... 91
Appendix G: Definitions of Discharge Disposition Institutions ................................................. 97
Appendix H: Revised Trauma Score ....................................................................................... 99
Appendix J: Acceptable Procedures Performed in the ICU ................................................... 101
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Revision History
Date
Version Description
Data Elements Affected
August 2010
1.0
Initial document
N/A
March 2011
2.0
Definition and code corrections
All
July 2012
3.0
Definition or value changes
Postal Code
Comorbidities
Separation Status
Intensive Care Unit Days
Code corrections
Appendix F—Pneumonia
Appendix J—Procedures Performed in the ICU
Clarifications
Injury Type
Protective Devices
Modes of Transport
Time of Arrival
Blood Alcohol Concentration
Number of Ventilator Days
OR Procedures
Comorbidities (ICD-10-CA)
Complications (ICD-10-CA)
Effective date changed to 2012
All new and revised data elements
Deletion
Appendix G—List of Valid Institution Numbers
per Province
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Acknowledgements
This document was made possible by the contributions of the following people:
•
Dr. Avery Nathens, Trauma Association of Canada
•
Dr. Mary Van Wijngaarden Stephens, Trauma Association of Canada
•
Ms. Maureen Brennan, Trauma Association of Canada/Trauma Registry Information
Specialists of Canada
•
Ms. Ali Moses McKeag, Canadian Institute for Health Information
•
Ms. Tonia Forte, Canadian Institute for Health Information
•
Ms. Tamara Williams, Canadian Institute for Health Information
•
Ms. Beth Sealy, Provincial Trauma Registry Representative, Nova Scotia
•
Ms. Sharon Kasic, Provincial Trauma Registry Representative, British Columbia
•
Ms. Nasira Lakha, Provincial Trauma Registry Representative, British Columbia
•
Ms. Christi Findlay, Provincial Trauma Registry Representative, Alberta
•
Ms. Irma Brown, Provincial Trauma Registry Representative, Alberta
•
Mr. Mike Hoppensack, Provincial Trauma Registry Representative, Manitoba
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Section 1—Introduction
The National Trauma Registry (NTR) is made up of two data sets: the minimal data Set (MDS)
and the comprehensive data set (CDS). The NTR MDS is downloaded from the Discharge
Abstract Database and Hospital Morbidity Database and includes all hospital admissions coded
with a range of selected International Classification of Disease (ICD) cause of injury codes. The
NTR CDS is made up of detailed trauma data that is collected at specific trauma hospitals
across the country and submitted to CIHI. This document will focus on the NTR CDS. Details on
the data elements included in the NTR MDS can be found on CIHI’s website at www.cihi.ca/ntr.
The purpose of the National Trauma Registry Comprehensive Data Set Data Dictionary is to
provide a clear definition of and data entry instructions for each data element within the NTR
CDS. This will provide consistency in data collection across the country as well as aid in the
interpretation of this data. An additional benefit will be increased data quality.
The NTR CDS is managed by the Canadian Institute for Health Information (CIHI). Data is
obtained from participating facilities in nine provinces (British Columbia, Alberta, Saskatchewan,
Manitoba, Ontario, Quebec, New Brunswick, Nova Scotia and Newfoundland and Labrador).
The goals of the NTR are to
•
Contribute to the reduction of injuries and related deaths in Canada by providing data which
will allow for the examination of national injury epidemiology;
•
Facilitate provincial and international injury comparisons;
•
Increase awareness of injury as a public health problem in Canada;
•
Assist injury prevention programs; and
• Facilitate injury research.
The NTR CDS consists of information on patients hospitalized with major trauma in participating
hospitals in Canada. Trauma cases are selected based on an Injury Severity Score (ISS)
greater than 12 and the presence of specific external cause of injury codes that meet the
definition of trauma. Many participating provinces use specialized trauma software (such as
Collector from Digital Innovation and Tri-Code from Tri-Analytics, Inc.) to collect the data on
injury cases. NTR CDS data is a subset of participating provincial trauma registries and is
electronically submitted to CIHI.
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National Trauma Registry Comprehensive Data Set—Data Dictionary
A trauma case is included in the NTR CDS if it
•
Has an ISS greater than 12, using an international scoring system created to calculate the
severity of injury;
•
Has an ICD external cause of injury code that meets the definition of trauma (see Appendix B
for more detail); and
•
Meets one of the following criteria:
− Admitted to a participating hospital; or
− Treated in the emergency department of a participating hospital (not admitted); or
− Died in the emergency department of a participating hospital after treatment was initiated
(not admitted).
The NTR Advisory Committee (NTRAC) is co-chaired by members of the Trauma Association of
Canada (TAC). Traditionally, the co-chair positions have been filled by a TAC full member and a
member of the Trauma Registry Information Specialists of Canada (TRISC). NTRAC includes
provincial representation from trauma care experts from across the country and has played a
key role in the development of the NTR. The role of this group has included advising on the
goals and objectives of the NTR, uses of the data, definitions, inclusion/exclusion criteria, data
quality issues, report formats and development of promotional strategies.
Although an NTR CDS data submission specifications document exists, the need for a
comprehensive NTR CDS data dictionary was identified. This project, a joint effort between TAC
and CIHI, was initiated in 2005. An NTRAC subcommittee was formed with representation from
TAC (members who are medical doctors), TRISC and CIHI. Input was sought from provincial
trauma registry contacts from submitting provinces as well as NTRAC members. The process
involved a comprehensive review of the existing NTR CDS data elements and existing
definitions. Changes were made to some existing NTR CDS data element names and
definitions, and new data elements were proposed for inclusion in the data set.
The American National Trauma Data Standard Dictionary was referred to during the
development of the NTR data dictionary to guide decisions on data element definitions to allow
for international data comparisons.
History
The establishment of the NTR, including the acquisition, analysis and dissemination of national
injury data, is consistent with the mission, vision and corporate goals of CIHI. CIHI worked
toward the establishment of the NTR from the creation of the Ontario Trauma Registry in May
1992 at the Hospital Medical Records Institute, one of CIHI’s founding organizations.
The number of data elements in the NTR CDS was expanded from 17 to 45 for the collection of
1999–2000 data, as approved by members of the NTR CDS Working Group and as part of
CIHI’s Roadmap Initiative. Elements added include the following:
2
•
Sports/Recreational Activity Code;
•
Work-Related Code;
National Trauma Registry Comprehensive Data Set—Data Dictionary
•
Protective Devices;
•
Total Revised Trauma Score on Arrival;
•
Severity Codes and ISS Body Regions (AIS 1990); and
• Various data elements related to vital signs upon arrival at the trauma hospital.
The following data elements were added in 2012, as the outcome of the NTR data dictionary
development project:
•
Transferring Institution
•
ED Bypass
•
Systolic Blood Pressure on Arrival at Scene
•
Heart Rate on Arrival at Scene
•
Unassisted Respiratory Rate on Arrival at Scene
•
Glasgow Coma Scale—Eye at Scene
•
Glasgow Coma Scale—Verbal at Scene
•
Glasgow Coma Scale—Motor at Scene
•
Total Glasgow Coma Scale at Scene
•
Time of Arrival
•
Temperature on Arrival
•
Heart Rate on Arrival
•
Post-ED/-Arrival Destination
•
Intensive Care Unit Days
•
Date of OR Procedures
•
Comorbidities
•
Injury Severity Score (AIS 2005, Update 2008)
•
Predot Injury Codes (AIS 2005, Update 2008)
•
Severity Codes and ISS Body Region (AIS 2005, Update 2008)
• MAIS Code by ISS Body Region (AIS 2005)
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Participating Facilities and Provinces
Table 1: Participating Provinces and Number of Facilities, NTR CDS, 1999–2000 to 2010–2011
Number of Participating Facilities by Fiscal Year
Province
1999–
2000
2000–
2001
2001–
2002
2002–
2003
2003–
2004
2004–
2005
2005–
2006
2006–
2007
2007–
2008
2008–
2009
2009–
2010
2010–
2011
B.C.
5
8
6
6
7
9
8
9
10
12
9
9
Alta.
4
4
4
4
4
4
4
4
4
9
10
11
Sask.
0
0
0
0
0
0
0
0
0
0
2
2
Man.
1
1
1
1
1
1
1
1
1
1
1
1
Ont.
13
13
13
13
13
13
13
13
13
13
13
13
Que.
0
6
6
6
6
6
6
59
59
59
59
61
N.B.
0
1
1
1
1
1
1
1
1
1
1
1
N.S.
2
9
10
10
10
10
10
10
10
10
10
10
P.E.I.
0
0
0
0
0
0
0
0
0
0
0
0
N.L.
0
0
0
0
3
3
3
3
3
3
3
3
In previous years, the number of participating provincial/regional trauma registries and facilities
has differed slightly in the NTR CDS. As well, there is significant variation in trauma system
configuration across provinces, as well as some re-assignments of facility numbers when
mergers take place. Therefore, trends and comparisons over time and across provinces should
be interpreted with caution.
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Data Dictionary Layout
The data elements are grouped according to the type of data they cover. Each data element will
have the following specifications:
Name in Database
The actual name of the field in the NTR CDS
Definition
The NTR definition of the data element
Data Type
The type of data that can be entered into the field, usually CHAR for character, DATE for
date or NUMB for number. For instance, NUMB indicates that the field is restricted strictly
to numeric values.
Data Element Length
The number of characters required for that data element. For example, “21” cannot be
entered into a field with a data element length of 1. When decimal places are accepted for
a data element, they are denoted by a number following a comma. For example, “5, 2”
denotes a total field length of 5, including 2 decimal places.
Mandatory
A simple yes or no signifying whether the data element is mandatory for submission to the
NTR CDS
Field Values
A list of the possible values that may be entered into the field for the data element, either
the format of the field or a range of accepted values
Constraints
Any constraints on the values that can be input
Null Values
Null values accepted in most fields. Submitted null values are transformed on site at CIHI
into the required format for the database (see page 6).
Source
Indicates whether the data is calculated or directly input
Hierarchy
Source hierarchy for finding data elements in the patient’s chart
Additional Information Any additional directives for entering data into the data element will be written in this box. It
also contains any other information that would be useful for someone who is either
documenting the data or analyzing the information.
Uses of Data
How the data element is used
History
Historical changes to the data elements, with effective dates of changes
Trauma Defined
A trauma case is included in the NTR CDS if it
•
Has an ISS greater than 12, using AIS 1990 or AIS 2005, an international scoring system
created to calculate the severity of injury;
•
Has an ICD external cause of injury code that meets the definition of trauma (see Appendix B
for more detail); and
•
Meets one of the following criteria:
− Admitted to a participating hospital; or
− Treated in the emergency department of a participating hospital (not admitted); or
− Died in the emergency department of a participating hospital after treatment was initiated
(not admitted).
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Null Values
Missing Value Label
6
Collector Value
Database Value
Not Known
(Unknown)
U
9; or
99 (for data elements with 9 as an allowable value); or
999 (for data elements with 99 as an allowable value)
Not Applicable
(Inappropriate)
I
8; or
88 (for data elements with 8 as an allowable value); or
888 (for data elements with 88 as an allowable value)
•
Not known: This null value applies if, at the time of patient care documentation or data
abstraction, information was not known. Translating the Collector value to the database value
is done when data is received at CIHI.
•
Not applicable: This null value code applies if, at the time of patient care documentation, the
information requested was not applicable to the patient, the hospitalization or the patient care
event. For example, if the patient is not ventilated, then VENTILATION_DAYS is not applicable.
Translating the Collector value to the database value is done when data is received at CIHI.
National Trauma Registry Comprehensive Data Set—Data Dictionary
Section 2—Data Elements
Section 2A—Demographic Data
Institution Number
Name in Database
INSTITUTION_NUM
Definition
Unique institution identifier
Data Type
CHAR
Data Element Length 5
Mandatory
Yes
Field Values
Institution numbers as assigned by the provincial/territorial ministries of health
Constraints
00000–99999
Null Values
No null values accepted
Source
Direct data entry or software default
Hierarchy
Provincial ministry of health Master Numbering System
Additional
Information
Defined as a number assigned by the corresponding provincial ministry of health that
identifies the institution that provided the care. The first digit identifies the province.
Consistent with the institution’s DAD submission number. See Appendix G.
Uses of Data
Report trauma by province and institution
History
Effective April 1, 2012, institutions are required to submit under their DAD numbers (fivecharacter codes assigned to reporting facilities by provincial/territorial ministries of health as
described above)
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Trauma Number
Name in Database
TRAUMA_NUM
Definition
Unique injury event identifier assigned by the trauma centre
Data Type
CHAR
Data Element Length 15
Mandatory
Yes
Field Values
0000000, 9999999
Constraints
0000000, 9999999
Null Values
No null values accepted
Source
Direct data entry or auto-generated by software
Hierarchy
Additional
Information
Defined as a unique number assigned by the trauma centre to identify each patient injury
event. This data element can hold up to 15 digits.
Uses of Data
Identify records
History
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Fiscal Year of Patient Discharge
Name in Database
FISCAL_YEAR
Definition
Fiscal year of patient discharge
Data Type
CHAR
Data Element Length 4
Mandatory
Yes
Field Values
Format: yyyy
Constraints
1990–2020
Null Values
No null values accepted
Source
Direct data entry
Hierarchy
1. Face sheet
2. Patient unit nursing notes
3. Physician orders
Additional
Information
A fiscal year begins April 1 and ends March 31. A fiscal year is named by the year that it
begins in (on April 1); for example, April 1, 2003, to March 31, 2004, is fiscal year 2003.
