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DRAFT Example

SCOAP Data Dictionary

1

Specifications for Discharges beginning 1/1/2010

Contents

* Indicates significant edits/additions with the current version of the dictionary

3B1) Initials

3B2) Hospital Identification Code

3B3) Date of birth

3B4) Medical/Hospital record number (optional)

3*B5) Admit date & time

3*B6) Discharge date & time

3B7) Gender

3*B9) Race

3*B10) Ethnicity

3B8) Age at admit

3Units of Measure for Height & Weight

3B11) Height

3B12) Weight

3*B13) Insurance

3B14) Transfer from another hospital

3B15) Residence zip code

3C1) Current cigarette smoker

3C2) Recent laboratory values

3C3) Current/recent medications

3C4) Home oxygen use

3C5) Home mobility device use

3D1) Hypertension

3D2) Diabetes

3D3) Asthma

3D4) History of Sleep Apnea

3D5) Coronary Artery Disease

3D6) History of Venous Thrombolembolism

3D7) History of HIV or AIDS

3E1) Primary Surgeon

3E1a) Surgeon Specialty

3*E2) Other Physician Identification

3*E3) Anesthesia provider

3E4) Appendectomy

3E4.1) Indication: Appendicitis

3E4.2) Indication: Appendeceal mass / cancer

3E4.3) Indication: Appendectomy - Other

3E5) Bariatric

3E5.1) Indication: Morbid Obesity

3E5.2) Indication: Bariatric Surgery Other

3E6) Colon

3E6.1) Indication: Cancer of the Colon

3*E6.2) Indication: Diverticular disease

3E6.3) Indication: Trauma

3E6.4) Indication: Radiation Colitis

3E6.5) Indication: Volvulus

3E6.6) Indication: Arteriovenous Malformation

3E6.7) Indication: Ischemic Colon

3E6.8) Indication: Polyps

3E6.9) Indication: Rectal Prolapse

3E6.10) Indication: Gastrointestinal (GI) Bleeding

3E6.11) Indication: Perforation

3E6.12) Indication: Cancer of the Rectum

3E6.13) Indication: Bowel Obstruction

3E6.14) Indication: Colostomy

3E6.15) Indication: Ulcerative Colitis

3E6.16) Indication: Crohns Disease

3E6.17) Indication: Stricture

3*E6.18) Indication: Gynecological Malignancy

3*E6.19) Indication: Iatrogenic Colectomy

3E6.20) Indication: Colon Surgery Other

3F1) Time of First Incision

3F2) In-room Close Time

3F3) Date of Surgery

3F4) In-room Close Date

3F5) Surgical Approach

3F6) ASA Class

3*F7) Highest Perioperative Blood Glucose

3F8) Insulin Used Perioperatively

3*F9) Highest blood glucose on post op day 1

3*F10) Highest blood glucose on post op day 2

3F11) Lowest post-op blood glucose

3F12) Lowest Intra-operative Temperature

3F13) Death in the Operating Room

3F14) First Temperature on Arrival to Recovery Room

3*G1) DVT Prophylaxis- Within 24 hour of incision

3*G2) DVT Prophylaxis Ordered Post - op

3*G3) DVT Prophylaxis Order on Discharge

3G4) Intermittent pneumatic compression in the OR

3G5) Beta Blocker administered within 24 hours pre-op

3*G6) Beta Blocker administered intraoperatively

3G7) Beta Blocker ordered within 24 hrs post-op

3G8) Antibiotics: On antibiotics for the treatment of infection

3G9) Antibiotics: Were prophylactic antibiotics indicated

3G9a) Antibiotics: Administered within 60 minutes

3G9b) Antibiotics: Discontinued within 24 hours

3G10) Pain management: Epidural

3G10a) Pain management: PCEA

3G11) Pain management: PCA

3G12) Pain management: NSAID

3G13) Pain management: Narcotic drip

3G14) Pain management: Other

3G14a) Pain management: Other, specify modality

3G15) Entereg administered

3*G16) Aloxi administered

3*G17) Statin post-op

3G18) Nasogastric tube

3G19) Gastrostomy tube drainage

3*G20) Estimated Blood Loss

3G21) Red blood cell transfusion

3G21a) Red blood cell transfusion units

3*G21b) Lowest hemoglobin

3*G22) Red blood cell transfusion after 24 hrs post-op

3*G22a) Red blood cell transfusion units

3*G22b) Lowest hemoglobin

3*G23) Last hemoglobin prior to discharge

3G24) Mechanical ventilation

3G24a) Mechanical ventilation hours

3*G25) Highest Creatinine

3*G26) Postoperative events

3*G27) Discharge Disposition

3G27a) Discharge: Death Specification

3H1) Reintervention: Any

3H2) Reintervention: Abdominal re-operation

3H2.1) Reintervention: Colostomy or ileostomy

3H2.2) Reintervention: Abscess drainage

3H2.3) Reintervention: Operative Drain Placement

3H2.4) Reintervention: Gastrostomy

3H2.5) Reintervention: Gastrostomy revision

3H2.6) Reintervention: Anastomotic revision

3H2.7) Reintervention: Band Replacement

3H2.8) Reintervention: Band/port revision

3H2.9) Reintervention: Wound revision or evisceration

3H2.10) Reintervention: Negative re-exploration

3*H2.11) Reintervention: Reoperation for bleeding

3H2.12) Reintervention: Other Reoperation

3H3) Reintervention: Tracheal reintubation

3H4) Reintervention: NG tube replacement

3H5) Reintervention: Tracheostomy

3H6) Reintervention: Percutaneous drain

3H7) Reintervention: Anticoagulation therapy for DVT

3H8) Reintervention: Anticoagulation therapy for PE

3*H9) Reintervention: Antibiotic for infection

3H10) Reintervention: Wound reopened

3H11) Reintervention: Radiologically demonstrated leak

3H12) Reintervention: Radiologically demonstrated fistula

3H13) Reintervention: Other

3I1) Bariatric: Prior foregut surgery

3*I2) Bariatric: Procedure of record

3I3) Bariatric: Stomach divided

3*I4) Post-op urinary catheter

3*I5) Bariatric: Distal anastomosis technique

3*I6) Bariatric: Proximal anastomosis technique

3I7) Bariatric: Anastomosis tested

3I7.x) Bariatric: Anastomosis test type

3*J1) Appendectomy: Pregnant

3*J2) Appendectomy: ER/Urgent Visit

3*J3) Appendectomy: Admit through ER

3J4) Appendectomy: Concurrent procedure performed

3*J5) Appendectomy: Preoperative imaging

3J6) Appendectomy: Appendeceal pathology

3J7) Appendectomy: Perforated appendix

3K1) Colon/rectal: Prior surgery

3K2) Colon/rectal: Procedure order/importance

3K3) Colon/rectal: Resection within 30 days

3*K4) Colon/rectal: Procedure priority & procedure staging

3*K5) Colon/rectal: Operation type

3K6) Colon/rectal: Ostomy type

3*K7) Colon/rectal: Anastomosis

3*K8) Colon/rectal: Anastomosis technique

3K9) Colon/rectal: Anastomosis tested

3*K10) Colon/rectal: Post-op urinary catheter

3*K11) Colon/rectal: Bowel Prep

3*K12) Colon/rectal: Diet advanced

3*K13) Colon/rectal: Post-op cancer diagnosis

3K14) Colon/rectal: Lymph nodes removed

3K15) Colon/rectal: Lymph nodes positive for cancer.

