The Society of Thoracic Surgeons

Frequently Asked Questions: Adult Cardiac Surgery Database

Version 2.52.1

 August, 2006

How to use the “interactive” FAQ Document:

1.  To review all clinical questions in an individual section, click on the section title below.

Section A:  seq# 40-80

Section F:  seq# 750-870

Section K:  seq# 1630-1880

Section P:  seq# 2710-3010

Section B:  seq# 100-210

Section G:  seq# 890-1040

Section L:  seq# 1920-2350

Section Q:  seq# 3020-3080

Section C:  seq# 220-340

Section H:  seq# 1050-1200

Section M:  seq# 2360-2560

Section R:  seq# 3090-3210

Section D:  seq# 350-550

Section I:  seq# 1210-1500

Section N:  seq# 2570-2600

Section S:  seq# 3220-3240

Section E:  seq# 560-670

Section J:  seq# 1520-1620

Section O:  seq# 2610-2700

2.      To review an individual Seq# clinical question, click on the Seq# title below.

310 ICUInHrs                                   2470 OCarAFib

340 TotHrICU                                  2560 OCarOthr

440 RenFail                                     2710 Complics                                                            

490 InfEndo                                     2750 COpReOth                                                         

850 ArrhyTyp                                   2780 CISternDeep

1050 NumDisV                                2830 CNStrokP

1260 EmergRsn                              2950 COtCoag

1280 OpCAB                                    3090-3180 Section R.

1310 OpOCard                                3220 Readm30

1380 PerfusTm                                3240 ReadmPro

1410 XClampTm

1640 OpMitral

1650 OpTricus

3.  CC/TM:  Corrections/Clarifications to Training Manual

NEW

Date

SeqNo

FieldName

Definition

350

Weight (kg)

Indicate the weight of the patient in kilograms.

360

Height (cm)

Indicate the height of the patient in centimeters.

370

RF-Smoker

Indicate whether the patient has a history confirming any form of tobacco use in the past (cigarettes, cigar, tobacco chew, etc.).

7/04

If a patient is a daily smoker of marijuana, would it be appropriate to code “yes” to seq# 370?

No, the intent is to capture a history of any form of tobacco use. Marijuana is not a tobacco product.

380

RF-Smoker-Current

Indicate whether the patient is a current smoker.  Patients with a use of tobacco (cigarettes, cigar, tobacco chew etc.) within one month of surgery are considered to be current smokers.

From version 2.41

The version 2.35 definition for smoking was use of cigarettes within one month of surgery.  My understanding was that use of other tobacco products within one month was considered a past smoker.  Version 2.41 definition states that any tobacco product use within one month is considered present use.  Is this a change to the smoking definition?

The 2.41 definition is not a change in intent, but is now written more clearly.  The intent is to capture any tobacco use within 1 month as current use. (4-19-02)

12/04

If a patient is using nicotine patches, is this to be coded as 'yes' for current smoker?

No, do not code "yes" to current smoker if a patient is using nicotine patches or nicotine gum.

390

RF-Family History CAD

Indicate if the patient has/had any direct blood relatives (parents, siblings, children) who have had any of the following DIAGNOSED at age <55:

1. Coronary Artery Disease (angina, previous CABG or PCI)

2. MI

3. Sudden cardiac death without obvious cause.

If the patient is adopted, or the family history is unavailable, code "No".

From version 2.41

6/03

How do I answer the question of family history of CAD when the patient is adopted?

Code as “no”.

From version 2.41

11/03

In regards to family history--the definition reads “yes” if early onset (<55).  I am currently reviewing a chart of a 76 yr old. Her father had first MI in his 60's and died of MI in his 70's.  Her mother died at 84 of MI.  How can that not be classified as + family history?  Those folks probably never doctored like people do today and if they did-did they have the technology to prove they had CAD? I would like to classify this woman as having + family history.  What would the correct classification be? 

CAD noted prior to age 55 is a much stronger predictor than CAD that occurs and is diagnosed later in life.  Later in life CAD is more of an indicator of lifestyle.  If your patient's family's CAD was diagnosed after age 55 do not code as "yes" to family history of CAD.