Uses of Data
Report injury by year of patient discharge
History
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Province
Name in Database
PROVINCE_CODE
Definition
Submitting province identification
Data Type
CHAR
Data Element Length 2
Mandatory
Yes
Field Values
NL—Newfoundland and Labrador
PE—Prince Edward Island
NS—Nova Scotia
NB—New Brunswick
QC—Quebec
ON—Ontario
MB—Manitoba
SK—Saskatchewan
AB—Alberta
BC—British Columbia
NT—Northwest Territories
YK—Yukon
NV—Nunavut
Constraints
Same as field values
Null Values
No null values accepted
Source
Direct data entry or auto-generated by software
Hierarchy
Additional
Information
Defined as the province submitting the data
Uses of Data
Report injury by province
History
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Unique Personal Identifier
Name in Database
HEALTH_CARD_NUM
Definition
Provincial health care number
Data Type
CHAR
Data Element Length
12
Mandatory
Yes
Field Values
As per provincial health insurance lists
Constraints
Within the ranges of provincial health insurance lists
Null Values
Not known
Not applicable
Source
Direct data entry
Hierarchy
Face sheet
Additional Information
Defined as provincial health care number (HCN).The HCN may be from a province other
than the province of treatment; for example, if the patient is being treated in Ontario but
lives in Quebec, the HCN would be patient’s Quebec HCN.
If the patient is an insured resident of a reporting province or territory but the HCN is not
available, enter 0. If the patient is a resident of another country, has federal government
coverage (RCMP, veterans, etc.) or has chosen not to register for health insurance,
enter 1.
Stored in the database as an encrypted number (HEALTH_CARD_ENCRYPT_NUM).
The encryption routine is performed by CIHI upon loading data into the database, with
the exception of Manitoba Health (its HCNs are encrypted prior to data submission
to CIHI).
Uses of Data
Potentially link records
Identify persons
Track recurrence of trauma
History
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Age
Name in Database
AGE
Definition
The patient’s age in years at the time of arrival at the trauma centre
Data Type
NUMB
Data Element Length
5, 2
Mandatory
Yes
Field Values
Age in years
Constraints
0–120
Null Value
Not known
Source
Calculated using
1. Date of birth
And
2. Date of Admission (when patient is not admitted use Date of Arrival)
Hierarchy
Date of birth (not transmitted to NTR CDS):
1. ED physician record
2. ED nursing record
3. Face sheet
Date of Admission or Date of Arrival
Additional Information For patients younger than 1 year old, express as a fraction using a decimal (for example,
enter 0.25 for 3 months old)
Uses of Data
History
12
Report by age
National Trauma Registry Comprehensive Data Set—Data Dictionary
Sex
Name in Database
SEX_CODE
Definition
The patient’s sex
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
M—Male
F—Female
Constraints
N/A
Null Value
Not known
Source
Direct data entry
Hierarchy
1. Face sheet
2. ED physician record
3. ED nursing record
Additional Information
Uses of Data
Report by sex (gender)
History
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Postal Code
14
Name in Database
RECIPIENT_POSTAL_CODE
Definition
The postal code of the patient’s usual residence
Data Type
CHAR
Data Element Length
6
Mandatory
Yes
Field Values
Format: A#A#A#, XX
Constraints
6 bytes, alphanumeric
Null Values
Not known (UUUUUU)
Not applicable (IIIIII)
Source
Direct data entry
Hierarchy
1. ED physician record
2. ED nursing record
3. Face sheet
Additional Information
Postal Code is released as a three-digit forward sortation area only.
If the patient resides out of the country, enter not applicable. If patient is homeless,
enter XX.
Uses of Data
Geospatially represent injury
History
Effective April 1, 2012, change in field values to identify homeless patients
National Trauma Registry Comprehensive Data Set—Data Dictionary
Section 2B—Injury Data
Date of Injury
Name in Database
INJURY_DATE
Definition
The date the patient was injured
Data Type
DATE
Data Element Length
8
Mandatory
Yes
Field Values
Format: yyyymmdd
Constraints
19940101–20200101
Null Value
Not known
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
5.
Additional Information
If a partial date is known, enter U for the unknown portion; for example, enter 200107UU
if the day is unknown
Uses of Data
Report on time elapsed from injury to treatment
EMS run sheet
ED physician record
ED nursing record
Trauma nurse flow sheet
Trauma physician record
History
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Time of Injury
Name in Database
INJURY_TIME
Definition
The time the patient was injured, using the 24-hour clock
Data Type
CHAR
Data Element Length
4
Mandatory
No
Field Values
Format: hhmm
Constraints
Null Values
If the value cannot be estimated, select U to record not known.
If a value can be estimated to the hour only, use HHUU.
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
5.
Additional Information
Estimates of time of injury should be based upon reports by the patient, witnesses,
family or a health care provider. Other proxy measures (such as dispatch time) should
not be used.
Uses of Data
Report on time elapsed from injury to treatment
History
16
EMS run sheet
ED physician notes
ED nursing notes
Trauma nurse flow sheet
Trauma physician record
National Trauma Registry Comprehensive Data Set—Data Dictionary
Place of Incident (ICD-9-CM)
Name in Database
CM_INJURY_PLACE_CODE (for ICD-9)
Definition
The ICD-9-CM place of injury category that describes the place of injury for the patient’s
most serious injuries
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
0—Home
1—Farm
2—Mine
3—Industry
4—Recreation
5—Street
6—Public building
7—Residential institution
8—Other
9—Unspecified
Constraints
0–9
Null Values
No null values accepted
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
5.
EMS run sheet
ED physician notes
ED nursing notes
Trauma nurse flow sheet
Trauma physician record
Additional Information
Uses of Data
History
ICD-9-CM discontinued:
B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002
Sask., Alta., N.W.T., Nun., Ont.: 2002–2003
N.B.: 2003–2004
Man.: 2004–2005
Que.: 2006–2007
Notes:
ICD-9-CM codes may still be entered in the appropriate field past the adoption date of
ICD-10-CA; however, these will not be populated in the NTR.
If no longer entering ICD-9, these fields must be zero-filled before submission to the NTR.
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Place of Incident (ICD-10-CA)
Name in Database
ICD10_ INJURY_PLACE_CODE (for ICD-10)
Definition
The ICD-10-CA place of injury category that describes the place of injury for the patient’s
most serious injuries
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
0—Home
1—Residential institution
2—School, other institution and public area
3—Sports and athletic area
4—Street and highway
5—Trade and service area
6—Industrial and construction area
7—Farm
8—Other specified place
9—Unspecified place
Constraints
0–9
Null Values
No null values accepted
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
5.
EMS run sheet
ED physician notes
ED nursing notes
Trauma nurse flow sheet
Trauma physician record
Additional Information
18
Uses of Data
Report on location of injury (place of incident)
History
ICD-10-CA adopted:
B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002
Sask., Alta., N.W.T., Nun., Ont.: 2002–2003
N.B.: 2003–2004
Man.: 2004–2005
Que.: 2006–2007
National Trauma Registry Comprehensive Data Set—Data Dictionary
Injury Etiology (ICD-9-CM)
Name in Database
CM_INJURY_ETIOLOGY_CODE
Definition
The four-digit ICD-9-CM external cause of injury code (E code) that reflects the cause of
the patient’s most serious injuries
Data Type
CHAR
Data Element Length
5
Mandatory
Yes
Field Values
ICD-9-CM E-codes
Constraints
ICD-9-CM E-codes
Null Values
No null values accepted
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
5.
Additional Information
Accepted values may range from three to five digits. The decimal point should not be
included.
EMS run sheet
ED physician notes
ED nursing notes
Trauma nurse flow sheet
Trauma physician record
Uses of Data
History
ICD-9-CM discontinued:
B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002
Sask., Alta., N.W.T., Nun., Ont.: 2002–2003
N.B.: 2003–2004
Man.: 2004–2005
Que.: 2006–2007
Notes:
ICD-9-CM codes may still be entered in the appropriate field past the adoption date of
ICD-10-CA; however, these will not be populated in the NTR.
If no longer entering ICD-9, these fields must be zero-filled before submission to the NTR.
19
National Trauma Registry Comprehensive Data Set—Data Dictionary
Injury Etiology (ICD-10-CA)
20
Name in Database
ICD_10_INJURY_ETIOLOGY_CODE
Definition
The ICD-10-CA external cause of injury code that reflects the cause of the patient’s most
serious injuries
Data Type
CHAR
Data Element Length
7
Mandatory
Yes
Field Values
ICD-10-CA external cause of injury codes as listed in Appendix B
Constraints
External cause of injury codes as listed in Appendix B
Null Values
No null values accepted
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
5.
Additional Information
Submission must be made in ICD-10-CA. The decimal point must not be included.
Uses of Data
Report on cause of injury
History
ICD-10-CA adopted:
B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002
Sask., Alta., N.W.T., Nun., Ont.: 2002–2003
N.B.: 2003–2004
Man.: 2004–2005
Que.: 2006–2007
EMS run sheet
ED physician notes
ED nursing notes
Trauma nurse flow sheet
Trauma physician record
National Trauma Registry Comprehensive Data Set—Data Dictionary
Injury Type
Name in Database
INJURY_TYPE_CODE
Definition
An indication of the type of mechanism leading to the patient’s most serious injury,
defined by AIS severity
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
1—Blunt
2—Penetrating
3—Burn
4—Drowning/asphyxia
Constraints
1–4
Null Value
Not known
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
5.
Additional Information
An injury is defined as penetrating only if the patient is impaled by an object or if a missile
enters or strikes the body. Missiles include bullets and pieces of glass or metal. Impaling
objects may include, but are not limited to, knives, nails and fence posts. For patients with
more than one injury type (for example, blunt and penetrating), consider the most serious
injury to determine injury type.
EMS run sheet
ED physician notes
ED nursing notes
Trauma nurse flow sheet
Trauma physician record
Injury type 4 (Drowning/asphyxia) should be used for cases of drowning, near drowning or
asphyxiation, including suffocation, hanging, etc.
Blast injuries should be coded as blunt.
Uses of Data
Report by type of injury
History
Effective April 1, 2012, change in allowable field values: addition of field value 4
21
National Trauma Registry Comprehensive Data Set—Data Dictionary
Nature of Injury Codes (ICD-9-CM)
Name in Database
CM_DIAG_CODE
Definition
ICD-9-CM diagnosis codes that reflect the patient’s injuries
Data Type
CHAR
Data Element Length
5
Mandatory
Yes
Field Values
All ICD-9-CM codes in the range 800 to 959
Constraints
Limited to codes 800 to 959 in the appropriate ICD-9-CM manual
Null Values
No null values accepted
Source
Direct data entry
Hierarchy
1. Composite of
a. Medical progress reports
b. Radiology reports
c. Operative reports
d. Autopsy reports
2. Discharge summary
3. ED physician notes
Additional Information
The decimal point should not be included.
Up to 27 codes can be reported per patient record; field therefore recurs 27 times.
Uses of Data
Report injury diagnoses
History
Effective April 1, 2012, change in data element name (previously
INJURY_CM_DIAG_CODE)
ICD-9-CM discontinued:
B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002
Sask., Alta., N.W.T., Nun., Ont.: 2002–2003
N.B.: 2003–2004
Man.: 2004–2005
Que.: 2006–2007
Notes:
ICD-9-CM codes may still be entered in the appropriate field past the adoption date of
ICD-10-CA; however, these will not be populated in the NTR.
If no longer entering ICD-9, these fields must be zero-filled before submission to the NTR.
22
National Trauma Registry Comprehensive Data Set—Data Dictionary
Nature of Injury Codes (ICD-10-CA)
Name in Database
ICD10_DIAG_CODE
Definition
ICD-10-CA diagnosis codes that reflect the patient’s injuries
Data Type
CHAR
Data Element Length
7
Mandatory
Yes
Field Values
All ICD-10-CA codes in the range S to T
Constraints
Limited to S and T codes in the appropriate ICD-10-CA manual
Null Values
No null values accepted
Source
Direct data entry
Hierarchy
1. Composite of
a. Medical progress reports
b. Radiology reports
c. Operative reports
d. Autopsy reports
2. Discharge summary
3. ED physician notes
Additional Information
The decimal point should not be included.
It is expected that the most up-to-date version of ICD-10-CA Folio will be used
when coding.
Up to 27 codes can be reported per patient record; field therefore recurs 27 times.
Uses of Data
Report injury diagnoses
History
Effective April 1, 2012, change in data element name (previously
INJURY_ICD10_DIAG_CODE)
ICD-10-CA adopted:
B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002
Sask., Alta., N.W.T., Nun., Ont.: 2002–2003
N.B.: 2003–2004
Man.: 2004–2005
Que.: 2006–2007
23
National Trauma Registry Comprehensive Data Set—Data Dictionary
Sports/Recreational Activity Code
Name in Database
ACTIVITY_CODE
Definition
The sport or recreational activity the injured person was participating in when injured
Data Type
CHAR
Data Element Length
3
Mandatory
No
Field Values
See Appendix A
Constraints
Codes outlined in Appendix A
Null Values
Not known
Not applicable
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
5.
Additional Information
Select the appropriate activity if the person was injured while participating in or
observing any sports or recreational activity, regardless of whether the person was being
paid to participate
Uses of Data
Report by sports and recreational activity
History
24
EMS run sheet
ED physician notes
ED nursing notes
Trauma nurse flow sheet
Trauma physician record
National Trauma Registry Comprehensive Data Set—Data Dictionary
Work-Related Code
Name in Database
WORK_RELATED_FLAG
Definition
Indication of whether the injury occurred during paid employment
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
Y—Yes
N—No
Constraints
Y/N
Null Values
Not known
Not applicable
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
5.
EMS run sheet
ED physician notes
ED nursing notes
Trauma nurse flow sheet
Trauma physician record
Additional Information
Uses of Data
Track occupational injuries
History
25
National Trauma Registry Comprehensive Data Set—Data Dictionary
Protective Devices
Name in Database
PROTECTIVE_DEVICE_CODE
Definition
Protective devices (safety equipment) in use or worn by the patient
at the time of the injury
Data Type
CHAR
Data Element Length
2
Mandatory
Yes
Field Values
0—None
1—Seatbelt: Lap and shoulder belt
2—Seatbelt: Lapbelt only
6—Airbag deployment
8—Helmet
12—Other
13—Rear-Facing Infant Seat
14—Forward-Facing Child Seat (With Harness)
15—Booster Seat
16—Seatbelt NFS
18—Child Safety Seat, Unspecified as to Type
19—Eye Protection/Visor (Sports/Recreational)
20—Lifejacket/Personal Floatation Device
21—Sports-Specific Pads
22—Hard Hat (Work-Related)
23—Safety Harness/Restraining Bar (Work-Related)
24—Safety/Protective Clothing (Work-Related)
25—Goggles/Eye Protection (Work-Related)
Constraints
0–2, 6, 8, 12–16, 18–25
Null Values
Not known
Not applicable
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
5.
