Frequently Asked Questions - 1st DRAFT

 

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

 

 

2610

Blood Prod

Indicate whether blood products were transfused any time postoperatively. 

Postoperatively is defined as any blood started after the initial surgery.  Include blood transfused after the initial surgery, including any blood transfused during a reoperative surgery.

 

4/04

Does autologous blood count when coding this field?

Do not count pre-donated (autologous) blood, cell saver, pump residual and/or chest tube recirculated blood. 

 

 

2620

Blood Prod-RBC Units

Indicate the number of units of Red Blood Cells that were transfused any time

postoperatively.

 

 

2630

Blood Prod-FFP Units

Indicate the number of units of Fresh Frozen Plasma that were transfused any time postoperatively.

 

 

2640

Blood Prod-Cryo Units

Indicate the number of units of Cryoprecipitate that were transfused any time

postoperatively.

 

 

2650

Blood Prod-Platelet Units

Indicate the number of units of Platelets that were transfused any time postoperatively.

 

6/04

 

It is imperative that each site understand their institution’s definition for Random Donor Platelets (RDP) and Single Donor Platelets (SDP) when coding seq# 1500, Intraop Blood Products – Platelet Unit and seq# 2650, Blood Products - Platelet Units.  Because of platelet “unit” definition variation between institutions, “A ten pack of platelets = 10 units, not one unit” is no longer applicable.

 

Following is a guideline for assessing platelet utilization across multiple medical centers.

 

RDP:  count the dose pack as one unit.  A dose pack may consist of 4, 6, 8, 10 or any number of donor platelets obtained from random donors. The number of units coded is not volume dependant.

 

SDP or Plateletpharesis:  count as one unit.  One unit is compromised of platelets derived from a single donor.  The number of units coded is not volume dependant.

 

 

2660

Extubated in OR

Indicate whether the patient was extubated prior to leaving the OR during the initial surgery.

 

1/05

 

Seq# 2660-2700, Intubation Fields

If a patient is transferred to another hospital and remains intubated and on the ventilator at the time of transfer what date/time is used as the time of extubation?

Use the patient’s discharge date and time.

 

 

4/05

OR to ICU, patient intubated.  ICU, patient extubated.  Back to OR, intubated and extubated in OR.  Do not count OR Reop intubation as a re-intubation.  Reop OR intubation hours do not get captured.

OR to ICU, patient intubated.  ICU, patient extubated.  Back to OR, intubated.  Back to ICU remains intubated.  Reintubated during hospital stay = yes.  Additional vent hours start once patient arrives back in ICU.  Do not include operative intubation times in the initial or additional vent hour fields.

OR to ICU, patient intubated.  Back to OR intubated from initial surgery.  Back to ICU remains intubated.  All ventilation hours are initial vent hours, but vent time in OR is not counted.

 

 

2670

Initial Hours Ventilated

Indicate the number of initial hours post operation for which the patient was ventilated before any reintubation.  Number of hours includes hours ventilated post-operatively until removal of the endotracheal tube or if patient has tracheostomy tube, until no longer ventilator dependent.  Leave blank if the patient was extubated on the operating table.  Any patient ventilated > 24 hours is coded as a Pulmonary Complication of "Prolonged Ventilation",

From version 2.41

 

How should postop vent hours be counted? 

 

The definition calls for leaving this field blank if extubation occurs on the table.  There are two practical problems associated with using a blank for extubation on the table.  First, there will be an assumption of on-table extubation when the field may have been left blank due to lack of information, careless omission or other error.  Second, the vendors have the option of making “Post Op Vent Hours Total” a calculated field.  Consider the following not-uncommon scenario: The patient is extubated on the table, transported to the ICU where re-intubation is required for 10 hours.  With a calculated field, “Post Op Vent Hours Total” = <NULL> + 10 = <NULL>.  Both of these problems are solved by using “0” for “Initial Hours Ventilated” when extubation is on the table.

Initial hours ventilated should include the hours from postop intubation time to time of extubation.  This does not include re-intubation time.  Re-intubation should be reported under Additional Hours Ventilated.  For centers extubating in the OR, the Postop Vent Hours = 0. (4-19-02)

From version 2.41

6/03

Should post-op vent time start at the end of surgery or when the patient leaves the OR or when the patient arrives in the ICU?

Post-op vent times begin when the patient arrives in the ICU or your institutions equivalent to an ICU. 

From version 2.41

7/03

If you have a patient that is extubated post-op but maintained for two days on bi-pap to prevent reintubation, does the bi-pap time count towards initial hours ventilated? 

The intent of this field is to capture the number of hours that a patient was ventilated postoperatively till removal of the endotracheal tube.  Therefore, once the patient is extubated, stop counting initial hours ventilated.

