ACS NSQIP Pediatric SCR: Complex Clinical Scenarios and Variable Review

Transcription

1 ACS NSQIP Pediatric SCR: Complex Clinical Scenarios and Variable Review

2 Disclosures The following planners, speakers, moderators, and/or panelists of the CME/CEU activity have no relevant financial relationships with commercial interest to disclose: Jacqueline Saito, MD, FACS Catherine Grant BSN, RN Claudia Byrd BS, RN

3 AGENDA Review Difficult Definitions Quiz

4 14 Patient with a subgaleal shunt in place Planned removal and placement of ventricular peritoneal shunt The VP shunt procedure is the principal operative procedure. No, would be selected for the variable of First Time Permanent Shunt, and the additional shunt variables would not be abstracted for this case. A True B False

5 14 No, would be selected for the variable of First Time Permanent Shunt, and the additional shunt variables would not be abstracted for this case. ANSWER B False Rationale: The VP shunt would be considered a first time permanent shunt. A subgaleal shunt is considered a temporary measure. The CSF shunt variables would be abstracted for this case.

6 15 12 year-old girl presents for an external ventricular drain (EVD) placement Hydrocephalus due to a brain tumor Tumor resection is planned three days after the EVD placement EVD placement on 3/5 is the principal operative procedure Subsequent procedures: 3/8-tumor resection performed 3/12-EVD was internalized to ventriculoperitoneal (VP) shunt 3/16-VP shunt to EVD for infection 3/29-EVD to VP shunt

7 15 Subsequent procedures: 3/8-tumor resection performed 3/12-EVD was internalized to ventriculoperitoneal (VP) shunt 3/16-VP shunt to EVD for infection 3/29-EVD to VP shunt How many (if any) Unplanned Reoperations would be assigned to this case? A 1 B 2 C 3

8 15 How many (if any) Unplanned Reoperations would be assigned to this case? ANSWER C 3 Rationale: Three Unplanned Reoperations would be assigned to this case. The 3/8, 3/16, and 3/29 cases would be considered unplanned as they were not planned at the time of the principal operative procedure.

9 EVD Scenario 15: Key Points If the EVD was the principal operative procedure or in place at the time of the principal operative procedure, the subsequent removal or permanent shunt placement would be considered planned. If an unplanned EVD is placed after the principal operative procedure any subsequent removal or permanent shunt placement would then also be considered unplanned.

10 2 6-week-old former 26-week gestation male infant Past history of medically managed necrotizing enterocolitis Status post patent ductus arteriosus ligation Currently on a ventilator with documented bradycardic episodes Last nursing check the patient noted to have hematochezia and abdominal distention Emergent abdominal x-ray-abdominal free air noted WBC count was 35 Underwent an exploratory laparotomy

11 2 6-week-old former 26-week gestation male infant Operative Notes: Small intestine, resection: Generalized diffuse necrotizing enterocolitis extending to both proximal and distal cecal resection margins. - Perforation with focal diffuse purulent serositis noted. POD 1 dopamine started, WBC 37, and HR 181 Surgeon noted: hemodynamic instability requiring dopamine, severe hypoxia with worsening CXR. Based on this information, would postoperative Sepsis be assigned to this case? A B C None Sepsis would be assigned to this case. Septic shock would be assigned to this case.

12 2 Would postoperative Sepsis be assigned to this case? ANSWER C Septic shock would be assigned to this case. Rationale: Although Sepsis was present preoperatively, progression to Septic Shock postoperatively is assigned as the Postoperative Occurrence of Septic Shock. SIRS: WBC 37, and HR 181 Infection criteria met (intraoperative findings) and dopamine initiated.

13 Sepsis Scenario 2: Sepsis Key Points If sepsis present preoperatively, Postoperative Sepsis assigned only with new infection source or if patient progresses to Septic Shock

14 2 6-week-old male infant underwent an exploratory laparotomy as Principal Operative Procedure Prematurity: Born at 26 weeks gestational age Respiratory Respiratory distress syndrome of newborn Gastrointestinal Feeding problems in newborn Central Nervous System Disturbance of temp regulation Bilateral grade II IVH Cardiac Patent ductus arteriosus s/p ligation Persistent pulmonary hypertension Hematologic Anemia of neonatal prematurity GU: Bilateral hydronephrosis Endocrine: Congenital hypothyroidism Skeletal: Polydactyl