3K16) Colon/rectal: Metastatic disease

3K17) Colon/rectal: Cancer Margins

3*K18) Colon/rectal: T Stage

3*K19) Colon/rectal: Procedure done for palliation

3*K20) Colon/rectal: Preoperative neoadjuvant treatment

3*K21) Colon/rectal: Distance of the tumor from the anal verge

3*K22) Colon/rectal: Tumor fixed to underlying structures

3*K23) Colon/rectal:Total mesorectal excision (TME)

3*K24) Colon/rectal: Stage determination methodology

3*K25) Colon/rectal: Diverticular disease

3*K26) Colon/rectal: Prior episodes of diverticular disease

3*L) Post-discharge: 30-day follow up

3*L1) Post-discharge: Wound occurrences

3*L2) Post-discharge: Respiratory occurrences

3*L3) Post-discharge: Urinary tract occurrences

3*L4) Post-discharge: CNS occurences

3*L5) Post-discharge: Cardiac occurrences

3*L6) Post-discharge: Other occurences

3*L7.x) Post-discharge: Readmitted to acute care

3*L8) Post-discharge: Death

3Appendix A: Medications

3Appendix B: Colon/rectal procedure diagram

* Indicates significant edits/additions with the current version of the dictionary

B1) Initials

Location: Adult Form, B. Demographics

Definition: First 2 initials of last name/ First 2 initials of first name.

Example: John Smith: Last Name: SM First Name: JO

(Historic information: Was only first initial of both names)

SORCE alias:

xxx

xxx

ARMUS Variable Name(s):

Field Format: Text

Value Codes:

Allowable Values: two characters: A thru Z for each name; 4 characters total

Data Storage Type: Character

Suggested Data Source: Admission/demographic sheet

Abstraction Notes: This is a required field; unable to analyze the data without this information.

Exclusions: None

B2) Hospital Identification Code


Definition: Numer code assigned to each hospital by SCOAP

SORCE alias:

siteid


Field Format: Number

Value Codes:

Allowable Values:

Data Storage Type: Numeric

Suggested Data Source: New site id numbers are assigned by FHCQ when a hospital begins participation in SCOAP

Abstraction Notes: This is a required field; unable to retrieve or analyze the data by hospital without this information. This field should be populated automatically online. Verify that it is correct at the time of data entry.

Exclusions: None

B3) Date of birth


Definition: Date patient was born

SORCE alias:

dobdt


Field Format: Date

Value Codes:

Allowable Values: mm/dd/yyyy



Abstraction Notes: This is a required field; must know the date of birth in order to verify that this is an adult and for potential risk adjustment.

Exclusions: None

B4) Medical/Hospital record number (optional)


Definition: The specific hospital record number

SORCE alias:

hosprec


Field Format: Text

Value Codes:

Allowable Values: Characters & Numbers: Dependent on hospital



Abstraction Notes: This is an optional field; is for hospitals internal use only. You will want to know your hospitals decision regarding whether or not to include this information as generation of surgeon specific reports is dependent on entering this information.

Exclusions: As this is totally an optional field, no entries for this data element are required.

*B5) Admit date & time


Definition: Date & time patient was admitted to the hospital

SORCE alias:

admitdt

admittm


Field Format: Date, Time

Value Codes:

Allowable Values: mm/dd/yyyy, 00:00 23:59

Data Storage Type: Date/time


Abstraction Notes: This is a required field; must know the admit date in order to calculate LOS. If the patient was admitted as an observation patient vs as in inpatient but then went on to have surgery as an inpatient, use the date that the patient was admitted as an observation patient.

Exclusions: None

*B6) Discharge date & time


Definition: Date & time patient was discharged

SORCE alias:

dischdt

dischtm


Field Format: Date, time

Value Codes:

Allowable Values: mm/dd/yyyy, 00:00 23:59

Data Storage Type: Date/Time

Suggested Data Source: Admission/demographic sheet or discharge summary

Abstraction Notes: This is a required field; must know the discharge date in order to calculate LOS.

Exclusions: None

B7) Gender


Definition: Gender of the patient; male or female

SORCE alias:

sex


Field Format: Multiple Choice

Value Codes:1 = male

2 = female

Allowable Values:



Abstraction Notes: In case of question about gender where there has been a gender change (either via surgery and/or other treatments), answer with what the chart says the gender is with the following exception: If the gender change has been from female to male, but the ovaries remain, this patient should be coded as female.

Exclusions: None. This is a required field as data analysis sometimes differentiates males from females.

*B9) Race


Definition: Race: Select from the following choices of race. If documentation indicates the patient has more than one race (e.g. Black-White or Indian-White), select the first listed race.

Hispanic/Latino Ethnicity is a separate variable (listed below) where you can report the patients ethnicity.

American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American: A person having origins in any of the black racial groups of Africa. Terms such as "Haitian" can be used in addition to "Black or African American.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White: A person having origins in any of the original peoples of Europe, the MiddleEast, or North Africa.

Unknown: if documentation does not state patients race, report as Unknown.

Note: Hispanic Ethnicity is required in addition to this data element.

Revision: April 1, 2009 4-2 ACS NSQIP

SORCE alias:



Value Codes:1 = American Indian/ Alaskan Native

2 = Asian

3 = Black/ African American

4 = Native Hawaiian/ Other Pacific Islander

5 = White

6 = NA/Unknown

Allowable Values:


Suggested Data Source: Admission/demographic sheet or discharge summary; H&P or Nursing History/ Admission note.

Abstraction Notes: Although the terms Hispanic and Latino are actually descriptions of the patients ethnicity, it is not uncommon to find them referenced as race. If the patients race is documented only as Hispanic/Latino, select White. If the patients race is documented as mixed Hispanic/Latino with another race, use whatever race is listed (e.g. Black-Hispanic select Black).

Exclusions: None.

*B10) Ethnicity

Location: Adult Form, B. Demographics,

Definition: Hispanic Ethnicity: Document if the patient is of Hispanic ethnicity or Latino. Hispanic or Latino is defined as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, "Spanish origin," can be used in addition to "Hispanic or Latino."

Although the terms Hispanic and Latino are actually descriptions of the patients ethnicity, it is not uncommon to find them referenced as race. If the patients race is documented only as

Hispanic/Latino, select White for race & indicate Hispanic or Latino for ethnicity. If the patients race is documented as mixed Hispanic/Latino with another race, be sure to indicate whatever race is listed (e.g. Black-Hispanic selectBlack) as well as Hispanic or Latino for ethnicity.

Indicate NA if unable to determine etnicity from medical record documentation.

SORCE alias:



Value Codes:

1 = Hispanic or Latino

2 = Not Hispanic nor Latino

3 = Not Available/Unknown

Allowable Values:


Suggested Data Source: Admission/demographic sheet or discharge summary; H&P or Nursing History/ Admission note.

Abstraction Notes: If the patients race is documented only as Hispanic/Latino, select White race & Hispanic/Latino ethnicity. If the patients race is documented as mixed Hispanic/Latino with another race, indicate Hispanic/Latino ethnicity and record race as whatever race is listed (e.g. Black-Hispanic - select Black).