 

5/04

Do ventilator hours get documented by rounding up to single hours or do minutes get included?

 

Ventilator hours are calculated with a decimal point so that minutes can be included.  Examples:

0.1 = 6 minutes

0.25 = 15 minutes

0.5 = 30 minutes

0.75 = 45 minutes etc.

 

11/04

A patient with a tracheostomy begins ventilator weaning – do we include the weaning hours for seq# 2670? 

Weaning time= ventilator time.  Capture the number of initial hours ventilated post operatively until removal of the endotracheal tube or if the patient has a trach, until no longer ventilator dependent.

 

01/06

 Initial extubation time-Does the time start with admission to the ICU or with skin closure in the OR.
Is Intra-op time when the the patient enters and leaves OR and is Post-op  when the patient is admitted to an ICU and transferred from one.

General Statement #1 in the FAQ defines “Pre-op", "intra-op" and "post-op" defined according to the STS Adult Cardiac Database.
 
Pre-op:  time period prior to the OR until the patient enters the OR
Intra-op:  from the time the patient enter the OR until the patient exits the OR
Post-op:  from the time the patient exits the OR until the patient leaves the hospital
Per the FAQ, Ventilation starts with ICU admission time.
Post-op vent times begin when the patient arrives in the ICU or your institutions equivalent to an ICU.  This is an entry from 6/03 and still applies to v2.52.1

 

 

2680

Re-intubated During Hospital Stay

Indicate whether the patient was reintubated during the hospital stay after the initial extubation.  This may include patients who have been extubated in the OR and require intubation in the postoperative period.

From  version 2.41

8/03

I had a patient return to the OR which required intubation.  Patient was extubated prior to leaving the OR.  Is this a reintubation?

No, this would not be a reintubation because it was a required intubation for the surgery.  As long as the patient was extubated in the OR, there is no reintubation and no additional vent hours.

 

8/04

Would self-extubation requiring immediate reintubation be collected as a reintubation?

 

As long as the reintubation was immediate, continue to collect as initial # of hours ventilated postoperatively.  If the patient was given a trial run once extubated, which fails, requiring reintubation, these hours would count towards additional hours ventilated post-op.

 

 

2690

Additional Hours Ventilated

Indicate how many additional hours the patient was ventilated postoperatively.

 

5/04

Do ventilator hours get documented by rounding up to single hours or do minutes get included?

 

Ventilator hours are calculated with a decimal point so that minutes can be included.  Examples:

0.1 = 6 minutes

0.25 = 15 minutes

0.5 = 30 minutes

0.75 = 45 minutes etc.

 

 

2700

Postop Vent Hours - Total

Indicate the total number of hours including any reintubation hours.  Any patient

ventilated > 24 hours should be coded as a Pulmonary Complication of "Prolonged Ventilation".  If extubated in the OR and no additional ventilation hours, enter zero in this field. 

From version 2.41

9/03

Does prolonged intubation include those hours after the initial extubation which may have been less than 24hrs?  Also if a patient was trached and was on trach shield during the day but back on the vent at night, do we include those vent hours?

Total vent hours included all hours until patient is non-vent dependent.  It does include all reintubation hours (excluding re-op OR intubation hours) and those hours of trach collar/vent at night hours.

 

 

2/04

Improvement of definition and additional clarification: 

Indicate the total number of hours including any reintubation hours.  Any patient

ventilated > 24 hours should be coded as a Pulmonary Complication of "Prolonged Ventilation".  If extubated in the OR and no additional ventilation hours, because the patient expired in the OR, this field would appropriately be left blank.  If patient survived initial surgery, extubated in the OR and no additional vent hours, enter “0”, zero.

 

Zero is the correct option for seq# 2700, VentHours, for the following situation:

 

If the patient survives and is extubated in the OR of the initial surgery and requires no reintubation

Seq# 2660:  Extubated in the OR = yes

Seq# 2680:  Re-Intubated during hospital stay = no

Seq# 2700:  Total Hours Ventilated Postop = zero

 

Blank is the correct option for seq# 2700, VentHours, for the following situation:

 

If the patient expires in the OR of the initial surgery

Seq# 2660:  Extubated in the OR = yes

Seq# 2680:  Re-Intubated during hospital stay = no

Seq# 2700:  Total Hours Ventilated Postop = blank

 

5/04

Do ventilator hours get documented by rounding up to single hours or do minutes get included?

 

Ventilator hours are calculated with a decimal point so that minutes can be included.  Examples:

0.1 = 6 minutes

0.25 = 15 minutes

0.5 = 30 minutes

0.75 = 45 minutes etc.