Trauma service activation

Codes and are used to report the total duration of time spent providing critical care services. CPT code is used to report the hospital admission and includes evaluation and admission to hospital, including later rounding on patient in ICU noncritical care on day of admission, accounting for the face-to-face time of the subsequent care delivered later that day and complexity of the medical decision making. The critical care and hospital admission are separately reportable. Although the surgeon was called in to consult, the consult codes are not reported because the surgeon decided to admit the patient to his service.

The ultrasound procedures require the 26 modifier professional component because the surgeon may only bill for the physician component of the service. In addition, any add-on codes must follow the primary code on the claim form. The trauma surgeon meets the ambulance in the ED and performs the ATLS, primary and secondary surveys, initial resuscitation, and complex medical decision making, including imaging studies, coordination with specialty services for an operation with multiple teams, and communication with family.

The patient is unable to provide a comprehensive history. The surgeon documents that the history is unobtainable and high-complexity medical decision making. The surgeon places bilateral chest tubes for hemopneumothoraces and performs a FAST exam, which shows free fluid in the abdomen. The surgeon directs the management of ventilation and blood product administration. The surgeon spends 60 minutes performing critical care in the ED and then takes the patient to the operating room, where he or she performs a laparotomy to pack and control a liver injury.

At the same session, a thoracic surgeon performs a thoracotomy with wedge resection of a bleeding lung and a pericardial window. The patient then goes to the intensive care unit, where the surgeon spends another 60 minutes supervising critical care.

Management of the liver hemorrhage is reported with CPT code CPT code is used to report the placement of the chest tubes, and the 50 modifier bilateral procedure is required because chest tubes were placed bilaterally. It is important to note that some payors that do not follow Medicare rules may require the reporting of bilateral procedures on two lines and The ultrasound procedure requires the 26 modifier professional component because in the facility the surgeon may only bill for the physician component of the service.

Add-on codes must follow the primary code on the claim form. Critical care codes and are used to report the total duration of time that a physician spent providing critical care.

If you have additional coding questions, contact the ACS Coding Hotline at between am and pm Mountain time, excluding holidays, or visit the Coding and Practice Management Corner. Accurate coding is the responsibility of the provider. This summary is only intended as a resource to assist in the billing process. Evaluation and Management Services Guide. Accessed April 17, Bulletin of the American College of Surgeons N. Saint Clair St. Chicago, IL Complexity of decision making helps to determine the level of CPT code billed When the surgeon fully documents the standard initial ATLS trauma evaluation, the level and complexity of medical decision making may become the critical element in determining the final level of coding.

Table 2. Table 5. Total duration and correct codes for reporting critical care services CPT defines critical care as: The direct delivery by a physician s or other qualified health care professional of medical care for a critically ill or critically injured patient. Table 6. Clinical scenarios Case 1: A year-old male involved in a motor vehicle accident MVA is brought to the ED with a fractured pelvis and small bleed from the spleen.

The general surgeon consults. Case 2: A year-old male is brought to the ED in shock with a gunshot wound to the chest. The RAH Trauma Service includes: an onsite helipad with capacity for two helicopters eight emergency resuscitation bays major complex multi-trauma Emergency Department ED with up to 70 treatment spaces state-of-the-art ICU with 60 bed capacity a hyperbaric service 10 emergency operating theatres Technical Suite rooms South Australian adult burns unit.

Staff information, service snapshot, student electives and useful links. RAH Trauma monthly snapshot. Trauma Service Medical Student Elective. Other Trauma Links. A process map was subsequently formulated, and a root-cause analysis was conducted with the aid of a fishbone diagram to outline the TTA pathway and identify areas that required improvement. Root-cause analysis identified structure and process barriers that prevented appropriate TTA.

Plan—Do—Study—Act cycles that focused on structure barriers included the following:. Altering TTA criteria to focus on anatomic and physiologic variables: with feedback from local clinical emergency department physicians and trauma surgeons as well as national experts at other level 1 Canadian trauma centres, we developed TTA criteria that were objective and based on anatomic and physiologic criteria.

Changing the composition of the trauma team: trauma team reconfiguration involved adding more senior clinicians and ensuring clarity regarding roles and responsibilities for all trauma team members.

The trauma team initially included the TTL or emergency department physician, junior and senior residents in general surgery, an orthopedic surgery resident, a neurosurgery resident and an anesthesiologist.

