Data Dictionary ; Revised ; ; , 07.07,09.07,04.08 Items in bold italics are recent changes/additions

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1 Data Dictionary ; Revised ; ; , 07.07,09.07,04.08 Items in bold italics are recent changes/additions Number Data element Definition Usual Source in Medical Demographic information Adults are age 18 years and older; children are greater than 6 months and less than 18 years of age; neonates or infants are less than 6 months of age. First initial last name Provide only the first initial of the last name. First initial first name Provide only the first initial of the first name. Hospital record number This is optional; for internal hospital use only if hospital downloads own data for internal analysis Gender (male/female) Male or female H&P, Op In the case of question about gender where there has been a gender change (either via surgery and/or other treatments), answer with what the chart says the gender is with following exception: If the gender change has been from female to male but the ovaries remain intact, this person should be coded as female. Height Height in inches or cm H&P, anesthesia record Round rather than including a decimal Weight Weight in pounds or kg; if more than one weight listed, the H&P, anesthesia record weight closest in time and prior to the operation. Round rather than including a decimal. NA if this information is not available. Date of birth Date of birth Face sheet (UB-92) Age at admit Age Residence zip code Zip code NA if not available Face sheet (UB-92) Primary insurance Insurance listed as the first insurance, regardless of whether the procedure in this record is covered or paid for by that Face sheet (UB-92)

2 insurance. If have private insurance, but their specific insurance company not listed, check other ; do not need to name the company. Admit date Date of admission to this hospital for the current stay, Face sheet, discharge regardless of source of admit (e.g., transfer, direct admit, ER) Discharge date Date of discharge from this hospital, regardless of disposition (e.g. to home, hospital, SNF). If patient died during this hospital stay, the discharge date is the date of death. If discharged to Hospice, mark SNF. Patient status 1 Current cigarette smoker Any use of tobacco cigarettes within one year of this admission. If smoking history is not mentioned anywhere, 2 Most recent labs within 30 days or on admit: albumin, creatinine, hemoglobin, WBCs 3 Current/recent medication use (immunosuppression, therapeutic anticoagulation, statins, beta blocker, ACE inhibitor, ARB) check no. Albumin: g/dl; creatinine: mg/dl; Hgb: g/dl; WBC: 10(3). NA if not available. Anticoagulants: documentation of use within 1 week of admission; all others, documentation of use upon admission (either at home or ordered on admit).see separate listing for medication names for your reference; it may not include very new medications. summary Face sheet, discharge summary H&P, nursing notes Lab record, H&P Medication record, H&P 4 Home 02 use Any use of oxygen at home. H&P, nursing assessment, discharge summary, D/C orders 5 Home mobility device use Use of any mobility device: includes walker, wheelchair, scooter, cane. The emphasis is on use; check no if it is mentioned that they have this device but do not use any of them currently. H&P, nursing assessment,, discharge summary, D/C orders 6 Comorbidities Hypertension: Yes/No Any mention of hypertension in the medical record on admit H&P, nursing assessment, Hypertension meds: none, single, multiple Do not include diuretics as medication for treatment of hypertension unless medical record specifically states the diuretic is being prescribed for hypertension. See separate listing for medication names for your reference; it may not include very new medications. Diabetes: Yes/No Any mention of diabetes in the medical record on admit; mark yes if borderline diabetic Medications that patient is using at the time of admit. Include the new injectable hypoglycemic agent Byetta in the category of single or multiple, non-insulin meds. Insulin plus other meds means other diabetes meds. Diabetes meds: none, single noninsulin, multiple non-insulin, insulin, insulin plus other meds anesthesia H&P, medication record H&P H&P, medication record