Additional Information
Field recurs four times.
Use values
EMS run sheet
ED physician notes
ED nursing notes
Trauma nurse flow sheet
Trauma physician record
• 0–2, 6, 8, 12–16 and 18 for vehicle-related injuries;
• 0, 8, 12 and 19–21 for sports and recreation-related injuries; and
• 0, 12 and 22–25 for work-related injuries.
This element is to be collected for any case where a protective device could have
been used.
26
Uses of Data
Better define injury cause and characterize injury patterns
History
Effective April 1, 2012, change in allowable field values: field values 3–5, 7, 9–11 and 17
will be retired
National Trauma Registry Comprehensive Data Set—Data Dictionary
Section 2C—Scene Data
Modes of Transport to Trauma Centre
Name in Database
TRANSPORTATION_MODE_CODE
Definition
Indicates the type of vehicle used to first transport the patient to the trauma centre
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
1—Land Ambulance
2—Helicopter Ambulance
3—Fixed-Wing Ambulance
6—Private Vehicle
7—Walk-in
8—Other
Constraints
1–3, 6–8
Null Value
Not known
Source
Direct data entry
Hierarchy
1. EMS run sheet
2. ED physician record
3. ED nursing record
Additional Information
This field recurs five times to allow for more than one mode of transport, if applicable.
These should be captured sequentially.
Only the transport of a patient to the trauma centre (that is, to the centre that is reporting
to the NTR CDS) should be captured.
If an ambulance is a charter fixed-wing ambulance, indicate “3—Fixed-Wing Ambulance,”
as the term “charter” has been discontinued.
Uses of Data
Evaluate data based on mode of transport utilized to reach the hospital
History
Effective April 1, 2012, change in data element definition and field values 4 and 5 will be
retired
27
National Trauma Registry Comprehensive Data Set—Data Dictionary
Systolic Blood Pressure on Arrival at Scene
28
Name in Database
SYSTOLIC_BLOOD_PRESSURE_SCENE
Definition
Patient’s first recorded systolic blood pressure (SBP) at the scene
Data Type
CHAR
Data Element Length
3
Mandatory
Yes
Field Values
000–250
Constraints
Valid SBP
Null Value
Not known
Source
Direct data entry
Hierarchy
Air or land EMS run sheet
Additional Information
Defined as the patient’s first recorded SBP upon arrival of EMS personnel at the scene. If
the SBP is not taken or not documented, document as not known.
Uses of Data
Assess baseline physiologic response to injury
History
Effective April 1, 2012, new data element
National Trauma Registry Comprehensive Data Set—Data Dictionary
Unassisted Respiratory Rate on Arrival at Scene
Name in Database
UNASSISTED_RESPIRATORY_RATE_SCENE
Definition
Patient’s first unassisted respiratory rate (RR) per minute at the scene
Data Type
CHAR
Data Element Length
2
Mandatory
Yes
Field Values
0–99
Constraints
Valid RR values
Null Values
Not known (if RR is not documented)
Not applicable (if patient is intubated prior to assessment of RR)
Source
Direct data entry
Hierarchy
Air or land EMS run sheet
Additional Information
Defined as the patient’s first recorded unassisted RR upon arrival of EMS personnel at
the scene. Enter 0 if patient is documented as vital signs absent (VSA) before assistance
is initiated. If the RR is not documented, enter not known. Enter not applicable if patient
respirations are assisted, that is, patient is intubated or being bagged.
Uses of Data
Assess baseline physiologic response to injury
History
Effective April 1, 2012, new data element
29
National Trauma Registry Comprehensive Data Set—Data Dictionary
Heart Rate on Arrival at Scene
30
Name in Database
HEART_RATE_SCENE
Definition
Patient’s first heart rate (rather) per minute at the scene
Data Type
CHAR
Data Element Length
3
Mandatory
Yes
Field Values
0–200
Constraints
Valid HR values
Null Value
Not known (if HR is not documented)
Source
Direct data entry
Hierarchy
Land or air EMS run sheets
Additional Information
Defined as the patient’s first recorded HR upon arrival of EMS personnel at the scene.
Enter 0 if patient is documented as vital signs absent (VSA) before assistance is initiated.
If the HR is not documented, enter not known.
Uses of Data
Assess baseline physiologic response to injury
History
Effective April 1, 2012, new data element
National Trauma Registry Comprehensive Data Set—Data Dictionary
Glasgow Coma Scale—Eye at Scene
Name in Database
GCS_EYE_CODE_SCENE
Definition
Patient’s first eye-opening response for the Glasgow Coma Scale (GCS) taken at
the scene
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
1—None
2—To pain
3—To voice
4—Spontaneous
Constraints
1–4
Null Value
Not known
Source
Direct data entry
Hierarchy
Land or air EMS run sheets
Additional Information
Defined as the patient’s first eye-opening response for the GCS documented upon arrival
of EMS personnel. If the eye-opening response is not documented or if the patient’s eyes
are swollen shut, enter not known.
Uses of Data
Assess baseline physiologic response to head injury
History
Effective April 1, 2012, new data element
31
National Trauma Registry Comprehensive Data Set—Data Dictionary
Glasgow Coma Scale—Verbal at Scene
32
Name in Database
GCS_VERBAL_CODE_SCENE
Definition
Patient’s first verbal response for the Glasgow Coma Scale (GCS) taken at the scene
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
1—None
2—Incomprehensible sounds
3—Inappropriate words
4—Confused
5—Oriented
Constraints
1–5
Null Value
Not known
Source
Direct data entry
Hierarchy
Land or air EMS run sheet
Additional Information
Defined as the patient’s first verbal response for the GCS documented upon arrival of
EMS personnel at the scene. If the verbal response is not documented or if the patient is
intubated, enter not known.
Uses of Data
Assess baseline physiologic response to head injury
History
Effective April 1, 2012, new data element
National Trauma Registry Comprehensive Data Set—Data Dictionary
Glasgow Coma Scale—Motor at Scene
Name in Database
GCS_MOTOR_CODE_SCENE
Definition
Patient’s first motor response for the Glasgow Coma Scale (GCS) taken at the scene
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
1—None
2—Extension
3—Flexion
4—Withdraws
5—Localizes
6—Obeys
Constraints
1–6
Null Value
Not known
Not applicable
Source
Direct data entry
Hierarchy
Land or air EMS run sheet
Additional Information
Defined as the patient’s first motor response for the GCS documented upon arrival of
EMS personnel at the scene. If the motor response of the GCS is not documented, enter
not known.
Uses of Data
Assess baseline physiologic response to head injury
History
Effective April 1, 2012, new data element
33
National Trauma Registry Comprehensive Data Set—Data Dictionary
Total Glasgow Coma Scale at Scene
Name in Database
TOTAL_GCS_SCENE
Definition
Patient’s first total Glasgow Coma Scale (GCS) at the scene
Data Type
CHAR
Data Element Length
2
Mandatory
Yes
Field Values
3–15
Constraints
3–15
Null Value
Not known
Source
Direct data entry or calculated value from eye, verbal and motor responses
Hierarchy
Land or air EMS run sheet
Additional Information
Defined as the total GCS documented upon arrival of EMS personnel at the scene. If the
GCS or any component of the GCS is not documented or if the patient was intubated at
the time GCS was calculated, enter not known.
If the individual components are not documented but the total GCS is documented, this
value may be used. If the documentation reflects the patient is awake, alert and oriented,
the total GCS may be assumed to be 15.
34
Uses of Data
Assess baseline physiologic response to head injury
History
Effective April 1, 2012, new data element
National Trauma Registry Comprehensive Data Set—Data Dictionary
Section 2D—Lead/Trauma Hospital:
Pre-Admission Data
Inter-Facility Transfer
Name in Database
INTER_FACILITY_TRANSFER
Definition
Indicates whether the patient was transported directly from the scene or was transferred
from another hospital
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
Y—Yes
N—No
Constraints
Y/N
Null Value
Not known
Source
Direct data entry or report development language populates NTR field as per NTR
definition.
Hierarchy
1. EMS run sheet
2. ED physician record
3. ED nursing record
Additional Information
Uses of Data
Evaluate data based on presence of an inter-facility transfer
History
Effective April 1, 2012, change in data element name (previously
DIRECT_ADMISSION_FLAG)
35
National Trauma Registry Comprehensive Data Set—Data Dictionary
Transferring Institution
36
Name in Database
TRANSFER_INST
Definition
Indicates the institution that the patient is being transferred from (to the reporting
trauma centre)
Data Type
CHAR
Data Element Length
5
Mandatory
Yes
Field Values
Defined as a number assigned by the corresponding provincial ministry of health that
identifies the institution that provided the care
Constraints
Limited to valid Institution Numbers
Null Values
Not known
Not applicable
Source
Direct data entry
Hierarchy
1. EMS run sheet
2. ED physician record
3. ED nursing record
Additional Information
Defined as a number assigned by the corresponding provincial ministry of health that
identifies the institution that provided the care. The first digit identifies the province.
Consistent with institution’s DAD submission number.
Uses of Data
Assess regional patient flow
History
Effective April 1, 2012, new data element
National Trauma Registry Comprehensive Data Set—Data Dictionary
ED Bypass
Name in Database
ED_BYPASS
Definition
Indicates whether the patient was admitted directly to an inpatient unit, bypassing the
emergency department at a trauma centre
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
Y—Yes
N—No
Constraints
Y/N
Null Value
Not known
Source
Direct data entry
Hierarchy
1. Nursing progress notes
2. Medical progress notes
3. EMS run sheet
Additional Information
Uses of Data
Identify patients who bypass the emergency department
History
Effective April 1, 2012, new data element
37
National Trauma Registry Comprehensive Data Set—Data Dictionary
Date of Arrival
Name in Database
ARRIVAL_DATE
Definition
Date the patient arrived at the trauma centre
Data Type
DATE
Data Element Length
8
Mandatory
Yes
Field Values
Format: yyyymmdd
Constraints
19940101–20200101
Null Values
No null values accepted
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
Additional Information
Date of arrival at ED or inpatient unit (if bypasses ED). Note: Can be different from Date
of Admission.
Uses of Data
Report on length of hospital stay
Report on month of arrival at hospital due to injury
History
38
EMS run sheet
ED nursing notes
ED physician notes
Inpatient unit nursing notes
National Trauma Registry Comprehensive Data Set—Data Dictionary
Time of Arrival
Name in Database
ARRIVAL_TIME
Definition
Time the patient arrived at the trauma centre
Data Type
CHAR
Data Element Length
4
Mandatory
Yes
Field Values
Format: hhmm
Constraints
0000–2359
Null Values
No null values accepted
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
Additional Information
Time of arrival at ED or inpatient unit (if bypasses ED). Note: Can be different from time
of admission.
Capture the actual time the patient was received or offloaded to whichever unit receives
him or her.
Uses of Data
Report on length of time from injury to definitive care
History
Effective April 1, 2012, new data element
EMS run sheet
ED nursing notes
ED physician notes
Inpatient unit nursing notes
39
National Trauma Registry Comprehensive Data Set—Data Dictionary
Temperature on Arrival
40
Name in Database
TEMPERATURE
Definition
Patient’s first recorded temperature within 15 minutes of arrival at trauma centre
Data Type
CHAR
Data Element Length
3
Mandatory
Yes
Field Values
25–50
Constraints
Valid temperature values
Null Value
Not known
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
Additional Information
Defined as the patient’s first recorded temperature upon arrival at the trauma centre (ED
or inpatient unit if ED bypass), within 15 minutes of arrival. If vitals are not taken in first 15
minutes, document as not known.
Uses of Data
Assess baseline physiologic response to injury
History
Effective April 1, 2012, new data element
ED nursing notes
Inpatient nursing flow sheet
ED physician notes
Trauma resuscitation record
National Trauma Registry Comprehensive Data Set—Data Dictionary
Systolic Blood Pressure on Arrival
Name in Database
SYSTOLIC_BLOOD_PRESSURE
Definition
Patient’s first recorded systolic blood pressure (SBP) at the trauma centre, within
15 minutes of arrival at trauma centre
Data Type
CHAR
Data Element Length
3
Mandatory
Yes
Field Values
000–250
Constraints
Valid systolic blood pressure
Null Value
Not known
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
Additional Information
Defined as the patient’s first recorded SBP upon arrival at the trauma centre (ED or
inpatient unit if ED bypass), within 15 minutes of arrival. If vitals are not taken in first
15 minutes, document as not known.
Uses of Data
Assess baseline physiologic response to injury
History
Effective April 1, 2012, change in data element definition: the observation interval is
15 minutes
ED nursing notes
Inpatient nursing flow sheet
Trauma resuscitation record
ED physician notes
41
National Trauma Registry Comprehensive Data Set—Data Dictionary
Intubation Code on Arrival
42
Name in Database
INTUBATION_FLAG
Definition
Code indicating whether patient was intubated prior to arrival at trauma centre
Data Type
CHAR
Data Element Length
1
Mandatory
No
Field Values
Y—Yes
N—No
Constraints
Y/N
Null Value
Not known
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
Additional Information
Patients intubated at transferring institution, scene or en route to trauma centre
Uses of Data
Indicate patients who have been intubated
History
Effective April 1, 2012, change in data element definition
EMS run sheet
Transferring hospital ED notes
ED nursing notes (trauma centre)
Transfer referral form
National Trauma Registry Comprehensive Data Set—Data Dictionary
Unassisted Respiratory Rate on Arrival
Name in Database
UNASSISTED_RESPIRATORY_RATE
Definition
Patient’s first recorded unassisted respiratory rate (RR) per minute, within 15 minutes of
arrival at trauma centre
Data Type
CHAR
Data Element Length
2
Mandatory
Yes
Field Values
0–99
Constraints
Valid RR values
Null Values
Not known
Not applicable
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
Additional Information
Defined as the patient’s first recorded unassisted RR upon arrival at the trauma centre
(ED or inpatient unit if ED bypass) within 15 minutes of arrival. Enter 0 if patient is
documented as vital signs absent (VSA) before assistance is initiated. If the RR is not
documented within the first 15 minutes, enter not known. If patient respirations are
assisted (that is, patient is intubated, ventilated or being bagged), enter not applicable.
