Data elements sent to NC DETECT from emergency departments, the Carolinas Poison Center data and the Pre-hospital Medical Information System data are detailed in three separate tables below.

Emergency Department Data

Data elements listed below are transmitted to NC DETECT via NCHESS, although Triage Note is currently an optional element.
Inclusion Criteria for NCHESS: Patients treated in the participant ED regardless of their disposition and patients triaged who then leave AMA or without being seen. Also patients treated in the ED and then admitted to the hospital are included.  Exclusion Criteria for NCHESS: Patients triaged away to a clinic or directly admitted to an inpatient unit.

Emergency Department Data Elements Typically Available in NC DETECT Line Listing Reports
Name Description/Notes
Internal Tracking ID NC DETECT-generated identifier that uniquely identifies a patient at that healthcare facility/system. Can be used to track repeat visits by the same patient to the same facility/system
Patient Age Available in years
Sex M (Male), F (Female), U (Unknown)
Patient City Patient’s city of residence
Patient County Patient’s county of residence
Patient ZIP Patient’s ZIP of residence (5-digit)
Patient State Patient’s state of residence
Visit ID NC DETECT-generated identifier that uniquely identifies that ED visit
Hospital Emergency department facility where patient sought care
Insurance Coverage (or Other Expected Source of Payment) Entity or person expected to be responsible for patient’s bill for this ED visit (private insurance, self-pay, Medicare, Medicaid, etc.)
Arrival Date and Time First date and time documented in patient’s record for this ED visit
Transport Mode Patient’s mode of transport to ED (walk-in, ground ambulance, etc.)
Chief Complaint Patient’s reason for seeking care or attention, expressed in terms as close as possible to those used by patient or responsible informant
Triage Notes Supporting information for Chief Complaint
Blood Pressure Blood pressure taken at triage (when available)
Initial Temperature Temperature taken at triage (in Celsius)
Disposition Patient’s anticipated location or status following ED visit (discharged, admitted, transferred, died, etc.)
Disposition Diagnosis Description Practitioner’s description of condition or problem for which services were provided during patient’s ED visit, recorded at time of disposition
ICD-9-CM Code(s)

ICD-10-CM Code(s)

ICD-9-CM Final Diagnosis or Injury Codes

ICD-10-CM Final Diagnosis or Injury Codes

 

Carolinas Poison Center (CPC) Data Elements

The Carolinas Poison Center (CPC) is the designated Statewide Poison Control Center for North Carolina and certified as a Regional Poison Control Center by the American Association of Poison Control Centers.  CPC is an emergency telephone resource of poisoning information, staffed 24 hours a day, seven days a week, by registered nurses and pharmacists (specialists in poison information) who are specially trained to provide diagnostic and treatment advice for acute and chronic poisonings to the public and healthcare professionals.
More information is available at www.ncpoisoncenter.org

CPC Data Elements Sent to NC DETECT
Data Element Description
Call Date and Time Date and time of call to CPC
Call Type Call type listed as exposure,  information or drug identification
Call Type Category Subcategories for information call types
Caller City City where call was made
Caller County County where call was made
Caller Location Code Zip code or area code/exchange of caller
Caller Site Location of caller at initial call (residence, workplace, etc.)
Caller State State where initial call was made
Caller Zip Zip code where call was made
Case Number Unique number for patient
Chronicity Records exposure as acute or chronic
Clinical Effects 9 categories of clinical effects (cardiovascular, dermal, gastrointestinal, hematologic/hepatic, neurological, ocular, renal/genitourinary, respiratory, and miscellaneous). Each clinical effect is recorded as no effect, related, not related, or unknown if related
Duration of Effect Duration of clinical effects
Exposure Duration Duration of chronic exposures
Exposure Reason Type of exposure if call type was an exposure call
Exposure Site Location of the patient when the exposure occurred
Final Health Care Facility Type of health care facility for patients transferred from the initial HCF to a second HCF
Follow up Number Number of follow-up contacts for each patient
Initial Health Care Facility Type of health care facility patient is in or referred to
Medical Outcome Final outcome of patient after final follow-up
Multiple Patients? Yes/No
Patient Age
Patient Age Group
Patient Gender
Patient Pregnancy Duration Number of weeks pregnant
Product ID Identifier for product involved in call
Related Case Number Case number of primary case/call related to patient
Route Exposure Route: Aspiration, Bite, Dermal, Ingestion, Inhalation, Ocular, Other, Otic, Parenteral, Rectal, Unknown, Vaginal
Scenarios 7 categories of possible exposure scenarios (dosing/therapeutic error, vapor/fume problems, child-resistant closure on product, access to product, confusion about product, pesticide problems, miscellaneous). Up to four scenarios can be selected per case
Substances Information on all substances involved in exposure
Therapies 2 categories of therapy provided (decontamination or other). Each therapy is recorded as not recommended, recommended, performed, recommended and performed, or recommended, known not performed.