15 2 What preoperative Congenital Malformations would you assign to this case? A B C D Extreme prematurity, pulmonary immaturity, cholestasis Respiratory distress syndrome, extreme prematurity Congenital hypothyroidism, persistent pulmonary hypertension, prematurity Congenital hypothyroidism

16 2 ANSWER D Congenital hypothyroidism Rationale: Diagnosis is on the Collect List

17 2 6-week-old male infant underwent an exploratory laparotomy as Principal Operative Procedure Prematurity: Born at 26 weeks gestational age Respiratory Respirator distress syndrome of newborn Gastrointestinal Feeding prblems in newborn Central Nervous System Disturbance of temp regulation Bilateral grade II IVH Cardiac Patent ductus arterios s/p ligation Persistent pulmonary hypertension Hematologic Anemia of neonatal prematurity GU: Bilateral hydronephrosis Endocrine: Congenital hypothyroidism Skeletal: Polydactyl

18 2 What would be assigned for the risk factor of Premature Birth? A B C D 24 completed weeks of gestation completed weeks of gestation completed weeks of gestation Unknown

19 2 ANSWER B completed weeks of gestation Rationale: The patient was born at 26 weeks gestation. This would indicate the patient completed 26 weeks of gestation.

20 2 6-week-old male infant underwent an exploratory laparotomy as Principal Operative Procedure Past surgical history status post patent ductus arteriosus ligation Cardiac Patent ductus arterios s/p ligation Persistent pulmonary hypertension What would be assigned for Cardiac Risk Factors and which Cardiac Diagnosis(es) would be entered into the workstation? A B C D No Cardiac Risk Factors Minor Cardiac Risk Factors Major Cardiac Risk Factors Severe Cardiac Risk Factors

21 2 What would be assigned for Cardiac Risk Factors and which Cardiac Diagnosis(es) would be entered into the workstation? ANSWER C Major Cardiac Risk Factors Rationale: Highest level of cardiac risk assigned Pulmonary Hypertension Major Patent ductus arteriosus (PDA) repaired Minor Diagnoses entered into workstation Pulmonary Hypertension Patent ductus arteriosus (PDA) repaired 747.0

22 2 6-week-old male infant underwent an exploratory laparotomy as Principal Operative Procedure Past medical history NEC Past surgical history status post patent ductus arteriosus ligation What would be assigned for the variable, Previous Cardiac Surgery/Cardiac Intervention? A Yes B No

23 2 What would be assigned for the variable, Previous Cardiac Surgery/Cardiac Intervention? ANSWER A Yes Rationale: Patient has history of PDA ligation

24 Congenital malformations Scenario 2: Key Points Some have no age requirement for diagnosis e.g. Malrotation (5 year old), Hirschsprung s disease (teenager) Other malformations specific age requirement e.g. Scoliosis may be congenital or acquired (include only if diagnosed <4 years old) Marked with asterisk*** in Collect List Please send questions to Clinical Support Used in revising Collect List

25 Scenario 2: Key Points During chart review, start with diagnoses, not ICD-9 codes Enter ICD-9 codes for diagnoses on Collect List into workstation Collect List ICD-9 code selected as broad, may differ from hospital record ICD-9 or ICD-10 code Congenital Malformation Collect List will not be updated to ICD-10 codes Enter congenital malformations that also apply to other preoperative variables in workstation e.g. Malrotation also collected in Esophageal/Gastric Disease/Intestinal variable

26 Scenario 2: Key Points 3 Cardiac Variables Previous Cardiac Surgery/Cardiac Intervention Cardiac ICD-9 Code Cardiac Risk Factors Review chart for cardiac disease (active diagnosis or history), including echocardiogram report, anesthesia note, etc. Repaired cardiac defect assigned unless spontaneous resolution documented (conditions with asterisk*** in list) Diagnostic cardiac catheterization not considered previous cardiac surgery in NSQIP-Peds

27 Scenario 2: Key Points Start with cardiac diagnoses recorded in medical record, not ICD-9 codes Do not record ICD-9 codes from medical record diagnosis lists unless confirmed by documentation and on Collect List Cardiac collect list will not be updated to ICD-10 codes ICD-9 codes used instead lieu of text names for database purposes Enter into the workstation associated ICD-9 code from Collect List Determine/classify most severe Cardiac Risk Factor listed on Collect List Check if cardiac diseases with asterisk documented as spontaneously resolved in medical record Record cardiac diagnoses based on Collect List regardless of medical record description as trivial, mild, moderate or severe

28 5 Four-year-old girl had a C3-T7 fusion with segmental instrumentation and a halo placement. On POD 3: Productive cough, tachypneic (48 breaths/min), Tmax 101⁰ F Pt. placed on 2 L/min oxygen by NC Chest x-ray impression: No acute pulmonary process. No focal pulmonary consolidation is seen. No pleural effusion or pneumothorax is identified. The cardiomediastinal silhouette is normal. The visible bony thorax is intact. Attending physician note: chest x-ray negative but clinical picture consistent with pneumonia. Start antibiotics.