400

RF-Diabetes

Indicate whether the patient has a history of diabetes, regardless of duration of disease or need for anti-diabetic agents.  Includes on admission or preoperative diagnosis.  Does not include gestational diabetes.

From version 2.41

6/03

Would I capture a patient here that had gestational diabetes

Do not code unless the patient continued to be treated (diet, oral, insulin) after the gestational period.

9/04

Patient is admitted with no history of diabetes preoperatively.  During the admission for an MI, glucose levels 200-300's.

Postoperative day #3, progress notes document new onset Diabetes with a preoperative HgA1C of 8.  Patient started on insulin and discharged on insulin.

Do we consider this patient to have Diabetes as a risk factor?

We get these types of questions often in regards to many of the risk factor fields.  To code "yes" to any of the risk factors that are collected, you need to know of the risk factor preoperatively.  In some clinical instances this rational may not make sense, but it is the best way to guarantee the collection of consistent data. 

The definition states:  Indicate whether the patient has a history of diabetes, regardless of duration of disease or need for anti-diabetic agents.  Includes on admission or preoperative diagnosis.  Does not include gestational diabetes.

In the case that you have described, please code "no" to the risk factor of Diabetes

9/04

The physician reports that the patient has been a "borderline” diabetic for years."  Can we capture "borderline" as a diabetic risk factor?

What needs to be determined is if the patient is a diabetic or not.  As you know, according to our definition the need for anti-diabetic agents is not a factor for coding "yes" to this field, so knowing that information will not help.  Talk with your physicians and try to determine if the patient has a history of diabetes.  As far as the term “borderline diabetic” -- shame on that physician.  That term was done away with a long time ago.  You either are or you are not a diabetic, like you are either pregnant or not pregnant.  Borderline diabetes describes impaired glucose tolerance, when the blood sugars are a little bit above normal, but not near the diabetic cut-off range.  If the patient is described as "borderline", do not capture as "yes" to diabetes.

410

RF-Diabetes-Control

Indicate the method of diabetic control.  Code the control method patient presented with on admission.  Patients placed on a pre-operative diabetic pathway of Insulin drip but at admission were controlled with NONE, diet or oral method are not coded as insulin dependent.  Choices are:

None = No treatment for diabetes.

Diet = Diet treatment only.

Oral = Oral agent treatment.

Insulin = Insulin treatment (includes any combination with insulin).

01/06

How would you capture the new drug byetta as it is an injection.

Byetta will have to be captured as a custom field until the next specification upgrade. Will consider adding to Seq# 410 DiabCtrl.

420

RF-Dyslipidemia

Indicate if the patient has a prior history of dyslipidemia diagnosed and/or treated by a physician. Criteria can include documentation of:

1. Total cholesterol greater than 200 mg/dl, or

2. LDL greater than or equal to 130 mg/dl, or

3. HDL less than 30 mg/dl, or

4. Admission cholesterol greater than 200 mg/dl, or

5. Triglycerides greater than 150 mg/dl.

Note: If treatment was initiated because the LDL was >100 mg/dl (2.59 mmole/l) in patients with known coronary artery disease, this would quantify as a "Yes".  Any pharmacological treatment qualifies as a "Yes".

From version 2.41

12/03

1.  Patient has no history of dyslipidemia  but is placed on a statin prophylactically due to a strong family history of dyslipidemia = code "no" to seq# 420, Dyslipidemia

2.  Patient has a positive history of dyslipidemia (abnormal cholesterol levels).  Patient placed on a statin resulting in a reduction of cholesterol levels to more "normal" levels = code "yes" to seq# 420, Dyslipidemia.

3.  Patient has no history of dyslipidemia but is placed on a statin for non- dyslipidemia reasons, i.e., anti-inflammatory reasons = code "no" to seq# 420, Dyslipidemia

430

RF-Last Creat Lvl

Indicate the most recent creatinine level prior to surgery.  A creatinine level should be collected on all patients for consistency, even if they have no prior history.  A creatinine value is a high predictor of a patient’s outcome and used in the predicted risk models.

