cardiac surgery & percutaneous cardiac interventions … surgery and percutaneous cardia… ·...

For reference only – Do Not Use For more information contact: [email protected]

Cardiac Surgery & Percutaneous Cardiac

Interventions Data Standards

September 2008

National Clinical Dataset Development Programme (NCDDP) Support Team Information Services Area 74A Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Tel: 0131 275 7066 Email to: [email protected] Website: www.clinicaldatasets.scot.nhs.uk/

mailto:[email protected]

http://www.clinicaldatasets.scot.nhs.uk/

Cardiac Surgery & Percutaneous Cardiac Interventions Data Standards

2

Overview & Background ................................................................................................ 5

Overview ....................................................................................................................... 5 Cardiac Surgery & Percutaneous Cardiac Interventions Data Standards..................... 5 Background to NCDDP ................................................................................................. 6 Generic Data Standards................................................................................................ 6 Clinical Terminology ...................................................................................................... 7 Date Recording ............................................................................................................. 7

Published Data Standards ............................................................................................. 9 Generic and Previously Consulted ................................................................................ 9

Data Standards under Development ........................................................................... 12 Data Standards Currently undergoing Change Control ............................................ 12 Clinical / Care Process ................................................................................................. 13 Assessment(s), Examinations(s) and Investigation(s).............................................. 13

1.1 Critical Pre-operative State ................................................................................... 13 1.2 Stage of Chronic Kidney Disease.......................................................................... 14 1.3 Suitable for Surgery/Procedure ............................................................................. 14 1.4 Ventilated Pre-op................................................................................................... 15 1.5 Waist-to-Hip Ratio (WHR) ..................................................................................... 15

Finding(s) and Result(s)............................................................................................... 16 2.1 Aorta Pathology..................................................................................................... 17 2.2 Cardiogenic Shock Present................................................................................... 17 2.3 Carotid Bruits Present ........................................................................................... 18 2.4 Catheter/Cannula Type(s) ..................................................................................... 18 2.5 Coronary Artery Finding(s) at Surgery .................................................................. 19 2.6 Coronary Artery Finding(s) at PCI ......................................................................... 19 2.7 Device Failure ....................................................................................................... 20 2.8 Device Failure Reason .......................................................................................... 20 2.9 Diffuse Coronary Disease ..................................................................................... 21 2.10 Extracardiac Arteriopathy .................................................................................... 21 2.11 FEV1 Less Than 50% Predicted ......................................................................... 22 2.12 Gp (Glycoprotein) IIb/IIIA Inhibitor Administered................................................. 22 2.13 Gp (Glycoprotein) IIb/IIIA Inhibitor Reason Administered ................................... 23 2.14 Gp (Glycoprotein) IIb/IIIA Inhibitor Reason Not Administered............................. 23 2.15 Heart Valve Disease Aetiology............................................................................ 24 2.16 Heart Valve Haemodynamic Dysfunction Type................................................... 24 2.17 Indication for PCI (Percutaneous Coronary Intervention).................................... 25 2.18 Intra-aortic Balloon Pump (IABP) Reason Used ................................................. 25 2.19 Left Ventricular End Diastolic Pressure............................................................... 26 2.20 Left Ventricular Function ..................................................................................... 27 2.22 Long Term Use of Corticosteroids or Bronchodilators......................................... 29 2.23 Mean Pulmonary Artery Wedge Pressure (PAWP)............................................. 29 2.24 MRSA Screening................................................................................................. 30 2.25 Myocardial Infarction Classification ..................................................................... 31 2.26 Operative Stage .................................................................................................. 32 2.27 Post Infarct Ventricular Septal Rupture ............................................................... 33 2.28 Primary wound Re-exploration ............................................................................ 33 2.29 Primary Wound Re-exploration Reason.............................................................. 34 2.30 Pulmonary Artery Systolic Pressure.................................................................... 34 2.31 Stenosis Diameter Range ................................................................................... 34 2.32 Thrombolysis Treatment Administered................................................................ 35


3

2.33 TIMI (Thrombolysis in Myocardial Infarction) Flow Code .................................... 35 Care Planning, Management and Outcome(s) ........................................................... 36

3.1 Chest Drains Total Number................................................................................... 36 3.2 Drainage Output .................................................................................................... 36 3.3 Cardiac Surgical Cover ......................................................................................... 37

Treatment(s) and Intervention(s)................................................................................. 38 4.1 Aorta Procedure .................................................................................................... 39 4.2 Aorta Section......................................................................................................... 39 4.3 Aortic Clamp Type................................................................................................. 40 4.4 Aortic Clamp Used ................................................................................................ 40 4.5 Atrial Ablation Lesion Set ...................................................................................... 41 4.6 Blood Conservation Method .................................................................................. 41 4.7 Cardiac Surgery Incision Site ................................................................................ 42 4.8 Cardiac Valve Procedure ...................................................................................... 43 4.9 Cardiac Valve(s) replaced/repaired Total Number ................................................ 43 4.10 Cardioplegia Infusion Method.............................................................................. 44 4.11 Cardioplegia Solution Used................................................................................. 44 4.12 Cardioplegia Temperature................................................................................... 45 4.13 Cardiopulmonary Bypass Conversion ................................................................. 45 4.14 Cardiopulmonary Bypass Used........................................................................... 45 4.15 Circulatory Support Used .................................................................................... 46 4.16 Conduit Anastomotic Device Used...................................................................... 46 4.17 Coronary Shunt Size ........................................................................................... 47 4.18 Coronary Shunt Used.......................................................................................... 47 4.19 Coronary Stabiliser Type..................................................................................... 47 4.20 Coronary Stabiliser Used .................................................................................... 48 4.21 CPB (Cardiopulmonary Bypass) Arterial Cannulation Site.................................. 48 4.22 CPB (Cardiopulmonary Bypass) Venous Cannulation Site................................. 49 4.23 Follow on PCI (Percutaneous Coronary Intervention) Procedure ....................... 49 4.24 Graft Conduit ....................................................................................................... 50 4.25 Haemostatic Method ........................................................................................... 51 4.26 Heart Valve(s) ..................................................................................................... 51 4.27 Intra-aortic balloon pump (IABP) Used................................................................ 52 4.28 Left Main Stem Protected.................................................................................... 52 4.29 Myocardial Protection - Predominant Method ..................................................... 52 4.30 Nature of Cardiac Diagnostic Procedure............................................................. 53 4.31 Nature of PCI (Percutaneous Coronary Intervention) Procedure........................ 54 4.32 Non Cardioplegic Myocardial Protection Method ................................................ 54 4.33 PCI (Percutaneous Coronary Intervention) Adjunctive Device(s) ....................... 55 4.34 Proximal Vascular Anastomoses Site ................................................................. 56 4.35 Renal Replacement Therapy............................................................................... 56 4.36 Renal Replacement Therapy Type...................................................................... 57 4.37 Simultaneous Procedure ..................................................................................... 57 4.38 Stent Type ........................................................................................................... 58 4.39 Thoracic and Vascular Procedure ....................................................................... 58 4.40 Valve Type .......................................................................................................... 59 4.41 Vascular Anastomosis Type................................................................................ 59

Care Journey and Encounter....................................................................................... 60 5.1 Cardiac Surgery Status ......................................................................................... 60 5.2 Hospital area ......................................................................................................... 61

Date(s) and Time(s)....................................................................................................... 62 6.1 Date and Time of Initial PCI (Percutaneous Coronary Intervention) Device ......... 62

Appendix 1 – Cardiac Post Op Complication(s) ........................................................ 63 Cardiac Post Op Complication(s) ................................................................................ 63

Appendix 2- Working Group ........................................................................................ 67


4

Membership of the Cardiac Surgery & Percutaneous Cardiac Interventions Working Group.................................................................................................................................... 67

Appendix 3- Consultation Distribution List ................................................................ 68 Appendix 4 – Cardiac Surgery & Percutaneous Cardiac Interventions - Proposed Change Control Data Items ........................................................................................................ 70


5

Overview & Background

Overview The National Advisory Committee for CHD (NACCHD) commissioned the development of Cardiac Surgery & Percutaneous Cardiac Interventions Data Standards for NHS Scotland in order to ensure a national approach to the collection of clinical and non-clinical data items relating to Cardiac Surgery & Percutaneous Cardiac Interventions. The aim is to support the implementation of an electronic integrated health record, and ensure inter-compatibility of national clinical information systems. A Clinical Working Group was established in December 2007 to progress this work, supported by the National Clinical Dataset Programme (NCDDP) Support Team in Information Services (ISD).

The Cardiac Surgery & Percutaneous Cardiac Interventions Data Standards will:

Define common data items recommended for collection in a wide variety of clinical settings.

Support the exchange of patient information between healthcare providers.

Support the consistent recording of patient information throughout NHS Scotland.

It is important to emphasise that these are data standards rather than a dataset. This means that the individual data standards included in this document need not all be recorded together in clinical systems but, where it is considered appropriate to record a particular item as part of a person’s care record, it should be recorded in accordance with the nationally agreed standard. The data standards contain data items from Generic Data Standards and other Clinical Datasets, which have previously been developed through the NCDDP and are freely available in the Clinical Datasets section of the web-based Health and Social Care Data Dictionary. Feedback was sought from the wider clinical community in order to ensure that these data standards are fit for purpose. We invited all interested organisations and individuals to take part in the consultation by completing a Consultation Response Form. Comments on all or any part of the document were welcomed.

Some background information on the NCDDP and the Cardiac Surgery & Percutaneous Cardiac Interventions Data Standards development can be found below. If you have any further queries, please go to our website or contact [email protected].

Cardiac Surgery & Percutaneous Cardiac Interventions Data Standards The membership of the Cardiac Surgery & Percutaneous Cardiac Interventions Working Group is shown in Appendix 2. This group agreed the inclusion of individual data items using the following criteria:

http://www.datadictionary.scot.nhs.uk/

http://www.isdscotland.org/isd/4998.html

mailto:[email protected]


6

• Is the data item one which would reasonably be expected to be collected for Cardiac Surgery & Percutaneous Cardiac Interventions?

• Is the data item required to prevent duplication of recording? • Is the data item necessary for the on-going health and healthcare of patients receiving

Cardiac Surgery & Percutaneous Cardiac Interventions Services? • Is the data item currently shared or likely to be shared in the future, amongst healthcare

professionals and key stakeholders? Once consultation was complete the Data Standards were submitted to the NCDDP Programme Board for formal approval as a national standard. Now approved the Cardiac Surgery & Percutaneous Cardiac Intervention Data Standards are freely and widely available through publication in the Health and Social Care Data Dictionary. Where possible the data standards are UK compatible. It is expected that the Cardiac Surgery & Percutaneous Cardiac Intervention Standards will be implemented within existing and emerging national clinical information systems and commercially procured national products, as well as being available to commercial developers to ensure the ability of their systems to support national information requirements.

Background to NCDDP

The National Clinical Dataset Development Programme (NCDDP) supports clinicians to develop sets of interoperable national datasets to facilitate the implementation of the integrated care records across NHS Scotland. These standards will:

• Support direct patient care, by reflecting current best practice guidance • Facilitate effective communication between health care professionals • Improve data quality and support secondary data requirements where possible including

data to support clinical governance • Be freely and widely available through publication in the web based Health & Social

Care Data Dictionary • Incorporate agreed national clinical definitions and implement national terminology • Be UK compatible where possible

The Chief Medical Officer established the programme in 2003 to support clinicians developing national clinical data standards, initially to support the national priority areas. These standards are an essential element of the Electronic Health Record, a central aim of the National e-Health Strategy. More information can be found on our website.

Generic Data Standards Data standards which are relevant to all patients and are used across specialties, disciplines and settings have already been developed by wider Generic Data Standards clinical working groups and approved as national data standards for NHS Scotland. The Cardiac Surgery & Percutaneous Cardiac Interventions Data Standards working group identified several generic data items as appropriate for inclusion in their standards. These data items are indicated next to the data item name and definition, which are listed in this document for information. The full detail of these existing standards are published on the web based Health and Social Care Data Dictionary.


http://www.show.scot.nhs.uk/clinicaldatasets/




7

Clinical Terminology The strategic standard for clinical terminology in NHS Scotland is SNOMED-Clinical Terms. This means that over the next few years, clinical information systems will progress to record clinical data using this international standard. The NCDDP Support Team will commence development of recommended SNOMED CT specifications as part of the data standards and datasets it supports.