Uses of Data
Assess baseline physiologic response to injury
History
Effective April 1, 2012, change in data element definition: the observation interval is
15 minutes
ED nursing notes
Inpatient nursing flow sheet
Trauma resuscitation record
ED physician notes
43
National Trauma Registry Comprehensive Data Set—Data Dictionary
Heart Rate on Arrival
44
Name in Database
HEART_RATE
Definition
Patient’s first recorded heart rate (HR) per minute, within 15 minutes of arrival at
trauma centre
Data Type
CHAR
Data Element Length
3
Mandatory
Yes
Field Values
0–200
Constraints
Valid HR values
Null Values
Not known
Not applicable
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
Additional Information
Defined as the patient’s first recorded HR upon arrival at the trauma centre (ED or
inpatient unit if ED bypass), within 15 minutes of arrival. Enter 0 if patient is documented
as vital signs absent (VSA) before assistance is initiated. If the HR is not documented
within the first 15 minutes, enter not known.
Uses of Data
Assess baseline physiologic response to injury
History
Effective April 1, 2012, new data element
ED nursing notes
Inpatient nursing flow sheet
Trauma resuscitation record
ED physician notes
National Trauma Registry Comprehensive Data Set—Data Dictionary
Paralytic Agents
Name in Database
PARALYTIC_AGENTS_FLAG
Definition
Paralytic agents administered when the Glasgow Coma Scale (GCS) was calculated at
the trauma centre
Data Type
CHAR
Data Element Length
1
Mandatory
No
Field Values
Y—Yes
N—No
Constraints
Y/N
Null Value
Not known
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
Additional Information
Common paralytic agents include rocuronium (Zemuron), vecuronium, cisatracurium
(Nimbex), succinylcholine, pancuronium (Pavulon) and atracurium
Uses of Data
Identify the validity of the motor component of the GCS
History
Effective April 1, 2012, change in data element definition
EMS run sheet
Transferring hospital ED notes
ED nursing notes (trauma centre)
Transfer referral form
45
National Trauma Registry Comprehensive Data Set—Data Dictionary
Glasgow Coma Scale—Eye
46
Name in Database
GCS_EYE_CODE
Definition
Patient’s first eye-opening response for the Glasgow Coma Scale (GCS) taken within the
first 15 minutes of arrival at the trauma centre
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
1—None
2—To pain
3—To voice
4—Spontaneous
Constraints
1–4
Null Value
Not known
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
Additional Information
Defined as the patient’s first eye-opening response for the GCS, documented within
15 minutes of arrival at the trauma centre. Enter not known if not documented or if
patient’s eyes are swollen shut.
Uses of Data
Assess baseline physiologic response to head injury
History
Effective April 1, 2012, change in data element definition: the observation interval is
15 minutes
ED nursing notes
Inpatient nursing flow sheet
Trauma resuscitation record
ED physician notes
National Trauma Registry Comprehensive Data Set—Data Dictionary
Glasgow Coma Scale—Verbal
Name in Database
GCS_VERBAL_CODE
Definition
Patient’s first verbal response for the Glasgow Coma Scale (GCS), taken within
15 minutes of arrival at the trauma centre
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
1—None
2—Incomrehensible sounds
3—Inappropriate words
4—Confused
5—Oriented
Constraints
1–5
Null Value
Not known
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
Additional Information
Defined as the patient’s first verbal response for the GCS, documented within 15 minutes
of arrival at the trauma centre. If the verbal response is not documented within the first
15 minutes or if the patient is intubated within the first 15 minutes of arrival at the trauma
centre, enter not known.
Uses of Data
Assess baseline physiologic response to head injury
History
Effective April 1, 2012, change in data element definition: the observation interval is
15 minutes
ED nursing notes
Inpatient nursing flow sheet
ED physician notes
Trauma resuscitation record
47
National Trauma Registry Comprehensive Data Set—Data Dictionary
Glasgow Coma Scale—Motor
48
Name in Database
GCS_MOTOR_CODE
Definition
Patient’s first motor response for the Glasgow Coma Scale (GCS), taken within
15 minutes of arrival at the trauma centre
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
1—None
2—Extension
3—Flexion
4—Withdraws
5—Localizes
6—Obeys
Constraints
1–6
Null Value
Not known
Not applicable
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
Additional Information
Defined as the patient’s first motor response for the GCS, documented within 15 minutes
of arrival at the trauma centre. If the motor response of the GCS is not documented within
15 minutes of arrival at the trauma centre, enter not known.
Uses of Data
Assess baseline physiologic response to head injury
History
Effective April 1, 2012, change in data element definition: the observation interval is
15 minutes
ED nursing notes
Inpatient nursing flow sheet
ED physician notes
Trauma resuscitation record
National Trauma Registry Comprehensive Data Set—Data Dictionary
Total Glasgow Coma Scale
Name in Database
TOTAL_GCS
Definition
Patient’s total Glasgow Coma Scale (GCS), within 15 minutes of arrival at trauma centre
Data Type
CHAR
Data Element Length
2
Mandatory
Yes
Field Values
3–15
Constraints
3–15
Null Value
Not known
Source
Direct data entry or calculated value from eye, verbal and motor responses
Hierarchy
1.
2.
3.
4.
Additional Information
Defined as the total GCS, documented within 15 minutes of patient arrival at the trauma
centre. If the GCS or any component of the GCS is not documented or if the patient is
intubated within 15 minutes of the arrival at the trauma centre, enter not known.
ED nursing notes
Inpatient nursing flow sheet
ED physician notes
Trauma resuscitation record
If the individual components are not documented but the total GCS is documented within
15 minutes of arrival at the trauma centre, this value may be used. If the documentation
reflects the patient is awake, alert and oriented, the total GCS may be assumed to be 15.
Uses of Data
Assess baseline physiologic response to head injury
History
Effective April 1, 2012, change in data element definition: the observation interval is
15 minutes
49
National Trauma Registry Comprehensive Data Set—Data Dictionary
Total Revised Trauma Score on Arrival
Name in Database
TOTAL_RTS
Definition
Calculated field based on Glasgow Coma Scale, systolic blood pressure and unassisted
respiratory rate
Data Type
CHAR
Data Element Length
4, 2
Mandatory
Yes
Field Values
0–7.84
Constraints
0–7.84
Null Value
Not known
Source
Calculated using
1. Glasgow Coma Scale
And
2. Systolic blood pressure
And
3. Unassisted respiratory rate
Hierarchy
1.
2.
3.
4.
Additional Information
If any component required to calculate the Revised Trauma Score (RTS) is not applicable
or unknown, enter not known.
ED nursing notes
Inpatient nursing flow sheet
ED physician notes
Trauma resuscitation record
See Appendix I for calculation of the RTS.
Uses of Data
History
50
Assess baseline physiologic response to injury
National Trauma Registry Comprehensive Data Set—Data Dictionary
Blood Alcohol Concentration
Name in Database
BLOOD_ALCOHOL_CONCENTRATION
Definition
The patient’s blood alcohol concentration (BAC) in SI units at the trauma centre
Data Type
NUMB
Data Element Length
5, 1
Mandatory
Yes
Field Values
Format: ####.#
Constraints
Null Value
Not known
Source
Direct data entry
Hierarchy
1. Lab results
2. ED physician notes
Additional Information
Defined as the first blood alcohol levels (in mmol/L) drawn at the trauma centre,
regardless of time elapsed since the injury.
Results less than 2 count as 0.
Enter not known if the BAC was not drawn or is not documented.
Enter the value or not known.
Uses of Data
Report incidence of alcohol in relation to injury
History
Effective April 1, 2012, change to allowable null values (not applicable no longer allowed;
age younger than 9 removed)
51
National Trauma Registry Comprehensive Data Set—Data Dictionary
Post-ED/-Arrival Destination
Name in Database
POST_ED_DESTINATION
Definition
The destination of the patient after discharge from the emergency department or
arrival at the hospital if ED bypass
Data Type
NUMB
Data Element Length
1
Mandatory
Yes
Field Values
1—Another acute care hospital
2—Another trauma centre
3—OR
4—ICU
5—Ward
6—Died in emergency (DIE)
7—Discharge home
8—Other
Constraints
1–8
Null Values
No null values accepted
Source
Direct data entry
Hierarchy
1. ED physician record
2. ED nursing notes
3. Inpatient nursing notes
Additional Information
52
Uses of Data
Report on post-ED destination
History
Effective April 1, 2012, new data element
National Trauma Registry Comprehensive Data Set—Data Dictionary
Section 2E—Lead/Trauma Hospital: PostAdmission Data
Date of Admission
Name in Database
ADMISSION_DATE
Definition
Date the patient is registered as an inpatient at the trauma centre
Data Type
DATE
Data Element Length
8
Mandatory
Yes
Field Values
Format: yyyymmdd
Constraints
19940101–20200101
Null Value
Not applicable
Source
Direct data entry
Hierarchy
1. Face sheet
2. Physician orders
3. Inpatient nursing notes
Additional Information
Defined as the date that the patient is registered as an inpatient.
If the patient died in the emergency department or was discharged home from the
emergency department, enter not applicable.
Can be different from Date of Arrival or date registered in the ED.
Uses of Data
Report injury by patient length of stay
History
53
National Trauma Registry Comprehensive Data Set—Data Dictionary
Length of Stay
Name in Database
LOS_DAYS
Definition
Total number of hospital days from Date of Admission to Date of Discharge
(including death)
Data Type
NUMB
Data Element Length
4
Mandatory
Yes
Field Values
≥1
Constraints
1, 9999
Null Value
Not applicable
Source
Calculated field using
1. Date of Admission and
2. Date of Discharge (including death)
Hierarchy
Additional Information
Defined as the total number of hospital days from Date of Admission to Date of Discharge
(including death). Include alternative level of care days. Do not include days following
transfer to a rehabilitation facility, whether or not it is included in the same institution.
Patients who were admitted and discharged or died on the same day have a length of
stay (LOS) of 1 day. LOS must be included for all admitted patients.
If the patient is not admitted, LOS should be not applicable.
Uses of Data
History
54
Report on patient length of stay
National Trauma Registry Comprehensive Data Set—Data Dictionary
Intensive Care Unit Days
Name in Database
ICU_LOS
Definition
The total days spent in any intensive care unit (ICU) in the trauma centre
Data Type
NUMB
Data Element Length
3
Mandatory
Yes
Field Values
≥1
Constraints
1–999
Null Value
Not applicable
Source
Direct data entry
Hierarchy
1. ICU flow sheet
2. Medical progress notes
3. Physician orders
Additional Information
If the patient does not stay in an ICU, enter not applicable.
An ICU is defined as having a nurse-to-patient ratio ≤1:2.
Uses of Data
Report on intensive care unit days and severity of patient injury
History
Effective April 1, 2012, new data element
55
National Trauma Registry Comprehensive Data Set—Data Dictionary
Predot Injury Codes (AIS 1990)
Name in Database
AIS_PREDOT_CODE_90
Definition
Abbreviated Injury Scale (AIS) 1990 predot codes that describe all injuries
Data Type
CHAR
Data Element Length
6
Mandatory
Yes
Field Values
Valid AIS code
Constraints
110099–919610
Null Values
No null values accepted
Source
Direct data entry or software-generated coding from injury text or ICD codes
Hierarchy
Injuries as described in the medical record and supporting documentation:
1. Trauma physician notes
2. Operative notes
3. Radiology reports
4. Autopsy reports
5. Medical progress notes
Additional Information
Predot is the first six digits of the AIS code (digits preceding the decimal point). It may be
manually entered or coded using coding software.
Refer to the AIS 90 dictionary for more details related to the interpretation of the six digits
of the predot code.
Up to 27 predot codes can be accepted per patient record; field therefore recurs 27 times.
56
Uses of Data
Report injury by AIS body region and specific injury details
History
Effective April 1, 2012, change in data element name (previously AIS_PREDOT_CODE)
National Trauma Registry Comprehensive Data Set—Data Dictionary
Predot Injury Codes (AIS 2005, Update 2008)
Name in Database
AIS_PREDOT_CODE_05
Definition
Abbreviated Injury Scale (AIS) 2005 (update 2008) predot codes that describe all injuries
Data Type
CHAR
Data Element Length
6
Mandatory
Yes
Field Values
Valid AIS code
Constraints
010000–916000
Null Values
No null values accepted
Source
Direct data entry or software-generated coding from injury text or ICD codes
Hierarchy
Injuries as described in the medical record and supporting documentation:
1. Trauma physician notes
2. Operative notes
3. Radiology reports
4. Autopsy reports
5. Medical progress notes
Additional Information
Predot is the first six digits of the AIS code (digits preceding the decimal point). It may be
manually entered or coded using coding software.
Refer to the AIS 2005 dictionary for more details related to the interpretation of the six
digits of the predot code.
Up to 27 predot codes can be accepted per patient record; field therefore recurs 27 times.
Uses of Data
Report injury by AIS body region and specific injury details
History
Effective April 1, 2012, new data element
57
National Trauma Registry Comprehensive Data Set—Data Dictionary
Severity Codes and ISS Body Regions (AIS 1990)
Name in Database
SEVERITY_CODE_90
Definition
Abbreviated Injury Scale (AIS) 1990 severity and ISS body region codes that reflect the
patient’s injuries
Data Type
CHAR
Data Element Length
2
Mandatory
No
Field Values
1st digit: 0, 1, 2, 3, 4, 5, 6, 9
2nd digit: 1, 2, 3, 4, 5, 6, 9
Constraints
1st digit: 0–6, 9
2nd digit: 1–6, 9
Null Values
No null values accepted
Source
Direct data entry (manual coding) or software-generated (Tri-Code) coding from injury text
or ICD codes
Hierarchy
Injuries as described in the medical record and supporting documentation:
1. Trauma physician notes
2. Operative notes
3. Radiology reports
4. Autopsy reports
5. Medical progress notes
Additional Information
The first digit represents severity, ranging from 1 (minor) to 6 (major), with 9 representing
unknown severity. Tri-Code will display 0 when an ICD-9 code generates more than one
predot code. In the case of a manually coded record, this does not apply. In certain
instances, an ICD-9 code will be generated without an AIS code; therefore, the AIS will
be blank.
