Acute Coronary Syndromes (ACS) Dataset

Transcription

1 For reference only Do Not Use For more information contact: Acute Coronary Syndromes (ACS) Dataset These are standards current on 10 th May 2007 National Clinical Dataset Development Programme (NCDDP) Support Team Information Services Area 54E Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Tel: to: NCDDPsupportteam@isd.csa.scot.nhs.uk Website:

2 PATIENT DETAILS... 4 Patient Identification and Demographics Table... 4 General Practice Details Table... 5 Ambulance Incident Number... 5 ADMISSION DETAILS... 6 Date/ Time of Symptom Onset {ACS}... 6 Date/ Time Call for Help {ACS}... 7 Date/ Time Arrival at Hospital {ACS}... 7 Admitted/ Transfer from location... 8 Patient Admin Status... 8 Initial Diagnosis {ACS}... 8 Method of Admission {ACS}... 9 Admission Ward {ACS} Admitting Consultant Identifier Admitting Consultant Type {ACS} Seen by Cardiologist ADMISSION TREATMENT Where was Aspirin / other Anti platelet Given? Reason Aspirin Not Given Aspirin Contraindications Clopidogrel Reason Clopidogrel Not Given Clopidogrel Contraindications Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Reason Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Not Given Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Contraindications THROMBOLYSIS ECG Determining Reperfusion Treatment Date/ Time of 1st ECG Date/ Time of ECG Determining Reperfusion Treatment Place First ECG Performed Was Reperfusion Attempted Reason Thrombolytic Treatment Not Given Thrombolytic Drug Date/ Time of Reperfusion Treatment Reason if Delay Before Thrombolytic Treatment Where was Initial Reperfusion Treatment Given Bleeding Complications as a Result of Reperfusion Therapy Reperfusion Outcome BLOOD RESULTS Serum Total Cholesterol (Admission) {ACS} Cardiac Enzymes/ Markers Raised Peak Serum Creatinine Kinase Peak Troponin Troponin Assay CHD RISK FACTORS Smoking Status Family History of CHD Acute Coronary Syndromes Dataset 2

3 Previous Myocardial Infarction Previous Angina Hypertension Chronic Kidney Disease Diabetes Management Previous Percutaneous Coronary Intervention (PCI) Previous Coronary Artery Bypass Graft (CABG) INVESTIGATIONS DURING ADMISSION Exercise Tolerance Test Reason for no Exercise Tolerance Test Echocardiography LV Function as Result of Echocardiogram Reason for No Echocardiography Referral for Coronary Angiography Date of Referral for Coronary Angiogram Coronary Angiography During This Admission {ACS} Date of Coronary Angiogram INTERVENTIONS DURING ADMISSION Referral for Revascularisation Date of Referral for Revascularisation Revascularisation {ACS} Date of Revascularization COMPLICATIONS DURING ADMISSION Heart Failure {ACS} Angina {ACS} Reinfarction Cardiac Arrest Date/ Time of 1st Cardiac Arrest Outcome of 1st Cardiac Arrest CARDIAC REHABILITATION Referral to Cardiac Rehabilitation Service Date of Referral to Cardiac Rehabilitation Service Reason for No Referral to Cardiac Rehabilitation DISCHARGE DETAILS Discharge Date {ACS} Discharge Diagnosis {ACS} Discharged on Aspirin / other Antiplatelet Discharged on Warfarin Discharged on Clopidogrel Discharged on Beta Blocker Discharged on Angiotensin Inhibitor Discharged on Statin Discharge Destination {ACS} Discharge / transfer to - location Cause of Death in Hospital {ACS} Person Death Date Episode Sign Off Acute Coronary Syndromes Dataset 3

4 PATIENT DETAILS Patient Identification and Demographics Table Generic Data Items Data Item Definition Format Location Code G This is the reference number of any building 5 characters or set of buildings where events pertinent to NHS Scotland take place. Locations include hospitals, health centres, GP surgeries, clinics, NHS board offices, nursing homes, schools and patient/client s home. Health Record Identifier A Patient Health Record Identifier is a code 14 characters G (set of characters) used to uniquely identify a patient within a health register or a HEALTH RECORDS SYSTEM, e.g. PAS. CHI Number G The Community Health Index (CHI) is a 10 characters population register, which is used in Scotland for health care purposes. The CHI number uniquely identifies a person on the index. Surname G That part of a person's name which is used to describe family, clan, tribal group, or marital association. 35 characters Forename G The forename or given name of a person 35 characters Person Birth Date G The date on which a person was born or is officially deemed to have been born, as recorded on the Birth Certificate. 10 characters (CCYY-MM- DD) Person Current Gender G Ethnic Group (Self Assigned) G Postcode G A statement by the individual about the gender they currently identify themselves to be (i.e. self-assigned). A statement made by the service user about their current ethnic group The code allocated by the Post Office to identify a group of postal delivery points. 1 character Up to 6 characters (2 + 4) 8 characters G The above data items have already been approved and are available in the Health & Social Care Data Dictionary. Acute Coronary Syndromes Dataset 4