The general surgery staff physician and general surgery chief were added to facilitate trauma resuscitation processes, trauma management and treatment decisions.

Clarifying roles for each member of the trauma team: senior leadership within the trauma team facilitated clarification of roles and responsibilities, and efficiently directed actions of the trauma team. Collaboration with the other major trauma centre in the city allowed TTA criteria to be consistent. Trauma team activation was also added as a mandatory agenda item for discussion at monthly trauma committee meetings.

This funding also facilitated access to alphanumeric pagers to improve TTA notification. Providers also supply the receiving facility with key clinical information that can be included with TTA using the alphanumeric paging system. It should be noted that a prehospital triage tool existed before project implementation that successfully diverted all patients with major trauma to 1 of 2 major trauma centres within our region.

The form required explanation of the clinical scenario and would allow our hospital to record instances in which the trauma team is activated unnecessarily. This was facilitated by clear leadership support and sponsorship from the health care organization Alberta Health Services and leadership within Alberta Health Services Trauma Services and prehospital care teams.

Process improvement involved the following actions:. Communication and dissemination of the updated TTA protocols and team roles: a list of responsibilities for each trauma team member was disseminated and posted in the emergency department as a visual reminder. Discussions with each group further clarified any uncertainty regarding roles within the trauma team.

We also performed monthly TTA simulations where the focus was on trauma team dynamics communication, delegation of tasks, leveling of hierarchy, and education around leadership and crisis resource management principles and further strengthening roles and responsibilities. Ongoing education regarding new TTA criteria: to ensure uptake of the new TTA criteria, additional educational sessions were held with medical staff, residents and frontline emergency department staff.

Criteria for TTA were also outlined on laminated quick-reference cards on lanyards given to all trauma team members medical and nonmedical. Ongoing audits of TTA compliance: data were collected and charted on posters that were displayed in a visible, transparent manner for all stakeholders.

Formal root-cause analysis identified key stakeholders, and, with their engagement, a process map was created that identified major barriers to achieving high rates of TTA compliance Fig.

The fishbone and Pareto diagrams in Fig. Poor buy-in from surgical subspecialties, lack of staff surgeon involvement, inconsistent TTL coverage and miscommunication with prehospital providers were outlined as key problems. Other major barriers identified included subjective TTA criteria, uncertain TTA process, lack of clarity regarding the role of the trauma team, inconsistent notification process for the trauma team and reluctance to activate the trauma team owing to its junior composition.

Trauma team activation process map used to identify areas of improvement. Fishbone diagram showing barriers to successful trauma team activation TTA.

Reasons cited as barriers to compliance with trauma team activation TTA protocols identified on root-cause analysis.

Baseline data were collected for patients from April to August Change cycle implementation in August was associated with an increase in TTA compliance to Compliance averaged During this time, the rate of TTA for penetrating trauma increased. Also, the number of missed TTAs due to process errors decreased, from 2. Run chart displaying compliance with trauma team activation TTA based on the current criteria throughout project, April —February Letters correspond to steps in Table 1.

However, the number of missed TTAs due to process errors decreased to 0. The mean time that patients spent in the acute care area of the emergency department was 3 hours and 54 minutes, and their total time in the emergency department was 4 hours and 14 minutes.

Trauma quality indicators measured following the implementation of rapid change cycles, October to February The success of process-specific PDSA cycles hinges on previous background review of practice standards that are evidence based, stakeholder analysis, staff engagement and structure solutions, which should be the primary actions of a change project. This goal was met by July and was sustained for the following 7 months. Undertriage occurs because of inadequate triage scoring systems despite good interrater reliability , 24 , 25 undertriage of older patients, 16 , 23 , 26 different triage rates based on experience and profession, 15 , 16 neurosurgical injuries 27 , 28 and poor compliance with TTA protocols, as we showed in our hospital.

Penetrating trauma is diverse, and low rates of TTA for penetrating trauma are likely because emergency physicians feel comfortable treating patients with distal extremity or superficial penetrating trauma without the support of a large trauma team if they are in stable condition.

Overtriage is similarly detrimental, yet some degree of overtriage may be necessary to capture all the patients requiring trauma team treatment. In keeping with the Donabedian approach, we brought together stakeholders to more fully understand the reasons behind poor TTA compliance.

Multidisciplinary working groups helped engage staff with participative techniques during the initial stages of the project. This was likely in part due to engagement but may have also been due to a Hawthorne effect, as there were fluctuations almost back to baseline over time.