The second digit designates the ISS body region as defined in the AIS 90 dictionary. A 9
will be generated for certain injuries that are listed in the AIS that are included for
reporting frequency of injury but for which an ISS is not generated.
This is a recurring field with 27 possible entries.
58
Uses of Data
Report by AIS 90 severity and ISS body region
History
Effective April 1, 2012, name change
National Trauma Registry Comprehensive Data Set—Data Dictionary
Severity Codes and ISS Body Regions (AIS 2005, Update 2008)
Name in Database
SEVERITY_CODE_2005
Definition
Abbreviated Injury Scale (AIS) 2005 (update 2008) severity and ISS body region codes
that reflect the patient’s injuries
Data Type
CHAR
Data Element Length
2
Mandatory
Yes
Field Values
1st digit: 0, 1, 2, 3, 4, 5, 6, 9
2nd digit: 1, 2, 3, 4, 5, 6, 9
Constraints
1st digit: 0–6, 9
2nd digit: 1–6, 9
Null Values
No null values accepted
Source
Direct data entry (manual coding) or software-generated coding from injury text, AIS drilldown or ICD code to AIS look-up table
Hierarchy
Injuries as described in the medical record and supporting documentation:
1. Trauma physician notes
2. Operative notes
3. Radiology reports
4. Autopsy reports
5. Medical progress notes
Additional Information
The first digit represents severity, ranging from 1 (minor) to 6 (major), with 9 representing
unknown severity.
The second digit designates the ISS body region as defined in the AIS 2005 dictionary.
This is a recurring field with 27 possible entries.
Uses of Data
Report by AIS 2005 severity and ISS body region
History
Effective April 1, 2012, additional field and name
59
National Trauma Registry Comprehensive Data Set—Data Dictionary
MAIS Code by ISS Body Region (AIS 1990)
Name in Database
MAXIMUM_CODE_BY_ISS _90 (1–6)
Definition
Calculated field based on the highest Abbreviated Injury Scale (AIS) score, based on AIS
90, recorded by ISS body region
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
1—Minor
2—Moderate
3—Serious
4—Severe
5—Critical
6—Maximum
Constraints
1–6
Null Values
No null values accepted
Source
Direct data entry or software-generated coding from injury text or ICD codes
Hierarchy
Injuries as described in the medical record and supporting documentation:
1. Trauma physician notes
2. Operative notes
3. Radiology reports
4. Autopsy reports
5. Medical progress notes
Additional Information
Defined as the maximum AIS code per body region injured, based on AIS 90. ISS body
regions are
1—Head or neck
2—Face
3—Chest
4—Abdominal or pelvic contents
5—Extremities or pelvic girdle
6—External
Uses of Data
History
60
Effective April 1, 2012, change in data element name (previously
BODY_REGION_CODE_(1–6))
National Trauma Registry Comprehensive Data Set—Data Dictionary
MAIS Code by ISS Body Region (AIS 2005, Update 2008)
Name in Database
MAXIMUM_CODE_BY_ISS_2005_(1–6)
Definition
Calculated field based on the highest Abbreviated Injury Scale (AIS) score, based on AIS
2005 (update 2008), recorded by ISS body region
Data Type
CHAR
Data Element Length
1
Mandatory
Yes
Field Values
1—Minor
2—Moderate
3—Serious
4—Severe
5—Critical
6—Maximum
Constraints
1–6
Null Values
No null values accepted
Source
Direct data entry or software-generated coding from injury text or ICD codes
Hierarchy
Injuries as described in the medical record and supporting documentation:
1. Trauma physician notes
2. Operative notes
3. Radiology reports
4. Autopsy reports
5. Medical progress notes
Additional Information
Defined as the maximum AIS code per body region injured, based on AIS 2005. ISS body
regions are
1—Head or neck
2—Face
3—Chest
4—Abdominal or pelvic contents
5—Extremities or pelvic girdle
6—External
Uses of Data
Calculate ISS and report by maximum AIS by body region in AIS 2005
History
Effective April 1, 2012, new data element
61
National Trauma Registry Comprehensive Data Set—Data Dictionary
Injury Severity Score (AIS 1990)
62
Name in Database
INJURY_SEVERITY_SCORE_90
Definition
The patient’s Injury Severity Score (ISS) for this injury event as calculated based on the
Abbreviated Injury Scale (AIS) 90 once all injury information is available or at the time of
patient discharge
Data Type
CHAR
Data Element Length
2
Mandatory
Yes
Field Values
0–75
Constraints
13–75
Null Values
No null values accepted
Source
Calculated field using
1. AIS severity code and
2. ISS body region
Hierarchy
Injuries as described in the medical record and supporting documentation:
1. Trauma physician notes
2. Operative notes
3. Radiology reports
4. Autopsy reports
5. Medical progress notes
Additional Information
Calculated field based on the AIS severity code. The ISS is the sum of the squares of the
highest AIS code in each of the three most severely injured ISS body regions. The six
body regions are
1—Head or neck
2—Face
3—Chest
4—Abdominal or pelvic contents
5—Extremities or pelvic girdle
6—External
Uses of Data
Report by injury severity
History
Effective April 1, 2012, change in data element name (previously
INJURY_SEVERITY_SCORE)
National Trauma Registry Comprehensive Data Set—Data Dictionary
Injury Severity Score (AIS 2005, Update 2008)
Name in Database
INJURY_SEVERITY_SCORE_05
Definition
The patient’s Injury Severity Score (ISS) for this injury event as calculated based on the
Abbreviated Injury Scale (AIS 2005, update 2008) once all injury information is available
or at the time of patient discharge
Data Type
CHAR
Data Element Length
2
Mandatory
Yes
Field Values
0–75
Constraints
None
Null Values
No null values accepted
Source
Calculated field using
1. AIS severity code and
2. ISS body region
Hierarchy
Injuries as described in the medical record and supporting documentation:
1. Trauma physician notes
2. Operative notes
3. Radiology reports
4. Autopsy reports
5. Medical progress notes
Additional Information
Calculated field based on the AIS severity code. The ISS is the sum of the squares of the
highest AIS code in each of the three most severely injured ISS body regions. The six
body regions are
1—Head or neck
2—Face
3—Chest
4—Abdominal or pelvic contents
5—Extremities or pelvic girdle
6—External
Uses of Data
Report by injury severity
History
Effective April 1, 2012, new data element
63
National Trauma Registry Comprehensive Data Set—Data Dictionary
Number of Ventilator Days
Name in Database
VENTILATION_DAYS
Definition
The number of days the patient was intubated and mechanically ventilated intermittently
or continuously, excluding non-intubated patients on BIPAP and intubated patients on
CPAP at the hospital
Data Type
NUMB
Data Element Length
3
Mandatory
Yes
Field Values
≥1
Constraints
1–999
Null Values
Not known
Not applicable
Source
Direct data entry
Hierarchy
1. Respiratory therapy flow sheet
2. Special care unit flow sheet
Additional Information
Only the number of ventilator days at the trauma centre (the reporting hospital) should be
captured, not the ones from the transferring hospital. The number of ventilator days does
not include the day ventilation is begun (unless there is only one day of ventilation, in
which case the number of ventilator days = 1).
For example, if a patient is on a ventilator from March 3 to March 5, the number of
ventilator days = 2.
Patients on BIPAP are not counted as having ventilator days. The time patients are
ventilated solely while in the OR is not counted as ventilator days.
If a patient is not mechanically ventilated at any time during the hospital stay, enter not
applicable. If the patient is mechanically ventilated but the length of time is not
documented, enter not known.
Uses of Data
History
64
Report ventilation requirements of trauma patients
National Trauma Registry Comprehensive Data Set—Data Dictionary
OR Procedures (ICD-9-CM)
Name in Database
CM _PROC_CODE
Definition
ICD-9-CM codes describing operative procedures performed on the patient; procedures
must be related to the injury (that is, do not enter operative procedures performed as a
result of a complication)
Data Type
CHAR
Data Element Length
5
Mandatory
No
Field Values
Valid ICD-9-CM procedure code
Constraints
ICD-9-CM procedure codes
Null Value
Not applicable
Source
Direct data entry
Hierarchy
1. Operative reports
2. Medical progress notes
Additional Information
Up to 10 procedure codes may be collected.
The decimal point should not be included and fields should be left justified.
Uses of Data
Report on operative management of trauma patients
History
ICD-9-CM discontinued:
B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002
Sask., Alta., N.W.T., Nun., Ont.: 2002–2003
N.B.: 2003–2004
Man.: 2004–2005
Que.: 2006–2007
Notes:
ICD-9-CM codes may still be entered in the appropriate field past the adoption date of
ICD-10-CA; however, these will not be populated in the NTR.
If no longer entering ICD-9, these fields must be zero-filled before submission to the NTR.
65
National Trauma Registry Comprehensive Data Set—Data Dictionary
OR Procedures (ICD-10-CA)
Name in Database
CCI_PROC_CODE
Definition
CCI codes describing operative procedures performed on the patient
Data Type
CHAR
Data Element Length
10
Mandatory
Yes
Field Values
Valid CCI procedure codes
Constraints
CCI procedure codes
Null Value
Not applicable
Source
Direct data entry
Hierarchy
1. Operative reports
2. Medical progress notes
Additional Information
Up to 10 procedure codes can be recorded per patient visit to the OR, with the possibility
of 25 operative visits.
Only those procedures performed at the trauma centre (the reporting hospital) should be
included, not those performed at the referring hospital.
Procedures must be performed in the OR or, in certain instances, in the ICU (see
Appendix J for a list of acceptable procedures performed in the ICU).
If the patient is not operatively managed, enter not applicable.
The decimal point should not be included.
Uses of Data
Report on operative management of trauma patients
History
Up to 15 additional operative episodes can be recorded, for a total of 25; include
procedures performed in the ICU
ICD-10-CA adopted:
B.C., N.L., N.S., P.E.I., Y.T.: 2001–2002
Sask., Alta., N.W.T., Nun., Ont.: 2002–2003
N.B.: 2003–2004
Man.: 2004–2005
Que.: 2006–2007
66
National Trauma Registry Comprehensive Data Set—Data Dictionary
Date of OR Procedures (ICD-10-CA)
Name in Database
DATE_OR_PROCEDURE
Definition
Date the operative procedure was performed
Data Type
DATE
Data Element Length
8
Mandatory
Yes
Field Values
Format: yyyymmdd
Constraints
19940101–20200101
Null Values
Not known
Not applicable
Source
Direct data entry
Hierarchy
1. Operative reports
2. Medical progress notes
Additional Information
Date is collected for up to 25 operative visits.
Must be performed in the OR or in the ICU (refer to Appendix J for a list of valid
procedures performed in the ICU).
If the patient is not operatively managed, enter not applicable.
Uses of Data
Report on operative management of trauma patients
History
Effective April 1, 2012, new data element.
Number of operative visits expanded from 10 to 25 and definition expanded to include all
operative visits within the hospitalization, not only those associated with the injury.
67
National Trauma Registry Comprehensive Data Set—Data Dictionary
Comorbidities
Name in Database
COMORBIDITIES
Definition
A condition present at the beginning of hospital observation and/or treatment that may or
may not have a significant influence on the patient’s hospitalization (LOS) and/or
significantly influence the management or treatment of the patient
Data Type
CHAR
Data Element Length
2
Mandatory
Yes, unless data element COMORBIDITIES_ICD10_DIAG_CODE is completed
Field Values
1—No NTR comorbidities are present
2—Alcoholism
3—Ascites within 30 days
4—Attention deficit disorder/attention deficit hyperactivity disorder
5—Autism/Asperger’s
6—Bleeding disorder
7—Chemotherapy for cancer within 30 days
8—Cirrhosis
9—Congenital anomalies
10—Congestive heart failure
11—Current smoker
12—Currently requiring or on dialysis
13—CVA/residual neurological deficit
14—Diabetes mellitus
15—Disseminated cancer
16—Do not resuscitate (DNR) status
17—Drug use
18—Esophageal varices
19—Functionally dependent health status
20—History of angina within past one month
21—History of myocardial infarction within past six months
22—History of revascularization/amputation for PVD
23—Hypertension requiring medication
24—Impaired sensorium
25—Obesity
26—Prematurity
27—Respiratory disease
28—Steroid use
Constraints
Valid comorbid condition from approved list; see Appendix E for conditions and definitions
Null Value
Unknown
Source
Direct data entry
Hierarchy
1.
2.
3.
4.
Additional Information
Enter any comorbid conditions from the approved list, regardless of condition influence on
LOS or treatment.
Patient history and physical
Medical progress notes
Medical consultation notes
Discharge summary
Up to 10 comorbidities can be accepted per patient record; field therefore recurs 10 times.
See Appendix E for definitions of comorbid conditions.
68
Uses of Data
Report on common comorbid conditions
History
Option to use this field or data element COMORBIDITIES_ICD10_DIAG_CODE
National Trauma Registry Comprehensive Data Set—Data Dictionary
Comorbidities (ICD-10-CA)
Name in Database
COMORBIDITIES_ICD10_DIAG_CODE
Definition
A condition present at the beginning of hospital observation and/or treatment that may or
may not have a significant influence on the patient’s hospitalization (LOS) and/or
significantly influence the management or treatment of the patient
Data Type
CHAR
Data Element Length
7
Mandatory
Yes, if data element COMORBIDITIES is not collected
Field Values
Valid ICD-10 codes for comorbidities
Constraints
Valid ICD-10 codes for comorbidities
Null Value
Not applicable
Source
Direct data entry
Hierarchy
1. Patient history and physical
2. Medical progress notes
3. Medical consultation notes
4. Discharge summary
Additional Information
Enter any comorbid conditions from the approved list, regardless of condition influence
on LOS or treatment. Up to 10 comorbidities can be accepted per patient record; field
therefore recurs 10 times. See Appendix E for definitions of comorbid conditions. In the
event there is no corresponding ICD-10 code, yes, no or not applicable should be
entered in a separate data field to capture this information.