Date Recording It is good record-keeping practice always to identify the date of recording of any clinical information. It is expected that all clinical information systems should include ‘date stamping’ as standard functionality; therefore the Cardiac Surgery & Percutaneous Cardiac Interventions Data Standards do not deal with this issue. In many clinical situations, the date of an event, investigation, etc. is required for clinical purposes and should be visible to the health care professional. This date may not be the same as the date on which the data are entered onto the system. In these instances the system must allow the health care professional to enter whichever date is appropriate. These issues must be addressed during system specification and development. The date format for storage and management within a system should conform to the 1Government Data Standards Catalogue format: CCYY-MM-DD. However, this does not preclude entry or display of data on the user interface using the traditional DD-MM-CCYY format. An example of a date & time in correct format is: 1997-07-16T19:20 +01:00 (CCYY-MM-DDThh:mmTZD) It is recommended that a time should always be recorded with the appropriate date and not on its own, however it may not be necessary to display the date along with the time. This is of particular importance where any calculations or analyses are likely to be performed. Automated times recorded by IT systems should include all elements of the time, i.e. hours, minutes and seconds, and are expected to be actual. Where times are entered manually, it is likely that only the hours and minutes will be required, although in some circumstances only hours may be required. Time or any element of the time (hours, minutes or seconds) may be actual or estimated. In some circumstances only an actual time may be acceptable, whilst in others an estimated time may be allowed. In the latter situation, it may be necessary to identify whether the time recorded is actual or estimated. Times identified as actual may be used in calculations and analyses. Times marked as estimated should be treated with caution and the implications of undertaking any calculations or analyses should be considered in the particular context within which the time is recorded or to be made subsequent use of. Where an estimated time is allowed, the appropriate degree of verification detail required should be decided, again dependent on the context in which it is recorded and how the time is to be used. 1Government Data Standards Catalogue 1. All times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00. 2. Values of any element less than 10 should be entered with a zero in the first position. 3. All times for UK transactions/events will be assumed to be GMT.

http://www.isdscotland.org/isd/4048.html


8

4. Systems should record whether the time is Coordinated Universal Time or British Summer Time in the “Time zone designator”. This will allow time elapsed to be calculated correctly, for example for A&E waiting times.


9

Published Data Standards Generic and Previously Consulted Person Demographic(s) Socio-Environmental Detail(s) Patient Identification Lifestyle Person Family Name Current Tobacco and Nicotine Consumption Status Person Title Current Physical Activity Status Name Element Position Family Circumstances Person Name Status Family History of Coronary Heart Disease Preferred Name Clinical/Care Process Previous Person Family Name Problem(s) and Issue(s) Person Given Name Symptom Severity (Ischaemic Chest Pain) Person Initials Symptom Severity (Breathlessness) {CHD} Person Preferred Forename Duration (Symptom) Person Name Suffix Symptom Pattern CHI Number Symptom Onset Health Record Identifier Symptom Description (Pain) {Palliative Care} Address (BS7666) Assessment(s), Examination(s) and

Investigation(s) Postcode Body Mass Index UK Telephone number Heart Rate Internet Email Address Height Person Birth Date Weight Person Death Date Waist Circumference Person Current Gender Systolic Blood Pressure Person Marital Status Diastolic Blood Pressure Person Sex at birth Anatomical Site Diversity Exercise Tolerance Test (Investigation) Ethnic Group (Self Assigned) Exercise Tolerance Test Protocol Type Preferred Language Reason for No Exercise Tolerance Test Preferred Communication Method Electrocardiography (Investigation) Interpretation Assistance Indicator Reason for No Electrocardiography

Echocardiography Carer(s), Care Professional(s), Team(s), Service(s), Organisation(s) or Sector(s) Reason for no Echocardiography Specified General Medical Practitioner Registered GP Practice Code

Stress Test Method

GP General Medical Council Number Chest Pain/Discomfort Characteristics Specified General Medical Practitioner Role Chest Pain Aetiology General Practice Registration Status of Patient Finding(s) and Results Location Code Exercise Tolerance Test Total Time Clinic Name Exercise Tolerance Test Abnormal Results Associated Professional Exercise Tolerance Test Cessation Reason Associated Professional Identifier Cardiopulmonary Exercise Test Result (Peak VO2) Associated Professional Role Cardiopulmonary Exercise Test Result (Anaerobic

Threshold) Associated Professional Employing Organisation Name

ECG Determining Reperfusion Treatment Electrocardiography Results {CHD}

Associated Professional Employing Organisation Type

Cardiopulmonary Exercise Test Result (Respiration Exchange Ratio)

Referral Source Referring Specialty

Cardiopulmonary Exercise Test Result (Oxygen Desaturation)

Associated Person Electrocardiography Rhythm Abnormal Results Associated Person Role Associated Person Relationship to client/patient

Electrocardiography Lead (12-Lead) RR Interval (ECG) Result


10

Finding(s) and Results(Cont..) Finding(s) and Results(Cont..) P Wave (ECG) Result Magnetic Resonance Imaging Scan (Heart) Results PR Interval (ECG) Result Magnetic Resonance Imaging Result (Left

Ventricular Mass) QRS Duration (ECG) Result Magnetic Resonance Imaging Result (Late

Enhancement) QRS Amplitude (ECG) Result Magnetic Resonance Imaging Result (Left

Ventricular End - Diastolic Volume) Q Waves (Pathological) (ECG) Result Magnetic Resonance Imaging Result (Left

Ventricular End - Systolic Volume) ST Segment Height of Elevation/Depression (ECG) Magnetic Resonance Imaging Scan (Heart)

Abnormal Results QT Interval (ECG) Result Right ventricular End-Diastolic Dimension(ECHO) ST Segment (ECG) Result Multiple Gated Acquisition (MUGA) Abnormal

Results T Wave (ECG) Result Ejection Fraction (Heart) Electrocardiography (Signal Averaged) Results Tilt Table Test Results High Frequency Low Amplitude Duration (ECG) Result

Tilt Table Test Result (Angle of Tilt)

Root Mean Square Voltage of the Terminal 40ms (ECG) Result

Tilt Table Test Result (Duration)

QRS Duration (Filtered) (ECG) Result Tilt Table Test Result (Blood Pressure Monitoring Method)

Electrocardiography (Ambulatory) Monitoring Result (Ventricular Extrasystoles)

Exercise Capacity

Electrocardiography (Ambulatory) Monitoring Result (Longest Pause)

Carotid Sinus Massage (Supine)

Electrocardiography (Ambulatory) Monitoring Result (Electrophysiology)

Carotid Sinus Massage (Standing / Tilted)

Echocardiogram Results Myocardial Segments (Observed) Echocardiogram Abnormal Results {CHD} Myocardial Segments (Abnormal) Echocardiogram Results (Left Atrium) CHD Probability Status Echocardiogram Results (Left Atrium) – Diameter Bruce Protocol Treadmill Staging Results Echocardiogram Results (Left Atrium) – Volume Pulmonary Function Test Result Echocardiogram Results (Left Ventricle) Care Planning, Management and

Outcome(s) Echocardiogram Results (Left Ventricle) – Regional Wall Motion Score

Reason for No Coronary Angiography

Echocardiogram (Dyssynchrony) Results Coronary Angiography (Investigation) Echocardiogram Results (Left Ventricle) – End Diastolic Dimension

Reason for No Myocardial Perfusion Imaging

Echocardiogram Results (Left Ventricle) – End Systolic Dimension

Reason for No Referral to Cardiac Rehabilitation

Echocardiogram Results (Significant Valve Disease)

Level of Surgical/Clinical Supervision

Echocardiogram Results (Significant Valve Disease) – Aortic Valve Gradient

Treatment and Intervention(s)

Echocardiogram Results (Significant Valve Disease) – Aortic Valve Gradient Area

Procedure(Clinical Imaging)

Echocardiogram Results (Significant Valve Disease) – Mitral Valve Structure Abnormalities

Care Journey and Encounter

Echocardiogram Results (Significant Valve Disease) – Endocarditic Vegetations

Urgency of Referral

Echocardiogram Results (Significant Valve Disease) – Tricuspid Regurgitation Velocity

Reason for Referral

Referral Type Echocardiogram Results (Significant Valve Disease) – Estimated Peak Pulmonary Artery Pressure Referral Response


11

Echocardiogram Results (Other Abnormalities) Date(s) and Time(s) Medication and Device(s) Date Medication or Device Name Date and Time Medication or Device Code Date of Referral Medication or Device Status Date Referral Received Duration Date First Seen by Associated Professional Medication Dosage Date 1st Appointment Created Route of Administration Dates and Times of Laboratory Processes and

Procedures Risk(s) and Alert(s) Date of Referral for Coronary Angiogram Previous Angina Date of Coronary Angiogram Previous Myocardial Infarction Laboratory Investigation(s) Cerebrovascular Disease Group Name Heart Failure Result (Investigation/Test) Phase 1 Biochemistry

Investigations/Test Hypertension Antimicrobial Agent (Antimicrobial Agent) Diabetes Mellitus Infection Risk Status Peripheral Vascular Disease Laboratory Investigations – Specimen Type Chronic Kidney Disease Micro-organism Detection Result Asthma Micro-organism Name (Micro-organism) Hyperlipidaemia Reason for Investigation/Test Request Previous Coronary Artery Bypass Graft (CABG) Units (Investigation/Test) Previous Percutaneous Coronary Intervention (PCI) Investigation/Test Name (Investigation/Test) Generic Consent Standards


12

Data Standards under Development The following data standards are currently under development and impact on Cardiac Surgery & Percutaneous Cardiac Interventions. Autoglous Red Cells Blood Loss Volume Blood Product(s) Cardiac Output Central Venous Pressure(CVP) Operative Procedure Name Surgical Position of Patient Surgical Approach/Access Type of Diathermy Volume of Autoglous Red Cells Transfused Units of Blood Cross Matched Units of Blood/Blood Products Transfused

Data Standards Currently undergoing Change Control The following data standards have been produced by modifying the existing item that is displayed in the Health and Social Care Data Dictionary. Its adoption will mean that change control is required to the existing items. Please refer to Appendix 4 – Cardiac Surgery & Percutaneous Cardiac Interventions - Proposed Change Control Data Items for a comparison of the existing and proposed data standard. Admission Type {Mental Health} Cardiac Enzymes/Markers Raised Cardiac Surgery Procedure Type Date/Time of Symptom Onset {ACS} Ejection Fraction – Heart Electrocardiography (Ambulatory) Monitoring Results {Electrophysiology} Method of Referral Previous Percutaneous Coronary Intervention (PCI) Referral Source {Generic Referral} Research Status The following Data items are applicable to Cardiac Surgery & Percutaneous Cardiac Interventions but are undergoing change control via the Operating Theatres Phase II Data Standards Development. Anaesthetic and/or Sedation Type Dates and Times of Theatre Processes and Operating Procedures Route of Administration


13

Clinical / Care Process

Assessment(s), Examinations(s) and Investigation(s) Data Item Number Critical Pre-operative state 1.1 Stage of Chronic Kidney Disease 1.2 Suitable for Surgery/Procedure 1.3 Ventilated Pre Op 1.4 Waist-to-Hip Ratio 1.5

1.1 Critical Pre-operative State Definition: The patient’s immediate state in the pre-operative period. Format: Characters Field length: 2 Codes and values: Code Value Explanatory Note 00 Not Critical 01 Critical The patient would be classed as Critical Pre-operative if they have

experienced one or more of the following; ventricular tachycardia, fibrillation, aborted sudden death, pre-operative cardiac massage, pre-operative ventilation before arrival in the anaesthetic room, pre operative inotropic support, intra-aortic balloon counterpulsation or preoperative acute renal failure (anuria or oliguiria <10ml/h).