440

RF-Renal Fail

Indicate whether the patient has 1) a documented history of renal failure and/or 2) a history of creatinine > 2.0.  Prior renal transplant patients are not included as pre-op renal failure unless since transplantation their creatinine has been or currently is > 2.0.

From version 2.41

9/03

Pt comes to the ER and is diagnosed with an Aortic Dissection and is rushed to surgery. Creatinine on admission is 2.6. No previous history of renal failure documented in the chart. Do you still count this as a history of renal failure even though you know the increased creatinine is due to his recent dissection?

Yes, code as renal failure.  This patient’s pre-op Creatinine level meets the criteria for renal failure for the STS.

CC/TM

2/04

The intent of this field is to capture those patients with a history of renal failure.  The Training Manual asks the question in the “Data Field Intent” column “Is the patient currently in renal failure….”  The statement should read, “Does the patient have a history of renal failure (past of present) as defined by the clinical criteria in the definition.

NEW!

08/06

Our HIM coders tell us according to the National Kidney Foundation & CMS there are now 6 classes of Chronic Kidney Disease based on the GFR and we need to document which our patients fall into preoperatively. We have found the GFR to be abnormally low (15-59) on many patients with a seemingly normal creatinine levels. Their GFR result would put them in a Stage III or IV chronic kidney diesease designation.  These patients with seemingly normal renal function (by creatinine level)really have significant chronic renal disease/ dysfunction and are at a higher risk for postop renal failure than their preop creatinine would indicate. Can we code yes, history of pre-op renal failure, using the GFR, as directed by the National Kidney Foundation and CMS? 

No, current specifications do not include GFR as a measure of renal failure.  Specification upgrades may redefine to include GFR.

450

RF-Renal Fail-Dialysis

Indicate whether the patient is currently undergoing dialysis.

5/04

Does the STS consider “ultrafiltration”, “CVVH/CVVH-D” or “CRRT” as a form of dialysis?

After contacting a number of Nephrologists, ultrafiltration should not be coded as dialysis, but CVVH, CVVH-D and CRRT should be coded as dialysis. 

460

RF-Hypertension

Indicate whether the patient has a diagnosis of hypertension, documented by one of the following:

a. Documented history of hypertension diagnosed and treated with medication, diet and/or exercise.

b. Blood pressure >140 systolic or >90 diastolic on at least 2 occasions.

c. Currently on antihypertensive medication.

03/06

Pt in ESRD and on dialysis.  Doctors state pt has htn, but the pt is not on any meds.  Assume pt htn r/t volume overload - can I code as htn based on this information?  The pt was admitted as elective CABG and I used the only 2 vs prior to surgery induction. First one in preop and second one is the first vs on anesthesia record prior to induction.  I realize that the second vs could be elevated r/t anxiety.  Can I use these 2 vs to code as htn?

If there are 2 pressure readings > 140/80, then HTN can be coded along with the physicians clinical diagnosis. It is not our position to determine the rationale without supporting clinical evidence. The patient may have a history of HTN and no anti-hyperrtensive meds, but may be on some non-conventional meds that also address their HTN such as a diuretic. Given the information given, code HTN=yes if the 2 BP readings meet definational criteria.

470

RF-CVA

Indicate whether the patient has a central neurologic deficit persisting more than 72 hours. (i.e. extremity weakness or loss of motion, loss of consciousness, loss of speech, field cuts).

From version 2.41

6/03

If a patient had a CVA several years prior to the heart surgery and has no residual symptoms, do we code this as a CVA “yes” then remote?

Code as “yes” to CVA.  If a patient had a CVA in the past, regardless of their current symptoms, this history may have a significant impact on the CT surgery outcome.  Yes, code it as a “remote” interval.

480

RF-CVA-When

Indicate when the CVA events occurred.  Those events occurring within two weeks of the surgical procedure are considered recent, while all others are considered remote.

