NEW DEFINITION FORMAT AND

DIFFICULT VARIABLE DEFINITIONS

Bruce L. Hall, MD, PhD, MBA, FACSClinical Support Physician Lead

Paula Farrell, RN, BSNACS NSQIP Clinical Support Specialist

Case Studies&

Using the New Format

Acute Renal Failure

Question:I’m wondering if I should assign the preoperativevariable of Acute Renal Failure? The patient has an increase in BUN, however,thelab values are “normal”. I’ve included the labvalues below. 7/1/2012 13:03 BUN 12, Creatinine 3.10 7/2/2012 11:23 BUN 16, Cr 3.017/2/2012 14:00 OR Date

Acute Renal FailureAnswer: The intent of the variable is to capture patients whodemonstrated renal compromise within 24 hours prior tosurgery. This patient would meet criteria under scenario Aof the definition, as the most recent lab values were within24 hours prior to the principal operative procedure; eventhough the values are within your hospitals “normal” range,they show an increase in BUN. Additionally, bothcreatinine results are >3mg/dl; even though the valueshave decreased within 24 hours prior to surgery, per thedefinition the 2 creatinine results must be above 3mg/dl.

Acute Renal Failure

Question: Should I assign the preoperative risk factor of‘Acute Renal Failure’ to the following case? Thepatient has a diagnosis of ARF in the chart,however the BUN decreased prior to surgery andso did the creatinine. The lab values are as follows. 7/15/2012 13:03BUN 40, Creatinine 3.01 7/16/2012 11:23BUN 35, Cr 3.007/16/2012 14:00OR Date

Acute Renal Failure

Answer:Even though there is a diagnosis of acuterenal failure, and the most recent lab values are within 24 hours prior to the principal operativeprocedure, there is a decrease in BUN and thecreatinine is not >3mg/dl within 24 hours of theprincipal operative procedure, thus the variable of‘Acute Renal Failure’ would not be assigned.

Currently Requiring or On Dialysis

Question: The patient I’m reviewing in NSQIP has Stage 4 chronic kidney disease, but is largely asymptomatic. Preoperative creatinine was 5.99, measured several weeks before surgery. I am assessing the placement of the laparoscopic peritoneal dialysis catheter as the principal operative procedure. The physicians anticipate starting dialysis one month after his surgery. The patient did not otherwise require dialysis preoperatively. Should I assign the preoperative variable of ‘Currently Requiring or On Dialysis’?

Currently Requiring or On Dialysis

Answer: As the patient will not receive dialysis until a month after the surgery, the case would not meet criteria to assign the preoperative variable of ‘Currently Requiring or On Dialysis’. Dialysis must me initiated within 48 hours following the placement of the catheter.

Open Wound

Question:

Is a peritoneal dialysis catheter considered an "open wound"?

Open Wound

Answer: With tubes, drains and catheters, such as G-tubes, dialysis catheters, etc., a surgical wound is indeed created. That wound or hole is then considered closed by the insertion of the tube or catheters and typically there is no fascia/skin to close or reapproximate and therefore is not considered a preop open wound. An exception to this rule is a penrose drain, as this is an open drainage system.

Surgical Wound(s) Closure

Question: For surgical wound closure, what would I select if a puncture site for a vascular case was sealed with pressure only?

Surgical Wound(s) Closure

Answer: You would assign, ‘All layers of incision (deep and superficial) are fully closed’ as with puncture sites there is not a true incision.

Surgical Wound(s) Closure

Question:

I have a case in which the fascia was not closed but the skin was closed with a running suture. What should I assign for wound closure?

Surgical Wound(s) Closure

Answer:

You would assign the option of ‘All layers of incision (deep and superficial) are fully closed’. Due to the fact that the skin is closed, this layer is susceptible to a Superficial Incisional Surgical Site Infection.

Surgical Wound(s) Closure

Question: Patient had an anterior, lateral, and posterior fasciotomy of the leg. Per the documentation, fasciotomy incisions were closed with rubber band technique and a bulky dressing was applied. What should I assign for wound closure?

Surgical Wound(s) Closure

Answer: You would assign the option of ‘No layers of incision are surgically closed’. A fasciotomy (an incision into the fascia/deep layer) is performed to release swelling/edema of the affected area/limb and the incision (fascia) is left open following the procedure to allow the swelling/edema to decrease. The rubber band technique gradually closes the wound by providing continuous tension from the rubber bands.