Related Data Item(s): Aorta Section, Associated Professional Role, Cardiac Procedure Type, Cardiac Surgery Status, Date, Person Birth Date, Diagnosis, Extracardiac Arteriopathy, FEV 1 Less Than 50% Predicted, Intra-aortic balloon pump (IABP) used, Left Ventricular Function, Long Term Use of Corticosteroids or Bronchodilators, Person Current Gender, Post Infract Ventricular Septal Rupture, Pulmonary Artery Systolic Pressure, Suitable for Surgery/Procedure, Thoracic and Vascular Procedures. Further Information: The above Related Data Items may be used to record the information to calculate the Euroscore (European System for Cardiac Operative Risk Evaluation) risk assessment. Further details can be found at www.euroscore.org

http://www.euroscore.org/


14

1.2 Stage of Chronic Kidney Disease Main Source of Standard: Derived from Sign Guideline 103; Diagnosis and Management of Chronic Kidney Disease. Definition: The stage of chronic kidney disease. Format: Characters Field length: 3 Codes and values: Code Value Sub Code Sub Values Explanatory Note 01 Stage 1 Kidney damage with normal or high eGFR

90mL/min or more 02 Stage 2 Kidney damage and mild decrease in eGFR

60-89mL/min or more A Stage 3A Moderate decrease in eGFR 45-59mL/min 03 Stage 3 B Stage 3B Moderate decrease in eGFR 30-44

04 Stage 4 Severe decrease in eGFR 15 to 29mL/min 05 Stage 5 Established Renal Failure(ERF) eGFR less

than 15mL/min Related Data Item(s): Date, Diagnosis, Laboratory Investigations, Renal Replacement Therapy, Renal Replacement Therapy Type. Recording Guidance: It is suggested that the explanatory notes for each value are made visible to system users. 1.3 Suitable for Surgery/Procedure Definition: An indication of whether the patient is deemed clinically suitable for surgery/procedure. Format: Characters Field Length: 2 Codes and Values:

Related Data Item(s): Aorta Section, Associated Professional Role, Cardiac Procedure Type, Cardiac Surgery Status, Critical Pre-Operative State, Date, Person Birth Date, Diagnosis, Extracardiac Arteriopathy, FEV 1 Less Than 50% Predicted, Left Ventricular Function, Long Term Use of Corticosteroids or Bronchodilators, Person Current Gender, Post Infract Ventricular Septal Rupture, Pulmonary Artery Systolic Pressure, Thoracic and Vascular Procedures. Further Information: The above Related Data Items may be used to record the information to calculate the Euroscore (European System for Cardiac Operative Risk Evaluation) risk assessment. Further details can be found at www.euroscore.org.

Code Value 00 Not Suitable 01 Suitable 99 Not Known



15

1.4 Ventilated Pre-op Definition: A record of whether the patient was ventilated pre-operatively. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes 99 Not known

Related Data Item(s): Cardiac Procedure Type, Hospital area. 1.5 Waist-to-Hip Ratio (WHR) Source of Information: Derived from the Centres for Disease Control and Prevention (CDC). Definition: Waist-to-Hip Ratio (WHR) is the ratio of the waist circumference to the hip circumference. Format: Numeric (n.nnn) Field length: 5 Codes and Values: N/A Related Data Item(s): Body Mass Index, Height, Person Current Gender, Weight Further Information: WHR is not intended for children and those individuals who are less than five feet in height or those who have a body mass index (BMI) of 35 or above. Waist Circumference is the distance around the smallest area of the waist, usually just above the belly button Hip Circumference is the distance around the largest area of the hips, usually the widest part of the buttocks.


16

Finding(s) and Result(s) Data Item Number Aorta Pathology 2.1 Cardiogenic Shock Present 2.2 Carotid Bruits Present 2.3 Catheter/Cannula Type 2.4 Coronary Artery Findings at Surgery 2.5 Coronary Artery Findings at PCI 2.6 Device Failure 2.7 Device Failure Reason 2.8 Diffuse Coronary Disease 2.9 Extracardiac Arteriopathy 2.10 FEV1 less than 50% Predicted. 2.11 Gp (Glycoprotein) IIb/IIIA Inhibitor Administered 2.12 Gp (Glycoprotein) IIb/IIIA Inhibitor Reason Administered 2.13 Gp (Glycoprotein) IIb/IIIA Inhibitor Reason Not Administered 2.14 Heart Valve Disease Aetiology 2.15 Heart Valve HaemodynamicDysfunction Type 2.16 Indication for PCI (Percutaneous Coronary Intervention) 2.17 Intra-aortic Balloon Pump (IABP) Reason Used 2.18 Left Ventricular End Diastolic Pressure 2.19 Left Ventricular Function 2.20 Coronary Artery Lesion Type 2.21 Long Term use of Corticosteroids or Bronchodilators 2.22 Mean Pulmonary Artery Wedge Pressure (PAWP) 2.23 MRSA Screening 2.24 Myocardial Infarction Classification 2.25 Operative Stage 2.26 Post Infarct Ventricular Septal Rupture 2.27 Primary Wound Re-exploration 2.28 Primary Wound Re-exploration Reason 2.29 Pulmonary Artery Systolic Pressure 2.30 Stenosis Diameter Range 2.31 Thrombolysis Treatment Administered 2.32 TIMI (Thrombolysis in Myocardial Infarction) Flow Code 2.33


17

2.1 Aorta Pathology Definition: The type of pathological involvement of the aorta or aortic graft. Format: Characters Field Length: 3 Codes and Values: Code Value Sub Codes Sub Values 01 Aneurysm 02 Syphilis 03 Dissection 04 Transection 05 Coarctation 06 Atheroma 07 Marfan’s Syndrome 08 Mycosis 09 Congenital

A Native infection 10

Infection B Graft infection

11 Other Connective Tissue Disorder

98 Other (specify) 99 Not Known

Related Data Item(s): Aorta Procedure, Aorta Section, Cardiac Procedure Type, Cardiac Valve Procedure. Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field. 2.2 Cardiogenic Shock Present Definition: A record of whether the patient has evidence of tissue hypoperfusion in the context of elevated left ventricular filling pressure. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes 99 Not Known

Related Data Item(s): Catheter/Cannula Type, Diastolic Blood Pressure, Left Ventricular End Diastolic Pressure, Operative Stage, Systolic Blood Pressure.


18

2.3 Carotid Bruits Present Definition: A record of the presence of carotid bruits on auscultation. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes 99 Not Known

2.4 Catheter/Cannula Type(s) Definition: The type(s) of catheter/cannula used. Format: Characters Field length: 2 Codes and Values: Code Value Explanatory note 01 Pulmonary Artery Flotation Catheter Swan Ganz 02 Central Venous Catheter Central Venous Line 03 Epidural Catheter 04 Urinary Catheter 05 Radial Artery Cannula Arterial Line 06 Peripheral Venous Cannula 98 Other(specify) 99 Not Known

Related Data Item(s): Anatomical Site, Associated Professional Role, Cardiac Procedure Type Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field


19

2.5 Coronary Artery Finding(s) at Surgery Definition: The visual finding(s) of the state of the coronary artery at the site of the arteriotomy. Format: Characters Field length: 2 Codes and values: Code Value 01 Calcified 02 Atheromatous 03 Dissected 04 Normal appearance 05 Thrombus 98 Other (specify) 99 Not Known

Related Data Item(s): Diagnosis, Proximal Vascular Anastomoses, Vascular Anastomosis Type. Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field. 2.6 Coronary Artery Finding(s) at PCI Definiton: The state of the lesion undergoing PCI Format: Characters Field length: 3 Codes and values: Code Value Sub Code Sub Value

A Mild B Moderate

01 Calcium Present

C Severe A Grade A B Grade B C Grade C D Grade D

02 Dissected

E Grade E 03 Thrombus 98 Other (specify) 99 Not Known

Related Data Item(s): Diagnosis. Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field.


20

2.7 Device Failure Definition: A record of whether the device failed. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes 99 Not Known

Related data item(s): Device failure Reason. 2.8 Device Failure Reason Common Name: Reason for Device Failure Definition: The reason for the device failure. Format: Characters Field length: 2 Codes and Values: Code Value 01 Iatrogenic 02 Intrinsic 99 Not Known

Attributes: Definite Probable Related data item(s): Device failure.


21

2.9 Diffuse Coronary Disease Definition: A record of whether disease is present proximal to and distal to the site of the procedure. Format: Characters Field length: 2 Codes and values:

Related Data Items: Coronary Artery Findings at Surgery, Coronary Artery Findings at PCI (Percutaneous Coronary Interventions). 2.10 Extracardiac Arteriopathy Definition: A record of evidence of arterial disease outwith the coronary circulation. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes 99 Not Known

Related Data Item(s): Aorta Section, Associated Professional Role, Cardiac Procedure Type, Cardiac Surgery Status, Critical Pre-Operative State, Date, Person Birth Date, Diagnosis, FEV 1 Less Than 50% Predicted, Left Ventricular Function, Long Term Use of Corticosteroids or Bronchodilators, Person Current Gender, Post Infract Ventricular Septal Rupture, Pulmonary Artery Systolic Pressure, Suitable for Surgery/Procedure, Thoracic and Vascular Procedures. Further Information: The above Related Data Items may be used to record the information to calculate the Euroscore (European System for Cardiac Operative Risk Evaluation) risk assessment. Further details can be found at www.euroscore.org

Code Value 00 No 01 Yes 99 Not known



22

2.11 FEV1 Less Than 50% Predicted Definition: A record of whether FEV1 is less than 50% predicted Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes 99 Not Known

Related Data Item(s): Aorta Section, Associated Professional Role, Person Birth Date, Cardiac Procedure Type, Cardiac Surgery Status, Critical Pre-Operative State, Date, Diagnosis, Left Ventricular Function, Long Term Use of Corticosteroids or Bronchodilators, Person Current Gender, Pulmonary Artery Systolic Pressure, Post Infract Ventricular Septal Rupture, Pulmonary Function Test, Pulmonary Function Test Result, Suitable for Surgery/Procedure, Thoracic and Vascular Procedures. Further Information: The above Related Data Items may be used to record the information to calculate the Euroscore(European System for Cardiac Operative Risk Evaluation) risk assessment. Further details can be found at www.euroscore.org 2.12 Gp (Glycoprotein) IIb/IIIA Inhibitor Administered Definition: A record of whether Gp (Glycoprotein) IIb/IIIA Inhibitor was administered. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes 99 Not Known

Related data item(s): Gp (Glycoprotein) IIb/IIIA Inhibitor Reason Administered, Gp (Glycoprotein) IIb/IIIA Inhibitor Reason not Administered.



23

2.13 Gp (Glycoprotein) IIb/IIIA Inhibitor Reason Administered Definition: The reason why Gp (Glycoprotein) IIb/IIIA Inhibitor was administered. Format: Characters Field length: 2 Codes and values: Code Value Explanatory Note 01 High Risk Clinical Presentation e.g. ACS 02 High Risk procedure e.g. Multiple stents deployed, bifurcation

stenting, LMS stenting 03 Unsatisfactory angiographic

appearance Intra-coronary thrombus/ <TIMI III flow in target vessel

98 Other(Specify) 99 Not Known

Related data item(s): Gp (Glycoprotein) IIb/IIIA Inhibitor Administered. Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field. 2.14 Gp (Glycoprotein) IIb/IIIA Inhibitor Reason Not Administered Definition: The reason why Gp (Glycoprotein) IIb/IIIA Inhibitor was not administered. Format: Characters Field length: 2 Codes and values: Code Value Sub Code Sub Value Explanatory Note 01 Good result in low risk

patient

02 Recent Lysis (<24hrs) Recent thrombolysis (within 24 hours)

A Recent Bleed B Thrombocytopenia C Coagulopathy

03 Haematological contraindication

Z Other 04 Previous adverse

reaction


Related data item(s): Gp (Glycoprotein) IIb/IIIA Inhibitor Administered. Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field.


24

2.15 Heart Valve Disease Aetiology Definition: The cause of native or prosthetic valve failure. Format: Characters Field Length: 3 Codes and Values: Code Value Sub

Code Sub Values

01 Congenital 02 Degenerative

A Active Endocarditis B Previous Endocarditis

03 Infection

Z Other 04 Rheumatic 05 Annuloaortic Ectasia 06 Calcific Degeneration 07 Ischaemic 08 Functional

Regurgitation

09 Thrombosis 10 Dehiscence 11 Embolism 12 Intrinsic Valve Failure 13 Haemolysis 98 Other(specify) 99 Not Known

Related Data Item(s): Cardiac Procedure Type, Heart Valve(s), Valve Type. Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field. 2.16 Heart Valve Haemodynamic Dysfunction Type Definition: A record of the type of haemodynamic dysfunction of the heart valve. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No Dysfunction 01 Stenosis 02 Regurgitation 03 Mixed 99 Not Known

Related Data Item(s): Heart Valve(s), Pulmonary Artery Wedge Pressure (PAWP). Recording guidance: IT Systems should allow for multiple recordings.


25

2.17 Indication for PCI (Percutaneous Coronary Intervention) Main Source of Standard: Derived from BCIS (British Cardiovascular Intervention Society) Definition: The indication for PCI (Percutaneous Coronary Intervention). Format: Characters Field length: 3 Codes and values: Code Value Sub

code Sub Value Explanatory Notes

A Unstable Angina B Non ST elevation

myocardial infarction

01 Acute Coronary Syndrome

C ST segment elevation myocardial infarction

02 Stable Angina Stable patients with symptomatic or silent ischaemia.

03 Stable coronary /LV anatomy

Stable patients without angina because PCI believed to offer prognostic benefit or would improve ventricular function to include PCI for arrhythmia.