29 5 Would the postoperative occurrence of Pneumonia be assigned to this case? A B Yes No

30 5 Would the postoperative occurrence of Pneumonia be assigned to this case? ANSWER B No Rationale: Pneumonia would not be assigned as the radiologic component of the pneumonia was not met. Imaging: no infiltrate, consolidation, opacity, nor cavitation Vital signs: T 101 F Signs/symptoms: New cough Increased oxygen requirement

31 Postoperative Pneumonia (multiple requirements) Imaging Scenario 5: Key Points Two imaging tests required for patients with underlying pulmonary or cardiac disease Asthma not considered pulmonary disease requiring two chest radiologic exams Labs Signs and Symptoms Multiple Scenarios (A-D) Scenarios A and B can be utilized for any age

32 4 A 16 year-old patient was involved in a car accident Suffered compound fracture of the ulna Degloving of ankle and foot Would this case be included for abstraction as a principal operative procedure, if all other systematic sampling criteria are met? A B Yes No

33 4 A 16 year-old patient was involved in a car accident Suffered compound fracture of the ulna Degloving of ankle and foot Would this case be included for abstraction as a principal operative procedure, if all other systematic sampling criteria are met? ANSWER B No Rationale: This case would be excluded as it involves more than one system as there was a fracture and degloving injury. The location of the injuries occurred on different limbs

34 4 14-year-old boy suffered an injury playing basketball He suffered one continuous clean break involving both the tibia and fibula without any other injuries. He went to the OR the next day, and his diagnosis code lands in the S80 realm. Would this case be included for abstraction as a principal operative procedure, if all other systematic sampling criteria are met? A B Yes No

35 4 14-year-old boy suffered one continuous clean break involving both the tibia and fibula without any other injuries. Would this case be included for abstraction as a principal operative procedure, if all other systematic sampling criteria are met? ANSWER A Yes Rationale: This case would be eligible for abstraction as it occurred in the same isolated limb section.

36 4 5 year-old presents to your hospital with a history of tracheostomy dependence and subglottic stenosis Multiple microlaryngoscopy and bronchoscopy (MLB) procedures with dilations reconstruction in May of 2012-with subsequent restenosis Revision 3/2017 Stent removal 5/5 (not captured in NSQIP) On 5/16/17, this patient falls into your cycle for microlaryngoscopy with endoscopic removal of suprastomal granulation tissue and balloon dilation Should the 5/16/17 case be included for abstraction as a principal operative procedure, if all other systematic sampling criteria are met? A B Yes No

37 4 5 year-old presents to your hospital with a history of tracheostomy dependence and subglottic stenosis Would this case be included for abstraction as a principal operative procedure, if all other systematic sampling criteria are met? ANSWER A Yes Rationale: This case appears to be related to disease progression rather than a complication of the prior surgery and would be abstracted as a principal operative procedure.

38 4 5 year-old presents to your hospital with a history of tracheostomy dependence and subglottic stenosis Multiple microlaryngoscopy and bronchoscopy (MLB) procedures with dilations reconstruction in May of 2012-with subsequent restenosis Revision 3/2017 Stent removal 5/5 (not captured in NSQIP) On 5/16/17, this patient falls into your cycle for microlaryngoscopy with endoscopic removal of suprastomal granulation tissue and balloon dilation Would you collect the Procedure Specific/Targeted Tracheostomy variables for this case? A B Yes No

39 4 5 year-old presents to your hospital with a history of tracheostomy dependence and subglottic stenosis Would you collect the Procedure Specific/Targeted Tracheostomy variables for this case? ANSWER B No Rationale: In this scenario, the patient already had a tracheostomy prior to the 5/16 case. Additionally, the patient is over the age of two. Collect variables when: Patient less than two years of age and included CPT code Tracheostomy is the principal operative procedure (the tracheostomy was not the principal operative procedure in this scenario).