5 General Practice Details Table Generic Data Items Data Item Definition Format Registered GP Practice Code G General Medical Practitioners provide general medical services to the population either in partnership with other GMPs or on a single-handed basis. The term GP practice covers both partnerships and singlehanded practices. Each GP practice in Scotland is identified by a unique GP practice code. The practice code is a four-digit code plus a check digit with ranges of codes allocated to each Health Board. 6 characters (right justified) Data Items Data Item Definition Format Ambulance Incident Number A record of the ambulance incident number as per the Scottish Ambulance Service Patient Record Form (PRF). 1 Ambulance Incident Number Definition: A record of the ambulance incident number as per the Scottish Ambulance Service Patient Record Form (PRF). Format: 1 N/A Further Information: The ambulance incident number is comprised of 2 letters - 7 digits - 3 digits. Acute Coronary Syndromes Dataset 5

6 ADMISSION DETAILS Data Items Data Item Definition Format Date/ Time of Symptom Onset {ACS} A record of the time to within 10 minutes, if possible, when 25 characters (CCYY- MM-DDThh:mmTZD) Date/ Time Call for Help {ACS} Date/ Time Arrival at Hospital {ACS} Admitted/ Transfer from location Patient Admin Status Initial Diagnosis {ACS} Method of Admission {ACS} Admission Ward {ACS} Admitting Consultant Identifier Admitting Consultant Type {ACS} Seen by Cardiologist symptoms began. A record of the time of the initial call by patient, relative or attendant. Date/time patient first arrives at hospital. The type of location from which a patient is admitted or transferred for care. A record of the patients administration status A record of a working diagnosis at the time of admission. A record of the process by which the patient was admitted to hospital. Refers to the unit to which the patient is admitted either from A&E or directly by ambulance service and where patient will spend majority of first 24 hours in hospital. A record of the unique identifier for the clinician having primary rather than advisory care of the patient immediately (first 24 hours) after admission to hospital A record of the clinician having primary rather than advisory care of the patient immediately (first 24 hours) after admission to hospital A record of whether the patient is seen by a cardiologist or other physician with a specialist interest in cardiology, at any time during this admission. 25 characters (CCYY- MM-DDThh:mmTZD) 25 characters (CCYY- MM-DDThh:mmTZD) ISD reference file 7 characters 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) Acute Coronary Syndromes Dataset 6

7 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 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 Date/ Time Call for Help {ACS} Definition: A record of the time of the initial call by patient, relative or attendant. Format: 25 characters (CCYY-MM-DDThh:mmTZD) 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: This may be to a GP, NHS 24, or the ambulance service. This time may be available from the ambulance service record as the time of the emergency call but may only be correct when a 999 call is made to the Ambulance service. Make sure you know to whom the initial call was made. If the call was to a GP (or deputising service), or NHS 24 you will have to establish this time as accurately as possible from the patient. The call time should be taken from the ambulance patient report form (PRF) and is when the caller's telephone number, exact location of the incident and nature of chief complaint are known. Recording Guidance: Valid date >1/1/2000 and <= today. Use 24 hour clock Date/ Time Arrival at Hospital {ACS} Definition: A record of the date/time patient first arrives at hospital Format: 25 characters (CCYY-MM-DDThh:mmTZD) N/A Acute Coronary Syndromes Dataset 7

8 Sub-data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Date not required Level 3 Not known Further information: Either A&E, CCU, MAU, or assessment unit. Routine ambulance data. It is recommended that this be used by all as the time of arrival rather than time of registration or time of first ECG. Use A&E registration time if self presented or time of ambulance arrival at hospital if direct admission. Recording Guidance: Valid date >1/1/2000 and <= today. Use 24 hour clock Admitted/ Transfer from location Definition: The type of location from which a patient is admitted or transferred for care. Format: 25 characters (CCYY-MM-DDThh:mmTZD) N/A Further information: ISD Reference File. This is only relevant for those patients who are admitted/transferred directly from another NHS Location for revascularisation or inpatient angiography with a view to revascularisation. This is not relevant for those patients admitted from home. This is the location of where a patient has been admitted or transferred from. A location is any building or set of buildings where events pertinent to the NHSSCOTLAND take place. Locations include hospitals, health centres, GP surgeries, clinics, NHS board offices, nursing homes, schools and patients/clients home. Patient Admin Status Definition: A record of the patient s administration status 01 NHS 02 Private 03 Amenity NHS patient but procedure carried out in private hospital. 04 Visitor Any patient that does not live in the local catchment area, includes holiday makers and overseas tourists Initial Diagnosis {ACS} Definition: A record of a working diagnosis at the time of admission. Acute Coronary Syndromes Dataset 8

9 01 Definite myocardial infarction Diagnosis based on unequivocal changes of infarction on admission ECG (ST elevation) 02 Probable myocardial infarction 03 Acute coronary syndrome 04 Chest pain of uncertain cause and appropriate history. Should be used where there is strong likelihood of infarction on history and an abnormal ECG without ST elevation or LBBB. This is a working diagnosis needing confirmation by further ECGs and/or biochemical markers. See 'Reason if delay before thrombolytic treatment for advice on what to enter when first ECGs are not diagnostic and a subsequent ECG is diagnostic and results in reperfusion treatment being given. Includes appearance at admission of non Q wave (subendocardial) infarction. Covers all other suspected acute coronary syndromes where confirmation of diagnosis subject to troponin results Single episode of cardiac sounding chest pain with admission thought appropriate to exclude ischaemic event. 05 Other initial diagnosis Other (usually non-cardiac) diagnosis such as acute aortic dissection, pancreatitis, etc subsequently found to be an infarction. Also to be used where patient is already in hospital. Further information: The primary purpose is to identify those patients who are admitted with a diagnosis of definite MI (ST elevation MI). Do not change initial diagnosis on the basis of further ECGs or enzymes/markers. Note: This standard will be updated when a new definition of Acute Coronary Syndrome is available. Method of Admission {ACS} Definition: A record of the process by which the patient was admitted to hospital. 01 Called GP who saw patient before calling emergency services 02 Called GP who called emergency service before seeing patient Use also when patient sees GP at surgery, drop in night time clinic etc. In some instances the GP may not actually see the patient. Acute Coronary Syndromes Dataset 9