98 Other(specify) 99 Not Known

Related Data Item(s): Chest Pain Aetiology, Echocardiogram Results, Electrocardiography (Investigation), Electrocardiography Lead (12 Lead), Nature of Cardiac Diagnostic Procedure, Nature of PCI (Percutaneous Coronary Intervention) Procedure. Recording guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field. 2.18 Intra-aortic Balloon Pump (IABP) Reason Used Definition: Reason for use of intra-aortic balloon pump. Format: Characters Field length: 2 Codes and values: Code Value 01 Haemodynamic Instability 02 Unstable angina 03 Cardiopulmonary Bypass Wean 04 Prophylactic 98 Other(specify) 99 Not Known


26

Related Data Item(s): Cardiopulmonary Bypass Used, Chest Pain Aetiology, Chest Pain/Discomfort Characteristics, Echocardiogram Results (Left Ventricle) Ejection Fraction (Heart), Electrocardiography (Investigation), Heart Rate, Intra-aortic balloon pump (IABP) used, Mean Pulmonary Artery Wedge Pressure, Operative Stage. Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field. 2.19 Left Ventricular End Diastolic Pressure Definition: A record of the left ventricular end diastolic pressure as measured in millimetres of mercury. Format: Numeric (nnn) Field length: 3 Codes and values: N/A Related Data Item(s): Echocardiography (Investigation), Echocardiogram Investigation Type, Echocardiogram Results.


27

2.20 Left Ventricular Function Definition: The function of the left ventricle based on ejection fraction. Format: Characters Field length: 2 Codes and values: Code Value Explanatory Note 01 Normal LVEF>=50% 02 Moderately Impaired LVEF 30-49% 03 Severely Impaired LVEF <30% 99 Not Known Not Measured

Related Data Item(s): Aorta Section, Associated Professional Role, Cardiac Procedure Type, Cardiac Surgery Status, Critical Pre-Operative State, Date, Person Birth Date, Diagnosis, Echocardiogram Results (Left Ventricle), Ejection Fraction (Heart), Extracardiac Arteriopathy, FEV 1 Less Than 50% Predicted, Intra-aortic balloon pump (IABP) used, Long Term Use of Corticosteroids or Bronchodilators, Magnetic Resonance Imaging Scan (Heart) Abnormal Results, Person Current Gender, Post Infract Ventricular Septal Rupture, Pulmonary Artery Systolic Pressure, Suitable for Surgery/Procedure, Thoracic and Vascular Procedures. Further Information: The above Related Data Items may be used to record the information to calculate the Euroscore (European System for Cardiac Operative Risk Evaluation) risk assessment. Further details can be found at www.euroscore.org



28

2.21 Coronary Artery Lesion Type Definition: The type of coronary lesion. Format: Characters Field length: 2 Codes and values: Code Value Sub Code Sub Value Explanatory Notes 01 Denovo Lesion 02 Re-stenosis of

angioplasty Angioplasty refers to

angioplasty without stent insertion

03 In stent re-stenosis 04 In lesion re-stenosis 05 Chronic Total Occlusion Greater than 3

months 06 Acute Occlusion Less than 3 months 07 Bifurcation lesion

A Angulation of lesion 45-90

B Angulation of coronary lesion greater than 90

C Angulation of artery 45-90

08 Tortuousity

D Angulation of coronary artery greater than 90

09 Plaque Shift 98 Other (specify) 99 Not Known

Related data item(s): Anatomical site, Duration, Stent Type. Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field.


29

2.22 Long Term Use of Corticosteroids or Bronchodilators Definition: A record of whether there is current long term (more than 6 months) use of Corticosteroids or bronchodilators. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes 99 Not Known

Related Data Item(s): Aorta Section, Associated Professional Role, Cardiac Procedure Type, Cardiac Surgery Status, Critical Pre-Operative State, Date, Person Birth Date, Diagnosis, Echocardiogram Results (Left Ventricle), Ejection Fraction (Heart), Extracardiac Arteriopathy, FEV 1 Less Than 50% Predicted, Intra-aortic balloon pump (IABP) used, Left Ventricular Function, Magnetic Resonance Imaging Scan (Heart) Abnormal Results, Person Current Gender, Post Infract Ventricular Septal Rupture, Pulmonary Artery Systolic Pressure, Suitable for Surgery/Procedure, Thoracic and Vascular Procedures. Further Information: The above related data items may be used to record the information to calculate the Euroscore (European System for Cardiac Operative Risk Evaluation) risk assessment. Further details can be found at www.euroscore.org 2.23 Mean Pulmonary Artery Wedge Pressure (PAWP) Definition: A record of the mean pulmonary artery wedge pressure as an estimation of left atrial pressure as measured in millimetres of mercury. Format: Numeric (nnn) Field length: 3 Codes and values: N/A Related Data Item(s): Cardiac Procedure Type, Catheter/Cannula Type.



30

2.24 MRSA Screening

Definition: A record of whether MRSA Screening was undertaken. Format: Characters Field length: 2 Codes and Values: Code Value 00 No 01 Yes 99 Not Known

Related Data Item(s): Anatomical Site, Antimicrobial Agent (antimicrobial Agent), Infection Risk Status, Investigation/Test Name (Investigation/Test), Laboratory Investigations – Specimen Type, Medication or Device Code, Medication or Device Name, Micro-organism detection result, Micro-organism Name (Micro-organism), Reason for Investigation/Test Request, Units (Investigation/Test).


31

2.25 Myocardial Infarction Classification Main source of Item: European Society of Cardiology Classification of Myocardial Infarction. Definition: The type of myocardial infarction. Format: Characters Field length: 2 Codes and values: Code Value Explanatory Note 01 Type 1 Spontaneous Myocardial infarction related to ischaemia due to a primary

coronary event such as plaque erosion and/or rupture, fissuring, or dissection.

02 Type 2 Myocardial Infarction Secondary to ischaemia due to either increased oxygen demand or decreased supply, e.g. coronary artery spasm, coronary embolism, anaemia, arrhythmias, hypertension or hypotension.

03 Type 3 Sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggestive of myocardial ischaemia, accompanied by presumably new ST elevation, or new LBBB, or evidence of fresh thrombosis in a coronary artery by angiography and/or autopsy, but death occurring before blood samples could be obtained, or at a time before the appearance of biomarkers in the blood.

04 Type 4a Myocardial infarction associated with PCI. 05 Type 4b Myocardial infarction associated with stent thrombosis as documented by

angiography or at autopsy. 06 Type 5 Myocardial infarction associated with CABG.

Related Data Item(s): Cardiac Procedure Type, Chest Pain Aetiology, Date/Time of symptom onset, Diagnosis, ECG Determining Reperfusion Treatment, Electrocardiography (Investigation), Electrocardiography Results, Indication for PCI (Percutaneous Coronary Intervention), Nature of Cardiac Diagnostic Procedure, Nature of PCI (Percutaneous Coronary Intervention) Procedure. Recording Guidance: It is suggested that the explanatory notes for each value are made visible to system users. Further Information: Universal Definition of Myocardial Infarction is described in Myocardial infarction redefined: A consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction. Eur Heart J. 2000; 21: 1502–1513; J Am Coll Cardiol. 2000; 36: 959–969


32

2.26 Operative Stage Definition: Indicates the operative stage. Format: Characters Field Length: 3 Codes and values: Code Value Sub

Code Sub Value Explanatory Note

01 Pre operative The period prior to the commencement of a procedure (e.g. Anaesthesia/surgery)

02 Intra operative

The period during the active procedure (e.g. anaesthesia/surgery)

The period following conclusion of the procedure (e.g. anaesthesia/surgery)

A Immediate Post Operative

Within 24 hours of the procedure ending

03 Post operative

B Late Post Operative

The 24 hours following the immediate post op stage


Related Data Item(s): Cardiac Procedure Type. Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field.


33

2.27 Post Infarct Ventricular Septal Rupture Definition: A record of whether the patient had a ventricular septal rupture following myocardial infarction. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes 99 Not Known

Related Data Item(s): Aorta Section, Associated Professional Role, Cardiac Procedure Type, Cardiac Surgery Status, Critical Pre-Operative State, Date, Person Birth Date, Diagnosis, Extracardiac Arteriopathy, FEV 1 Less Than 50% Predicted, Intra-aortic balloon pump (IABP) used, Left Ventricular Function, Long Term Use of Corticosteroids or Bronchodilators, Person Current Gender, Pulmonary Artery Systolic Pressure, Suitable for Surgery/Procedure, Thoracic and Vascular Procedures. Further Information: The above related data items may be used to record the information to calculate the Euroscore (European System for Cardiac Operative Risk Evaluation) risk assessment. Further details can be found at www.euroscore.org 2.28 Primary wound Re-exploration Definition: A record of whether the patient required re-exploration of the primary wound during the same admission. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes 99 Not known

Related Data Item(s): Cardiac Procedure Type, Primary Wound Re-exploration Reason.



34

2.29 Primary Wound Re-exploration Reason Definition: Reason for primary wound re-exploration. Format: Characters Field length: 2 Codes and values: Code Value 01 Bleeding 02 Tamponade 03 Cardiac arrest 04 Valvular problems 05 Graft Problems 98 Other(specify) 99 Not Known

Recording Guidance: IT systems should allow for multiple recordings. Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field. 2.30 Pulmonary Artery Systolic Pressure Definition: A record of the pulmonary artery systolic pressure as measured in millimetres of mercury. Format: Numeric (nnn) Field length: 3 Codes and values: N/A Related data item(s): Echocardiogram Results, Echocardiography (Investigation). 2.31 Stenosis Diameter Range Definition: The percentage (%) range of Stenosis present in an artery or branch. Format: Characters Field length: 2 Codes and values: Code Value 01 0% 02 1-49% 03 50-74% 04 75-94% 05 95-99% 06 100% 99 Not Known


35

Related Data Item(s): Anatomical Site, Operative Stage, TIMI (Thrombolysis in Myocardial Infarction) Flow Code. 2.32 Thrombolysis Treatment Administered Definition: A record of whether the patient received thrombolytic treatment. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes 99 Not known

Related data item(s): Date and Time, Medication Dosage, Medication or Device Code, Medication or Device Name, Route of Administration. Recording Guidance: IT systems should flag if thrombolytic treatment has been given less than 30 days prior. 2.33 TIMI (Thrombolysis in Myocardial Infarction) Flow Code Definition: A record of coronary blood flow in the artery relevant to the infarct. Format: Characters Field length: 2 Codes and values: Code Value Explanatory Notes 00 TIMI 0 No flow down vessel 01 TIMI 1 Some flow down vessel but does not reach distally by end of a normal

angiographic run 02 TIMI 2 Flow reaches distal vessel by end of a normal angiographic run but flow is

much slower than normal 03 TIMI 3 Normal flow 99 Not known

Related data item(s): Anatomical Site, Nature of Cardiac Diagnostic Procedure, Stenosis Diameter Range. Further Information: The TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) Trial: Phase I findings. N Engl J Med 1985;312:932-936.


36

Care Planning, Management and Outcome(s) Data Item Number Chest Drains Total Number 3.1 Drainage Output 3.2 Cardiac Surgical Cover 3.3

3.1 Chest Drains Total Number

Definition: The total number of chest drains inserted. Format: Numeric (nn) Field length: 2 Codes and Values: N/A Related Data Item(s): Anatomical Site, Date and Time. 3.2 Drainage Output

Definition: Total drainage in millilitres from drainage tubes. Format: Numeric (nnnn) Field length: 4 Codes and Values: N/A Related Data Item(s): Anatomical Site, Cardiac Procedure Type, Chest Drains Total Number, Date and Time, Hospital area. Recording Guidance: IT systems should allow for multiple recordings.


37

3.3 Cardiac Surgical Cover Definition: The type of cardiac surgical cover available. Format: Characters Field length: 3 Codes and values: Code Value Sub Codes Sub Values Explanatory Note 00 None No cover required 01 Off Site Cover from a hospital

performing Cardiac Surgery

A Informal On Site Surgeon unaware of intended procedure

02 On Site

B Formal On Site Surgeon aware of intended procedure

99 Not Known Related data item(s): Associated Professional, Associated Professional Identifier, Associated Professional Role, Location Code.