3 See separate listing for medication names for your reference; it may not include very new medications. Asthma: Yes/No H&P, anesthesia record Steroid use Indicate yes if either IV, po, inhaled. Check all that apply. H&P, medication record History of VTE: Yes/No Any documentation of venous thrombolembolism, e.g., H&P pulmonary embolus or deep vein thrombosis. History of sleep apnea: Yes/No H&P, anesthesia record History of CPAP If Yes to history of sleep apnea, does patient use CPAP H&P, anesthesia record (continuous positive airway pressure) or BiPAP (bi-level positive airway pressure), or APAP-an auto-titrating CPAP machine. Coronary artery disease: Yes/No Any diagnosis of coronary artery disease, regardless of severity H&P or treatment. Includes angina. History of MI Documentation of MI, regardless of date or type. H&P PCI, CABG or other coronary intervention Documentation of PCI, CABG, AICD, regardless of date. Check all that apply. H&P History of HIV/AIDS: Yes/No Yes, if any documentation of positive HIV/AIDS status H&P Operative data: for all patients 7 Primary surgeon Hospital s ID for primary surgeon; optional if hospital wants to collect it. Do not submit by surgeon name; only by an ID number 8 Diagnosis or indication for operation Choose diagnosis or indication for the surgery from the drop down lists; check all that apply. Do not indicate the actual CPT or ICD9 code. This item is extremely important; is this item is left blank, the case cannot be included in the data analysis. 9 Time of first incision Use 24-hour clock to indicate the time of the first incision; if both anesthesia start time and operation start time are listed, use operation start time. NA if this information not available. 10 In-room close time Use 24-hr clock to indicate time of incision closure in OR; if both anesthesia end time and operation end time are listed, use operation end time. NA if this information not available. Op record, discharge record Op record, discharge record Anesthesia record OR record Anesthesia record OR record 11 Date of surgery Indicate the date (mm/dd/yyyy) on which the operation began. Anesthesia record OR record 12 In-room close date Indicate the date (mm/dd/yyyy) on which the operation ended. Anesthesia record OR record 13 Method of surgical procedure Laparoscopic; lap converted to open; open (no lap ports); lap, Operative record

4 hand assisted. Lap, hand assisted means when an additional incision is made that is ~ the size of a hand so that a hand can be inserted to assist inside the abdomen.. 14 ASA class Class I, II, III, or IV NA if Class not available. Already Anesthesia record intubated if that is the situation. 15 Was insulin used in the OR: Any use of insulin in OR; if patient entered OR with insulin Anesthesia record drip, answer Yes. Respond independent of a diagnosis of diabetes. 16 Highest perioperative blood glucose the highest of these three: Fasting BG recorded anytime prior to the surgery on the day of surgery; BG during surgery; or BG within 60 min. after the surgery. Value in mg Anesthesia record Indicate Not performed if this testing not done. 17 Lowest intraoperative temperature In Centigrade NA if not available. Anesthesia record 17.5 Death in the OR: Indicate if death occurred in the OR. 18 First temp on arrival to recovery room In Centigrade NA if not available. Not applicable if death in the OR 19 Perioperative interventions: Heparin, low molecular weight heparin or synthetic factor Xa inhibitor administered Was heparin, Coumadin, LMW heparin or synthetic factor Xa inhibitor ordered post-op: Was heparin, Coumadin, LMW heparin or synthetic factor Xa inhibitor ordered on discharge? For all of the above three items: If no, was there a contraindication documented? Administered within 24 hours of incision (include pre or post op administration within 24 hrs of incision). Include pre and post-op orders as long as within the 24 hrs of incision. If heparin is ordered IV, indicate number of units ordered per hour; can be per 24 hrs if that is the order. Regardless of answer to answer immediately above, indicate if there was an order for any of these for in-hospital use after the first 24 hrs. If the orders change during the post-op period, use the latest orders for your response. You do not need to check to see if the patient actually received the ordered medication. Not applicable if death in the OR Not applicable if discharge disposition is death. Any documentation in the record by any provider that there was a contraindication to patient receiving either heparin, Coumadin, LMW heparin or synthetic factor Xa inhibitor. For the within 24 hrs of incision data element, if the patient is having emergent surgery and is on maintenance Coumadin, and the patient is being given medication such as Vit K to reverse the effects of Coumadin, this would be a clear contraindication to having any of the DVT chemoprophylaxis medications in the within 24 hrs of Surgery record and/or medication administration records Post-op orders Discharge or transfer orders H&P, Operative record, progress notes