10 03 Called GP, told to make own way to hospital 04 Called Made own way to hospital (did not call anyone) 06 Patient admitted from outpatient setting This includes Rapid Access Chest Pain Clinics 07 Patient already in hospital If the patient is already in hospital with another diagnosis it is only necessary to enter the date of symptom onset and the date of arrival at hospital. 08 Transferred in for PCI/Surgery Use when admitted by transfer from another hospital for consideration of primary or rescue angioplasty or surgical procedure. 09 Transferred in for primary treatment Use this option for transfer from any other hospital for primary treatment (e.g. thrombolysis) or where split management of acute coronary events takes place. If transfer is for primary or rescue angioplasty use option Other Includes other routes of entry to hospital (became ill visiting hospital etc) Further Information: In every case the caller refers to the patient or other nonprofessional in attendance. Admission Ward {ACS} Definition: A record of the unit to which the patient is admitted either from A&E or directly by ambulance service and where patient will spend majority of first 24 hours in hospital. 01 Coronary care unit A unit specified for this purpose including those with shared facilities with ITU, or HDU, or a dedicated CCU which is part of a general medical ward or a dedicated cardiac ward and where the major part of early management takes place. 02 Acute admissions unit A unit for the assessment of non-specific acute medical admissions. 03 General medical ward Where this is separate from a CCU. 04 Intensive therapy unit Where this is separate from a CCU, and is not the usual place of care for early infarction (post-arrest or when CCU is full, etc). 05 Cardiac ward (non A cardiac ward without a specific CCU function CCU) 06 Stepdown ward A facility normally used primarily for patients after initial care on CCU Acute Coronary Syndromes Dataset 10

11 07 Died in A&E Very important for interpretation of mortality data. 98 Other To record patients admitted to non-medical wards or who had infarction while already in hospital. Further Information: If patient admitted direct to Catheter Lab, enter facility to which patient admitted on leaving lab. Admitting Consultant Identifier Definition: A record of the unique identifier for the clinician having primary rather than advisory care of the patient immediately (first 24 hours) after admission to hospital Format: 7 characters N/A Further Information: This is not the A&E consultant. The admitting consultant identifier has the same format as the General Medical Council number. Admitting Consultant Type {ACS} Definition: A record of the clinician having primary rather than advisory care of the patient immediately (first 24 hours) after admission to hospital 01 Cardiologist Cardiologist or physician with a major interest in cardiology. 02 Other general physician All other physicians. 98 Other Patient admitted under another discipline, e.g. surgeon. Further Information: This is not the A&E consultant Seen by Cardiologist Definition: A record of whether the patient is seen by a cardiologist or other physician with a specialist interest in cardiology, at any time during this admission. Code Value 00 No 01 Yes Acute Coronary Syndromes Dataset 11

12 02 Discussed with cardiologist but not seen Further Information: Patients may be admitted by a general physician then later seen by a cardiologist. Acute Coronary Syndromes Dataset 12

13 ADMISSION TREATMENT Data Items Data Item Definition Format Where was Aspirin / other Anti platelet Given? A record of if and when aspirin or other anti platelet drug was first given to patient. Reason Aspirin Not Given Aspirin Contraindications Clopidogrel Reason Clopidogrel Not Given Clopidogrel Contraindications Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Reason Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Not Given Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Contraindications A record of the reason aspirin/other anti-platelet was not given. A record of the reason aspirin/other anti-platelet is contraindicated. A record of whether Clopidogrel was given on admission. A record of the reason Clopidogrel was not given on admission. A record of the reason why Clopidogrel is contraindicated. A record of whether Heparin (Low Molecular Weight Heparin or Intravenous Heparin) was given on admission. A record of the reason Heparin (Low Molecular Weight Heparin or Intravenous Heparin) was not given. A record of the reason why Heparin (Low Molecular Weight Heparin or Intravenous Heparin) is contraindicated. Where was Aspirin / other Anti platelet Given? Definition: A record of if and when aspirin or other antiplatelet drug was first given to patient. 00 Not given 01 Already on aspirin / antiplatelet drug 02 Aspirin / antiplatelet drug given out of hospital Regular use of aspirin / antiplatelet before this episode. Ignore the administration of additional doses by paramedics. Aspirin or other anti platelet drug started for this episode before admission. Acute Coronary Syndromes Dataset 13