490

RF-Infect Endocard

Indicate whether the patient has a history of infectious endocarditis documented by one of the following:

1. positive blood cultures

2. vegetation on echocardiography

3. documented history of infectious endocarditis

From version 2.41

9/03

We have a lot of patients with a history of endocarditis which was treated and required a valve replacement. These same patients are now returning for a second cardiac surgery on a separate valve (eg:  endocarditis was on Aortic valve and patient now returns for mitral valve replacement that is not related to endocarditis). Should I classify the patient has having a history of treated endocarditis?

Yes, seq# 490 = yes, seq# 500 = treated.

From version 2.41

11/03

We have many patients return with a history of endocarditis that have required valve replacement in the past.  The documentation is inadequate to meet the STS definition of endocarditis but the patients clearly have a history of endocarditis based on the documentation of valve replacement due to endocarditis.  I am coding these as “no” for a history of endocarditis because they do not meet the criteria of the STS definition.  Is this correct?

The Definition Task Force states that the intent is to capture patients that have a history, either past or present, of endocarditis in this field, not just to capture those patients that present with “current” endocarditis requiring valve surgery.  Therefore, code "yes" if history of endocarditis, which includes this admission and in the past.  For patients with a past history of endocarditis, a positive blood culture is not necessary to code as “yes”.  For those patients presenting with endocarditis on admission, a positive blood culture is necessary to code as “yes”.

8/04

Patient had AVR + MVR for AI and MR. Surgeon thought one excised valve looked suspicious and sent to pathology.  The valve grew out strep.  There were no preoperative blood cultures sent.  The patient is now on Vancomycin for endocarditis. Should Infectious Endocarditis still be answered as No?

We get these types of questions often.  To code "yes" to any of the risk factors that are collected, you need to know of the risk factor preoperatively.  Although in some ways this does not seem to make sense, we feel it is the most consistent way for the sake of the data as a whole.  Please code as "no".

NEW!

08/06

 I read the FAQ 490 dated 8-04. Based on this standard a patient who does not have documentation of infectious endocarditis, vegetation, or positive blood cultures in preop documentation but vegetation is objectively found intraop and documented would be answered as "no" for inf endo. Is this correct? If so, is this negating the STS objective of reflecting actual risk for this patient? Is acceptance of objective intraop findings documentation that helps to truly define clinical pt risk something the Definitions Committee would consider accepting to accurately stratify this type of patient?

You are correct, you do not collect endocarditis that is not documented preoperatively.  While I appreciate the associated risk of endocarditis, this would also apply to other situations and is therefore not appropriate to capture. 

500

RF-Infect Endocard Type

Indicate the type of endocarditis the patient has.  If the patient is currently being treated for endocarditis, the disease is considered active. If no antibiotic medication (other than prophylactic medication) is being given at the time of surgery, then the infection is considered treated.

510

RF-Chronic Lung Dis

Indicate whether the patient has chronic lung disease, and the severity level according to the following classification:

No;

Mild: FEV1 60% to 75% of predicted, and/or on chronic inhaled or oral bronchodilator therapy.

Moderate: FEV1 50% to 59% of predicted, and/or on chronic steroid therapy aimed at lung disease.

Severe: FEV1 <50% predicted, and/or Room Air pO2 < 60 or Room Air pCO2 > 50.

From version2.41

8/03

No PFT’s performed and yet the physicians are documenting chronic lung disease in medical record.

If no PFT’s are obtained, which can be common, look to the remaining STS definition points for chronic lung disease to code this field.

Mild:  ...and/or chronic inhaled or oral bronchodilator therapy.

Moderate:  ...and/or chronic steroid therapy aimed at lung disease.

Severe:  ...and/or room air PO2 < 60 or room air PCO2 >50. 

If the STS definition points are not met, either with or without PFT’s, no matter what the chart says, chronic lung disease should not be coded as "yes".

03/06

 If a patient does not have a diagnosis of lung disease documented and no FEV1 was done but the PAO2 is <60 and the PACO2 is >50 can we put yes for chronic lung disease. 