Surgical Site Infection

Question: If MD documents cellulitis after a procedure, the wound is opened and cultures are sent that return positive for E. coli, should I assign an SSI?

Surgical Site Infection

Answer: The diagnosis of cellulitis alone would not meet criteria to assign an SSI. However, because cellulitis signifies redness, swelling, pain/tenderness and the physician opened the incision, thereby treating the wound as if it were an infection, and the culture returned positive, you would be able to assign a superficial SSI to this case.

Surgical Site InfectionQuestion:

I have a patient who had an open appendectomy. During the case they encountered pus in the abdomen, which cultured positive for E. Coli; fascia and skin were closed at the end of the case and no drains were placed. On POD #4 the patient developed what appeared to be a pelvic abscess, per CT and the patient went to Interventional Radiology for aspiration, 35ml of pus was drained and cultured positive for E. coli. Would this qualify for an organ/ space SSI? Could I also assign PATOS to the case?

Surgical Site InfectionAnswer:

As the incision was closed, fascia and skin, and no drains were placed, a postoperative organ/space SSI would be assigned.

Additionally, as pus was encountered during the principal operative procedure in the organ/space, organ/space PATOS would be assigned.

UTIQuestion:

The patient I’m reviewing had a preop urine culture which grew E coli >100,000. She was treated with a 7 day course of Cipro, which ended 5 days prior to surgery, and there is no further documentation regarding the UTI. Postop the patient developed a fever and a urine culture was sent which grew Enterococcus >100,000. I assigned a postop UTI, but can I assign PATOS?

UTIAnswer:

UTI PATOS would not be assigned to this case as the patient had completed treatment for the preoperative UTI and there is no additional documentation regarding any active signs or symptoms at the time of the principal operative procedure.

UTI

Question: In the case I’m reviewing the patient did not have any signs or symptoms due to a foley, but their urine culture returned positive. Can I assign a postop UTI?

UTI

Answer: NSQIP only captures symptomatic UTIs and as the patient did not develop symptoms, a postoperative UTI would not be assigned to the case.

Hospital Readmission

Question: The patient I’m reviewing underwent a laminectomy. He was discharged home and 9 days later readmitted as an inpatient due to a stroke. Would I assign the unplanned readmission as likely related to the principal operative procedure?

Hospital Readmission

Answer: As you cannot definitively say that readmission was not related to the principal operative procedure (the laminectomy), you would answer ‘Yes’ to the question ‘Was this readmission likely related to the principal operative procedure’.

Hospital ReadmissionQuestion:

If the readmission diagnosis does not meet the NSQIP definition criteria to assign the postop occurrence, should it be assigned as the reason for the readmission? For example, the patient I am reviewing was readmitted 6 days after surgery with a diagnosis of sepsis. The findings, however, don’t meet the NSQIP definition of Sepsis. Should I still select Sepsis from the dropdown list as the primary suspected reason for the unplanned readmission, even though it doesn’t match the NSQIP definition?

Hospital Readmission

Answer: As sepsis was assigned as the readmitting diagnosis, you would document as such. However, please note that for the readmission variable the readmitting diagnosis does not have to also meet NSQIP criteria for the same occurrence. Thus, per your scenario you would document sepsis as the cause of the readmission, but you would not capture it as an occurrence.

Unplanned Return to OR

Question: I have a case in which the patient had extensive wounds that were infected including her sacrum, perianal, buttock, and thigh areas. The original surgery was a debridement of the necrotic tissue and in the operative note the surgeon commented that there would probably be multiple trips to the OR. The patient returned to the OR on POD 1 and POD 3 for additional debridement and on POD 10 for skin grafting. Would I document these returns to the OR as unplanned?

Unplanned Return to OR

Answer: As there is documentation that multiple trips to the OR might be needed in the operative note for the principal operative procedure, the returns to the OR would not be considered as unplanned operations.

Algorithms Preoperative Open Wound

Preoperative Steroid/ImmunosuppressantUse for a Chronic Condition

Surgical Wound ClosureVein Thrombosis

Hospital ReadmissionUnplanned Return to OR

30-Day Follow-Up

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