40 Inclusion/Exclusion: Scenario 4: Key Points Only one case, per patient, per 30 days can be abstracted in NSQIP Related to attribution of occurrence to a specific procedure Procedures performed due to pathology are not considered complications Procedures performed to treat the patient s underlying disease/problem are not considered complications Cases within the trauma range would be excluded Include cases where there is an isolated limb section fracture and included CPT code Send questions to Clinical Support if clarification is needed

41 1 25 month-old patient with encephalocele repair at an outside hospital approximately a year and a half ago. Presents to ED Mental status changes and acute respiratory distress Concerns for acute hydrocephalus EVD placed urgently Ventriculoperitoneal shunt placed (principal operative procedure)on 6/9 EVD removed Uneventful hospital course Discharged 6/11

42 1 25 month-old patient with encephalocele repair at an outside hospital approximately a year and a half ago. VP shunt placed 6/9. Presents to ED on 6/19 Fever 39.0 C, HR 170, and increased fussiness on 6/19 Returned to the OR on 6/20 A VP shunt removal CSF culture positive What would be assigned for the postoperative occurrence of Sepsis/Septic Shock? None B C D SIRS Sepsis Septic Shock

43 1 What would be assigned for the postoperative occurrence of Sepsis/Septic Shock? ANSWER B Sepsis Rationale: Patient met SIRS criteria 39.0 C and HR 170 Positive CSF culture from reoperation without evidence of a preoperative infection (new source of infection)

44 1 25 month-old patient with encephalocele repair at an outside hospital approximately a year and a half ago. VP shunt placed 6/9. Presents to ED on 6/19 Fever 39.0 C, HR 170, and increased fussiness on 6/19 Returned to the OR on 6/20 VP shunt removal CSF culture positive Which wound occurrence would be assigned to this case? A B C D Superficial Incisional SSI Deep Incisional SSI Organ/Space SSI None

45 1 Which wound occurrence would be assigned to this case? ANSWER C Organ/Space SSI Rationale: Organ/Space SSI criteria met by positive CSF culture Organ/Space SSI criteria: Purulent drainage from drain placed through stab wound into organ/space Organisms isolated from aseptically obtained culture of fluid or tissue in organ/space Abscess or other evidence of infection involving organ/space found on direct examination, during reoperation, or by histopathologic or radiologic examination* Diagnosis of organ/space SSI by surgeon or attending physician

46 1 25 month-old patient with encephalocele repair at an outside hospital approximately a year and a half ago. VP shunt placed 6/9. Presents to ED on 6/19 Fever 39.0 C, HR 170, and increased fussiness on 6/19 Returned to the OR on 6/20 VP shunt removal CSF culture positive Should Unplanned Reoperation be assigned? A B Yes No

47 1 Should Unplanned Reoperation be assigned? ANSWER A Yes Rationale: The 6/20 procedure was not planned at the time of the principal operative procedure on 6/9. The procedure occurred in the operating room.

48 Postoperative SSI differs from Postoperative Sepsis If sepsis present preoperatively, Postoperative Sepsis assigned only with new infection source or if patient progresses to Septic Shock SSI Assign all SSIs meeting variable criteria SSIs assigned whether infection new or continuation of infection present during principal operative procedure Unplanned Reoperation Scenario 1: Sepsis Key Points A Return to OR must occur either in a Main OR, or in the ICU Excludes procedures done in radiology suites, other procedure rooms, etc., from Unplanned Reoperation, even though these settings might otherwise be eligible for index cases

49 5 14 year-old girl with Scheuermann's kyphosis Posterior spine fusion (principal operative procedure) Received 500 mls of PRBCS of cell saver Postoperative Day 2 Received 300 mls of allogeneic PRBCs This information would be entered on either the Essential case form or the Spine Procedure targeted variables. This would not be entered in all three fields. A B True False

50 5 14 year-old girl with Scheuermann's kyphosis Posterior spine fusion (principal operative procedure) Received 500 mls of PRBCS of cell saver Postoperative Day 2 Received 300 mls of allogeneic PRBCs ANSWER B False Rationale: The volumes would be entered in all three fields. Essentials Variable: Transfusion Intraop/Postop (RBC Within The First 72 Hours of the Surgery Start Time)-800 ml Spine Variables: Intraoperative Transfusion-500 ml Volume Postoperatively (RBC Volume started after Procedure/Surgery Finish Time through the first 72 hours from the Procedure/Surgery Start Time)-300 ml