 

Pre-hospital Medical Information System (PreMIS) Data Elements

The Prehospital Medical Information System (PreMIS) is an internet based EMS information system. The PreMIS system provides a data entry and reporting capability for the evaluation of EMS patient care and system performance. The system is in use by over 800 EMS agencies, 40,000 technicians, and maintains over 1,000,000 records per year. More information is available at www.emspic.org

PreMIS Data Elements available in NC DETECT reports
Data Element Description / Notes
Agency county EMS Agency county
Agency name EMS Agency name
Anatomic location Pick list: Abdomen, Back, Chest, Extremity-Lower, Extremity-Upper, General/Global, Genitalia, Head, Neck
Chief complaint Free-text narrative of the patient’s chief complaint, as close as possible
Destination Name
Destination Type
Dispatch complaint Abdominal Pain, Allergic Reaction, Animal Bites, Assault, Back Pain, Breathing Problems, Burns, Carbon Monoxide/Inhalation, Cardiac/Respiratory Arrest, Chest Pain, Choking, Convulsions/Seizure, Diabetic Problem, DOA, Drowning, Electrocution, Eye Problem, FALLS/Back Injury, FIRE, HAZARDOUS MATERIAL, Headache, Heart Problems, Heat/Cold Exposure, Hemorrhage/Laceration, Industrial/Machinery Accidents, Ingestion/Poisoning, LIFE LINE, OVERDOSE/POISONING, Pregnancy/Childbirth, PSYCHIATRIC/SUICIDE, SEIZURES, Sick Person, Stab/Gunshot Wound, STANDBY/SPECIAL EVENT, STROKE, SUBSTANCE ABUSE, Traffic Accident, TRANSPORT, Traumatic Injuries, Unconscious, Unknown Problem/Man Down, Transfer/Interfacility/Palliative Care, MCI
Incident address
Incident city
Incident Disposition Treated, Refused, Dead. EMS calls with an incident disposition of Cancelled, No Treatment Required, or No Patient Found are not sent to NC DETECT.
Incident Facility Code
Incident Location Type
Incident state
Incident zip code
Mass casualty Yes/No
Patient address city
Patient address state
Patient address zip code
Patient age
Patient age unit (Years, Months, Days, Hours)
Patient birth date
Patient Destination date and time
Patient gender
Patients at scene single or multiple
Primary symptom name Pick list: Bleeding, Breathing Problems, Change in Responsiveness, Choking, Death, Device/Equipment Problem, Diarrhea, Drainage/Discharge, Fever, HEADACHE, Malaise, Mass/Lesion, Mental/Psych, MENTAL STATUS CHANGE, Nausea/Vomiting, NONE DETECTED, Pain, Palpitations, Rash/Itching, Swelling, Transport Only, Weakness, Wound
Provder Primary Impression
Provider Secondary Impression
Secondary complaint Free-text narrative of the patient’s secondary complaint(s), as close as possible a quote from the patient
Secondary symptom name See Primary Symptom Name
Unit notified timestamp
Vital Signs: Blood pressure, Temperature, pulse oximetry, respiratory rate
Work related Yes / No / Not Recorded