Exclusions: None.

B8) Age at admit


Definition: Age of patient on admit date in years

SORCE alias: computedage;

Historic variables: age, ageunit


Field Format: Number

Value Codes:

Allowable Values: numbers (18 100)



Abstraction Notes: The age will be automatically calculated when you have entered the birth date of the patient as well as the admit date. This data element is listed, not because you have to calculate the age, but because you will see this on the hard copy of the tool. If the calculated age does not appear correct there maybe a problem with either the admission date or birth date, as entered in the database.

Exclusions: None. This is a required field as data analysis sometimes differentiates depending on the age of the patient and to be sure that the patient is an adult for data analysis.

Units of Measure for Height & Weight


Definition: Indicate English if height and weight will be recorded as inches and pounds, respectively. Indicate Metric if height and weight will be recorded as cm and kilograms, respectively. The units for height and weight must be consistent; both must be English or both must be Metric.

SORCE alias:

measunit



Value Codes:1=English

2=Metric

3=Na

Allowable Values:


Suggested Data Source:

Abstraction Notes: This field is required in order to enter the values for height and weight in the subsequent fields.

Exclusions: None

B11) Height


Definition: Height of patient in inches or cm

SORCE alias:

inch

cm

Historic variables: ft heightn


Field Format: Numbers

Value Codes:

Allowable Values: (inch) 40 - 90 or (cm) 100 - 210


Suggested Data Source: Nursing assessment; H&P

Abstraction Notes: Round rather than including a decimal. This information is especially important for the surgeries for which it is important to know the BMI, as the BMI is calculated from the height and weight.

Exclusions: None

B12) Weight


Definition: Weight of patient in pounds or kilograms

SORCE alias:

lbs

kgs

Historic variable: weightn(weight NA)


Field Format: Numbers

Value Codes:

Allowable Values: (lbs) 0 600 or (kgs) 0 232.00


Suggested Data Source: Nursing assessment; H&P

Abstraction Notes: Round rather than including a decimal. This is especially important for the surgeries for which it is important to know the BMI, as the BMI is calculated from the height and weight.

Exclusions: None

*B13) Insurance


Definition: What type of insurance does the patient have, if any

SORCE alias: Insurance Variables (check all that apply)

ins_priv

ins_mcare

ins_mcaid

ins_tri

ins_ihs

ins_va

ins_self

ins_unins

ins_landi

privatetype

(private insurance specification)

Historic variable: insurnce


Field Format: Yes/No

Multiple choice

Value Codes:

type of private insurance:

1=Regence

2=Premera

3=First Choice

4=Group Health

5=Aetna

6=Cigna

7=Uniform Medical

8=United Healthcare

9=Kaiser

10=Other Private

Allowable Values: Any option that is listed; may check both private and uninsured and/or self pay if the patient has private insurance but that policy does not cover this procedure.


Suggested Data Source: Admission/demographic/face sheet

Abstraction Notes: Check all that appy, regardless of whether or not the procedure in the record is covered or paid for by that insurance or health plan. If have private insurance, check private and then indicate which private company the patient has. If have private insurance, but the specific insurance company isnt identified, check other.

If the patient is uninsured and/or are self pay, check these appropriately. This information is important so that data analysis by health plan can be done.

Exclusions: This section is optional if the hospital objects to providing this data.

B14) Transfer from another hospital


Definition: Was this admission a transfer from another hospital

SORCE alias:

transfer



Value Codes:1 = Yes

2 = No

Allowable Values:


Suggested Data Source: Admission/demographic sheet or H&P

Abstraction Notes: The intent of this data element is assist in data analysis as when the patient has been transferred from another hospital, this often means that the patient is more complex and/or has already had complications from a procedure.

Exclusions: None.

B15) Residence zip code


Definition: Zip code of patients primary residence

SORCE alias:

zipcode


Field Format: Yes/No; Number

Value Codes:

Allowable Values: US or Canadian zip codes; either 5 digit or 9 digit



Abstraction Notes: US or Canadian zip codes may be entered. This information is potentially important for data analysis by zip code.

Exclusions: None

C1) Current cigarette smoker

Location: Adult Form, C. Risk Factors

Definition: Any use of tobacco or marijuana cigarettes within one year of this admission.

SORCE alias:

cursmkr



Value Codes:1 = Yes

2 = No

Allowable Values:


Suggested Data Source: Nursing admission record or H&P

Abstraction Notes: If smoking history is not mentioned anywhere, check no.

The intent of this question is to have information for risk adjustment.

Exclusions: None

C2) Recent laboratory values


Definition: Most recent labs within 30 days prior to the surgery; creatinine, hemoglobin, WBCs; may be up to 6weeks prior to the surgery for albumin and pre-albumin. If collected, report lab value. In the event there is more than one value for any of these, e.g. a WBC was done both 25 days prior and upon admission, record the most recent.

SORCE alias:

Lab Value

Value NA

albumin

albna

creat

creatna

hgb

hgbna

wbc

wbcna

prealbum

prealbna



Value Codes:

Allowable Values: Albumin: 1- 6 g/dl;

Creatinine: 0.1 15.0 mg/dl;

Hgb: 10 - 20 g/dl;

WBC: 0.5 30.0 10(3).

Pre-albumin: mg/dL;


Suggested Data Source: Nursing admission record, laboratory reports or H&P. If the H&P differs from the nursing admission record or the laboratory reports, take the nursing admission record or laboratory reports.

Abstraction Notes: The intent of this question is to have information for risk adjustment. Pre-albumin can be used rather than albumin

Exclusions: None

C3) Current/recent medications


Definition: Current/recent medications use: immunosuppressants, statins, beta blockers, ACEI or ARB, therapeutic anticoagulation within 1 week of surgery.

SORCE alias:

immuno

statin

betablkr

aceiarb

anticoag



Value Codes:1 = Yes

2 = No

Allowable Values:


Suggested Data Source: Nursing admission record, medication record, or H&P. If the nursing admission record/medication record differs with the H&P, take the information in the nursing admission record/medication record.

Abstraction Notes: The intent of this question is to have information for risk adjustment. Anticogulants: documentation of use within 1 week of admission; all others-documentation or report of patient of use upon admission, either at home or ordered upon admit. Chemotherapy for cancer treatment is not considered to be an immunosuppressant medication.

Exclusions: None

C4) Home oxygen use


Definition: Any use of oxygen use at home

SORCE alias:

oxygenuse



Value Codes:1 = Yes

2 = No

Allowable Values:


Suggested Data Source: Nursing admission record, medication record, or H&P

Abstraction Notes: The intent of this question is to have information for risk adjustment. The emphasis is on current use; not just that they have it available or have used it in the past. Use of CPAP or BiPap does not count as using oxygen at home.

Exclusions: None

C5) Home mobility device use


Definition: Use of any mobility device: includes walker, wheelchair, scooter, cane.

SORCE alias:

mobility



Value Codes:1 = Yes

2 = No

Allowable Values:


Suggested Data Source: Nursing assessment, medication record, or H&P

Abstraction Notes: The intent of this question is to have information for risk adjustment. The emphasis is on use; check no if it is mentioned that the device is at home but not used currently.