14 03 Aspirin / antiplatelet drug given after arrival in hospital Patient not previously taking any antiplatelet drug. Reason Aspirin Not Given Definition: A record of the reason aspirin/other anti-platelet was not given. 00 None No reason given 01 Contraindicated Clinical reason aspirin/other anti-platelet should not be given 02 Adverse Reaction Patient experienced unwanted effects/allergic to aspirin/other anti-platelet 03 Not tolerated Patient cannot tolerate aspirin/other antiplatelet 04 Not indicated e.g. person may already be on a similar medication 05 Patient declined Patient chose not to be prescribed aspirin/other antiplatelet 98 Other Aspirin Contraindications Definition: A record of the reason aspirin/other anti-platelet is contraindicated. Code Value 01 Allergic 02 GI Bleed 03 Dyspepsia 04 Severe liver abnormalities 05 Intolerant 06 Cerebral haemorrhage 07 Haemoptysis 08 Pregnant Further Information: Contra-indication in pregnancy should be supported by clinical data (teratogenicity or foetotoxicity) or by strong pre-clinical data such as teratogenicity, mutagenicity and carcinogenicity at low doses. (European Medicines Agency Evaluation of Medicines for Human Use - Doc. Ref.: EMEA/CHMP/64302/2005 (CHMP)) Acute Coronary Syndromes Dataset 14

15 Clopidogrel Definition: A record of whether Clopidogrel was given on admission. Code Value 00 No 01 Yes Further Information: This is relevant for only those patients who are deemed as Acute Coronary Syndrome patients on admission. Reason Clopidogrel Not Given Definition: A record of the reason Clopidogrel was not given on admission. 00 None No reason given 01 Contraindicated Clinical reason Clopidogrel should not be given 02 Adverse Reaction Patient experienced unwanted effects/allergic to Clopidogrel 03 Not tolerated Patient cannot tolerate Clopidogrel 04 Not indicated Patient may already be on a similar medication 05 Patient declined Patient chose not to be prescribed Clopidogrel 98 Other Further information: Where clinical guidelines recommend the prescription of a specific drug or class of drug for a particular condition, this data item allows the recording of the reason why that guidance was not followed. It is intended to support the clinical governance agenda Clopidogrel Contraindications Definition: A record of the reason why Clopidogrel is contraindicated. 00 None None 01 Specific clinical diagnosis 02 Co-morbidities This includes concomitant diseases 03 Demographic factors e.g. gender, age Acute Coronary Syndromes Dataset 15

16 04 Predispositions This includes metabolic or immunological factors and prior adverse reactions 05 Pregnancy 06 Lactation 07 Strong theoretical reasons e.g. on grounds of pharmacokinetics, pharmacodynamics, or common state of knowledge in medicine Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Definition: A record of whether Heparin (Low Molecular Weight Heparin or Intravenous Heparin) was given on admission. Code Value 00 No 01 Yes Further Information: This is relevant for only those patients who are deemed as Acute Coronary Syndrome patients on admission. Reason Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Not Given Definition: A record of the reason Heparin (Low Molecular Weight Heparin or Intravenous Heparin) was not given. 00 None No reason given 01 Contraindicated Clinical reason Heparin should not be given 02 Adverse Reaction Patient experienced unwanted effects/allergic to Heparin 03 Not tolerated Patient cannot tolerate Heparin 04 Not indicated Patient may already be on a similar medication 05 Patient declined Patient chose not to be prescribed Heparin 98 Other Acute Coronary Syndromes Dataset 16

17 Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Contraindications Definition: A record of the reason why Heparin (Low Molecular Weight Heparin or Intravenous Heparin) is contraindicated. 00 None None 01 Specific clinical diagnosis 02 Co-morbidities This includes concomitant diseases 03 Demographic factors e.g. gender, age 04 Predispositions This includes metabolic or immunological factors and prior adverse reactions 05 Pregnancy 06 Lactation 07 Strong theoretical reasons e.g. on grounds of pharmacokinetics, pharmacodynamics, or common state of knowledge in medicine Acute Coronary Syndromes Dataset 17

18 THROMBOLYSIS Data Items Data Item Definition Format ECG Determining Reperfusion Treatment A record of the ECG appearances upon which a decision to offer reperfusion treatment including angioplasty, Date/ Time of 1st ECG Date/ Time of ECG Determining Reperfusion Treatment Place First ECG Performed Was Reperfusion Attempted Reason Thrombolytic Treatment Not Given Thrombolytic Drug Date/ Time of Reperfusion Treatment Reason if Delay Before Thrombolytic Treatment Where was Initial Reperfusion Treatment Given Bleeding Complications as a Result of Reperfusion Therapy Reperfusion Outcome was based. A record of the date and time of the first ECG recorded after the start of symptoms. A record of the date and time the ECG that determined the reperfusion treatment, was taken. A record of where the first ECG was performed. A record of whether or not reperfusion was attempted on this patient. A record of the explanation of why thrombolysis was not performed where it might be expected to be performed. A record of the agent for first thrombolytic treatment. A record of the date and time of start of reperfusion treatment whether by bolus or infusion. A record of the reason for delay, if any, before thrombolytic treatment is given. A record of where the initial reperfusion treatment was given A record of bleeding complications due to reperfusion therapy A record of the result of primary thrombolytic treatment prior to any further reperfusion treatment 25 characters (CCYY- MM-DDThh:mmTZD) 25 characters (CCYY- MM-DDThh:mmTZD) 25 characters (CCYY- MM-DDThh:mmTZD) ECG Determining Reperfusion Treatment Definition: A record of the ECG appearances upon which a decision to offer reperfusion treatment including angioplasty, was based. Acute Coronary Syndromes Dataset 18