Provinces have the ability to collect additional comorbid conditions but must collect those
listed in Appendix E at a minimum. Comorbidity data may be captured using data
element, COMORBIDITIES, which has comorbidities listed in a drop-down menu, as an
alternative to this data element, which captures comorbidities as ICD-10 codes.
Uses of Data
Report on common comorbid conditions
History
Effective April 1, 2012, new data element
69
National Trauma Registry Comprehensive Data Set—Data Dictionary
Complications
Name in Database
COMPLICATION_CM_DIAG_CODE
Definition
A condition arising after the beginning of hospital observation and/or treatment that
usually has a significant influence on the patient’s hospitalization (LOS) and/or
significantly influences the management or treatment of the patient
Data Type
CHAR
Data Element Length
7
Mandatory
Yes, unless COMPLICATION_ICD10_DIAG_CODE is completed
Field Values
1—No NTR-listed medical complications occurred
2—Abdominal compartment syndrome
3—Abdominal fascia left open
4—Acute renal failure
5—Acute respiratory distress syndrome (ARDS)
6—Bleeding
7—Cardiac arrest with CPR
8—Coagulopathy
9—Decubitus ulcer
10—Deep surgical site infection
11—Drug or alcohol withdrawal syndrome
12—Deep vein thrombosis (DVT)/thrombophlebitis
13—Extremity compartment syndrome
14—Graft/prosthesis/flap failure
15—Intracranial pressure elevation
16—Myocardial infarction
17—Organ space surgical site infection
18—Osteomyelitis
19—Pneumonia
20—Pulmonary embolism
21—Stroke/CVA
22—Superficial surgical site infection
23—Systemic sepsis
24—Unplanned intubation
25—Unplanned return to the ICU
26—Unplanned return to the OR
27—Urinary tract infection
28—Wound disruption
Constraints
Valid complications from approved NTR list; see Appendix F
Null Value
Not applicable
Source
Direct data entry
Hierarchy
1. Medical progress notes
2. Medical consultation notes
3. Discharge summary
Additional Information
Up to 10 complications can be accepted per patient record; field therefore recurs 10
times. See Appendix F for definitions of complications.
Provinces have the ability to collect more complications but must collect those listed in
Appendix F at a minimum.
Provinces have the choice of populating this data element or data element
COMPLICATION_ICD10_DIAG_CODE.
70
Uses of Data
Report on common complications
History
Effective April 1, 2012, change in data element name
National Trauma Registry Comprehensive Data Set—Data Dictionary
Complications (ICD-10-CA)
Name in Database
COMPLICATION_ICD10_DIAG_CODE
Definition
A condition arising after the beginning of hospital observation and/or treatment that
usually has a significant influence on the patient’s hospitalization (LOS) and/or
significantly influences the management or treatment of the patient
Data Type
CHAR
Data Element Length
7
Mandatory
Yes, if data element COMPLICATION_CM_DIAG_CODE is not collected
Field Values
Valid ICD-10 codes for complications
Constraints
Valid ICD-10 codes for complications
Null Value
Not applicable
Source
Direct data entry
Hierarchy
1. Medical progress notes
2. Medical consultation notes
3. Discharge summary
Additional Information
Up to 10 complications can be accepted per patient record; field therefore recurs
10 times. See Appendix F for a list of mandatory complications, their definitions and
corresponding ICD-10 codes. In the event there is no corresponding ICD-10 code, yes,
no or not applicable should be entered in a separate data field to capture this information.
Provinces have the ability to collect additional complications but must collect those
listed in Appendix F at a minimum. Complication data may be captured using data
element, COMPLICATION_CM_DIAG_CODE, which has complications listed in a
drop down menu, as an alternative to this data element, which captures complications
as ICD-10 codes.
Uses of Data
Report on common complications
History
Option to use this field or data element COMPLICATION_CM_DIAG_CODE to
capture complication.
Mandatory capturing of specific complications as listed in Appendix F.
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Date of Discharge
Name in Database
DISCHARGE_DATE
Definition
The date the patient was discharged from hospital or the emergency department or the
date the patient died in hospital
Data Type
DATE
Data Element Length
8
Mandatory
Yes
Field Values
Format: yyyymmdd
Constraints
19940101–20200101
Null Values
No null values accepted
Source
Direct data entry
Hierarchy
Inpatient discharge and death:
1. Face sheet
2. Physician discharge order
3. Inpatient nursing notes
4. Death certificate
ED visit only (alive or dead):
1. ED nursing notes
2. ED physician notes
3. Death certificate
Additional Information
Defined as the date the patient was discharged from hospital, died or was discharged
from the emergency department (if not admitted). Include alternative level of care days.
Do not include days following transfer to a rehabilitation facility, whether or not it is
included in the same institution.
Uses of Data
Generate length-of-stay numbers
History
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Separation Status
Name in Database
SEPARATION_STATUS_CODE
Definition
The status of the patient at discharge from the trauma centre
Data Type
CHAR
Data Element Length
2
Mandatory
Yes
Field Values
6—Discharged alive
7—Died in hospital after admission
8—Died in emergency, other than failed resuscitation attempt
9—Died after failed resuscitation attempt lasting between 5 and 15 minutes
10—DOA (declared dead on arrival) less than 5 minutes after presentation/resuscitation
efforts or no resuscitation attempt
Constraints
6–10
Null Values
No null values accepted
Source
Direct data entry
Hierarchy
Inpatient discharge and death:
1. Face sheet
2. Physician discharge order
3. Inpatient nursing notes
4. Death certificate
ED visit only (alive or dead):
1. ED nursing notes
2. ED physician notes
3. Trauma flow sheet
4. Death certificate
Additional Information
Enter 6 if the patient is discharged alive.
Enter 7 if the patient dies after admission to the hospital.
Enter 8 if the patient dies in the ED but resuscitation attempts take longer than 15 minutes
or patient decompensates after arrival and expires.
Enter 9 if the patient presents vital signs absent (VSA) and is pronounced after
resuscitation attempts lasting between 5 and 15 minutes.
Enter 10 if the patient presents VSA and has less than 5 minutes of resuscitation attempts
or no resuscitation efforts.
Uses of Data
Report trauma patient outcomes
History
Effective April 1, 2012, change in data element allowable field values: differentiation
between died in emergency (DIE) and dead on arrival (DOA)
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Discharge Disposition
Name in Database
DISCHARGE_DISPOSITION_CODE
Definition
The location to which the patient is discharged or the service arranged for the patient
immediately upon discharge from hospital
Data Type
CHAR
Data Element Length
2
Mandatory
Yes
Field Values
1—Home
2—Home with support services
3—Another acute care facility
4—General rehabilitation facility
5—Chronic care facility
6—Nursing home
7—Special rehabilitation facility
8—Foster care and/or children’s aid
9—Other
10—Died
Constraints
1–10
Null Values
No null values accepted
Source
Direct data entry
Hierarchy
1. Inpatient nursing notes
2. Medical progress notes
3. Physician orders
4. Discharge summary
Additional Information
Document for all admitted and non-admitted patients who are discharged alive from the
hospital or who died in the hospital or in the emergency department.
See Appendix H for definitions of each field value.
74
Uses of Data
Report on patient outcomes
History
Effective April 1, 2012, change in data element allowable field values
National Trauma Registry Comprehensive Data Set—Data Dictionary
Section 3—Appendices
Appendix A: Sports/Recreational Activity Codes
Sports and Recreation
1
Aerobics
2
Aircraft—Recreational Motorized (e.g. Fixed Wing)
3
Aircraft—Recreational Non-Motorized (e.g. Glider)
4
All-Terrain Vehicle (ATV)
5
Amusement Rides
6
Auto Racing
7
Badminton
8
Baseball (Hard Ball, Soft Ball, T-Ball, Slo-Pitch)
9
Basketball
10
Billiards/Pool/Shuffleboard
11
Boating—Motorized
12
Boating—Non-Motorized (Canoe, Kayak, Rowboat, Sailboat, Pedal Boat)
16
Boating—Windsurf/Sail Board
18
Boating—Waverunners, SeaDoos, etc.
19
Boating—Other, Unspecified
20
Boxing (Organized, Would Not Include Children at Play)
21
Bowling (5 or 10 Pin)
22
Cricket
23
Croquet/Lawn Bowling
24
Curling
25
Cycling—Driver (if Unspecified, Assume Driver)
26
Cycling—Passenger
27
Cycling—Unicycles
28
Dancing
29
Darts
30
Dirt Biking/Mini Biking/Motocross
31
Diving
32
Fencing
33
Fire (Open Flames Outdoors—e.g. Charcoal and Gas Barbecues, Camp Fires)
34
Fireworks—User
35
Fireworks—Observer
36
Fishing
37
Football
38
Go-Carting
39
Golf
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Sports and Recreation (cont’d)
76
40
Gymnastics (Organized—Would Not Include Children at Play)
41
Handball
42
Hang-Gliding/Para-Sailing
43
Hiking
44
Horseback Riding
45
Hockey—Ice (if Type of Hockey Is Unspecified, Assume Ice or Street Depending on
Season)
46
Hockey—Non-Ice, Non-Inline Hockey
48
Hockey—Inline
49
Horseshoes
50
Hunting—Bow and Arrow, Gun, Knives
53
Jogging/Running
54
Lacrosse
55
Lawn Darts
56
Luge/Bobsled
57
Martial Arts (Judo, Kendo, Karate, Tae Kwon-Do, Jiu-Jitsu, etc.)
58
Mountaineering/Rock Climbing
59
Playground Equipment (Swings, Slides, Monkey Bars, Teeter-Totter in Any Location)
60
Play Not Further Specified (i.e. Running, Jumping, Skipping, General Play Activities)
61
Racquetball
62
Ringette
63
Rugby
64
Scuba Diving
65
Shooting—Bow and Arrow (i.e. Targets), Gun (i.e. Non-Hunting Use of Firearm, Targets,
Rifle Range, Skeet)
67
Skateboarding
68
Skating—Ice (Use in Winter Season if Type of Skating Is Not Specified)
69
Skating—Inline
70
Skating—Roller
71
Skiing—Downhill—Recreational (Use if Type of Skiing Is Not Specified)
72
Skiing—Downhill—Racing
73
Skiing—Cross-Country
74
Ski Jumping (Includes Moguls and Aerial Stunts)
75
Sky Diving/Parachuting
76
Snowboarding
77
Snowmobiling—Driver (Assume Driver if Not Specified)
78
Snowmobiling—Passenger
79
Snowmobiling—Towed Behind on Toboggan, Tube, Sleigh
80
Soccer
81
Squash
National Trauma Registry Comprehensive Data Set—Data Dictionary
Sports and Recreation (cont’d)
82
Swimming—Pool
83
Swimming—Open Water
84
Swimming—Wading Pool, Location Unspecified
85
Tennis
86
Tobogganing/Sledding/Snow Tubing (Not Towed)
87
Track and Field (Organized)
88
Trampoline
89
Volleyball
90
Walking (for Exercise)
91
Water Polo
92
Waterskiing/Tubing
93
Weightlifting (Recreational or Organized, Includes Exercise Equipment)
94
Wrestling (Organized, Does Not Include Children at Play)
95
Observer of Sporting Event
97
Non-Motorized Scooters
98
Rodeo Sports
999
Other
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Appendix B: Inclusion Lists—ICD-10-CA
The following lists the categories used for trauma reporting purposes based on the NTR
definition. “Incident” and “unintentional” have been substituted for the terms “accident” and
“accidental” used in the ICD definitions.
ICD-10-CA
External Cause Code Category
Definition
V01–V99
Transport Incidents
V01–V06, V09–V90
Land Transport Incidents
V91–V94
Water Transport Incidents
V95–V97
Air and Space Transport Incidents
V98–V99
Other and Unspecified Transport Incidents
W00–W19
Unintentional Falls
W20–W46, W49
Exposure to Inanimate Mechanical Forces
W50–W60, W64
Exposure to Animate Mechanical Forces
W65–W70, W73, W74
Unintentional Drowning and Submersion
W75, W76, W77, W81, W83, W84
Other Unintentional Threats to Breathing, Except Due to Inhalation of Gastric
Contents, Food or Other Objects
W85–W94, W99
Exposure to Electric Current, Radiation and Extreme Ambient Air Temperature
and Pressure
X00–X06, X08, X09
Exposure to Smoke, Fire and Flames
X10–X19
Contact With Heat and Hot Substances
X30–X39
Exposure to Forces of Nature
X50
Overexertion and Strenuous or Repetitive Movements
X52
Prolonged Stay in Weightless Environment
X58–X59
Unintentional Exposure to Other and Unspecified Factors
X70–X84
Intentional Self-Harm, Excluding Poisoning
X86, X91–X99, Y00–Y05, Y07–Y09 Assault, Excluding Poisoning
Y20–Y34
Event of Undetermined Intent, Excluding Poisonings
Y35–Y36
Legal Intervention and Operations of War
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Appendix C: Exclusion Lists—ICD-10-CA
The following lists the ICD-10-CA external cause codes that are excluded from the National
Trauma Registry based on the definition of trauma.
ICD-10-CA
ICD-10-CA Code Exclusions Definition
W78–W80
W78 Inhalation of Gastric Contents
W79 Inhalation and Ingestion of Food Causing Obstruction of Respiratory Tract
W80 Inhalation and Ingestion of Other Objects Causing Obstruction of
Respiratory Tract
X20–X29
Contact With Venomous Animals and Plants
X40–X49*
Unintentional Poisoning and Exposure to Noxious Substances
X51
Travel and Motion
X53, X54, X57, Y06
X53 Lack of Food
X54 Lack of Water
X57 Unspecified Privation
Y06 Neglect and Abandonment
X60–X69*
Intentional Self-Harm by Poisoning
X85, X87–X90*
Assault by Poisoning
Y10–Y19*
Poisoning of Undetermined Intent
Y40–Y59
Drugs, Medicaments and Biological Substances Causing Adverse Effects in
Therapeutic Use
Y60–Y69
Misadventures to Patients During Surgical and Medical Care
Y70–Y82
Medical Devices Associated With Adverse Incidents in Diagnostic and Therapeutic
Use
Y83–Y84
Surgical and Other Medical Procedures as the Cause of Abnormal Reaction of the
Patient or of Later Complication, Without Mention of Misadventure at the Time of the
Procedures
Y85–Y89
Sequelae of External Causes of Morbidity and Mortality
Y90–Y98
Supplementary Factors Related to Causes of Morbidity and Mortality
Classified Elsewhere
Note
* These cases will be excluded but will be reported on separately.