5 incision time frame. Intermittent compression in OR: Intermittent compression boots applied in the OR. OR Beta-blocker: Administered within 24 hrs pre-operatively Physician Orders Was a beta-blocker ordered post-op: On antibiotics for treatment of infection? Antibiotics within 60 min of incision: Were antibiotics discontinued within 24 hrs after closure: Pain management postop orders: Epidural ordered within 24 hr post-op: PCA ordered within 24 hr post-op: NSAID ordered within 24 hr post-op: Regardless of answer to question immediately above, indicate if beta blocker was ordered as a regularly-administered medication (not prn) within 24 hrs post-op. You do not need to check to see if the patient actually received the ordered medication. If yes, do not answer the following two questions as patient is being treated for an infection vs being given a prophylactic antibiotic. If the antibiotic is administered > 60 min. of incision, answer No. EXCEPTION: If either vancomycin or a fluoroquinolone is the antibiotic administered, these need to be administered over a two hour time period. If these are administered within two hours prior to the incision, answer Yes. Answer regardless of when antibiotics were started (previous question). E.g., if ABX started 90 minutes before incision and discontinued 12 hrs after closure: answer Yes. Not applicable if death in the OR or if antibiotics continued for the treatment of an infection even though patient was originally put on antibiotics as prophylaxis.. This question applies only to colorectal and bariatric procedures. Within 24 hours post-op; not applicable if death in the OR You do not need to check to see if the patient actually received the ordered medication. Contraindications are patient refusal, any coagulopathy, concurrent use of enoxaparin/heparin, and patient anatomy that makes epidural placement not feasible. You do not need to check to see if the patient actually received the ordered medication. Contraindications are inability of the patient to understand or manipulate the PCA or opioid intolerance. You do not need to check to see if the patient actually received the ordered medication. Contraindications are intolerance of NSAIDS, kidney or liver disease, and platelet dysfunction or a coagulopathy. See separate listing for NSAID medication names for your reference; it may not include very new medications. Physician Orders H&P Medication Administration /OR Physician Orders Physician Orders Physician Orders Physician Orders

6 Narcotic drip Contraindication is opioid intolerance. Other pain management If yes, specify other pain management modality ordered within 24 hrs post-op; name class of drug and route Note: po narcotics are not included in this data element as are looking at more advanced pain control approaches. Nasogastric tube: patient left OR with NGT in place: G tube: patient left OR with G tube in place to drainage: RBC transfusion: in OR, or within 24 hrs post-op. Mechanical ventilation beyond recovery room: Not applicable. Not applicable if death in the OR RBC transfusion means packed red blood cells. If no packed RBCs were transfused, enter 0 as leaving it blank will be tallied as a missing answer. You can indicate yes if the transfusion was started; do not need to verify that the transfusion was completed. If the patient is a chronic ventilator patient, the response to this is not applicable-the number of ventilator hours post op for these patients does not represent a complication. Not applicable if death in the OR If Yes, how many hours total? Total hours of mechanical ventilation until discharge; if patient is on and off ventilator, estimate total hours. Not applicable if pt is a chronic ventilator patient, or if death in the OR. Physician Orders Medication Administration OP notes, anesthesia record, nursing or medicine progress notes, PACU record Intraoperative record, PACU record, post-op nursing or medicine progress notes Physician Orders Progress Notes Nursing