19 01 ST segment elevation Appearances considered typical of acute myocardial infarction. 02 Left bundle branch block New LBBB. Whether or not LBBB is 'new' causes practical difficulties. In order to confirm this it is necessary to have evidence that it did not exist before this event, by comparing with previous ECGs. It follows that unless there is definite ST segment elevation in addition to LBBB, the admission diagnosis for a patient with LBBB of uncertain duration has to be 'Probable MI'. Can be used to calculate TIMI risk score for Acute MI. 03 ST segment depression Any degree of ST segment depression involving more than one lead without any ST elevation (except a VR). 04 T wave changes only Includes non Q wave infarction. 05 Other abnormality All other abnormalities thought potentially relevant to this admission e.g. arrhythmias, conduction disturbances. 06 Normal ECG Further information: This can include any 12 lead ECG performed in the pre hospital setting. If ST Elevation consistent with infarction is recorded on any ECG during the episode, regardless of treatment, the final diagnosis should be Myocardial Infarction (ST Elevation). Date/ Time of 1st ECG Definition: A record of the date and time of the first ECG recorded after the start of symptoms Format: 25 characters (CCYY-MM-DDThh:mmTZD) N/A Sub data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Not known Recording Guidance: Valid date >1/1/2000 and <= today. Use 24 hour clock Date/ Time of ECG Determining Reperfusion Treatment Definition: A record of the date and time the ECG that determined the reperfusion treatment, was taken Format: 25 characters (CCYY-MM-DDThh:mmTZD) Acute Coronary Syndromes Dataset 19

20 N/A Sub data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Not known Recording Guidance: Valid date >1/1/2000 and <= today. Use 24 hour clock Place First ECG Performed Definition: A record of where the first ECG was performed. 01 Ambulance An ECG performed in any location by ambulance paramedic staff as a result of an emergency call 02 In hospital In this hospital 98 Other healthcare facility Includes general practice or care home where the ECG was performed by a non paramedic Further Information: This refers to the first ECG recorded, not necessarily the diagnostic ECG. Was Reperfusion Attempted Definition: A record of whether or not reperfusion was attempted on this patient. 00 No 01 Thrombolytic drug Includes one or more doses of any thrombolytic agent, although only timing of the first dose to be recorded. Use even if there was reason for delay before treatment. 02 Primary PCI Either as an elective decision or because thrombolytic treatment contraindicated. 03 Facilitated PCI PCI performed in the acute setting as soon as possible after thrombolysis for acute STEMI (or new LBBB) with a clear history of MI, provided as a routine treatment in addition to thrombolysis. Where, as a part of an agreed protocol, thrombolysis is given before a PCI is Acute Coronary Syndromes Dataset 20

21 performed. Further information: This data item only refers to the initial reperfusion strategy. Reperfusion therapy implies either lytic therapy (thrombolytic drug) or mechanical treatment (PCI) or both. Reason Thrombolytic Treatment Not Given Definition: A record of the explanation of why thrombolysis was not performed where it might be expected to be performed. 00 No reasons No reason why thrombolysis not performed. This should include any administration failures 01 Contraindicated Generally acknowledged clinical contraindication to performing thrombolysis exists. This should include too late, risk of haemorrhage, uncontrolled hypertension, previous stroke, recent surgery etc 02 Not indicated No clinical indication for thrombolysis 03 Clinical Decision Clinical judgement of inappropriateness of thrombolysis in an individual patient due to their specific set of circumstances 04 Not available Thrombolysis not available 05 Not applicable 06 Patient declined Patient chose not to have thrombolysis 07 Diagnostic uncertainty 08 Primary PCI 98 Other Further Information: Thrombolytic therapy may be expected when clinical guidelines recommend thrombolysis should be performed. Thrombolytic Drug Definition: A record of the agent given for thrombolytic treatment. Format: Characters Field length: 2 Code Value 01 Alteplase 02 Reteplase 03 Streptokinase 04 Tenecteplase Acute Coronary Syndromes Dataset 21

22 05 Urokinase 98 Other Related data items: Thrombolysis Status, Date / Time of Reperfusion Treatment, Reason for no Thrombolysis {CHD} Date/ Time of Reperfusion Treatment Definition: A record of the date and start time of reperfusion treatment whether by bolus or infusion. Format: 25 characters (CCYY-MM-DDThh:mmTZD) N/A Sub data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Not known Further information: Required for calculation of time of arrival to time of thrombolysis. Required for time from onset symptoms to time of thrombolysis. Required for time from onset symptoms to time of thrombolysis. Recording Guidance: Valid date >1/1/2000 and <= today. Use 24 hour clock Reason if Delay Before Thrombolytic Treatment Definition: A record of the reason for delay, if any, before thrombolytic treatment is given. 00 No delay This means that there was no operational delay regardless of the time to treatment. 01 Sustained hypertension As defined by local protocol. 02 Clinical concern about recent cerebrovascular event or surgery If delay results from need to check on significance of recent cerebrovascular event or operative procedure. 03 Delay obtaining consent If patient requests delay - use only when the patient wishes to take time to consider use of a conventional (non trial) thrombolytic drug. Other delays obtaining consent, or arranging randomisation for a therapeutic study should be recorded under 98 Other. Acute Coronary Syndromes Dataset 22

