2018 AQI NACOR DATA ELEMENT CONCEPTUAL …

1 2018 AQI NACOR data ELEMENT CONCEPTUAL DEFINITIONS VERSION JANUARY 2018 Page 1 of 94 2018 AQI NACOR data ELEMENT CONCEPTUAL DEFINITIONS Version January 2018 This document clarifies data ELEMENT CONCEPTUAL definitions and intent. Synonyms, examples, exclusions and/or notes are included where appropriate and available. Clarifications to these will be made on an as-needed basis. Updates to the official CONCEPTUAL definitions will be made on an annual basis. Comments or recommendations should be sent to This version includes the data elements in AQI NACOR data ELEMENT CONCEPTUAL Definitions and a new set of comorbidity data elements released in December 2017.

2 AQI NACOR data ELEMENT CONCEPTUAL Definitions for Use During CY 2018 December 2017 Page 2 of 94 TABLE OF CONTENTS MINIMUM data SET data elements .. 10 ANESTHESIA START TIME .. 10 ANESTHESIA END (FINISH) TIME .. 10 ANESTHESIA TYPE .. 10 ANESTHESIA PHYSICAL STATUS CLASSIFICATION .. 12 CPT CODE ANESTHESIA .. 15 CPT CODE SURGICAL .. 15 DATE OF SERVICE .. 15 FACILITY ID .. 15 ICD CODE .. 15 PATIENT AGE .. 16 PATIENT DATE OF 16 PATIENT SEX .. 16 PAYMENT METHOD .. 17 PROVIDER CREDENTIALS .. 17 PROVIDER ID .. 19 PROVIDER NPI NUMBER .. 20 UNIQUE ANESTHESIA EPISODE OF CARE ID .. 20 ADMINISTRATIVE data elements .

3 21 ADMISSION STATUS .. 21 COVERAGE CODE .. 21 LOCATION .. 24 PATIENT CHARACTERISTICS .. 29 PROCEDURE STATUS .. 30 TIME .. 30 OUTCOME data elements .. 32 32 ACIDEMIA .. 32 ACUTE KIDNEY INJURY (AKI) .. 32 ADVERSE DRUG REACTION (ADR) .. 32 AIRWAY OBSTRUCTION .. 32 AIRWAY TRAUMA .. 33 AMNIOTIC FLUID EMBOLISM .. 33 ANAPHYLAXIS .. 33 ARRHYTHMIA .. 33 AQI NACOR data ELEMENT CONCEPTUAL Definitions for Use During CY 2018 December 2017 Page 3 of 94 ASPIRATION .. 33 AWARENESS .. 34 BRADYCARDIA .. 34 BURN INJURY .. 34 CANNOT VENTILATE .. 34 CARDIAC ARREST .. 34 CASE CANCELLED BEFORE ANESTHESIA START TIME.

4 35 CASE CANCELLED BEFORE ANESTHESIA INDUCTION TIME .. 35 CASE CANCELLED AFTER ANESTHESIA INDUCTION TIME .. 35 CASE DELAY .. 35 CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION (CLABSI) .. 36 CENTRAL LINE PLACEMENT INJURY .. 36 CEREBROVASCULAR ACCIDENT .. 36 COAGULOPATHY .. 36 COMA .. 37 CORNEAL INJURY .. 37 DEATH .. 37 DEEP VEIN THROMBOSIS .. 37 DELAYED EMERGENCE .. 38 DELIRIUM .. 38 DIFFICULT 38 DIFFICULT MASK VENTILATION .. 38 ELECTROLYTE ABNORMALITY .. 39 EMERGENCE DELIRIUM .. 39 EQUIPMENT/DEVICE FAILURE OR MALFUNCTION .. 39 FAILED INTUBATION .. 39 FALL .. 40 FAT EMBOLISM .. 40 HEMODYNAMIC INSTABILITY.

5 40 HIGH SPINAL OR EPIDURAL .. 40 40 HYPERGLYCEMIA .. 40 HYPERTENSIVE EPISODE .. 41 HYPERTHERMIA .. 41 HYPOGLYCEMIA .. 41 HYPOTENSIVE EPISODE .. 41 HYPOXEMIA .. 41 AQI NACOR data ELEMENT CONCEPTUAL Definitions for Use During CY 2018 December 2017 Page 4 of 94 INADEQUATE PAIN CONTROL .. 42 INADEQUATE REVERSAL OF NEUROMUSCULAR BLOCK .. 42 INFECTION FOLLOWING EPIDURAL OR SPINAL ANESTHESIA .. 42 INFECTION FOLLOWING PERIPHERAL NERVE BLOCK .. 43 ITCHING .. 43 IV INFILTRATION .. 44 KIDNEY FAILURE .. 44 LOCAL ANESTHETIC SYSTEMIC TOXICITY .. 44 MALIGNANT 44 MEDICATION ERROR .. 44 MULTIPLE ORGAN FAILURE.