7 20 Discharge disposition Home (patient s or friend s home), rehab facility, skilled nursing facility, other hospital, other location (e.g., hotel, homeless shelter, homeless), death. Indicate if death in the OR, within 24 hrs after leaving the OR or after 24 hours post op. Discharge summary, discharge orders 21 If patient had any of the following surgical operations or therapies listed below during this hospitalization and following the abdominal procedure, select all that apply and indicate the date first performed after surgery. If had none of these, check None. This section not applicable if death in the OR. Intent of this question is to capture interventions and therapies most likely associated with the abdominal procedure recorded on this form. Check all that apply along with the dates: Abdominal reoperation: colostomy or ileostomy (rescue stoma); abscess drainage; operative drain placement; gastrostomy; gastrostomy revision, re-exploration/washout; anastomotic revision; band replacement; band/port revision; wound revision or evisceration; negative re-exploration; other [specify] tracheal reintubation; NG replacement; tracheostomy placement of percutaneous drain (date); anticoag therapy for presumed/confirmed DVT; anticoagulation therapy for presumed/confirmed PE; wound re-opened. Wound reopended does not include routine wound care-routine wound care refers to situations where the wound may have been left open in the OR and packing/removing packing and/or probing to keep the wound open may be taking place on a daily basis. This data element refers to situations where the closed wound is reopened secondary to an infection. Anastomotic leak; check if a leak demonstrated by barium enema, upper GI and/or CT scan. Enterocutaneous fistula; check if this demonstrated by barium enema, upper GI and/or CT scan. If an intervention was performed more than once, e.g., tracheal re-intubation twice, indicate the date of the first time it was done. Progress notes or discharge diagnoses list Operation-specific information: Complete only for the appropriate operation. Complete one form for each procedure; do not list multiple procedures on the same form.

8 Bariatric 22 Prior foregut surgery Documentation of any previous operation in the abdomen, regardless of date or facility. Include if it took place during this hospitalization, but prior to this operation. Foregut includes abdominal esophagus, stomach, small intestine, small bowel H&P, discharge summary. resection. 23 Procedure of record: type of procedure The procedure being recorded on this form. Bypass [proximal or distal], biliopancreatic bypass, biliopancreatic bypass with duodenal switch, adjustable band [and size]. Proximal gastric bypass is a Roux limb less than or equal to 150 cm. Indicate the band size for the lap band procedure. AP standard is a brand name that is an 11cm size and AP Large is a 12.2 cm size. In the unusual event that a band surgery is converted to a bypass, the operation type is a bypass surgery and yes should be checked on the prior foregut surgery question above. Op record, discharge summary 24 Was stomach divided Yes/No/NA NA for lap band surgeries Op record 25 Was anastamosis tested Yes/No/NA NA for lap band surgeries Op record If yes, how tested: Scope, methylene blue, air injected via tube or syringe, palpation/inspection, other (specify briefly). Check all that apply Op record Appendectomy Abstract charts only for non-elective appendectomies; not for incidental appendectomies or for trauma 26 Was another abdominal or pelvic procedure performed concurrently 27 Preop imaging within 24 hours: CT scan, ultrasound Imaging results: consistent with appendicitis, not consistent with appendicitis, indeterminate Answer Yes if another procedure such as a colectomy or ovarian cystectomy was performed at the same time as the appendectomy If yes, indicate whether the concurrently performed procedure was gynecologic in nature or was a colon or gall bladder procedure Was any imaging done within 24 hours prior to this appendectomy? If yes, indicate if CT or ultrasound. If other type of imaging done (e.g., abdominal xray), leave blank. Plain films do not count as pre-op imaging for the dx of appendicitis. If either CT or ultrasound, indicate if scan results were consistent with, not consistent with appendicitis, or indeterminate. Op record Imaging studies Radiology report

9 28 Prior ER visit within one week prior to the operation: Answer yes if patient seen in any ER or urgent care (includes a physician office visit if the patient was seen urgently) setting within one week of and prior to this operation. Answer No if patient only seen in this hospital s ER, and admitted immediately from that ER visit. The intent of the question is to identify patients who were seen for suspected appendicitis in an urgent or emergent situation within a week prior to this procedure. If there was an ER/urgent care visit in this time ER record, H&P 29 Pathology results: appendeceal pathology frame that is clearly non-abdominal (e.g., fracture), answer No. Pathology results confirm appendeceal pathology: confirmed or consistent with appendicitis, inflammation, appendeceal tumor. Statements in the path report such as mild early or very early appendicitis indicate appendeceal pathology. Pathology report 30 Perforated appendix: Patient experienced perforated appendix. Pathology report Colon Operation 31 Prior colon or pelvic surgery Documentation of any previous operation in the colon or pelvis, regardless of date or facility; includes hysterectomy and small bowel resection. Include if it took place during this H&P, Admit note, progress notes hospitalization, but prior to this operation. 32 If colostomy performed, was there a prior Yes/No H&P colon resection within 30 days? If yes, name of hospital at which performed Indicate if known (free text). Otherwise leave blank. H&P, Discharge Summary 33 Procedure priority Elective, non-elective. An elective procedure is one that is H&P, admit note, progress performed on a patient whose symptoms and/or disease has note been stable in the days or weeks prior to the procedure. Typically elective cases are scheduled at least several days before the procedure. Non-elective procedures (which include urgent and emergent status) are required to minimize or address further clinical deterioration. 34 Operation type Check the type of operation that was performed. Low anterior resection references removal of sigmoid colon and/or top of rectum with re-attachment of the colon and lower rectum. Lf hemicolectomy includes +/- removal of transverse colon; this also includes sigmoid colon resection. Rt hemicolectomy includes resection of the terminal ileum and partial cecetomy as well as an ileocecal resection and cecum to transverse colon bypass. Abdominoperineal resection references removal of the rectum from a combined approach with both an abdominal and perineal incision. Total abdominal colectomy means all of Op