23 04 Cardiac arrest Cardiac arrest includes an arrest occurring before arrival in hospital. 05 Obtaining consent for a therapeutic trial Consent for a therapeutic trial. Use only for an approved study 06 Hospital Administrative Failure Includes any valid procedural reason why thrombolytic treatment was delayed in hospital 07 Ambulance procedural delay 08 Ambulance 12 lead ECG not diagnostic of STEMI 09 Consideration for primary PCI 10 No identifiable reason for delay 98 Other including portering delay. This includes e.g. incorrect address or difficulty finding address, unable to gain entry to patient s house, patient reasons e.g. initial refusal to go to hospital or extended domestic arrangements, or adverse weather conditions. When initial ambulance ECG is not diagnostic of STEMI. Where consideration for primary PCI led to a delay in providing thrombolysis. On review of clinical case no valid reason for delay is obvious (retrospective data entry) Further Information: NHSQIS require 50% of patients to receive thrombolysis within 30 minutes of admission Where was Initial Reperfusion Treatment Given Definition: A record of where the initial reperfusion treatment was given. 01 Ambulance This includes the patient's home. 02 GP / Out of Hours 03 Community hospital 04 In A&E Regardless of who initiated treatment there. 05 In CCU (direct admission) A patient who enters CCU directly from an ambulance without assessment by hospital clinical staff before arrival. 06 In CCU (slowtrack) Implies admission via A&E or other assessment unit where a diagnosis of definite infarction was made, followed by transfer to CCU where thrombolytic treatment was initiated. 07 Elsewhere in hospital Includes acute admission units, general medical wards and catheter laboratories. Bleeding Complications as a Result of Reperfusion Therapy Definition: A record of bleeding complications due to reperfusion therapy. Acute Coronary Syndromes Dataset 23

24 Code Value 00 None 01 Intracranial bleed 02 Retroperitoneal bleed 03 Any other spontaneous bleed with Hb fall >= 5g or Hct > 15% 04 Bleed from any non-intracranial or non-retroperitoneal site with Hb fall > 3g and < 5 g 05 Bleed from any non-intracranial or non-retroperitoneal site with Hb fall <=3 g Further Information: This can be used for both thrombolytic treatment and any bleed post PCI. Options are listed in order of precedence: use the highest item that applies. Use if any antiplatelet/ anticoagulant/ fibrinolytic drug is thought to be responsible for bleeding. Reperfusion Outcome Definition: A record of the result of primary thrombolytic treatment prior to any further reperfusion treatment 01 Successful Reduction in ST Segment elevation by >50% within 90 minutes 02 Unsuccessful Persistent ST Segment elevation despite thrombolysis after 90 minutes 03 Not applicable Record if thrombolytic treatment is not administered Further Information: An example of primary thrombolytic therapy is an additional dose of thromboytic drug. Acute Coronary Syndromes Dataset 24

25 BLOOD RESULTS Data Items Data Item Definition Format Serum Total Cholesterol (Admission) {ACS} A record of a fasting sample serum total cholesterol level taken within 24 hours of nn.nn (mmol/l) Cardiac Enzymes/ Markers Raised Peak Serum Creatinine Kinase Peak Serum Troponin Troponin Assay admission A record of whether or not the patient has raised cardiac enzymes / markers The highest serum creatinine kinase level in a series of measurements. The highest serum troponin level in a series of measurements, during this admission. A record of the specific type of troponin assay used nnn (units) nnn.nn (units) Serum Total Cholesterol (Admission) {ACS} Definition: A record of a fasting sample serum total cholesterol level taken within 24 hours of admission Format: nn.nn (mmol/l) N/A Further Information: Cholesterol levels change within 24 hrs of an MI and do not return to normal levels for up to 3 months Cardiac Enzymes/ Markers Raised Definition: A record of whether or not the patient has raised cardiac enzymes / markers 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 Acute Coronary Syndromes Dataset 25

26 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 If the patient dies before bloods are taken enter 'Not known'. Peak Serum Creatinine Kinase Definition: The highest serum creatinine kinase level in a series of measurements. Format: nnn (units) N/A Further information: The biochemical definition of acute infarction and acute coronary syndromes has to take account of proposed changes of biochemical criteria which have not yet gained widespread agreement or acceptance. Entry of the peak value for the two markers allows either or both to be recorded. This allows for the reality that some Trusts are using different cut off points for troponin for the definition of infarction. The rest are likely still to be using creatine kinase (CK). Where serial CK levels are measured, the peak (highest) value should be recorded, but in situations where a single CK level is measured, this should be used. Peak Troponin Definition: The highest serum troponin level in a series of measurements. Format: nnn.nn (units) N/A Further information: These values are presently collected for future analysis when standardisation of troponin assay is feasible. Where serial troponin levels are measured, the peak (highest) value should be recorded, but in situations where a single troponin level is measured, this should be used. This data item should record the highest level during this admission. Troponin Assay Definition: A record of the specific type of troponin assay used. 01 Troponin I 02 Troponin T Acute Coronary Syndromes Dataset 26

27 Further information: It is important to know which assay type is used to measure troponin since different assays will have different reference ranges. Acute Coronary Syndromes Dataset 27

28 CHD RISK FACTORS Data Items Data Item Definition Format Smoking Status A record of tobacco consumption at date of contact. Family History of CHD A record of family history of premature CHD by diagnosis. Previous Myocardial A record of whether or not an Infarction individual has had a confirmed diagnosis of MI in the past confirmed by abnormal ECG findings e.g. Q-wave (and/or ETT and angiography results). Option for >1 with attached dates. Previous Angina A record of whether the patient has previously been diagnosed with angina. Hypertension A record of whether or not an individual is already receiving treatment (drug, dietary, or lifestyle) for hypertension, or has a record of BP > 140/90 Chronic Kidney Disease A record of whether or not the individual has chronic kidney disease. Diabetes Management The type(s) of management of a Previous Percutaneous Coronary Intervention (PCI) Previous Coronary Artery Bypass Graft (CABG) patient s diabetes. A record of whether or not reperfusion of coronary arterial blood-flow by PTCA was performed prior to this admission. A record of whether or not reperfusion of coronary arterial blood-flow by CABG was performed at any time prior to this admission. Smoking Status Definition: A record of tobacco consumption at date of contact. Acute Coronary Syndromes Dataset 28