Exclusions: None

D1) Hypertension

Location: Adult Form, D. Comorbidities

Definition: Any mention of hypertension in the medical record on admit, if yes, select the best response to the number of individual medications used to treat the hypertension: no meds; single med; multiple meds. Please see Appendix A for a list of medications commonly used to treat hypertension.

SORCE alias:

hyprtnsn

hyprmeds



Multiple Choice

Value Codes:1=Yes;2=No

1=No meds

2=Single med

3=Multiple meds

Allowable Values:


Suggested Data Source: H&P, nursing assessment, Emergency Room notes, anesthesia record

Abstraction Notes: The question applies to all cases.

Exclusions: Do not assume that a patient is hypertensive if the only indication of such is that the patient is on one of the drugs that is commonly used to treat hypertension as these medications are also used for other conditions.

Pulmonary hypertension is excluded; is not hypertension.

D2) Diabetes


Definition: Any mention of diabetes in the medical record on admit, if yes, select the best response to the individual medications used in treatment: no meds; single non-insulin, multiple non-insulin; insulin; insulin plus other meds.. Please see Appendix A for a list of commonly used medications.

SORCE alias:

diabetes

diameds



Multiple Choice


1=No meds

2=Single non-insulin

3=Multiple non-insulin

4=Insulin

5=Insulin plus other meds

Allowable Values:



Abstraction Notes:

If the record indicate borderline diabetic select yes.

Include the new injectable hypoglycemic agent Byetta in the category of single or multiple, non-insulin meds.

Do not mark the patient as being diabetic unless this is clearly a diagnosis. Patients may be on metformin for a metabolic syndrome, but this does not mean they are diabetic.

Exclusions: None

D3) Asthma


Definition: Any mention of asthma in the medical record on admit, if yes, select the best response to the individual medications used in treatment: steroid use; inhalant; none. This element is designed so abstractors may select both steroid and inhalant or none. Please see Appendix A for a list of suggested medications.

SORCE alias:

asthma

steroid

inhalant

no_asthmed



Value Codes:1= Yes

2 = No

Allowable Values:



Abstraction Notes: Route of steroid may be IV, PO, or inhaled.

Exclusions: None

D4) History of Sleep Apnea


Definition: Any mention of sleep apnea in the medical record on admit.Iif yes, does the patient use a CPAP (continuous positive airway pressure), BiPAP (bi-level positive airway pressure), APAP (auto-titrating CPAP) machine, or any other assisted breathing apparatus for the treatment of sleep apnea.

SORCE alias:

slpapnea

cpap_adult1

Historic variable: cpap_adult0



Multiple Choice


1=CPAP

2=None

Allowable Values:



Abstraction Notes:

Exclusions: None

D5) Coronary Artery Disease


Definition: Any diagnosis of coronary artery disease or angina. If yes, is there documentation of Myocardial Infarction (MI), Percutaneous Coronary Intervention (PCI), Coronary Artery Bypass Graft (CABG), or Automatic Implantable Cardioverter Defibrillators (AICD).

SORCE alias

cad

hxmi

cadsurg

cad_none

Historical variable: cadtype



Multiple Choice


1=History of MI

2=PCI, CABG, AICD

3=Both

4=None

Allowable Values:



Abstraction Notes: Check all that apply.

Exclusions: None

D6) History of Venous Thrombolembolism


Definition: Any documentation that the patient has a history of venous

thrombolembolism including pulmonary embolus or deep vein thrombosis.

SORCE alias:

vtehx



Value Codes:1 = Yes

2 = No

Allowable Values:


Suggested Data Source: H&P, nursing assessment, Emergency Room notes

Abstraction Notes:.

Exclusions: None

D7) History of HIV or AIDS


Definition: Any documentation in the medical record that the patient is HIV

positive or has AIDS.

SORCE alias:

hivaids



Value Codes:1 = Yes

2 = No

Allowable Values:



Abstraction Notes:

Exclusions: None

E1) Primary Surgeon

Location: Adult Form, E. Operative

Definition: This is an optional field that individual hospitals may use, if they choose, to identify the primary surgeon for each case. Do not submit names; only ID numbers as this information is to be used for specific surgeon data reports with the name of the surgeon known only to the hospital

SORCE alias:

surgeon


Field Format: Text

Value Codes:Determined by individual hospitals

Allowable Values: Codes only; no names


Suggested Data Source: Internal physician ID#

Abstraction Notes: Consistency within site is essential for proper use of this field: If letters are used in the code be sure that there is no distinction between upper and lower case. For example, M1234 and m1234 will be interpreted as the same id number.

Exclusions: This is an optional field, but if your hospital wants this information, there are no exclusions.

E1a) Surgeon Specialty


Definition: Indicate the primary surgeons specialty; General/colorectal or OB/GYN surgeon

SORCE alias:

surgeontype



Value Codes:

1=General/colorectal surgeon

2=OB/GYN surgeon

Allowable Values:


Suggested Data Source: Internal hospital information; Medical Records

Abstraction Notes: If the surgeon specialty is not known, check with your QI Dept or with Medical Records. This field is required whether or not the individual surgeon is identified.

Exclusions: None

*E2) Other Physician Identification


Definition: This is an optional field that individual hospitals may use, if they choose, to identify an additional physician for each case. Do not submit names; only ID.

SORCE alias:


Field Format: Text


Allowable Values: Codes only; no names. Letters and numbers allowed


Suggested Data Source: Internal physician ID#

Abstraction Notes: Consistency within site is essential for proper use of this field: If letters are used in the code be sure that there is no distinction between upper and lower case. For example, M1234 and m1234 will be interpreted as the same id number. Some sites may want to use this field to identify additional physicians.


*E3) Anesthesia provider


Definition: This is an optional field that individual hospitals may use, if they choose, to identify an anesthesia provider for each case. Do not submit names; only ID.

SORCE alias:


Field Format: Text


Allowable Values: Codes only; no names


Suggested Data Source: Internal physician/anesthesia provider ID#

Abstraction Notes: Consistency within site is essential for proper use of this field: If letters are used in the code be sure that there is no distinction between upper and lower case. For example, M1234 and m1234 will be interpreted as the same id number.


E4) Appendectomy


Definition: Indicate that the SCOAP eligible procedure is a non-elective appendectomy. A non-elective appendectomy is one done in the context of an acute condition; not done as an elective procedure along with another operation.

Note Enter information for only one procedure type: Appendectomy, Bariatric or Colon. An affirmative response (Yes) to either question 27, 28, or 29 will insure the appropriate questions are available for data entry. The other two procedure questions should be given a negative response (No).

SORCE alias:

appendectomy



Value Codes:1 = Yes

2 = No

Allowable Values:


Suggested Data Source: H&P, OR record, OR log, anesthesia record, discharge record

Abstraction Notes: Extremely important that procedure is checked. Other data collected, recorded and reported is dependant on the procedure group reported.

Exclusions

E4.1) Indication: Appendicitis


Definition: Non-elective procedure only done in the context of an acute condition; procedure is not described as an elective, planned, interval, or incidental case.

SORCE alias:

ind_appy




Allowable Values:



Abstraction Notes: Extremely important that an operative procedure is checked. Cases are included or excluded from appropriate reports based on this element and this element is also used in many calculations for reporting.