10 the right transverse and left colon removed along with the sigmoid. In the rare event that the surgery is a perineal proctectomy with colanal handsewn anastomosis transanally this should be categorized as an Abdominal Perineal Resection. 35 Ostomy: colostomy, ileostomy, protective stoma or no ostomy 36 Anastamosis: Cannot be determined A protective stoma is when an ileostomy or colostomy is done at the same time as the anastomosis to protect it from leaking-most commonly done when a low rectal anastomosis is done. Colocolon (colon to colon(, Ileocolon (ileum to colon) Ileoanal (ileum to anal), coloanal (colon to anal) If you cannot determine what type of anastomosis was done, mark cannot be determined. Colon to rectum should be marked as a colocolon. Op record Op record If ileoanal or coloanal, was pouch created? Op record 37 Was anastamosis tested: Yes/No Op record If yes, how tested: Scope, methylene blue, air injected via tube or syringe, palpation/inspection, other (free text) Check all that apply Op record

11 38 #s 38 through 43 are not applicable if surgery not done for Cancer Pathology findings Pre-op diagnosis confirmed: yes, no In the event that the pre-op dx of CA was based on a prior colonoscopy and the surgery is a follow up procedure to remove additional suspicious tissue, and no additional cancer was found, this finding does not revoke the pre-op dx. In this event, the answer to this data element is yes unless there is a statement in the medical record to the Op record, path report 39 Number of lymph nodes removed and studied contrary. If none, indicate zero (0) While more lymph nodes may have been removed than were examined or studies, only state the number of lymph nodes that were removed and examined. While it may not always be appropriate/feasible for lymph nodes to be removed for a rectal cancer surgery, put (0) if none removed. Data analysis will not include these cases in the denominator for the current data reports. Path report. 40 Number lymph nodes positive for CA If none, indicate zero (0) Path report 41 Metastatic disease beyond lymph nodes, Path report e.g. liver, diaphragm, peritoneum 42 Margins free of CA: If yes, indicate Cm to both distal and proximal margins; NA if Path report info not available 43 T stage Check the appropriate stage; NA if info not available Path report Addendum for Neonates and Children Demographic Information Defines data elements that are specific to neonates/infants and children. Age at admit Indicate the number of days/months/years, e.g. 26 d, 13 w, 12 y If the infant was born at your facility and the surgery is done during this index hospitalization, put one day as the age at admit. See separate listing for medication names for your reference; it may not include very new medications. Most recent medications used preoperatively; within 30 days Developmental delay Check yes if stated as such by the surgeon/md. H&P GERD Gastroesophogeal reflux disease Prematurity 36 weeks or less Chronic lung disease Check yes is stated by the surgeon/md H&P Infant and Child Gastric

12 Procedures Preoperative evaluation, if yes UGI-Upper Gastrointestinal imaging UGI with SBFT-Upper GI with Small Bowel Folow Thru US-Ultrasound Define ph probe Infant and Child Non-Elective Appendectomy Infant and Child Colon Operation Did patient have a VCUG VCUG is a voiding cystourethrogram