29 10 Never smoked May have tried smoking once or twice 11 Ex smoker Has not smoked for at least 12 months 12 Current non-smoker Has stopped smoking within the past 12 months 13 Current smoker 97 Patient declined Patient chose not to disclose this information Further Information: Includes all types of tobacco consumption. Family History of CHD Definition: A record of family history of premature CHD by diagnosis. 00 No 01 Yes Further Information: A family history of CHD is pertinent in father or brother before 55 and mother or sister before 65. Previous Myocardial Infarction Common name: Previous MI, personal history of MI Definition: Record of whether or not an individual has had a confirmed diagnosis of MI in the past proven by ECG, cardiac enzymes or heart perfusion scan or other reliable methodology, but not on clinical features alone. 00 No 01 Yes Further information: Confirmed by history and/ or abnormal investigative findings e.g. Q-wave on ECG (and/or ETT and angiography results) indicative of STEMI. Recording guidance: Systems must allow for recording of multiple previous MI s, with associated dates. Previous Angina Acute Coronary Syndromes Dataset 29

30 Definition: A record of whether the patient has previously been diagnosed with angina. 00 No 01 Yes Further Information: Symptoms thought to be indicative of ischaemic cardiac pain either at rest or on exertion existing at least two weeks prior to this admission. Symptoms indicative of ischaemic heart disease include chest pain of cardiac nature at rest or on exertion which may be relieved by rest and/or medical therapy e.g. administration of nitrates. Note: This standard will be updated when a new definition of Acute Coronary Syndrome is available Hypertension Common name: HBP Definition: A record of whether or not an individual is already receiving treatment (drug, dietary, or lifestyle) for hypertension, or has a record of BP > 140/90 00 No 01 Yes Further information: The patient must have a BP >140/90 on two occasions prior to admission. Note: The definition of 'hypertension' is subject to periodic revision. The prevailing definition at the time of data recording should be used. This definition complies with current WHO-ISH and SIGN guidelines and will be updated to comply with new SIGN guidelines when they are available. Chronic Kidney Disease Common name: CKD Main source of standard: US National Kidney Foundation Definition: Record of whether or not the individual has chronic kidney disease. Acute Coronary Syndromes Dataset 30

31 00 No 01 Yes Further information: CKD is defined as either kidney damage or Glomerular Filtration Rate (GFR) <60mL/min/1.73m 2 for 3 months, where kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. This is the US National Kidney Foundation definition for Chronic Kidney Disease as published in Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification which can be found at: US National Kidney Foundation - K/DOQI guidelineshttp:// This definition will almost certainly be adopted by renal services and registries in both Scotland and England. The formula for calculation of estimated GFR is: e GFR = x SCr x age x (if female) x (if black) e GFR is reported in ml/min/1.73 m 2 SCr: serum creatinine in mg/dl (divide by 88.4 to convert from mol/l) CKD Stage Description egfr (ml/min/1.73m 2 ) 1 Kidney damage + normal or GFR >90 2 Kidney damage + mild GFR Moderate GFR Severe GFR Kidney failure <15 (or dialysis) Diabetes Management Definition: The type(s) of management of a patient s diabetes 00 None 01 Dietary Control 02 Oral Hypoglycaemic 03 Insulin 04 Not yet established Newly diagnosed diabetes for which definitive management has not yet been established Acute Coronary Syndromes Dataset 31

32 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. 00 No 01 Yes Previous Coronary Artery Bypass Graft (CABG) Definition: A record of whether or not reperfusion of coronary arterial blood-flow by CABG was performed at any time prior to this admission. 00 No 01 Yes Acute Coronary Syndromes Dataset 32

33 INVESTIGATIONS DURING ADMISSION Data Items Data Item Definition Format Exercise tolerance test A record of whether or not an individual has undergone an exercise tolerance test. Reason for no Exercise An explanation of why an tolerance test exercise tolerance test was not performed where it might be expected to be performed, e.g. when clinical guidelines recommend echo should be performed Echocardiography A record of whether or not echocardiographic investigation has been performed LV function as result of echocardiogram Reason for not performing echocardiogram Referral for coronary angiography Date of referral for coronary angiogram Coronary angiography during this admission {ACS} Date of coronary angiogram A high level report on the findings of an echocardiography investigation, with reference to abnormalities which may be related to ischaemic heart disease and/or valvular disease. An explanation of why no echocardiogram was performed where it might be expected to be performed, e.g. when clinical guidelines recommend echo should be performed A record of referral for coronary angiography in another hospital A record of the date a patient was referred for coronary angiogram A record of whether or not coronary angiography investigation has been performed for delineation of coronary arterial blood-flow during this admission A record of the date when a coronary angiogram was performed. 10 characters (CCYY- MM-DD) 10 characters (CCYY- MM-DD) Exercise Tolerance Test Common name: ETT, Exercise ECG Definition: A record of whether or not an individual has undergone an exercise tolerance test. Acute Coronary Syndromes Dataset 33