Exclusions: Appendectomies that are not the primary procedure (often referred to as incidental), or are categorized as planned, interval, or are done on an elective basis. For example, a patient who was taken to the OR for a total abdominal hysterectomy and during the procedure also had her appendix removed is considered to have had an incidental appendectomy and is therefore NOT considered to be a SCOAP case.

Please note that when pulling appendectomy case lists by the SCOAP defined ICD-9 or CPT codes, all appendectomies performed at your hospital will likely appear on the list. Each abstractor is to use their judgment as to whether the case is appropriate to submit to SCOAP based on the guidance in this definition.

E4.2) Indication: Appendeceal mass / cancer


Definition: Appendectomy done with the diagnosis of appendeceal mass or cancer; not for acute appendicitis

SORCE alias:

ind_mass




Allowable Values:


Suggested Data Source: H&P, OP record, OR log, anesthesia record, discharge record


Exclusions:

Note that when pulling appendectomy case lists by the SCOAP defined ICD-9 or CPT codes, all appendectomies performed at your hospital will likely appear on the list. Each abstractor is to use their judgment as to whether the case is appropriate to submit to SCOAP based on the guidance in this definition.

E4.3) Indication: Appendectomy - Other


Definition: Non-elective procedure only done in the context of an acute condition; procedure was not described as an elective, planned, interval, or incidental case.

SORCE alias:

ind_appoth

ind_apptxt

(other specified)



Text


Allowable Values:

Data Storage Type: Numeric; Character

Suggested Data Source: H&P, OP record, OR log, anesthesia record, discharge record

Abstraction Notes: Extremely important that an operative procedure is checked. Cases are included or excluded from appropriate reports based on this element and this element is also used in many calculations for reporting. This option should be extremely rare.

Exclusions: Appendectomies that are not the primary procedure (often referred to as incidental), or are categorized as planned, interval, or are done on an elective basis. For example, a patient who was taken to the OR for a total abdominal hysterectomy and during the procedure also had her appendix removed is considered to have had an incidental appendectomy and is therefore NOT considered to be a SCOAP case.

Please note that when pulling appendectomy case lists by the SCOAP defined ICD-9 or CPT codes, all appendectomies performed at your hospital will likely appear on the list. Each abstractor is to use their judgment as to whether the case is appropriate to submit to SCOAP based on the guidance in this definition.

E5) Bariatric


Definition: Indicate that the SCOAP eligible procedure is a bariatric procedure


SORCE alias:

bariatric




Allowable Values:




Exclusions

E5.1) Indication: Morbid Obesity


Definition: Procedure done in the context of treatment for morbid obesity. Procedure of record may be referred to as: gastric bypass, roux-en-y bypass, lap band, biliopancreatic bypass, or duodenal switch bypass.

SORCE alias:

ind_obese




Allowable Values:


Suggested Data Source: OR record, OR log, anesthesia record, discharge record


Exclusions: None

E5.2) Indication: Bariatric Surgery Other


Definition: Bariatric procedures which are performed for reasons other than the treatment of morbid obesity

SORCE alias:

ind_obesoth

ind_obestxt

(other specified)



Text


Allowable Values:




Exclusions: None

E6) Colon


Definition: Indicate that the SCOAP eligible procedure is a colon/rectal operation


SORCE alias:

colonrectal




Allowable Values:




Exclusions

E6.1) Indication: Cancer of the Colon


Definition: Procedure done for treatment for cancers of the colon or large intestine, which is the lower part of the digestive system. Most colon cancers begin as small, benign clumps of cells called adenomatous polyps. Over time these polyps become colon cancers.

SORCE alias:

ind_cancer




Allowable Values:




Exclusions: None

During colectomy surgery for colon cancer, the cancer and nearby tissue is removed and the remaining sections of colon are rejoined (anastomosis).

During a colostomy, the surgeon removes the cancer and surrounding tissue then creates an opening (stoma) in the abdomen through which waste can leave the body. Colostomy can be permanent or temporary depending on the specific situation.

*E6.2) Indication: Diverticular disease


Definition: Diverticula are small, bulging pouches in the digestive tract, most commonly occurring in the large intestine but can also be found in the esophagus, stomach, and small intestine. Diverticulitis occurs when one or more of these pouches become inflamed or infected, causing severe abdominal pain, fever, nausea, and a marked change in bowel habits. This occurs in 10-25% of persons with diverticulosis. Tears in the colon leading to bleeding or perforations may occur; intestinal obstruction may occur (constipation or diarrhea does not rule out this possibility); and peritonitis, abscess formation, sepsis and fistula formation are also possible occurences. Serious cases of diverticulitis require surgical removal of the diseased portion of the colon.

SORCE alias:

ind_div (historic variable: diverticulitis)




Allowable Values:


Suggested Data Source: OP record, OR log, anesthesia record, discharge record


Exclusions: None

E6.3) Indication: Trauma


Definition: Procedures performed to correct trauma to the colon. Most commonly caused by traffic accidents or sporting injuries. When trauma is the indication for operation, determine whether the trauma was caused by blunt force or a penetrating injury.

SORCE alias:

ind_trauma

ind_traumatype(type specified)




Allowable Values:




Exclusions: None

E6.4) Indication: Radiation Colitis


Definition: Radiation colitis is a condition that occurs as a side effect of cancer radiation therapy to the abdomen or pelvis and occurs when a large number of cells in the colon die as a result of the radiation therapy. If radiation colitis is acute symptoms will most often develop within 8 weeks of starting treatment; if the condition is chronic, symptoms may not occur for months or years after beginning treatment. In very rare cases of severe radiation colitis, surgery will be performed to bypass the large intestine (colon resection) or remove it entirely (colectomy).

SORCE alias:

ind_rad




Allowable Values:




Exclusions: None

E6.5) Indication: Volvulus


Definition: Volvulus is a type of intestinal obstruction that involves twisting of the colon. The condition is sometimes referred to as a mechanical obstruction meaning that the intestine is physically either partial or completely blocked. Volvulus most commonly occurs in the small intestine but does occur in the colon about 15% of the time.

SORCE alias:

ind_volv




Allowable Values:




Exclusions: None

E6.6) Indication: Arteriovenous Malformation


Definition: Arteriovenous malformations (AVM), are dilated blood vessels which are usually located close to the inside surface of the bowel. AVMs have a tendency to bleed small amounts of blood over time which often results in anemia or low red cell count. Some AVMs can be cauterized but others are more extensive and require surgical intervention.

SORCE alias:

ind_art




Allowable Values:




Exclusions: None

E6.7) Indication: Ischemic Colon


Definition: Ischemic colitis is when part of the colon becomes inflamed and injured usually due to blood clots in the arteries leading to the colon. The cause is usually impaired blood flow to the colon which can lead to permanent colon damage. Chronic ischemic colitis is usually associated with the build-up of fatty deposits (atherosclerosis), but it can also be related to diabetes, a hernia, colon cancer or radiation to the abdomen. Less often, it can be caused by medications such as NSAIDs, hormone replacement therapy, antipsychotic drugs, or blood pressure pills. The term necrotic colon may be used instead of ischemic colon.

SORCE alias:

ind_isch




Allowable Values:




Exclusions: None

E6.8) Indication: Polyps


Definition: Polyps are small clumps of cells that form on the colon lining. The vast majority ore harmless, but some may become cancerous over time. They can cause rectal bleeding, a change in bowel habits and abdominal pain, but most do not cause symptoms so regular screening is recommended for early detection and removal. Most can be removed during a colonoscopy, but polyps that are too large or cannot be reached to be removed during the colonoscopy must be removed surgically.