13 Medications Note: lists are not all-inclusive, and trade names may change. Drug Class Names Comments Anticoagulants Heparin Coumadin Warfarin Low molecular weight heparin Fragmin (dalteparin) Lovenox (enoxaparin) Aristra (fondaparinux) Innohep (tinzaparin) Anticonvulsants Gabitrel (tiagebine) Lyrica (pregablin) Neurontin (gabapentin) Depakote/Depekene Keppra (levetiracetam) Tegretol (carbamzapine) Topomax (topiramte) Trileptal (oxcarbazine) Zonegran (zonisamide) Lamictal (lamotrigene) Klonopin (clonazepam) Valium (diazepam) Tranxene (chlorazepate) Antidiabetic agents Insulin Acarbose Glimepiride Glipizide Glyburide Metformin hydrochloride Miglitol Pioglitazone hydrochloride Rosiglitazone maleate Tolazamide Tolbutamide (with or without sodium) Anti-reflux agents??? Immunosuppressives/ steroids Prednisone Cortisone Methotrexate Cyclosporine Azasan (azathioprine) CellCept (mycophenoiate mofetil) Myfortic (mycophenolic acide) Neoral (cyclosporine) Prograf (tacrolimus) Rapamune (sirolimus) Sandimmune (cyclosporine) Do not include inhaled medications, e.g., for asthma. Beta Blockers Acebutolol Atenolol Betapace (sotalol) Betaxolol Bisoprolol Blocadren (timolol) Brevibloc (esmolol) Alone or in combination. * indicates combination drug.

14 Drug Class Names Comments Cartrol (carteolol) Carteolol Carvedilol Coreg (carvedilol) Esmolol Inderal (propranolol) Innopran ( ) Kerlone (betaxolol) Labetalol Levatol (penbutolol) Lopressor (metoprolol) Metoprolol Nadolol Normodyne (labetlol) Penbutolol Pindolol Proranolol Sectral (acebutolol) Sotalol Tenormin(atenolol) Timolol Toprol (metoprolol) Trandate (labetalol) Visken (pindolol) Zebeta (bisoprolol) *atenolol/chlorthalidone *bisoprolol/hctz *Corzide (bendroflumethiazide/nadolol) *HCTZ/propranolol *Inderide ( ) *Lopressor HCT ( ) *Tenoretic (atenolol/chlorthalidone) *Timolide (HCTZ/timolol) *Ziac (bisoprolol/hctz) Diuretics Dyazide (hydrochlorthiazide/triamterene) Maxzide (triamterene/hydrochorthiazide) Edecrin (ethacrynic acid) Lasix (furosemide) Dyrenium (triamterene) Diuril Midamor (amiloride HCL) Narcotics Actiq Avinza Combunox Demerol DepoDur Darvocet Dilaudid (hydromorphone) Duragesic Lortab MS Contin (morphine sulfate) Numorphan Morphine Sulfate OxyContin (oxycodone) Perocet Percodan Tylenol with Codeine Vicodin (hydrocodone)

15 Drug Class Names Comments Zydone Statins Atorvastatin calcium (Lipitor) Fluvastatin sodium (Lescol) Lovastatin (Mevacor) Pravastatin sodium (Pravachol) Rosuvastatin calcium (Crestor) Simvastatin (Zocor) ACE Inhibitors Benazepril hydrochloride Captopril Analapril Maleate Fosinopril Sodium Lisinopril Moexipril hydrochloride Perindopril erbumine Quianpril hydrochloride Ramipril trandolapril ARBs Candesartan Cilexitil Eprosartan Mesylate Irbesartan Losartan Potassium Olmesartan Medoxomil Telmisartan Valsartan NSAIDs Celecoxib Diclofenac (potassium or sodium) Diflunisal Etodolac Fenoprofen calcium Flurbiprofen (with/without sodium) Ibuprofen Indomethacin (with/without sodium trihydrate) Ketoprofen Ketorolac tromethamine Eclofenamate sodium Mefanemic acid Meloxicam Nabumetone Naproxen (with/without sodium) Oxaprozin Piroxicam Rofecoxib Sulindac Tolmetin sodium Valdecoxib