38

Treatment(s) and Intervention(s) Data Item Number Aorta Procedure 4.1 Aorta Section 4.2 Aortic Clamp Type 4.3 Aortic Clamp Used 4.4 Atrial Ablation Lesion Set 4.5 Blood Conservation Method 4.6 Cardiac Surgery Incision Site 4.7 Cardiac Valve Procedure 4.8 Cardiac Valve(s) Replaced/Repaired Total Number 4.9 Cardioplegia Infusion Method 4.10 Cardioplegia Solution Used 4.11 Cardioplegia Temperature 4.12 Cardiopulmonary Bypass Conversion 4.13 Cardiopulmonary Bypass Used 4.14 Circulatory Support Used 4.15 Conduit Anastomotic Device Used 4.16 Coronary Shunt Size 4.17 Coronary Shunt Used 4.18 Coronary Stabiliser Type 4.19 Coronary Stabiliser Used 4.20 CPB (Cardiopulmonary Bypass) Arterial Cannulation Site 4.21 CPB (Cardiopulmonary Bypass) Venous Cannulation Site 4.22 Follow on PCI (Percutaneous Coronary Intervention) Procedure 4.23 Graft Conduit 4.24 Haemostatic Method 4.25 Heart Valve(s) 4.26 Intra-aortic Balloon Pump (IABP) Used 4.27 Left Main Stem Protected 4.28 Myocardial Protection - Predominant Method 4.29 Nature of Cardiac Diagnostic Procedure 4.30 Nature of PCI (Percutaneous Coronary Intervention) Procedure 4.31 Non Cardioplegic Myocardial Protection Method 4.32 PCI (Percutaneous Coronary Intervention) Adjunctive Device(s) 4.33 Proximal Vascular Anastomoses Site 4.34 Renal Replacement Therapy 4.35 Renal Replacement Therapy Type 4.36 Simultaneous Procedure 4.37 Stent Type 4.38 Thoracic and Vascular Procedure 4.39 Valve Type 4.40 Vascular Anastomosis Type 4.41


39

4.1 Aorta Procedure Definition: The type of procedure carried out on the aorta. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Interposition tube graft 02 Tube graft + separate Aortic Valve Replacement (AVR) 03 Root replacement with composite valve graft and coronary re-implantation 04 Root replacement with preservation of native valve and coronary re-implantation 05 Homograft root replacement 06 Autograft root replacement (Ross Procedure) 07 Aortic patch graft 08 Sinus of Valsalva repair 09 Reduction aortoplasty 98 Other (specify) 99 Not Known

Related Data Item(s): Aorta Section, Aorta Pathology, Cardiac Procedure Type. Recording guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field. 4.2 Aorta Section Definition: The section of the aorta involved. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Root 02 Ascending 03 Arch 04 Descending 05 Abdominal 99 Not Known

Related Data Items: Aorta Pathology, Aorta Procedure, Cardiac Procedure Type, Thoracic and Vascular Procedure. Recording guidance: IT systems should allow for multiple recordings.


40

4.3 Aortic Clamp Type

Definition: The type of aortic clamp. Format: Characters Field length: 2 Codes and Values: Code Value 01 Vascular Clamp 02 Endoclamp 03 Transthoracic 98 Other (specify) 99 Not Known

Related Data Item(s): Aortic Clamp Used. Recording guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field. 4.4 Aortic Clamp Used Definition: A record of whether an aortic clamp was used. Format: Characters Field length: 2 Codes and Values:

Related Data Item(s): Aorta Section, Cardiac Surgery Incision Site, Cardiac Procedure Type, Date and Time, Echocardiography (Investigation) Echocardiogram Investigation Type Recording Guidance: IT systems should allow for multiple recordings.



41

4.5 Atrial Ablation Lesion Set Definition: A record of the atrial ablation lesion set. Format: Characters Field length: 2 Codes and Values: Code Value 01 Pulmonary Vein Isolation Lesion 02 Superior Pulmonary Vein Connecting Lesion 03 Inferior Pulmonary Vein Connecting Lesion 04 Atrial Appendage Connecting Lesion 05 Mitral Valve Lesion 06 Full Atrial Lesion Set including lesions to Tricuspid valve 07 Partial Atrial Lesion Set 98 Other(specify) 99 Not Known

Attributes: Left Right Related Data Item(s): Ablation Attempt, Ablation Energy Source, Ablation (Technical Success), Anatomical Site, Diagnosis. Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field. 4.6 Blood Conservation Method Definition: The method used for blood conservation Format: Characters Field length: 3 Codes and values: Code Values Sub Codes Sub Values

A Serine protease inhibitor 01 Drugs B Anti-fibrinolytics A Auto Transfusion B Pre Donation

02 Mechanical

C Cell Saver 98 Other(specify) 99 Not Known

Related Data Item(s): Blood Product(s), Medication or Device Name, Medication Dosage, Medication or Device Code, Route of Administration. Recording guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field.


42

4.7 Cardiac Surgery Incision Site Definition: A record of the site of the incision. Format: Characters Field length: 3 Codes and values: Code Value Sub Code Sub Value

A Median Sternotomy B Transverse Sternotomy

01 Sternotomy

C Hemi Sternotomy A Anterolateral Thoracotmy 02 Thoracotomy B Posterolateral Thoracotomy

03 Port-access 04 Laparotomy 98 Other(specify) 99 Not Known

Attributes: Incision: First Time Re-do Laterality: Left Right Related Data Item(s): Anatomical Site, Cardiac Procedure Type. Recording guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field.


43

4.8 Cardiac Valve Procedure Definition: A description of the type of procedure performed on the cardiac valve. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Replacement 02 Repair 03 Inspection 98 Other (specify) 99 Not Known

Related data item(s): Cardiac Procedure Type, Cardiac Valves Replaced/Repaired Total Number, Heart Valve(s), Heart Valve Disease Aetiology, Valve Type. Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field. 4.9 Cardiac Valve(s) replaced/repaired Total Number Common Name: Total number of cardiac valve(s) replaced/repaired. Definition: The number of Cardiac valves replaced or repaired. Format: Numeric (nnn) Field Length: 3 Codes and values: N/A Related data item(s): Cardiac Valve Procedure.


44

4.10 Cardioplegia Infusion Method Definition: The method by which the cardioplegia solution was infused. Format: Characters Field length: 2 Codes and values: Code Value 01 Antegrade 02 Retrograde 03 Antegrade and Retrograde 96 Not applicable

Attributes: Intermittent Continuous Related data item(s): Cardiopulmonary Bypass used, Cardioplegia Solution Used, Cardioplegia temperature, Myocardial Protection – Predominant Method. 4.11 Cardioplegia Solution Used Definition: The solution used to achieve myocardial preservation. Format: Characters Field length: 2 Codes and values: Code Value 01 Blood 02 Crystalloid 96 Not applicable

Related data item(s): Cardiopulmonary Bypass used, Cardioplegia Temperature, Cardioplegia Infusion Method, Myocardial Protection – Predominant Method.


45

4.12 Cardioplegia Temperature Definition: The temperature of cardioplegia solution used to achieve myocardial preservation. Format: Characters Field length: 2 Codes and values: Code Value Explanatory Note 01 Cold <15°C 02 Tepid 15 - 32°C 03 Warm > 32 °C 96 Not applicable

Related data item(s): Cardiopulmonary Bypass Used, Cardioplegia Solution Used, Cardioplegia Infusion Method, Myocardial Protection – Predominant Method. 4.13 Cardiopulmonary Bypass Conversion Definition: A record of whether it was necessary to convert to cardiopulmonary bypass during the procedure. Format: Characters Field length: 2 Codes and values:

Related Data Item(s): Cardiopulmonary Bypass Used, Dates and Times of Theatre Processes and Operative Procedures 4.14 Cardiopulmonary Bypass Used

Definition: A record of whether cardiopulmonary bypass was used. Format: Characters Field length: 2 Codes and values:




46

Related Data Item(s): Cardiopulmonary Bypass Conversion, CPB (Cardiopulmonary Bypass) Arterial Cannulation Site, CPB(Cardiopulmonary Bypass) Venous Cannulation Site, Date and Time, Dates and Times of Theatre Processes and Operative Procedures. 4.15 Circulatory Support Used Definition: The type of circulatory support used. Format: Characters Field length: 3 Codes and values: Code Value Sub Codes Sub Values 00 None 01 Intra-aortic balloon pump (IABP)

02 Cardiopulmonary Bypass Support (CPS)

03 Ventricular Assist Device (VAD) 04 Inotropes

A Transvenous Temporary Pacing 05 Temporary Pacing B External Temporary Pacing A Non Mechanical (External) 06 External cardiac massage B Mechanical


Related Data Item(s): Intra-aortic balloon pump (IABP) used, Intra-aortic balloon pump (IABP) Reason Used, Operative Stage, Procedure Status. Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field. 4.16 Conduit Anastomotic Device Used

Definition: A record of whether an anastomotic device was used. Format: Characters Field length: 2 Codes and values:

Related Data Item(s): Cardiac Procedure Type, Coronary Shunt Used, Graft Conduit, Proximal Vascular Anastomoses, Vascular Anastaomosis Type. Recording Guidance: IT Systems should allow for multiple recordings.



47

4.17 Coronary Shunt Size Definition: The size of the coronary shunt used as measured in mm. Format: Numeric (n.nn) Field length: 4 Codes and Values: N/A Related Data Item(s): Coronary Shunt Used Recording Guidance: IT Systems should allow for multiple recordings. 4.18 Coronary Shunt Used Definition: A record of whether a coronary shunt was used. Format: Characters Field length: 2 Codes and values:

Related Data Item(s): Anatomical Site, Cardiac Procedure Size, Conduit Anastomotic Device Used, Coronary Shunt Size, Proximal Vascular Anastomoses. 4.19 Coronary Stabiliser Type

Definition: The type of coronary stabiliser used. Format: Characters Field length: 2 Codes and Values: Code Value 01 Octopus 02 Guidant 98 Other(specify)99 Not Known

Related Data Item(s): Coronary Stabiliser Used



48

Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field. 4.20 Coronary Stabiliser Used

Definition: A record of whether coronary stabiliser was used. Format: Characters Field length: 2 Codes and Values:

Related Data Item(s): Cardiac Procedure Type, Coronary Stabiliser Type. 4.21 CPB (Cardiopulmonary Bypass) Arterial Cannulation Site Definition: The site of return to the body of oxygenated blood from the cardiopulmonary bypass circuit. Format: Characters Field length: 2 Codes and values: Code Value 01 Ascending aorta 02 Femoral artery 03 Subclavian artery 04 Axillary artery 05 Carotid artery 06 Descending aorta 07 Left ventricle 98 Other(specify) 99 Not Known

Attributes: Left Right Related Data Item(s): Cardiopulmonary Bypass Conversion, Cardiopulmonary Bypass Used. Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field.



49

4.22 CPB (Cardiopulmonary Bypass) Venous Cannulation Site

Definition: The site of return of blood from the body to the cardiopulmonary bypass circuit. Format: Characters Field length: 2 Codes and values: Code Value 01 Atrium 02 Femoral Vein 03 Internal Jugular Vein 04 Superior vena cava 05 Inferior vena cava 98 Other (specify) 99 Not Known

Attributes: Left Right Related Data Item(s): Cardiopulmonary Bypass Conversion, Cardiopulmonary Bypass Used. Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field. 4.23 Follow on PCI (Percutaneous Coronary Intervention) Procedure Definition: A record of whether PCI (Percutaneous Coronary Intervention) was undertaken following a planned diagnostic angiogram. Format: Characters Field length: 2 Codes and values:

Related data item(s): Cardiac Procedure Type, Coronary Angiography (Investigation), PCI (Percutaneous Coronary Intervention) Adjunctive Device(s)



50

4.24 Graft Conduit Definition: A description of the type of graft conduit used. Format: Characters Field Length: 2 Codes and values: Code Value 01 Pedicle Internal Mammary Artery 02 Pedicle Gastroepiploic Artery 03 Free Internal Mammary Artery 04 Free Gastroepiploic Artery 05 Radial artery 06 Long Saphenous Vein 07 Short Saphenous Vein 08 Cephalic vein 98 Other (specify) 99 Not Known

Attributes: Laterality Right Left Bilateral Related Data Item(s): Anatomical Site, Cardiac Procedure Type, Conduit Anastomotic Device Used, Procedure Status, Proximal Vascular Anastomoses, Vascular Anastomosis Type. Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field.