34 Code Value Explanatory Notes 00 No ETT not performed 01 Yes 02 Planned Includes requested and referred for 99 Unknown Related data items: Reason for no Exercise Tolerance Test Further information: For various clinical conditions, specific clinical guidelines recommended ETT investigation. Whether or not an ETT was performed in line with such guidelines may be needed to assess the quality of clinical care, as in the GMS Quality Outcomes Framework. Exercise tolerance testing (ETT) has been shown to be of value in assessing prognosis of patients with coronary artery disease. An ETT is also helpful in patients at high risk of CHD, where a positive test can provide useful prognostic information. (Ref. SIGN 51) Reason for no Exercise Tolerance Test Common name: Reason for no ETT, Reason for no exercise ECG Definition: An explanation of why an exercise tolerance test was not performed where it might be expected to be performed, e.g. when clinical guidelines recommend echo should be performed 00 No reason No reason why ETT not performed 01 Contraindicated Generally acknowledged clinical contraindication to performing ETT exists, e.g. physically incapable of performing the test, may have aortic stenosis or cardiomyopathy 02 Not indicated No clinical indication for ETT e.g. diagnosis of CHD is unlikely or the results of stress testing would not affect management 03 Clinical decision Clinical judgement of inappropriateness of ETT investigation in an individual patient due to their specific set of circumstances 04 Not available ETT investigation not available 05 Not applicable 06 Patient declined Patient chose not to have ETT Related data items: Exercise Tolerance Test Acute Coronary Syndromes Dataset 34

35 Further information: Exercise tolerance testing (ETT) is used principally to identify patients with reversible myocardial ischaemia who might benefit from revascularisation. (Ref. SIGN 41) Echocardiography Common name: Echo, Cardiac ultrasound Definition: A record of whether or not echocardiographic investigation has been performed. 00 No Not performed 01 Yes 02 Planned Includes requested and referred for 99 Unknown Sub data item: Type of echocardiogram: 1 Transthoracic 2 Transoesophageal 3 Mitral 4 Atrial Related data items: Echocardiogram Results {CHD} Reason for no Echocardiogram Further information: The Echocardiography must be performed during this admission. Echocardiography is established as the standard means of assessing cardiac structure and function in clinical practice. It permits measurement of left ventricular size, shape, wall thickness, contraction, and relaxation. In addition, valve structure and function can be assessed and thrombus detected. Right ventricular measurements can also be made and pericardial effusion excluded. (Ref. SIGN 35) It is used to assess patient s post-mi, in those with heart failure, valvular heart disease or congenital heart disease. For various clinical conditions, specific clinical guidelines recommended echo investigation. Whether or not an echo was performed in line with such guidelines may be needed to assess the quality of clinical care. LV Function as Result of Echocardiogram Common name: Echo Results {CHD} Definition: A high level report on the findings of an echocardiography investigation, with reference to abnormalities which may be related to ischaemic heart disease and/or valvular disease. Format: 3 characters Acute Coronary Syndromes Dataset 35

36 Code Value Sub cod e 00 Normal 01 Abnormal 02 Inconclusive 99 Unknown Sub value Explanatory Notes Abnormalities detected on echo, but nature of abnormality not specified A LV impairment Echo suggestive of left ventricular impairment B LV hypertrophy Echo suggestive of left ventricular hypertrophy C Significant valve Echo suggestive of D E disease Non-significant valve disease Other abnormality significant valve disease Echo suggestive of nonsignificant valve disease Related data items: Echocardiogram (Investigation) Recording guidance: Multiple abnormalities may be recorded. Reason for No Echocardiography Common name: Reason for no Echo Definition: An explanation of why no echocardiogram was performed where it might be expected to be performed, e.g. when clinical guidelines recommend echo should be performed. 00 No reason No reason why Echo not performed 01 Contraindicated Generally acknowledged clinical contraindication to performing Echo exists, e.g. physically incapable of performing the test 02 Not indicated No clinical indication for Echo 03 Clinical decision Clinical judgement of inappropriateness of Echo investigation in an individual patient due to their specific set of circumstances 04 Not available Echo investigation not available 05 Not applicable 06 Patient declined Patient chose not to have Echo 99 Unknown Related data items: Echocardiography (Investigation) Referral for Coronary Angiography Acute Coronary Syndromes Dataset 36

37 Definition: A record of referral for coronary angiography in another hospital. 00 No Not performed 01 Yes 02 Planned Includes requested and referred for Date of Referral for Coronary Angiogram Definition: A record of the date a patient was referred for coronary angiogram Format: 10 characters (CCYY-MM-DD) N/A Sub data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Not known Recording guidance: Valid date >1/1/2000 and <= today. Coronary Angiography During This Admission {ACS} Definition: A record of whether or not coronary angiography investigation has been performed for delineation of coronary arterial blood-flow during this admission 00 Not performed 01 Protocol driven investigation performed in this hospital 02 Symptom driven investigation performed in this hospital 03 Protocol driven investigation performed at another hospital/centre 04 Symptom driven investigation performed at another hospital/centre 05 Not indicated Clinician considers angiography necessary for management in the absence of continuing clinical symptoms. Angiography performed for continuing symptoms. Clinician considers angiography necessary for management in the absence of continuing clinical symptoms. Angiography performed for continuing symptoms. Acute Coronary Syndromes Dataset 37