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Appendix D: Injury Types
The following provides information on the specific diagnosis codes for the injury types described
in NTR reports.
Description
ICD-10 Code Range
Superficial
S00, S05.0, S05.1, S05.8, S05.9, S10, S20, S30, S40, S50, S60, S70, S80, S90, T00,
T09.0, T11.0, T13.0, T14.0
Musculoskeletal
S02, S12, S22, S32, S42, S52, S62, S72, S82, S92, T02, T08, T10, T12, T14.2, S03,
S13, S23, S33, S43, S53, S63, S73, S83, S93, T03, T11.2, T13.2, T14.3, S09.10,
S09.18, S16, S29.00, S29.08, S39.00, S39.08, S46, S56, S66, S76, S86, S96, T06.4,
T09.5, T11.5, T13.5, T14.6
Burns and Corrosion
T20, T32
Internal Organ
S06, S09.7, S09.8, S09.9, S26, S27, S36, S37, S39.6, T06.5
Crushing
S07, S17, S28.0, S38.0, S38.1, S47, S57, S67, S77, S87, S97, T04
Open Wound, Including
Traumatic Amputation
S01, S05.2–S05.7, S09.2, S11, S21, S31, S41, S51, S61, S71, S81, S91, T01, T09.1,
T11.1, T13.1, T14.1, S08, S18, S28.1, S38.2, S38.3, S48, S58, S68, S78, S88, S98,
T05, T11.6, T13.6, T14.7
Blood Vessels
S09.0, S15, S25, S35, S45, S55, S65, S75, S85, S95, T06.3, T11.4, T13.4, T14.5
Nerves and Spinal Cord
S04, S14, S24, S34, S44, S54, S64, S74, S84, S94, T06.0, T06.1, T06.2, T11.3,
T13.3, T14.4
Other and Unspecified
S19, S29.7, S29.8, S29.9, S39.7, S39.8, S39.9, S49, S59, S69, S79, S89, S99, T06.8,
T07, T09.8, T09.9, T11.8, T11.9, T13.8, T13.9, T14.8, T14.9, T15, T16, T18, T19,
T33, T34, T35, T66, T67, T68, T69, T70, T71, T73 (Excludes T73.0, T73.1), T75
(Excludes T75.3)
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Appendix E: List of Comorbidities and Accompanying Definitions
Alcoholism: To be determined based upon the brief screening tool used at your institution.
ICD-10-CA codes: F10.0–F10.9, F19.0, F19.2, Z13.3
Attention deficit hyperactivity disorder (ADHD)
ICD-10-CA code: F90.0
Ascites within 30 days: The presence of fluid accumulation (other than blood) in the peritoneal
cavity noted on physical examination, abdominal ultrasound or abdominal CT/MRI.
ICD-10-CA code: R18
Autism/Asperger’s
ICD-10-CA codes: F84.0, F84.1, F84.5
Bleeding disorder: Any condition that places the patient at risk for excessive bleeding due to a
deficiency of blood clotting elements (such as vitamin K deficiency, hemophilia, thrombocytopenia
or chronic anticoagulation therapy with Coumadin, Plavix or similar medications). Do not include
patients on chronic aspirin therapy.
ICD-10-CA codes: D68.4, D66, D68.1, D67.1, D68.0, D68.3, D69.1, D69.4, D69.5, D69.6,
D69.8, D69.9
Chemotherapy for cancer within 30 days: A patient who had any chemotherapy treatment for
cancer in the 30 days prior to admission. Chemotherapy may include, but is not restricted to,
oral and parenteral treatment with chemotherapeutic agents for malignancies, such as colon,
breast, lung, head and neck, and gastrointestinal solid tumors, as well as lymphatic and
hematopoietic malignancies, such as lymphoma, leukemia and multiple myeloma.
ICD-10-CA code: Z51.1
Cirrhosis: Documentation in the medical record of cirrhosis, which might also be referred to as
end-stage liver disease. If there is documentation of prior or present esophageal or gastric
varices, portal hypertension, previous hepatic encephalopathy or ascites with notation of liver
disease, then cirrhosis should be considered present. Cirrhosis should also be considered
present if documented by diagnostic imaging studies or at laparotomy/laparoscopy.
ICD-10-CA codes: K74.0–K74.6, K70.3, K70.4, K71.7
Congenital anomalies: Documentation of a cardiac, pulmonary, body wall, CNS/spinal, GI,
renal, orthopedic or metabolic congenital anomaly.
ICD-10-CA codes: Q00.0–Q99.9
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Congestive heart failure: The inability of the heart to pump a sufficient quantity of blood to
meet the metabolic needs of the body or the ability of the heart to do so only at an increased
ventricular filling pressure. To be included, this condition must be noted in the medical record as
CHF, congestive heart failure or pulmonary edema with onset or increasing symptoms within
30 days prior to injury. Common manifestations are
1. Abnormal limitation in exercise tolerance due to dyspnea or fatigue;
2. Orthopnea (dyspnea on lying supine);
3. Paroxysmal nocturnal dyspnea (awakening from sleep with dyspnea);
4. Increased jugular venous pressure;
5. Pulmonary rales on physical examination;
6. Cardiomegaly; and
7. Pulmonary vascular engorgement.
ICD-10-CA codes: I50.0, I50.1, I11, I13, I42.0–I42.9, I43.0–I43.8, I09.8
Current smoker: A patient who has smoked cigarettes in the year prior to admission. Do not
include patients who smoke cigars or pipes or use chewing tobacco.
No corresponding ICD-10-CA code; therefore, yes, no or not applicable should be entered in a
separate data field to capture this information.
Currently requiring or on dialysis: Acute or chronic renal failure prior to injury that was
requiring periodic peritoneal dialysis, hemodialysis, hemofiltration or hemodiafiltration.
ICD-10-CA code: Z99.2
CVA/residual neurological deficit: A history prior to injury of a cerebrovascular accident
(embolic, thrombotic or hemorrhagic) with persistent residual motor, sensory or cognitive
dysfunction (such as hemiplegia, hemiparesis, aphasia, sensory deficit or impaired memory).
ICD-10-CA codes: I60.0–I69.8
Diabetes mellitus: Diabetes mellitus prior to injury that required exogenous parenteral insulin
or an oral hypoglycemic agent.
ICD-10-CA codes: E10.0–E11.9, E13.0–E14.9
Disseminated cancer: Patients who have cancer
1. That has spread to one or more sites in addition to the primary site; AND
2. In whom the presence of multiple metastases indicates the cancer is widespread, fulminant or
near terminal. Other terms describing disseminated cancer include “diffuse,” “widely
metastatic,” “widespread” or “carcinomatosis.” Common sites of metastases include major
organs (such as the brain, lung, liver, meninges, abdomen, peritoneum, pleura and bone).
ICD-10-CA codes: C77.0–C80.9
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Do not resuscitate (DNR) status: The patient had a do not resuscitate (DNR) document or
similar advance directive recorded prior to injury.
No corresponding ICD-10-CA code; therefore, yes, no, unknown or not applicable should be
entered in a separate data field to capture this information.
Drug use: Mental and behavioural disorders due to the use of drugs.
ICD-10-CA codes: F11.0–F16.9, F19.0–F19.9, Z13.3
Esophageal varices: Engorged collateral veins in the esophagus that bypass
a scarred liver to carry portal blood to the superior vena cava. A sustained increase in portal
pressure results in esophageal varices, which are most frequently demonstrated by direct
visualization at esophagoscopy.
ICD-10-CA code: I86.4
Functionally dependent health status: Pre-injury functional status may be represented by the
ability of the patient to complete activities of daily living (ADLs), including bathing, feeding,
dressing, toileting and walking. This item is marked yes if the patient, prior to injury, was partially
dependent or completely dependent upon equipment, devices or another person to complete
some or all ADLs. Formal definitions of dependency are listed below:
1. Partially dependent: The patient requires the use of equipment or devices coupled with
assistance from another person for some ADLs. Any patient coming from a nursing home
setting who is not totally dependent would fall into this category, as would any patient who
requires kidney dialysis, home ventilator support or chronic oxygen therapy yet maintains
some independent functions.
2. Totally dependent: The patient cannot perform any ADLs for himself or herself. This would
include a patient who is totally dependent upon nursing care or a dependent nursing home
patient. All patients with psychiatric illnesses should be evaluated for their ability to function
with or without assistance with ADLs, just as non-psychiatric patients are.
No corresponding ICD-10-CA code; therefore yes, no, unknown or not applicable should be
entered in a separate data field to capture this information.
History of angina within past one month: Pain or discomfort between the diaphragm and the
mandible resulting from myocardial ischemia. Typically, angina is a dull, diffuse (fist-sized or
larger) substernal chest discomfort precipitated by exertion or emotion and relieved by rest or
nitroglycerin. Radiation often occurs to the arms and shoulders and occasionally to the neck,
jaw (mandible, not maxilla) or interscapular region. For patients on anti-anginal medications,
enter yes only if the patient has had angina within one month prior to admission.
ICD-10-CA codes: I20.0–I20.9
History of myocardial infarction within past six months: The history of a non–Q wave or a
Q-wave infarction in the six months prior to injury as diagnosed in the patient’s medical record.
ICD-10-CA code: I25.2
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History of revascularization/amputation for peripheral vascular disease: Any type of
angioplasty or revascularization procedure for atherosclerotic peripheral vascular disease (PVD)
(for example, aorta–femoral, femoral–femoral and femoral–popliteal) or a patient who has had
any type of amputation procedure for PVD (for example, toe amputations, transmetatarsal
amputations and below-knee or above-knee amputations). Patients who have had an
amputation for trauma or resection of abdominal aortic aneurysms would not be included.
No corresponding ICD-10-CA code; therefore, yes, no, unknown or not applicable should be
entered in a separate data field to capture this information.
Hypertension requiring medication: History of a persistent elevation of systolic blood
pressure greater than 140 mm Hg and a diastolic blood pressure greater than 90 mm Hg
requiring an antihypertensive treatment (such as diuretics, beta blockers, ACE inhibitors or
calcium channel blockers).
ICD-10-CA codes: I10.0–I10.9, I11–I15
Impaired sensorium: Patients should be noted to have an impaired sensorium if they had
mental status changes and/or delirium in the context of a current illness prior to injury. Patients
with chronic or long-standing mental status changes secondary to chronic mental illness (such
as schizophrenia) or chronic dementing illnesses (such as multi-infarct dementia or senile
dementia of the Alzheimer’s type) should also be included. Mental retardation would qualify
as impaired sensorium. For pediatric populations, patients with documented behaviour
disturbances, attention disorders, delayed learning or delayed development should be included.
ICD-10-CA codes: F00.0–F09, F70.0–F79.9, G30.0–G30.9, F90.0, F91.8, F91.9, F84.0, F81.9,
F80.0, F80.1, F80.8, F80.9, F81.3, F81.8
Obesity: A body mass index of 30 or greater.
ICD-10-CA codes: E66.0–E66.9
Prematurity: Documentation of premature birth, a history of bronchopulmonary dysplasia,
ventilator support for longer than seven days after birth or the diagnosis of cerebral palsy.
Premature birth is defined as infants delivered before 37 weeks from the first day of the last
menstrual period.
ICD-10-CA codes: G80.0–G80.9, P07.0–P07.3, P27.0–P27.9
CCI code: 1.GZ.31
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Respiratory disease: Severe chronic lung disease, chronic asthma, cystic fibrosis or chronic
obstructive pulmonary disease (COPD) (such as emphysema and/or chronic bronchitis)
resulting in any one or more of the following:
1. Functional disability from COPD (such as dyspnea or inability to perform ADLs);
2. Hospitalization in the past for treatment of COPD;
3. Requirement for chronic bronchodilator therapy with oral or inhaled agents; and/or
4. An FEV1 of less than 75% of predicted on pulmonary function testing.
Do not include patients whose only pulmonary disease is acute asthma. Do not include patients
with diffuse interstitial fibrosis or sarcoidosis.
ICD-10-CA codes: E84.0–E84.9, J40–J45.91
Steroid use: Patients who required the regular administration of oral or parenteral corticosteroid
medications (such as prednisone or Decadron) in the 30 days prior to injury for a chronic
medical condition (such as COPD, asthma, rheumatologic disease, rheumatoid arthritis or
inflammatory bowel disease). Do not include topical corticosteroids applied to the skin or
corticosteroids administered by inhalation or rectally.
No corresponding ICD-10-CA code; therefore, yes, no, unknown or not applicable should be
entered in a separate data field to capture this information.
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Appendix F: List of Complications and Accompanying Definitions
Abdominal compartment syndrome: The sudden increase in intra-abdominal pressure
resulting in alteration in the respiratory mechanism, hemodynamic parameters and renal
perfusion. Typically, patients with this syndrome are critically ill and require ventilator support
and/or reoperation.
ICD-10-CA code: T79.6
Abdominal fascia left open: No primary surgical closure of the fascia, or intra-abdominal
packs left at conclusion of primary laparotomy (damage control).
No corresponding ICD-10-CA code; therefore, yes, no, unknown or not applicable should be
entered in a separate data field to capture this information.
Acute renal failure: A patient who did not require dialysis prior to injury, who has worsening
renal dysfunction after injury requiring hemodialysis, ultrafiltration or peritoneal dialysis. If the
patient refuses treatment (such as dialysis), the condition is still considered present.