SORCE alias:

ind_polyp




Allowable Values:




Exclusions: None

E6.9) Indication: Rectal Prolapse


Definition: Rectal prolapse (rectum slips or falls out of place) occurs when the muscles and ligaments that hold the rectum firmly in place weaken due to age, long-term constipation and/or the stress of childbirth. Rarely, large hemorrhoids may cause rectal prolapse. Rectal prolapse can be partial, meaning that only the inner lining of the rectum protrudes from the anus. In the later stages, large portions of the rectum protrude from the anus. Corrective surgery may be done through an abdominal or perineal approach.

SORCE alias:

ind_prolap




Allowable Values:




Exclusions: None

E6.10) Indication: Gastrointestinal (GI) Bleeding


Definition: GI bleeding comes from many causes and is broken into 2 classifications, upper and lower. Upper GI bleeding originates from the first part of the GI tract: the esophagus, stomach, or duodenum. Most common causes are peptic ulcers, gastritis, or esophageal varicies.

Lower GI bleeding originates in the portions of the GI tract farther down the digestive system: segment of the small intestine, large intestine, rectum, and anus. Diverticulitis, polyps, hemorrhoids, anal fissures are most commonly the cause of the bleeding.

SORCE alias:

ind_gi




Allowable Values:




Exclusions: None

E6.11) Indication: Perforation

Location: Adult Form, E. Operative,

Definition: Perforation of the GI tract is defined as the complete penetration of the wall of the stomach, small intestine or large bowel which results in the leak of intestinal contents into the abdominal cavity. Perforation is always treated as an emergent situation and usually an exploratory laparotomy will be performed to close the defect and a peritoneal wash will be performed. The patient will be treated aggressively with antibiotics, IV fluids, and bowel rest.

SORCE alias:

ind_perf




Allowable Values:




Exclusions: None

E6.12) Indication: Cancer of the Rectum


Definition: Rectal cancer is cancer of the last 8 to 10 inches of the colon. Most rectal cancers begin as small, non-cancerous clusters of cells called adenomatous polyps.

SORCE alias:

ind_canrec




Allowable Values:




Exclusions: None

E6.13) Indication: Bowel Obstruction


Definition: Intestinal obstruction is a blockage of the small intestine or colon. The most common causes of obstruction are: adhesions, hernias or tumors. If left untreated, intestinal obstruction can cause the blocked parts of the intestine to die which can lead to perforation, severe infection, and shock. Obstructions are usually treated on an emergent basis.

SORCE alias:

ind_bowel




Allowable Values:




Exclusions: None

E6.14) Indication: Colostomy

Location: Adult Form, E. Operative,

Definition: A colostomy is a surgically created opening in the wall of the abdomen created from a remaining portion of the bowel for the elimination of body waste into a special bag. Sometimes a colostomy is temporary, allowing the colon or rectum time to heal after an extensive surgery but in some cases the colostomy may be permanent.

SORCE alias:

ind_colostomy




Allowable Values:




Exclusions: None

E6.15) Indication: Ulcerative Colitis


Definition: Ulcerative colitis is an inflammatory bowel disease that causes chronic inflammation of the digestive tract; the innermost lining of the colon and rectum are usually the most effected. Surgery usually means removing the entire colon and rectum which is called a proctocolectomy. Next the surgeon will create an ileoanal anastomosis by constructing a pouch from the end of the small intestine attached directly to the anuswhich spares the patient from dealing with a colostomy bag.

SORCE alias:

ind_ulc




Allowable Values:




Exclusions: None

E6.16) Indication: Crohns Disease


Definition: Crohns disease is a type of inflammatory bowel disease in which the lining of the digestive tract becomes inflamed. The inflammation often spreads deep into the layers of affected tissue which is both painful and debilitating to the patient. Surgery is only a temporary measure but can often provide the patient with years of remission. The surgeon will remove the damaged portion of the colon and reconnect the healthy sections. Sometimes the surgeon will also close fistulas or drain abscesses.

SORCE alias:

ind_crohns




Allowable Values:




Exclusions: None

E6.17) Indication: Stricture


Definition: Stricture is a form of bowel obstruction defined as a narrowing of the width of the passageway of the involved segments of the bowel. This narrowing is often caused by chronic inflammation which causes scarring of the tissue so strictures are commonly found in patients with Crohns disease. An intestinal obstruction that is caused by stricture can lead to perforation so surgery is often indicated. The surgeon will resect the entire narrowed segment of the bowel.

SORCE alias:

ind_strict




Allowable Values:




Exclusions: None

*E6.18) Indication: Gynecological Malignancy


Definition:

SORCE alias:




Allowable Values:




Exclusions: None

*E6.19) Indication: Iatrogenic Colectomy


Definition: Colon surgery that was done secondary to trauma/perforation, bleeding or ischemia secondary to a medical or surgical intervention

SORCE alias:




Allowable Values:




Exclusions: None

E6.20) Indication: Colon Surgery Other


Definition: Any colon surgery performed for a reason other than those listed. One example would be a case that was primarily an ovarian cancer (TAH) and it was discovered that the tumor invaded the colon.

SORCE alias:

ind_coloth

ind_coltxt(other specified)



Text


Allowable Values:




Exclusions: None

F1) Time of First Incision

Location: Adult Form, F. Intra Operative

Definition: Use 24-hour clock to indicate the time of the first incision.

SORCE alias: ):

incistime

incisna

(time not available)



Time (14:00 equals 2:00 p.m.)

Value Codes:

Allowable Values: 00:00 23:59

Data Storage Type: Numeric; Date/Time

Suggested Data Source: Anesthesia record, OR log

Abstraction Notes: If both the anesthesia start time and the operation start time are listed, use the operation start time. Select NA if this information is not available.

Exclusions: None

F2) In-room Close Time


Definition: Use 24-hour clock to indicate the time of incision closure in the OR.

SORCE alias:

closetime

closena

(time not available)



Time (14:00 equals 2:00 p.m.)

Value Codes:

Allowable Values: 00:00 23:59

Data Storage Type: Numeric; Date/Time


Abstraction Notes: If both the anesthesia end time and the operation end time are listed, use the operation end time which is defined as the end of the closure time. Select NA if this information is not available.

Exclusions: None

F3) Date of Surgery


Definition: Indicate the date on which the operation began

SORCE alias:

surgdt


Field Format: Date

Value Codes:




Abstraction Notes: This information is important as is used in data analysis for several metrics.

Exclusions: None

F4) In-room Close Date


Definition: Indicate the date on which the operation ended

SORCE alias:

closdt


Field Format: Date

Value Codes:




Abstraction Notes: This information is important as is used in data analysis for several metrics.

Exclusions: None

F5) Surgical Approach


Definition: What was the method of the surgical procedure?

Laparoscopic means that the procedure was done entirely through the vision of the laparoscope usually utilizing several small incisions and trocars

Laparoscopic converted to open means that after the surgeon began the operation an unexpected complication arose that made it necessary to open the abdomen

Laparoscopic, hand-assisted means that an additional incision was made that is the so that the surgeons hand could be inserted into the abdomen to assist the operation

Open means that there was one incision and no lap ports were used

Laparoscopic surgeries may have robotic assistance.