Lack of substantial results with initial efforts is likely why these crucial steps may often seem unimportant and may be overlooked. The success of subsequent PDSA cycles and change management efforts is largely attributable to the nonidentifiable understanding, awareness and engagement that occurred as a result of the work done before roll-out; i.

Examples of process-focused changes include steps G—K in Table 1. Structure-focused solutions generated trust and increased compliance by the providers who were involved with the working groups, as their responses resulted in obvious changes. The rate of compliance with TTA protocols increased from The immediate response to structure changes and provider-generated change was largely attributable to the relationships that were formed through working groups.

As an example, the working group identified lack of role clarification and trauma team composition as issues that reduced TTA compliance. The introduction of senior trauma team members general surgery chiefs and senior surgeon during the TTA, role clarification and consistent TTL scheduling steps C—E in Table 1 directly responded to these barriers and increased TTA compliance by enhancing the trauma team dynamics.

Role clarification, team dynamics and trauma leadership are all critical aspects of a successful trauma team. Rapid change cycles including implementation of standardized and objective TTA criteria clarified uncertainty as to when to activate the trauma team and helped facilitate TTA decision-making. Empowerment of prehospital personnel allowed them to preactivate the trauma team before arrival to improve trauma team notification, preparedness of trauma team members and compliance with TTA.

The TTA review form helped support root-cause analysis by facilitating feedback regarding TTA criteria and implementation issues. Participative techniques, reflective processes and feedback, as applied through this form, reduce resistance to change and aid sustainability.

Structure changes were supported with ongoing staff engagement and additional process solutions during August —February These included PDSA cycles regarding education, transparency of audit results and feedback on recent change cycles steps G—K in Table 1. These actions targeted other barriers by developing a team mentality for trauma, improving communication, providing data feedback, and further clarifying roles and responsibilities.

Alongside increased TTA compliance, our review of quality indicators showed that, with improved TTA compliance, quality indicators were similar to results published by other hospitals. For patients treated with TTA care, our time to the CT scanner was 78 minutes, compared to 41— minutes for others who have assessed their trauma team indicators.

Trauma team activation also resulted in timely treatment of severely injured patients, with a substantial proportion of TTAs occurring via prehospital activation, which allowed the trauma team to be on hand immediately at presentation. Future projects are suggested to assess the ISS before and after TTA interventions to better outline any unwanted overtriage that may result from changes as well as to assess the timeliness of treatment by the trauma team following patient arrival in the emergency department.

We also suggest assessing day mortality and hospital length of stay to better assess clinical outcomes of patients managed by TTA for others who are planning to apply this quality-improvement process. However, it should be recognized that an assumption of this project was that improved TTA compliance also improves care and quality indicators for trauma and decreases mortality rates and length of stay, as shown by other investigators.

In addition, researchers wishing to replicate this quality-improvement project could benefit from assessing the timeliness of TTA and extensively defining the demographic characteristics of patients who are not appropriately triaged to TTA. These data would benefit others to further improve the sensitivity and specificity of TTA criteria for diverse patient populations and better define methods of improving the timeliness of TTA.

We were limited in our change management process by baseline data collection only for patients with an ISS of 12 or greater, as the Alberta Trauma Registry records data only for these patients, whereas ongoing audits collected data for all such patients but also included those who may have had a lower ISS but met the new TTA criteria. In addition, the secondary measure of overtriage was not monitored during our study implementation.

Therefore, a potential risk exists that overtriage increased substantially to capture all patients with major trauma, although it is possible that overtriage was limited by our improved physiologic TTA criteria. Future projects could include assessment of overtriage as a quality indicator. Our study did not assess clinical outcomes before rapid change cycles and therefore cannot comment on any specific associated improvements in clinical outcomes.

The rate of compliance with TTA protocols improved from Baseline audits, a root-cause analysis to determine barriers, ongoing audits and transparency of data, as well as engagement of stakeholders to garner leadership support, determine organizational priority and carry out solutions were crucial.

Changing cultural perception and practice to achieve compliance with an existing protocol requires engagement of stakeholders from the beginning of any change process. This allows for successful PDSA rapid change cycle implementation that focuses first on structure barriers, followed by process and outcomes. Competing interests: V. Fawcett and S. Widder are members of the CJS editorial board, but they were not involved in the review or acceptance of this manuscript.

No other competing interests declared. Contributors: R.