ICD-10-CA codes: N17.0–N19, N25.0, N03.0–N05.9, I12, I13, T79.5
ARDS: Adult (acute) respiratory distress syndrome occurs in conjunction with catastrophic
medical conditions, such as pneumonia, shock, sepsis (or severe infection throughout the body,
sometimes also referred to as systemic infection, and possibly including or also called a blood
or blood-borne infection) and trauma. It is a form of sudden and often severe lung failure
characterized by PaO2/FiO2 of 200 or less, decreased compliance and diffuse bilateral
pulmonary infiltrates without associated clinical evidence of CHF. The process must persist
beyond 36 hours and require mechanical ventilation.
ICD-10-CA code: J80
CCI code: 1.GZ.31
Bleeding: Any transfusion (including autologous) of five or more units of packed red blood cells
or whole blood given from the time the patient is injured up to and including 72 hours later. The
blood may be given for any reason.
CCI code: 1.LZ.19
Cardiac arrest with CPR: The absence of a cardiac rhythm or presence of chaotic cardiac
rhythm that results in loss of consciousness requiring the initiation of any component of basic
and/or advanced cardiac life support. Excludes patients who arrive at the hospital in full arrest.
ICD-10-CA codes: I46.0–I46.9
Coagulopathy: Twice the upper limit of the normal range for PT or PTT in a patient without a
pre-injury bleeding disorder of this magnitude.
ICD-10-CA codes: D65–D68.2, D69.1, D69.30–D69.4
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Decubitus ulcer: A pressure sore resulting from pressure exerted on the skin, soft tissue,
muscle or bone by the weight of an individual against a surface beneath. Individuals unable to
avoid long periods of uninterrupted pressure over bony prominences are at increased risk for
the developing necrosis and ulceration.
ICD-10-CA codes: L89.0–L89.9
Deep surgical site infection: An infection that occurs within 30 days after an operation and
that appears to be related to the operation. The infection should involve deep soft tissues (such
as the fascial and muscle layers) at the site of incision and at least one of the following:
1. There is purulent drainage from the deep incision but not from the organ/space component of
the surgical site.
2. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the
patient has at least one of the following signs or symptoms: fever (greater than 38oC),
localized pain or tenderness, unless site is culture-negative.
3. An abscess or other evidence of infection involving the deep incision is found on direct
examination, during reoperation or by histopathologic or radiologic examination.
4. A deep incision infection is diagnosed by a surgeon or attending physician.
Note: Report infections that involve both superficial and deep incision sites as deep surgical site
infection. If a wound spontaneously opens as a result of infection, code for deep surgical site
infection and wound disruption.
ICD-10-CA code: T81.4
Drug or alcohol withdrawal syndrome: A set of symptoms that may occur when a person who
has been drinking too much alcohol or habitually using certain drugs suddenly stops. Symptoms
may include activation syndrome (that is, tremulousness, agitation, rapid heartbeat and high
blood pressure), seizures, hallucinations or delirium tremens.
ICD-10-CA codes: F10.3–F10.5
Deep vein thrombosis (DVT)/thrombophlebitis: The formation, development or existence of a
blood clot or thrombus within the vascular system, which may be coupled with inflammation.
This diagnosis may be confirmed by a venogram, ultrasound or CT scan. The patient must be
treated with anticoagulation therapy and/or placement of a vena cava filter or clipping of the
vena cava.
ICD-10-CA code: I80.2
Extremity compartment syndrome: A condition in which there is swelling and an increase in
pressure within a limited space (a fascial compartment) that presses on and compromises blood
vessels, nerves and/or tendons that run through that compartment. Compartment syndromes
usually involve the leg but can also occur in the forearm, arm, thigh and shoulder.
ICD-10-CA codes: M62.20–M62.29
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Graft/prosthesis/flap failure: Mechanical failure of an extracardiac vascular graft or
prosthesis, including myocutaneous flaps and skin grafts, requiring return to the operating
room or a balloon angioplasty.
ICD-10-CA codes: T82.0–T82.9
Intracranial pressure elevation: Intracranial pressure greater than 25 torr for longer than
30 minutes.
ICD-10-CA code: G93.2
Myocardial infarction: A new acute myocardial infarction occurring during hospitalization
(within 30 days of injury).
ICD-10-CA codes: I21.0–I21.9
Organ/space surgical site infection: An infection that occurs within 30 days after an operation
and which involves any part of the anatomy (organs or spaces) other than the incision, which
was opened or manipulated during a procedure. The infection must also involve at least one of
the following:
1. There is purulent drainage from a drain that is placed through a stab wound or puncture into
the organ/space.
2. Organisms are isolated from an aseptically obtained culture of fluid or tissue in the
organ/space.
3. An abscess or other evidence of infection involving the organ/space is found on direct
examination, during reoperation or by histopathologic or radiologic examination.
4. An organ/space SSI is diagnosed by a surgeon or attending physician.
ICD-10-CA codes: T81.4, T82.6, T82.7, T83.5, T83.6, T84.50–T84.58, T84.60–T84.69, T85.7,
T87.40–T87.49, Y83.0–Y83.9, Y88.3
Osteomyelitis: A condition that meets at least one of the following criteria:
1. Organisms are cultured from bone.
2. There is evidence of osteomyelitis on direct examination of the bone during a surgical
operation or histopathologic examination.
3. At least two of the following signs or symptoms with no other recognized cause are present:
fever (38°C), localized swelling, tenderness, heat or drainage at the suspected site of bone
infection and at least one of the following:
a. Organisms are cultured from blood;
b. There is a positive blood antigen test (such as H. influenzae or S. pneumoniae); and/or
c. There is radiographic evidence of infection, such as abnormal findings on X-ray, CT
scan, MRI scan or radiolabel scan (gallium, technetium, etc.).
ICD-10-CA codes: H05.0, M86.00–M86.19
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Pneumonia: Patients with evidence of pneumonia that develops during the hospitalization.
Patients with pneumonia must meet at least one of the following two criteria:
Criterion 1. Rales or dullness to percussion on physical examination of chest AND any of
the following:
a. New onset of purulent sputum or change in character of sputum;
b. Organism isolated from blood culture; and/or
c. Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing
or biopsy.
Criterion 2. Chest radiographic examination shows new or progressive infiltrate, consolidation,
cavitation or pleural effusion AND any of the following:
a. New onset of purulent sputum or change in character of sputum;
b. Organism isolated from the blood;
c. Isolation of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing or
biopsy;
d. Isolation of virus or detection of viral antigen in respiratory secretions;
e. Diagnostic single antibody titer (IgM) or fourfold increase in paired serum samples (IgG) for
pathogen; and/or
f.
Histopathologic evidence of pneumonia.
ICD-10-CA codes: J12.0–J18.9, J95.88
Pulmonary embolism: A lodging of a blood clot in a pulmonary artery with subsequent
obstruction of blood supply to the lung parenchyma. The blood clots usually originate from the
deep leg veins or the pelvic venous system. Consider the condition present if the patient has a
V-Q scan interpreted as high probability of pulmonary embolism or a positive pulmonary
arteriogram or positive CT angiogram.
ICD-10-CA codes: I26.0–I26.9
Stroke/CVA: Following injury, patient develops an embolic, thrombotic or hemorrhagic vascular
accident or stroke with motor, sensory or cognitive dysfunction (such as hemiplegia,
hemiparesis, aphasia, sensory deficit or impaired memory) that persists for 24 or more hours.
ICD-10-CA codes: I63.1–I63.9, I64
Superficial surgical site infection: Defined as an infection that occurs within 30 days after an
operation and that involves only skin or subcutaneous tissue of the incision and at least one of
the following:
1. There is purulent drainage, with or without laboratory confirmation, from the superficial incision.
2. Organisms are isolated from an aseptically obtained culture of fluid or tissue from the
superficial incision.
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3. At least one of the following signs or symptoms of infection is present: pain or tenderness,
localized swelling, redness or heat; and the superficial incision is deliberately opened by the
surgeon, unless incision is culture-negative.
4. Superficial incisional surgical site infection is diagnosed by the surgeon or attending physician.
Do not report the following conditions as superficial surgical site infection:
1. Stitch abscess (minimal inflammation and discharge confined to the points of suture penetration).
2. Infected burn wound.
3. Incisional SSI that extends into the facial and muscle layers (see deep surgical site infection).
ICD-10-CA code: T81.4
Systemic sepsis: Definitive evidence of infection, plus evidence of a systemic response to
infection. This systemic response is manifested by the presence of infection and TWO or more
of the following conditions:
1. Temperature higher than 38°C or lower than 36°C;
2. Sepsis with hypotension despite adequate fluid resuscitation combined with perfusion
abnormalities that may include, but are not limited to, lactic acidosis, oliguria or an acute
alteration in mental status. Patients who are on inotropic or vasopressor agents may not be
hypotensive at the time that perfusion abnormalities are measured;
3. HR higher than 90 BPM;
4. RR greater than 20 breaths/minute or PaCO2 lower than 32 mm Hg (less than 4.3 kPa); and
5. WBC greater than 12,000 cells/mm3, less than 4,000 cells/mm3 or greater than 10% immature
(band) forms.
ICD-10-CA codes: A40.0–A41.9, A49.9
Unplanned intubation: Patient requires placement of an endotracheal tube and mechanical or
assisted ventilation because of the onset of respiratory or cardiac failure manifested by severe
respiratory distress, hypoxia, hypercarbia or respiratory acidosis. In patients who were intubated
in the field or emergency department, or those intubated for surgery, unplanned intubation
occurs if they require reintubation after being extubated.
No corresponding ICD-10-CA code; therefore, yes, no, unknown or not applicable should be
entered in a separate data field to capture this information.
Unplanned return to the ICU: Unplanned return to the intensive care unit after initial
ICU discharge. Does not apply if ICU care is required for post-operative care of a planned
surgical procedure.
No corresponding ICD-10-CA code; therefore, yes, no, unknown or not applicable should be
entered in a separate data field to capture this information.
Unplanned return to the OR: Unplanned return to the operating room after initial operation
management for a similar or related previous procedure.
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No corresponding ICD-10-CA code; therefore, yes, no, unknown or not applicable should be
entered in a separate data field to capture this information.
Urinary tract infection: An infection anywhere along the urinary tract with clinical evidence of
infection, which includes at least one of
1. Fever higher than 38.5°C;
2. WBC higher than 100,000 or less than 3,000 per cubic millimetre;
3. Urgency;
4. Dysuria; or
5. Suprapubic tenderness.
ICD-10-CA code: N39.0
Wound disruption: Separation of the layers of a surgical wound, which may be partial or
complete, with disruption of the fascia.
ICD-10-CA code: T81.3
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Appendix G: Definitions of Discharge Disposition Institutions
1. Home—no support service from an external agency required; patient functions independently
2. Home with support services—senior’s lodge, attendant care, home care, meals on wheels,
homemaking, supportive housing, etc.
Examples:
a. A facility where supervisory care is not required on a continuing basis. The patient is
discharged and able to function independently within a group setting. Community
services would be brought in to provide support, when necessary.
b. The patient is discharged home with the support of home care workers who are
providing daily dressing changes and wound care.
3. Another acute care facility: patient is transferred to an acute care inpatient institution
(includes other acute, subacute, acute psychiatric, acute rehabilitation, acute cancer, acute
pediatric, etc.)
4. General rehabilitation facility—a rehabilitation unit or collection of beds designated for
rehabilitation purposes that is part of a general hospital offering multiple levels or types
of care
5. Chronic care facility—patient is discharged to a reporting facility that provides continuing
medical care by medical and allied medical staff
6. Nursing home—patient receives support services at some level
7. Special rehabilitation facility—a facility that may provide extensive and specialized
inpatient rehabilitation services; commonly a free-standing facility or a specialized unit
within a hospital
8. Foster care and/or children’s aid
9. Other
10. Died
Sources
Canadian Institute for Health Information, DAD Abstracting Manual, 2010–2011 (Ottawa, Ont.: CIHI, 2010). Canadian Institute for Health
Information, National Rehabilitation Reporting System Privacy Impact Assessment (Ottawa, Ont.: CIHI, 2009).
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Appendix H: Revised Trauma Score
Glasgow Coma
Scale (GCS)
Systolic Blood
Pressure (SBP)
Respiratory
Rate (RR)
Coded Value
13–15
90+
10–29
4
9–12
76–89
30+
3
6–8
50–75
6–9
2
4–5
1–49
1–5
1
3
0
0
0
Revised Trauma Score = 0.9368GCS + 0.7326SBP + 0.2908RR
RTS values range from 0 to 7.8408
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National Trauma Registry Comprehensive Data Set—Data Dictionary
Appendix J: Acceptable Procedures Performed in the ICU
Cardiovascular
Open cardiac massage
CCI codes: 1.HZ.09.LA-CJ
Angio-embolization
CCI codes: Specific CCI code related to the vessel of the site being embolized
IVC filter
CCI code: 1.IS.51.GR-KA
CNS
Insertion of ICP monitor
CCI codes: 1.AA.53.SE-PL, 1.AA.53.SZ-PL, 1.AC.53.DA-PL, 1.AC.53.SZ-PL, 1.AN.53.SE-PL,
1.AN.53.SZ-PL
Ventriculostomy
CCI codes: 1.AC.52.^^
Cerebral oxygen monitoring
CCI code: 1.AA.53.SE-PL
Musculoskeletal
Fasciotomy
CCI codes: 1.EP.72.WK, 1.SG.72.WK, 1.SY.72.WK, 1.TF.72.WK, 1.TQ.72.WK, 1.UY.72.WK,
1.VD.72.WK, 1.VR.72.WK, 1.WV.72.WK
Genitourinary
Ureteric catheterization (ureteric stent)
CCI codes: 1.PG.50.^^
Suprapubic cystostomy
CCI codes: 1.PM.52.HH-TS
Respiratory
Chest tube
CCI codes: 1.GV.52.DA-TS, 1.GV.52.HA-HE, 1.GV.52.LA-TS
Tracheostomy
CCI codes: 1.GJ.77.^^
Gastrointestinal
Gastrostomy/jejunostomy (percutaneous or endoscopic)
CCI codes: 1.NF.53.^^, 1.NK.53.^^
101
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Cette publication est aussi disponible en français sous le titre Registre national
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