SORCE alias:

surgproc



Value Codes:1=Laparoscopic

2=Lap converted to open

3=Lap, hand-assisted

4=Open

5=Laparoscopic, robotic assistance

Allowable Values:


Suggested Data Source: Operative record; OR log

Abstraction Notes: Unless the surgeon indicates that the laparoscopic surgery was hand assisted, indicate that the approach was laparoscopic. The use of instruments through an additional incision does not mean the approach was laparoscopic, hand assisted. Insertion of a hand is usually done to further explore or to assist with removal of larger than expected tissue. If the surgeon states in the operative report that the surgical approach was laparoscopic, but it is obvious from the report that the trocars were removed, abdoment deflated and the incision enlarged to allow hand assistance, this would be hand assisted.

Exclusions: None

F6) ASA Class


Definition: The American Association of Anesthesiologists (ASA) score subjectively categorizes patients into five subgroups by preoperative physical fitness. It was devised in 1941 by the ASA as a statistical tool for retrospective analysis of hospital records. ASA classification makes no adjustment for age, sex, weight, pregnancy, nature of the planned surgery, skill of the anesthesiologist or surgeon, or the degree of pre-theatre preparation or facilities for postoperative care.

Table 1. ASA Scores.

Class

Physical status

Example

I

A completely healthy patient

A fit patient with an inguinal hernia

II

A patient with mild systemic disease

Essential hypertension, mild diabetes without end organ damage

III

A patient with severe systemic disease that is not incapacitating

Angina, moderate to severe COPD

IV

A patient with incapacitating disease thatis a constant threat to life

Advanced COPD, cardiac failure

V

A moribund patient who is not expected to live 24 hours with or without surgery

Ruptured aortic aneurysm, massive pulmonary embolism

E

Emergency case

*Societies of Anesthesiologists

SORCE alias:

asaclass


Field Format: Mulitple Choice

Value Codes:1 = I

5 = Already Intubated

2 = II

6 = NA

3 = III

4 = IV

7 = V

Allowable Values:


Suggested Data Source: Anesthesia record

Abstraction Notes: There will not be an ASA score if the patient was already intubated; if intubated, check already intubated.

Exclusions: None

*F7) Highest Perioperative Blood Glucose


Definition: Record the highest fasting blood glucose test results within 24 hours of incision: blood glucose recorded prior to incision, any blood glucose result during time frame that the patient was in the OR, blood glucose result with 60-minutes of operative close time. If no test performed indicate No

SORCE alias:

peribg

bg_not

(blood glucose not performed)



Value Codes:1=Yes; 2=No

Allowable Values: 10 900 mg/dl


Suggested Data Source: Anesthesia record; OR log; H&P, RN intake assessment; OR holding records; ED records

Abstraction Notes: The question applies to ALL procedures: (appendectomy, colorectal and bariatric procedures).

Exclusions:

F8) Insulin Used Perioperatively


Definition: Was insulin administered during the perioperative period-anytime prior to incision on the day of surgery, during the time that the patient was in the OR, or within 60 minutes of the closing of the incision

SORCE alias:

insulin



Value Codes:1 = Yes;

2 = No

Allowable Values:


Suggested Data Source: Anesthesia record, OR log, nursing admit or preop notes, PACU record

Abstraction Notes: The question applies to all procedures and patients.

Exclusions:

*F9) Highest blood glucose on post op day 1


Definition: Highest recorded blood glucose during post op day 1

Check NA if not done. Post op day 1 is defined as the 24 hour time period that begins at midnight of the day following the day the surgery was finished. The day of surgery is day 0. Surgery finish time is defined as anesthesia end time.

SORCE alias:

postbg1

postbg1_na







Suggested Data Source: PACU record (if in PACU during any of post op day 1); nursing record/notes

Abstraction Notes: The question applies all procedures and all patients

Exclusions: Dearh in the OR

*F10) Highest blood glucose on post op day 2


Definition: Highest recorded blood glucose during post op day 2

Check NA if not done. Post op day 2 is defined as the 24 time period that begins at midnight of the second day following the day the surgery was finished. The day of surgery is day 0.

SORCE alias:

postbg2

postbg2_na







Suggested Data Source: Nursing record/notes

Abstraction Notes: The question applies to all procedures and all patients.

Exclusions: Death in the OR

F11) Lowest post-op blood glucose


Definition: Lowest recorded blood glucose during the 48 hrs ending at the close of Post Op Day 2. Post op day 2 is defined as the 24 time period that begins at midnight of the second day following the day the surgery was finished. The day of surgery is day 0.

SORCE alias:

lowpostbg

lowpostbg_na







Suggested Data Source: Nursing record/notes

Abstraction Notes: The question applies to all procedures and all patients.

Exclusions: Death in the OR

F12) Lowest Intra-operative Temperature


Definition: The lowest temperature recorded during the operation, after the incision and before closure

SORCE alias:

lowtemp

lowtpna

(temp not available)




Allowable Values: 32.0 41.0(degrees centigrade)


Suggested Data Source: Anesthesia record

Abstraction Notes: The question applies only to colorectal and bariatric procedures. The intent is to know if the patient was cold during the operation.

Exclusions: Appendectomy cases

F13) Death in the Operating Room


Definition: Did the patient expire while in the operating room?

SORCE alias:

or_death



Value Codes:1 = Yes

2 = No

Allowable Values:


Suggested Data Source: Anesthesia record; OR log; OP record, Discharge summary

Abstraction Notes: The question applies to all procedures.

Exclusions: None

F14) First Temperature on Arrival to Recovery Room


Definition: What was the first recorded temperature upon arrival to the recovery room or ICU? This is defined as within the 30 minute immediately prior to or the 15 minutes immediately after anesthesia end time. If there is no recorded temperature within 15 miutes after anesthesia end time, then check for the last temperature recorded within the 30minute time period just prior to anesthesia endtime

SORCE alias:

frsttemp

firstna

(temp not available)




Allowable Values: 34.0 41.0(degrees centigrade)


Suggested Data Source: PACU record; ICU record

Abstraction Notes: The question applies only to colorectal and bariatric procedures.

Exclusions: Appendectomy cases or if death in the OR

*G1) DVT Prophylaxis- Within 24 hour of incision

Location: Adult Form, G. Perioperative Interventions

Definition: Heparin or low molecular weight heparin or synthetic factor Xa administered within 24 hrs of incision. This time period is defined as 24 hours prior to the surgical incision through discharge from post-anesthesia care/recovery area. If yes, indicate medication, dosage and frequency of the order. If no, was contraindication documented?

SORCE alias:

Historic variable: hep12hr


Field Format

Allowable Values*

Within 24 hrs of incision

Multiple Choice

1=Yes, 2=No, 3=Contraindicated

Heparin

Yes/No

dose

Number

5000 10000 units

frequency

Multiple Choice

hours

Number

1 - 24

Enoxaparin

Yes/No

dose

Number

20 120 mg

frequency

Multiple Choice

hours

Number

1 - 24

Dalteparin

Yes/No

dose

Number

2500 10000 IU

frequency

Multiple Choice

hours

Number

1 - 24

Tinzaparin

Yes/No

dose

Number

10000 30000 units

frequency

Multiple Choice

hours

Number

1 - 24

Fondaparinux

Yes/No

dose

Number

2.5 10.0 mg

frequency

Multiple Choice

hours

Number

1 - 24


Suggested Data Source: Medication Administration Record, Perioperative Nursing Record, Anesthesia Record

Abstraction Notes: If IV order for Heparin indicate number of units ordered per hour; can be per 24 hours if that is the order. Patients on Coumadin for the treatment of atrial fibrillation meet this metric. While the surgeon may not have used the word contraindication, examples of contraindications are an order for Vitamin K and/or a blood transfusion.