51

4.25 Haemostatic Method Common Name: Arterial Access Site Management Definition: A record of the method used to achieve haemostasis at the site of arterial access. Format: Characters Field length: 3 Codes and values: Code Value Sub Codes Sub Values Explanatory Notes 01 Manual pressure

A Angioseal B Vasoseal C Perclose D Starclose

02 Invasive

Z Other A Duett B Radistop C TR Band D Femstop

03 External

Z Other 04 Direct suture Open repair of arteriotomy 98 Other (specify) Unlisted Related Data Item(s): Anatomical Site Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field. 4.26 Heart Valve(s) Definition: A record of the type of heart valve(s). Format: Characters Field Length: 2 Codes and Values: Code Value 01 Aortic 02 Mitral 03 Tricuspid 04 Pulmonary 99 Not Known

Recording Guidance: IT systems should allow for multiple recordings.


52

4.27 Intra-aortic balloon pump (IABP) Used Definition: A record of whether an intra-aortic balloon pump was used. Format: Characters Field length: 2 Codes and values:

Related Data Item(s): Intra-aortic balloon pump (IABP) Reason used, Operative Stage. 4.28 Left Main Stem Protected Definition: A record of whether the left main stem was protected. Format: Characters Field length: 2 Codes and values:

Related data item(s): PCI (Percutaneous Coronary Intervention) Adjunctive Device(s) 4.29 Myocardial Protection - Predominant Method Common Name: Predominant Method of Myocardial Protection. Definition: The predominant method of myocardial preservation during the procedure. Format: Characters Field length: 2 Codes and values: Code Value 01 Non-cardioplegic 02 Cardioplegia

Related data item(s): Cardioplegia Infusion Method, Cardioplegia Solution Used, Cardioplegia Temperature.




53

4.30 Nature of Cardiac Diagnostic Procedure Definition: The nature of the cardiac diagnostic procedure. Format: Characters Field length: 2 Codes and values: Code Value 01 Coronary Angiography 02 Left ventricular Angiography 03 Graft Angiography 04 Aortogram 05 Right Heart Catheterisation 06 Measurement of Arterial Venous Oxygen Concentration 07 Endomyocardial Biopsy 98 Other(specify) 99 Not Known

Attributes: Planned Indicated Performed Related Data Item(s): Anatomical Site, Nature of PCI (Percutaneous Coronary Intervention) Procedure. Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field.


54

4.31 Nature of PCI (Percutaneous Coronary Intervention) Procedure Definition: The nature of the PCI (Percutaneous Coronary Intervention) Procedure. Format: Characters Field length: 3 Codes and values: Code Value Sub

Code Sub Value

01 Elective – Chronic Stable Angina

02 PCI for Acute Coronary Syndrome /Non ST Elevation MI

A Primary B Rescue C Re-Infarction

03 PCI for STEMI

D Post-infarction 04 Hybrid 98 Other(specify) 99 Not Known

Related Data Item(s): Indication for PCI (Percutaneous Coronary Intervention) Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field. 4.32 Non Cardioplegic Myocardial Protection Method Definition: The predominant method of non cardioplegic myocardial preservation used. Format: Characters Field length: 2 Codes and values: Code Value 01 Aortic Cross Clamping with fibrillation 02 Fibrillation with perfusion 03 Cross clamp with direct coronary perfusion 04 Cross clamp and beating heart 05 Beating heart without cross clamp 96 Not applicable 98 Other(specify) 99 Not Known

Related data item(s): Aortic Clamp Used, Aortic Clamp Type, Dates and Times of Theatre Processes and Operative Procedures. Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field.


55

4.33 PCI (Percutaneous Coronary Intervention) Adjunctive Device(s) Definition: A record of the device used during PCI (Percutaneous Coronary Intervention). Format: Characters Field length: 3 Codes and values: Code Value Sub Code Sub Value Explanatory Notes 01 Angioscope

A Diver B Export C Pronto D Rescue Rescue Device E X-Sizer Thrombectomy Device F Angiojet Possis Angiojet G Acolysis

02 Thrombosuction Catheter

Z Other 03 Cutting Balloon 04 Directional Atherectomy

A Filter Wire B Spider C Emboshield D Cardioshield E Angioguard

05 Distal Embolic Protection

Z Other A Proxis 06 Proximal Embolic

Protection Z Other 07 Flow Wire

A Guidant Galileo B Novoste

Betacath

08 Brachytherapy

Z Other 09 Intracoronary Drug

Delivery Device Other than via stent

10 Intramycardial Injection 11 IVUS Intravascular ultrasound 12 Laser Angioplasty Device 13 OCT Optical coherence tomography 14 Pressure Wire 15 Rotational Atherectomy

16 Tornus Catheter 98 Other(specify) 99 Not Known Unlisted

Related data item(s): Cardiac Procedure Type, Date and time of First PCI Device, Intervention Site, Procedure Status, Stenosis Diameter, Valve Type. Recording Guidance: IT Systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field.


56

4.34 Proximal Vascular Anastomoses Site Definition: The site of the proximal connection of the conduit. Format: Characters Field length: 2 Codes and values: Code Value Explanatory Note 01 Aorta 02 Left Internal Mammary Artery (LIMA) 03 Right Internal Mammary Artery

(RIMA)

04 Saphenous Vein 96 Not Applicable No Proximal Anastomosis e.g. Pedicle

Mammary Graft 98 Other(specify) 99 Not Known

Related Data Item(s): Cardiac Incision Type, Cardiac Procedure Type, Coronary Artery Findings, Conduit Anastamotic Device, Graft Conduit, Vascular Anastomsois Type. Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field. 4.35 Renal Replacement Therapy Definition: A record of whether the patient is receiving renal replacement therapy. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes 99 Not Known

Related Data Item(s): Date, Dates and Times of Theatre Processes and Operative Procedures, Operative Stage, Renal Replacement Therapy Type, Stage of Chronic Kidney Disease.


57

4.36 Renal Replacement Therapy Type Definition: A record of the type of renal replacement therapy. Format: Characters Field length: 3 Codes and values: Code Value Sub

Code Sub Value

01 Haemodialysis A Venovenous 02 Haemofiltration B Arteriovenous

03 Haemodiafiltration A Continuous Ambulatory Peritoneal

dialysis (CAPD) 04 Peritoneal dialysis

B Automated Peritoneal Dialysis (APD)

05 Renal transplantation 99 Not Known

Related Data Item(s): Renal Replacement Therapy 4.37 Simultaneous Procedure Definition: A record of whether another procedure was carried out at the same time as the planned procedure. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes 99 Not Known

Related Data Item: Cardiac Procedure Type, Thoracic and Vascular Procedures.


58

4.38 Stent Type

Definition: Type of stent implanted. Format: Characters Field length: 2 Codes and values: Code Value 00 None 01 Bare Metal Stent 02 Drug Eluting Stent 03 Biodegradable Stent 04 Covered Stent 98 Other (specify) 99 Not Known

Related data item(s): Anatomical Site, Medication and Device name. Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field. This may be linked to the specific manufacturer/device code. 4.39 Thoracic and Vascular Procedure Definition: The type of thoracic or vascular procedure. Format: Characters Field length: 2 Codes and values: Code Value 01 Aortic 02 Peripheral Vascular 03 Carotid Endarterectomy 98 Other(specify) 99 Not Known

Attributes: Planned Indicated Performed Related Data Item(s): Cardiac Procedure Type, Simultaneous Procedure. Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field.


59

4.40 Valve Type Definition: The type of valve(s). Format: Characters Field Length: 2 Codes and Values: Code Value 01 Native 02 Mechanical 03 Biological 04 Homograft 05 Autograft 06 Ring 98 Other(specify) 99 Not Known

Attributes: Implanted Explanted Related Data Item(s): Cardiac Valve procedure, Heart Valve(s), PCI (Percutaneous Coronary Intervention) Adjunctive Device(s). Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field. This may be linked to the specific manufacturer/device code/Serial Number. 4.41 Vascular Anastomosis Type Definition: A description of the type of coronary anastomosis performed. Format: Characters Field Length: 2 Codes and values:

Related data item(s): Anatomical Site, Cardiac Procedure Type, Conduit Anastamotic Device, Graft conduit, Proximal Vascular Anastamoses

Recording Guidance: IT systems should allow for multiple recordings Users may wish to augment code 98 – “Other (specify)” with a free text field.

Code Value 01 End-to-side 01 Side-to-side 98 Other(specify) 99 Not known


60

Care Journey and Encounter Data Item Number Cardiac Surgery Status 5.1 Hospital Area 5.2

5.1 Cardiac Surgery Status

Common Name: Procedure Urgency. Definition: The clinical status of the patient at the time of cardiac surgery procedure. Format: Characters Field length: 2 Codes and values:

Related Data Item(s): Cardiac Procedure Type.

Code Values Explanatory Note 01 Elective Routine admission from the waiting list. The procedure can

be deferred without risk 02 Urgent Patients who require intervention or surgery on the current

admission for medical reasons. They cannot be sent home without procedure.

03 Emergency Unscheduled patients with ongoing refractory cardiac compromise. There should be no delay in surgery/intervention irrespective of the time of day, procedure carried out within 24 hours of referral.

04 Salvage Patients requiring resuscitation en-route to the operating theatre or prior to the induction of anaesthesia. Resuscitation following anaesthetic induction should not be included.


61

5.2 Hospital area Common Name: Hospital Department. Definition: The hospital area or department. Format: Characters Field Length: 3 Codes and values:

Related Data Item(s) Specialty. Recording guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field.

Code Values Sub Code Sub Value Explanatory Note 01 A&E 02 Anaesthetic Room 03 Cardiac Catheterisation

Laboratory

04 CCU Coronary Care Unit 05 Day Unit 06 Endoscopy Unit 07 HDU High Dependency Unit 08 Hybrid Laboratory 09 ITU Intensive Care Unit 10 Labour Suite 11 Operating Theatre 12 Outpatient Department 13 Pacemaker Room 14 Post op recovery area Post anaesthesia recovery

unit 15 Pre op assessment area 16 Rehabilitation unit 17 Reception 18 Radiology Department

19 Vascular Laboratory A Single Room 20 Ward B Open Ward

98 Other (Secify) 99 Not Known


62

Date(s) and Time(s) Data Item Number Date and Time to Initial PCI Device 6.1

6.1 Date and Time of Initial PCI (Percutaneous Coronary Intervention) Device Definition: A record of the date and time of first PCI (Percutaneous Coronary Intervention) device Format: Characters (CCYY-MM-DDThh:mm:ssTZD) Field Length: 25 Codes and Values: N/A Attributes: Balloon Inflation Aspiration Device Related Data Item(s): Anatomical Site, Cardiac Procedure Type, Device Failure, PCI (Percutaneous Coronary Intervention) Adjunctive Device(s).