Also if a patient had an FEV1 that met the criteria for mod lung disease without a diagnosis in the chart do we mark yes to chronic lung disease?

1) Yes, code Seq# 510 ChrLungD = Severe. The criteria reads, "FEV1<50% predicted, and/or Room Air pO2<60 or Room Air pCO2>50. So, if any one or combination of these criterion are met, code yes.

2) Yes, code Seq# 510 ChrLungD = Moderate. Per the definition, the decision to code Mild, Moderate, or Severe is made based on FEV value and/or chronic inhaled or bronchodilator therapy and/or chronic steroid therapy aimed at lung disease, and or room air pO2 level and/or room air pCO2 level. No written diagnosis is required.

520

RF-Immunosuppressive Rx

Indicate whether the patient has used any form of immunosuppressive therapy (i.e. systemic steroid therapy) within 30 days preceding the operative procedure. Does not include topical applications and inhalers or one time systemic therapy.

From version 2.41

Previously, the definition of preoperative steroids excluded the one time dose given in the cath lab.  These definitions do not exclude those patients.  Do we count a one time dose of steroids as immunosuppressive therapy?

One time doses of medication should not be included. The intent is to capture patients who are using steroids for long term or chronic (3-13-02)

From version 2.41

What are the types of immunosuppressive therapy?

There are 4 classes of drugs considered to be immunosuppressive.  They are Corticosteroids, Cytotoxic drugs, Antimetabolites and Cyclosporine.  Corticosteroids are included only if taken systemically—not prn asthma meds.  This group of drugs is commonly used to treat recipients of organ transplants, and also can be used in HIV patients. (3-13-02)

From version 2.41

9/03

Can we code this field as "yes" if inhaled steroids are used? The def:  leads me to think - yes - "Use of any form of immunosuppressive therapy (i.e. systemic steroid therapy) within 30 days preceding the operative procedure".

The rest of the definition reads, "...does not include topical applications and inhalers or one time systemic therapy."  Therefore, inhaled steroids should not be captured as "yes".

530

RF-Periph Vasc Dis

Indicate whether the patient has Peripheral Vascular Disease, as indicated by

claudication either with exertion or rest; amputation for arterial insufficiency; aorto-iliac occlusive disease reconstruction; peripheral vascular bypass surgery, angioplasty, or stent; documented AAA, AAA repair, or stent; positive non-invasive testing documented.  Does not include procedures such as vein stripping, carotid disease, or procedures originating above the diaphragm.

540

RF-Cerebrovascular Dis

Indicate whether the patient has Cerebro-Vascular Disease, documented by any one of the following: Unresponsive coma > 24 hrs; CVA (symptoms > 72 hrs after onset); RIND (recovery within 72 hrs); TIA (recovery within 24 hrs); Non-invasive carotid test with > 75% occlusion; or Prior carotid surgery.  Does not include neurological disease processes such as metabolic and/or anoxic ischemic encephalopathy.

550

RF-Cerebrovascular Dis Type

Indicate whether the patient has a history of cerebrovascular disease, documented by any one of the following:

1. Unresponsive Coma greater than 24 hours: Patient experienced complete mental unresponsiveness and no evidence of psychological or physiologically appropriate responses to stimulation.

2. Cerebrovascular Accident (CVA): Patient has a history of stroke, i.e., loss of

neurological function with residual symptoms at least 72 hours after onset.

3. Reversible Ischemic Neurologic Deficit (RIND): Patient has a history of loss of neurological function with symptoms at least 24 hours after onset but with complete return of function within 72 hours.

4. Transient Ischemic Attack (TIA): Patient has a history of loss of neurological function that was abrupt in onset but with complete return of function within 24 hours.

5. Non-invasive/invasive carotid test with greater than 75% occlusion.

6. Previous carotid artery surgery.

If more than one, select the most recent to the operative procedure.

CC/TM

3/04

The Training Manual, seq# 550, Clarification Section:  states “code the highest or most devastating event.”  This is incorrect and the Training Manual should state, according to the definition, to select the most recent event to the operative procedure.