Special note: The reason for the detailed data elements for this and the other DVT prophylaxis items are that after a 3 year period that ends December 2010, a grant will fund analysis of this data to determine if there is any relationship between DVT prophylaxis measures and re-admits for DVTs or pulmonary embolism.

Exclusions: Not applicable if death in the OR or for appendectomy case

*G2) DVT Prophylaxis Ordered Post - op


Definition: Heparin, LMW heparin, Coumadin synthetic factor Xa ordered post-op for in-hospital use after the first 24 hrs; if yes, indicate medication, dosage and frequency of the order. If no, was contraindication documented?

SORCE alias:

Historic variable: heppost


Field Format

Allowable Values*

Ordered Post-op

Multiple Choice


Heparin

Yes/No

dose

Number

5000 - 10000 units

frequency

Multiple Choice

hours

Number

1 - 24

days

Number

0 - 90

Enoxaparin

Yes/No

dose

Number

20 -120 mg

frequency

Multiple Choice

hours

Number

1 - 24

days

Number

0 - 90

Dalteparin

Yes/No

dose

Number

2500 - 10000 IU

frequency

Multiple Choice

hours

Number

1 - 24

days

Number

0 - 90

Tinzaparin

Yes/No

dose

Number

10000 -30000 units

frequency

Multiple Choice

hours

Number

1 - 24

days

Number

0 - 90

Fondaparinux

Yes/No

dose

Number

2.5 10.0 mg

frequency

Multiple Choice

hours

Number

1 - 24

days

Number

0 - 90

Coumadin

Yes/No

dose

Number

1.0 10.0 mg

frequency

Multiple Choice

hours

Number

1 - 24

days

Number

0 - 90


Suggested Data Source: Post-Op Physician Orders

Abstraction Notes: Indicate if there was an order for in-house use of prophylaxis after the first 24 hours post-op. If medication order changed during the hospital stay post-op, indicate all the medications that were ordered. If order for same medication changes during this time period, select order closest to discharge. You do not need to verify if prophylaxis was actually administered. Patients on the Coumadin for the treatment of atrial fibrillation may meet this metric. While the surgeon may not have used the word contraindication, examples of contraindications are an order for Vitamin K and/or a blood transfusion.

Exclusions: Not applicable if death in the OR or for appendectomy case

*G3) DVT Prophylaxis Order on Discharge


Definition: Heparin, LMW heparin, Coumadin synthetic factor Xa ordered on discharge; if yes, indicate medication, dosage and frequency of the order. If no, was contraindication documented?

Field Format

Allowable Values*

Ordered on discharge

Multiple Choice


Heparin

Yes/No

dose

Number

5000 - 10000 units

frequency

Multiple Choice

hours

Number

1 - 24

days

Number

0 - 90

Enoxaparin

Yes/No

dose

Number

20 -120 mg

frequency

Multiple Choice

hours

Number

1 - 24

days

Number

0 - 90

Dalteparin

Yes/No

dose

Number

2500 - 10000 IU

frequency

Multiple Choice

hours

Number

1 - 24

days

Number

0 - 90

Tinzaparin

Yes/No

dose

Number

10000 -30000 units

frequency

Multiple Choice

hours

Number

1 - 24

days

Number

0 - 90

Fondaparinux

Yes/No

dose

Number

2.5 10.0 mg

frequency

Multiple Choice

hours

Number

1 - 24

days

Number

0 - 90

Coumadin

Yes/No

dose

Number

1.0 10.0 mg

frequency

Multiple Choice

hours

Number

1 - 24

days

Number

0 - 90


Suggested Data Source: Discharge summary or discharge/transfer orders, Discharge Instruction Sheet

Abstraction Notes: If the discharge order includes only the medication dosage and frequency, but not the number of days, check number of days not specified. Patients on Coumadin for the treatment of atrial fibrillation may meet the criterion for this metric. While the surgeon may not have used the word contraindication, examples of contraindications are an order for Vitamin K and/or a blood transfusion.

Exclusions: Not applicable if discharge disposition is death or if appendectomy case

G4) Intermittent pneumatic compression in the OR


Definition: Was the patient on intermittent pneumatic compression in the OR? Yes or no

SORCE alias:

pneucomp

pneucomp_na

(not available)



Value Codes:1 =Yes

2= No

Allowable Values:


Suggested Data Source: OR record, anesthesia record; Physician orders

Abstraction Notes: This refers to whether or not the patient had intermittent compression boots applied and used in the OR. This is a care process to help prevent DVTs.


G5) Beta Blocker administered within 24 hours pre-op


Definition: Beta Blocker given within the 24 hour period prior to being in the OR

yes or no, or contraindicated.

SORCE alias:

betapre



Value Codes:1=Yes

2=No

3=Contraindicated

Allowable Values:


Suggested Data Source: H&P, MD or nursing admission notes, Preop notes; Physician orders

Abstraction Notes: There must be some documentation that the beta blocker was actually taken, but the documentation does not need to include the exact time; this cannot be inferred from the fact that the patient has been on beta blockers routinely.

Contraindications include low blood pressure, slow heart rate or if the patient is on vasopressors to raise their blood pressure; also if there is any documentation regarding a contraindication for any other reason. The intent of this and the next BB data element is to determine if those who were on BB medications prior to having surgery are not abruptly withdrawn.


*G6) Beta Blocker administered intraoperatively


Definition: Beta Blocker given within the intraopertive time period-the time when the patient is in the OR through discharge from the post anesthesia care/recovery area. If the patient is admitted to another location other than the post anesthesia area, e.g. ICU, the recovery period ends a maximum of 6 hours after arrival to the recovery area.

SORCE alias:



Value Codes:1=Yes

2=No

3=Contraindicated

Allowable Values:


Suggested Data Source: H&P, MD or nursing admission notes, Preop notes; Physician orders

Abstraction Notes: There must be some documentation that the beta blocker was actually given, but the documentation does not need to include the exact time; this cannot be inferred from the fact that the patient has been on beta blockers routinely.

Contraindications include low blood pressure, slow heart rate or if the patient is on vasopressors to raise their blood pressure; also if there is any documentation regarding a contraindication for any other reason. The intent of this and the next BB data element is to determine if those who were on BB medications prior to having surgery are not abruptly withdrawn.


G7) Beta Blocker ordered within 24 hrs post-op


Definition: Beta Blocker ordered within 24 hours post-op; beta blockers given anytime prior to incision and prior to discharge from the post anesthesia/recovery area are not included as being given post-op. Indicate yes or no, or contraindicated

SORCE alias:

betapost



Value Codes:1=Yes

2=No

3=Contraindicated

Allowable Values:


Abstraction Notes: Check if a beta blocker is ordered post-op as a regularly administe

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