63

Appendix 1 – Cardiac Post Op Complication(s) This Data Standard has been developed by the Cardiac Surgery & Percutaneous Cardiac Interventions Working Group but will not form part of NCDDP Standards or be published within The Health and Social Care Data Dictionary but may be implemented locally if required. Cardiac Post Op Complication(s) Definition: A record of any complications experienced post operatively. Format: Characters Field length: 3 Codes and values: Code Value Sub

Code Sub Value Explanatory Note

00 None 01 Abrupt Closure of

Branch Vessel

02 Abrupt Closure of Major Vessel

03 Acute Renal Failure 04 Adult Respiratory

Distress Syndrome

05 Amputation A Ascending 06 Aortic Dissection B Descending

07 Aortic Regurgitation A VT/VF Ventricular

Tachycardia/Fibrillation 08 Arrest

B PEA Pulseless Electrical Activity 09 Atrial Fibrillation 10 Bleeding peptic

ulceration

11 Brachial Plexus injury 12 Cardiac Arrest 13 Cardioverted

A Bleeding B Dissection

14 Cannulation Complication

Z Other A No residual

defect

B Mild residual defect

15 Cerebral Vascular accident (CVA)

C Severe residual defect

16 Complete Heart Block (CHB)

17 Cholecystitis 18 Coronary Artery

Perforation

19 Death 20 Defibrillated 21 Delayed Sternal


64

Closure 22 Drainage of

Pericardial Effusion

23 Dressler’s Syndrome 24 Deep Vein

Thrombosis (DVT)

25 Emergency CABG 26 Empyema 27 Equipment lost in

body

28 Fasciotomy 29 Femoral artery

embolectomy

30 Femoral Wound infection

31 Foot Drop 32 Haemothorax

requiring drain

33 Hepatic Failure 34 Iatrogenic Aortic

Dissection

35 Ischaemic limb 36 Jaundice 37 Left ventricular Wall

Dissection

38 Low Cardiac Output 39 Low Systemic

Vascular Resistance State

40 Major Bleed Intracranial hemorrhage or a 5 g/dl decrease in the

hemoglobin concentration or a 15% absolute decrease in the hematocrit

41 Mesenteric infarction 42 Minor Bleed

Observed blood loss: 3 g/dl decrease in the hemoglobin concentration or 10% decrease in the hematocrit No observed blood loss: 4 g/dl decrease in the hemoglobin concentration or

12% decrease in the hematocrit

A Cultured 43 MRSA B Infected

44 Multiorgan failure 45 Myocardial Infarction 46 Nasogastric feeding 47 Pancreatitis 48 Paraplegia 49 Paravalve Leak 50 Parenteral feeding 51 Perforated peptic

ulceration

52 Peripheral Neuropathy

53 Permanent


65

Pacemaker A Bypass 54 Peripheral vascular B Intervention A Occlusion B Pseudonuerysm

55 Peripheral Vessel

C Surgical Intervention

56 Postoperative elevated creatinine

57 Pressure Sore 58 Prolonged ileus 59 Prosthetic

Dysfunction

60 Prosthetic Valve Endocarditis

61 Psychosis requiring treatment

62 Pulmonary Embolus 63 Pulmonary Infection 64 Pulmonary Infection

requiring antibiotics

65 Pyrexia of unknown origin

66 Renal Failure A Bleeding B Tamponade C Low Cardiac

Output

67 Reopened

D Requiring CPB (Cardiopulmonary Bypass)

68 Re-ventilated 69 Septicaemia 70 Severe Heart Failure Heart Failure requiring

inotropic support. 71 Severe Pulmonary

Oedema Pulmonary Oedema

requiring ventilation, CPAP(continuous positive airway pressure) or inotropes in addition to diuretics.

72 Supraventricular Tachycardia (SVT)

73 Tamponade 74 Temporary

Pacemaker

A Open B Mini

75 Tracheostomy

C Percutaneous 76 Transient ischaemic

attack (TIA)

77 Urinary Retention 78 Urinary tract Infection 79 Ventricular Fibrillation 80 Ventricular

Tachycardia(VT)

81 Wound dehiscence 82 Wound infection


66

83 Wound leak 84 Wound Resuturing 98 Other(specify) 99 Not Known

Attributes: Deep Superficial Acute Chronic Recording Guidance: IT systems should allow for multiple recordings. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings. Related Data Item: Anatomical Site, Symptom Severity Level Symptom, Myocardial Infarction Classification Further Information: Postoperative complications can be classified in many ways, but the timing of onset or recognition is among the most useful classification systems. Short-term complications are those that are recognized almost immediately following the procedure, occurring within hours to up to thirty days following the procedure.


67

Appendix 2- Working Group Membership of the Cardiac Surgery & Percutaneous Cardiac Interventions Working Group Name Position Organisation Geoff Berg (Chair) Consultant Cardiac Surgeon NHS Greater Glasgow &

Clyde Ian W Colquhoun Consultant Cardiothoracic

Surgeon NHS Greater Glasgow & Clyde

John Irving Consultant Interventional Cardiologist

NHS Tayside

Robert R Jeffrey Consultant Cardiothoracic Surgeon

NHS Grampian

Mitchell Lindsay Consultant Cardiologist NHS Greater Glasgow & Clyde

Gerry Newlands IM&T Project Lead GJNH NHS Scotland Professor Jill Pell Henry Mechan Chair in Public

Health Caledonian University

James Spratt Consultant Interventional Cardiologist

NHS Forth Valley/Lothian

Vipin Zamvar Consultant Cardiothoracic Surgeon

NHS Lothian

Adam Redpath Programme Principal Coronary Heart Disease (CHD) and Stroke Programme

NHS National Services Scotland ISD

Jim Christie Clinical Physicist NHS Greater Glasgow & Clyde

Leigh Brown Information Manager, NCDDP NHS National Services Scotland ISD

Victoria Hunter Data and Terminology Developer, NCDDP


Mary McKinney Data and Terminology Developer, NCDDP



68

Appendix 3- Consultation Distribution List Chief Executives Medical Directors Directors of Public Health Chief Medical Officer Chief Nursing Officer National Advisory Committees Managed Clinical Networks (MCNs) NCDDP Stakeholders • Clinical eHealth Leads • Community Nursing Network (CNN) • Electronic Clinical Communications Implementation (ECCI) • Health & Social Care Information Centre, Datasets Development Programme (England) • Improving Mental Health Information Programme • Information Services Division, NSS • Information Standards Group • National Resource Centre for Ethnic Minority Health • NHS Education for Scotland • NHS Health Scotland • NHS Quality Improvement Scotland (QIS) • NHS24 • NMAHP e-Health Leads • Open Scotland Information Age Framework (OSIAF) • Royal College of General Practitioners (Scotland) • Royal College of Nursing (Scotland) • Royal College of Physicians, Edinburgh • Royal College of Physicians, London • Royal College of Physicians and Surgeons Glasgow • Royal College of Surgeons, Edinburgh • Royal College of Surgeons, England • Royal College of Psychiatrists • Scottish Clinical Information Management Practice (SCIMP) • Scottish Government Delivery Unit • Scottish Government Department of Health and Wellbeing • Scottish Government Health Delivery Directorate Improvement and Support Team • Scottish Government Health Directorate • Scottish Government Transformational Technologies Division • UK Data Standards Forum • Voluntary Health Scotland


69

Cardiac Surgery & Percutaneous Cardiac Interventions Specific • British Cardiovascular Intervention Society (BCIS) • British Heart Foundation • British Cardio-vascular Society • Cardiac Rehabilitation Interest Group Scotland • Central Cardiac Audit Database (CCAD) • Chest Heart and Stroke Scotland • CHD & Stroke Programme, Information Services • Myocardial Ischaemia National Audit Project (MINAP) • NHS Heart Improvement Programme • Scottish Cardiac Society • Scottish Revascularisation Register • SHARP – Scottish Heart and Arterial Risk Prevention • Society for Cardiothoracic Surgeons in Great Britain and Ireland (SCTS) • The Society of Clinical Perfusion Scientists of Great Britain and Ireland • Regional Planning Groups for Cardiac Services NCDDP Reference & Working Groups


70

Appendix 4 – Cardiac Surgery & Percutaneous Cardiac Interventions - Proposed Change Control Data Items Proposed Changes to Existing Data Standards Admission Type Summary of Change: To make data item more generic, remove “Mental Health” from formal name and the word “psychiatric” from definition. Existing Proposed Change Formal name: Admission Type {Mental Health} Common name(s): Type of Admission Main source of standard: SMR data standards Definition: This identifies whether or not the patient/client’s admission to psychiatric hospital was planned. Format: Characters Field Length: 2 Codes and values: Code Value Explanatory Notes10 Routine A routine admission occurs when a patient is

admitted as planned. 20 Urgent An urgent admission is a type of emergency

admission where the admission is delayed for hospital/patient reasons and the patient's condition is such that he/she is not clinically compromised or disadvantaged by the short delay. An example of an urgent admission is a patient who attends for an outpatient appointment at which the doctor decides there is a clinical need to admit the patient within the next few days.

Formal name: Admission Type Common name(s): Type of Admission Main source of standard: SMR data standards Definition: This identifies whether or not the patient/client’s admission to hospital was planned. Format: Characters Field Length: 2 Codes and values: Code Value Explanatory Notes 10 Routine A routine admission occurs when a patient is admitted

as planned. 20 Urgent An urgent admission is a type of emergency admission

where the admission is delayed for hospital/patient reasons and the patient's condition is such that he/she is not clinically compromised or disadvantaged by the short delay. An example of an urgent admission is a patient who attends for an outpatient appointment at which the doctor decides there is a clinical need to admit the patient within the next few days.

30 Emergency An emergency admission occurs when, for clinical


71

30 Emergency An emergency admission occurs when, for clinical reasons, a patient is admitted at the earliest possible time after seeing a doctor. The patient may or may not be admitted through A&E.

reasons, a patient is admitted at the earliest possible time after seeing a doctor. The patient may or may not be admitted through A&E.

Cardiac Enzymes/ Markers Raised Summary of Change: Amend codes and values to bring data item up to date and in line with Sign Guideline 93, Acute Coronary Syndrome. Existing Proposed Change Formal name: Cardiac Enzymes/ Markers Raised Definition: A record of whether or not the patient has raised cardiac enzymes / markers Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No Enzyme activity (CK, CKMB or other cardiac

enzyme) on a single sample NOT greater than twice the upper limit of normal for the hospital laboratory. For other markers e.g. troponin, use local normal range for infarction.

01 Yes Enzyme activity (CK, CKMB or other cardiac enzyme) on a single sample greater than twice the upper limit of normal for the hospital laboratory. For other markers e.g. troponin, use local normal range.

02 Test not done 98 Test done but

results not available

99 Not known If the patient dies before bloods are taken enter 'Not known'.

Formal name: Cardiac Enzymes/ Markers Raised Definition: A record of whether the patient has raised cardiac enzymes / markers Format: Characters Field Length: 2 Codes and values: Code Value Explanatory Notes 00 No Enzyme activity, Troponin concentration

that is NOT greater than the 99th centile of the local lab.

01 Yes Enzyme activity, Troponin concentration that is greater than the 99th centile of the local lab.

02 Test not done 98 Test done but

results not available

99 Not known If the patient dies before bloods are taken enter 'Not known'.

Related data items: Operative Stage


72

Cardiac Procedure Type

Summary of Change: Formal name and definition of item amended. Sub codes and sub values removed from 02 Valve Surgery as this information is collected through other cardiac data items. Further codes and values/ sub values added.

Existing Proposed Change Formal name: Cardiac Surgery Procedure Type Definition: A record of the type of cardiac surgery used to treat the patient. Format: Characters Field Length: 3 Codes and values: Code Value Sub

Code Sub Value

01 Coronary Artery Bypass Graft (CABG)

A Aortic Valve Replacement

B Tricuspid Valve Repair

C Tricuspid Valve Replacement

D Mitral Valve Repair E Mitral Valve

Replacement

02 Valve Surgery

Z Other 03 Cardiac Transplant

Formal name: Cardiac Procedure Type Definition: A record of the type of Cardiac procedure. Format: Characters Field Length: 3 Codes and values:

Code Value Sub Code

Sub Value

01 Coronary Artery Bypass Graft (CABG)

02 Valve Surgery A Cardiac B Pulmonary

03 Cardiopulmonary Transplant

C Cardiopulmonary 04 Pericardiectomy 05 Ventricular Septal

Repair

06 Ventricular Restorative Surgery

07 Aneurysmectomy A Left Ventricular 08 Placement of


73

04 Pericardiectomy 05 Ventricular Septal

Repair

06 Ventricular Restorative Surgery

07 Aneurysmectomy 08 Placement of

Pacemaker Leads

98 Other 99 Not Known

Pacemaker Leads 09 Acquired

Ventricular Septal Defect (VSD)

A Atrial Myxoma Excision 10 Cardiac Tumours Z Other(s)

11 Pulmonary Embolectomy

12 Cardiac Trauma A Brady pacing B Tachy C Resynchronisation

13 Device Therapy

Z Other A ASD Closure B PFO Closure C Stenting of coarctation

14 Congenital Cardiac

Z Other A Endarterectomy 15 Carotid Procedure B Stenting A Diagnostic 16 Heart

Catheterisation B Interventional 17 Arrythmia

Procedure

18 Surgery of the Aorta

A Myomectomy 19 Hypertrophic Cardiomyopathy (HOCM) Procedures

B Septal Ablation

20 Transcatheter Aortic Valve Implantation (TAVI)


Related Data Item: Procedure Status, Associated Professional Role, Associated Professional, Associated professional Identifier, Operative Stage, Date, Heart Valve(s) Attribute: Previous


74

Recording Guidance: IT Systems should allow for multiple recordings of this item. Users may wish to augment code 98 and Z -Other with a free text field for recording other Cardiac Surgery Procedures. These codes and values are intended to bridge the gap until all clinical systems can natively support SNOMED Clinical Terms (CT)

Date/ Time of Symptom Onset Summary of Change: To make data item more generic “ACS” to be removed from formal name. Existing Proposed Change Formal name: Date/Time of Symptom Onset {ACS} Definition: A record of the time to within 10 minutes, if possible, when symptoms began. Format: 25 characters (CCYY-MM-DDThh:mmTZD) Codes and values: N/A Sub-data item: Verification Level

Code Value Level 0 Actual Level 1 Estimated Level 2 Date not required Level 3 Not known

Further information: Where there is a prodrome of intermittent pain the time recorded should be the time of onset of those symptoms

Formal name: Date/Time of Symptom Onset Definition: A record of the time to within 10 minutes, if possible, when symptoms began. Format: 25 characters (CCYY-MM-DDThh:mmTZD) Codes and values: N/A Sub-data item: Verification Level

Code Value Level 0 Actual Level 1 Estimated Level 2 Date not required Level 3 Not known

Further information: Where there is a prodrome of intermittent pain the time recorded should be the time of onset of those symptoms which led the patient to


75

which led the patient to call for help. Routine ambulance data should be used to provide symptom onset information. Where admission followed an out of hospital cardiac arrest with no better information available use the time if arrest for onset of symptoms. Recording Guidance: Valid date >1/1/2000 and <= today. Use 24 hour clock

call for help. Routine ambulance data should be used to provide symptom onset information. Where admission followed an out of hospital cardiac arrest with no better information available use the time if arrest for onset of symptoms. Recording Guidance: Valid date >1/1/2000 and <= today. Use 24 hour clock

Ejection Fraction (Heart) Summary of Change: Definition, Format and Field length amended to make data item more streamlined. Further information removed. Existing Proposed Change Formal name: Ejection Fraction (Heart) Definition: A record of the patient’s ejection fraction (%) as assessed by specific cardiac investigation(s). Format: Numeric Field length: 3 Codes and values: N/A Attributes: Attribute name Single Regional Interest Dual Regional Interest Related data items: Echocardiogram Results (Left Ventricle) Magnetic Resonance Imaging Scan (Heart) Abnormal Results

Formal name: Ejection Fraction (Heart) Definition: A record of the measured ejection fraction (%.) Format: Numeric (nn.n) Field length: 4 Codes and values: N/A Attributes: Attribute name Single Regional Interest Dual Regional Interest Related data items: Echocardiogram Results (Left Ventricle), Magnetic Resonance Imaging Scan (Heart) Abnormal Results, Ejection Fraction Category


76

Further information: The ejection fraction is the amount of blood pumped divided by the amount of blood the ventricle contains.

Electrocardiography (Ambulatory) Monitoring Results {Electrophysiology} Summary of Change: Codes and values “00” amended to align with other values and explanatory note added. Existing Proposed Change Formal name: Electrocardiography (Ambulatory) Monitoring Results {Electrophysiology} Common name: Holter monitor, Electrocardiography - ambulatory Definition: A record of the results of a specific ambulatory ECG investigation, outlining whether it was judged to be normal or abnormal in relation to possible underlying heart disease. Where the ECG is judged to be abnormal, further information on the nature of the abnormality may be specified. Format: Characters Field length: 3 Codes and values: Code Value Sub

Code Sub Value Explanatory

Notes 00 Normal 01 Atrial Extrasystoles 02 Ventricular

Extrasystoles

03 Atrial Fibrillation

Formal name: Electrocardiography (Ambulatory) Monitoring Results {Electrophysiology} Common name: Holter monitor, Electrocardiography - ambulatory Definition: A record of the results of a specific ambulatory ECG investigation, outlining whether it was judged to be normal or abnormal in relation to possible underlying heart disease. Where the ECG is judged to be abnormal, further information on the nature of the abnormality may be specified. Format: Characters Field length: 3 Codes and values: Code Value Sub

CodeSub Value Explanatory

Notes 00 Sinus rhythm Normal 01 Atrial Extrasystoles 02 Ventricular

Extrasystoles

03 Atrial Fibrillation


77

04 Atrial Flutter 05 Atrial Tachycardia 06 Other Narrow QRS

Tachycardia

A Sustained Ventricular tachycardia

Sustained Ventricular Tachycardia: lasting more than 30 seconds or requiring emergency termination within 30 seconds

B Non sustained Ventricular tachycardia

C Supraventricular tachycardia with aberration

07

Wide QRS Tachycardia

Z Other 08

Ventricular Fibrillation

09 Pre-excitation A Sinus arrest 10 Sinus Bradycardia B Sino-atrial exit

block

A First degree B Second degree

(Wenkebach)

C Second degree (Mobitz II)

11 AV Block

D Third degree

12 Intraventricular Conduction Defects

A Atrial pacing 13 Paced Rhythm B Ventricular

pacing

04 Atrial Flutter 05 Atrial Tachycardia 06 Other Narrow QRS

Tachycardia

A Sustained Ventricular tachycardia

Sustained Ventricular Tachycardia: lasting more than 30 seconds or requiring emergency termination within 30 seconds

B Non sustained Ventricular tachycardia

C Supraventricular tachycardia with aberration

07

Wide QRS Tachycardia

Z Other 08

Ventricular Fibrillation

09 Pre-excitation A Sinus arrest 10 Sinus Bradycardia B Sino-atrial exit

block

A First degree B Second degree

(Wenkebach)

C Second degree (Mobitz II)

11 AV Block

D Third degree

12 Intraventricular Conduction Defects

A Atrial pacing 13 Paced Rhythm B Ventricular

pacing


78

Attributes: Pre-existence:

New (changed from previous ECG) Old (unchanged from previous ECG)

Sustained Paroxysmal Symptomatic Asymptomatic

Related data items: Investigation Record Electrocardiography (Ambulatory) Monitoring Result (Ventricular Extrasystoles) Electrocardiography (Ambulatory) Monitoring Result (Ventricular Extrasystoles Morphology) Electrocardiography (Ambulatory) Monitoring Result (Longest Pause) Recording guidance: The result of an investigation should be related to the date on which the investigation was performed. Systems must allow for the recording of multiple options.

14 Chronotropic Incompetence

99 Not known

Attributes: Pre-existence:

14 Chronotropic Incompetence

99 Not known


79

New (changed from previous ECG) Old (unchanged from previous ECG)

Sustained Paroxysmal Symptomatic Asymptomatic

Related data items: Investigation Record Electrocardiography (Ambulatory) Monitoring Result (Ventricular Extrasystoles) Electrocardiography (Ambulatory) Monitoring Result (Ventricular Extrasystoles Morphology) Electrocardiography (Ambulatory) Monitoring Result (Longest Pause) Recording guidance: The result of an investigation should be related to the date on which the investigation was performed. Systems must allow for the recording of multiple options.

Method of Referral Summary of Change: Amend data item to reflect current data standard development. Existing Proposed Change Formal name: Method of Referral Definition: A method of referral is the form in which a referral is sent and received. Notes A referral is made using one of the following methods:

Formal name: Method of Referral Common name(s): Referral Method Definition: A record of the method of referral. Format: Characters


80

• Letter/fax • telephone • in person i.e. the patient refers him/herself • electronic mail

Field Length: 2 Codes and values:

Attributes: Sent Received Not Known

Code Values Explanatory Note 01 Letter 02 Fax 03 Telephone 04 In Person The patient refers him/herself 05 Electronic Mail Email, SCI 98 Other 99 Not Known

Previous Percutaneous Coronary Intervention (PCI) Summary of Change: Definition amended to bring data item up to date. Existing Proposed Change Formal name: Previous Percutaneous Coronary Intervention (PCI) Definition: A record of whether or not reperfusion of coronary arterial blood-flow by PTCA was performed prior to this admission. Format: 2 characters Codes and values:

Formal name: Previous Percutaneous Coronary Intervention (PCI) Definition: A record of whether the patient has undergone previous PCI. Format: Characters Field length: 2


81

Code Value Explanatory Notes 00 No 01 Yes 99 Not known

Codes and values: Code Value 00 No 01 Yes 99 Not known

Referral Source

Summary of Change: “Generic Referral” removed from formal name. Sub codes and sub values added to 02 to expand source of referral from healthcare profession, service or organisation. “Police” removed from “ local authority” 03C and added to “other agency” 05E.

Existing Proposed Change Formal name: Referral Source {Generic Referral} Definition: The type of organisation, service, care professional or other individual making the referral. Format: Characters Field Length: 3 Codes and Values: Code Value Sub-Code Sub-

Value Explanatory Note

Non Professional

Includes any person not acting in an official professional capacity. E.g., includes relatives who are healthcare professionals but are not making the referral as part of their employment, rather in their capacity as a relative.

01A Self Referral

01

01B Associate Includes family,

Formal name: Referral Source Definition: The type of organisation, service, care professional or other individual making the referral. Format: Characters Field Length: 3 Codes and Values:

Code Value Sub Code

Sub Value Explanatory Note

01 Non Professional

Includes any person not acting in an official professional capacity. E.g., includes relatives who are healthcare professionals but are not making the referral as part of their employment, rather in their


82

d Person friends, employer, neighbour, good Samaritan.

02A GP Referral from usual GP practice/practice providing temporary general medical services

02B Specified other common healthcare referrers

Determined as appropriate to specific clinical data standards/datasets

02 Healthcare professional, service or organisation

02Z Other healthcare professionals

Another person acting in their official healthcare professional capacity but out with the groups specified above

03A Education 03B Social

Services

03C Police

03 Local Authority

03D Other Local Authority department

04 Private agency/organisation

E.g., Nursing home, care agency, hospice

05A Prison/Penal establishment

05B Judicial

05 Other agency

05C Voluntary Agency

capacity as a relative. 01A Self Referral 01B Associated

Person Includes family, friends, employer, neighbour, good Samaritan.

02A GP Referral from usual GP

practice/practice providing temporary general medical services. Usually referrals within working hours, but may be out-with hours where usual GP practice performs out of hours care.

02B Out of Hours Services

Referral out with normal working hours from a primary care OOH service.

02C NHS 24 02D A & E 02E Outpatient

Department

02F Specialist palliative Care Services

02G Learning Disabilities Services

02H Adult Mental Health

02J Hospital Paediatric Services

02K Community Paediatric Services

02L School Nurse 02M Health Visitor 02N Other

CAMHS

02 Healthcare profession, service or organisation

02P Same


83

05D Armed forces

98 Other The true value to be recorded is not covered by any of the specific given categories

99 Not known Related Data Items: See source of Referral table Further Information: A referral may be verbal or written by letter, fax or e-mail. A referral can be made wither with or without advance notification. For example, in most secondary and tertiary settings, a referral will usually be received before a patient presents whilst in emergency circumstances, a referral will often be received at the same time as a patient presents. Where more detail about the actual referrer is needed this should be recorded in related fields based on the appropriate data standards, for example Associated professional Details (identifier, role, employing organisation, etc.) or Associated Person Details (relationship, role etc) Recording Guidance: Codes and values should comply with those in the table above. The sub-codes and sub-values in the table are for guidance. Appropriate sub-codes and sub-values should be developed for each specific clinical data set. Only one referral source should be recoded.

Hospital 02R Other

Hospital

02Z Other healthcare professionals

Another person acting in their official healthcare professional capacity but out with the groups specified above

03A Education 03B Social

Services

03 Local Authority

03Z Other Local Authority department

e.g. Housing Department

04 Private agency / organisation

E.g., Nursing home, care agency, hospice

05A Prison/Penal establishment

05B Judicial 05C Voluntary

Agency

05D Armed forces

05 Other agency

05E Police 98 Other The true value to be

recorded is not covered by any of the specific given categories

99 Not known Related Data Items: See Source of Referral Table. Further Information: A referral may be verbal or written by letter, fax or e-mail. A referral can be made wither with or without advance notification. For example, in most secondary and tertiary settings, a referral will usually be received before a patient presents whilst in emergency circumstances, a referral will often be received at the same time as a patient presents.


84

Where more detail about the actual referrer is needed this should be recorded in related fields based on the appropriate data standards, for example Associated professional Details (identifier, role, employing organisation, etc.) or Associated Person Details (relationship, role etc) Recording Guidance: Only one referral source should be recorded.

Research Status Summary of Change: Amend definition to “interventional procedure” instead of “interventional investigation”. Existing Proposed Change Formal name: Research Status Definition: A record of whether the imaging or interventional investigation is part of a research study including a clinical trial. Format: Characters Field length: 2 Codes and values:


Sub data items: Start Date End Date

Formal name: Research Status Definition: A record of whether the imaging or interventional procedure is part of a research study including a clinical trial. Format: Characters Field length: 2 Codes and values:


Sub data items: Start Date End Date

cardiac surgery & percutaneous cardiac interventions … surgery and percutaneous cardia… ·...

Documents