6 45 MYOCARDIAL INFARCTION .. 45 MYOCARDIAL 45 OR FIRE .. 46 PERIOPERATIVE VISUAL LOSS .. 46 PERIPHERAL NEUROLOGIC DEFICIT AFTER REGIONAL ANESTHESIA .. 46 PNEUMONIA .. 46 PNEUMOTHORAX .. 47 POSITIONING INJURY .. 47 POSTDISCHARGE NAUSEA AND VOMITING .. 47 POSTDURAL PUNCTURE HEADACHE .. 48 POSTOPERATIVE COGNITIVE DYSFUNCTION .. 48 POSTOPERATIVE NAUSEA AND VOMITING .. 48 PROLONGED NEUROMUSCULAR BLOCK .. 48 PULMONARY EDEMA .. 49 PULMONARY EMBOLUS .. 49 RESPIRATORY ARREST .. 49 RESPIRATORY FAILURE .. 49 SEIZURE .. 49 SEPSIS .. 49 SHIVERING .. 50 SKIN OR MUCOUS MEMBRANE INJURY .. 50 SPINAL CORD INJURY .. 50 SPINAL HEMATOMA FOLLOWING SPINAL OR EPIDURAL ANESTHESIA.

7 50 SURGICAL SITE INFECTIONS (SSI) .. 50 TRANSFUSION REACTION .. 51 ULCER .. 51 AQI NACOR data ELEMENT CONCEPTUAL Definitions for Use During CY 2018 December 2017 Page 5 of 94 UNANTICIPATED TRANSFUSION .. 51 UNPLANNED CONVERSION TO GENERAL ANESTHESIA .. 52 UNPLANNED DURAL PUNCTURE .. 52 UNPLANNED ENDOBRONCHIAL INTUBATION .. 52 UNPLANNED ESOPHAGEAL INTUBATION .. 53 UNPLANNED HOSPITAL ADMISSION .. 53 UNPLANNED HYPOTHERMIA .. 53 UNPLANNED ICU ADMISSION .. 53 UNPLANNED POSTOPERATIVE VENTILATION .. 53 UNPLANNED REINTUBATION .. 54 UNPLANNED REOPERATION .. 54 UNPLANNED TRACHEAL EXTUBATION .. 54 VASCULAR INJURY.

8 54 VENOUS AIR EMBOLISM .. 55 VENTILATION FOR MORE THAN 24 HOURS POST PROCEDURE .. 55 WRONG PATIENT .. 55 WRONG PROCEDURE .. 55 WRONG SITE REGIONAL ANESTHESIA .. 55 WRONG SITE SURGERY .. 56 OUTCOME SEVERITY .. 56 OUTCOME TIME FRAME .. 57 COMORBIDITY data elements .. 59 CARDIOVASCULAR .. 59 ARTERIAL VASCULAR DISEASE .. 59 CARDIAC ARRHYTHMIA AND CONDUCTION ABNORMALITIES .. 59 2ND DEGREE HEART BLOCK .. 59 3RD DEGREE HEART BLOCK .. 59 ATRIAL FIBRILLATION .. 60 ATRIAL FLUTTER .. 60 AICD PRESENT .. 60 CONGENITAL LONG QT SYNDROME .. 60 LEFT BUNDLE BRANCH BLOCK .. 60 OTHER PAROXYSMAL TACHYCARDIA (MAT, PAT, ECTOPIC ATRIAL TACHYCARDIA, AVNRT).

9 60 PACEMAKER DEPENDENT .. 60 SI CK SINUS SYNDROME .. 60 VENTRICULAR FIBRILLATION .. 61 VENTRICULAR TACHYCARDIA .. 61 AQI NACOR data ELEMENT CONCEPTUAL Definitions for Use During CY 2018 December 2017 Page 6 of 94 CONGENITAL HEART DISEASE STATUS .. 61 CONGENITAL HEART DISEASE STRUCTURAL DEFECTS .. 61 ANOMALOUS PULMONARY VENOUS RETURN .. 61 ATRIAL SEPTAL DEFECT .. 62 ATRIOVENTRICULAR CANAL DEFECT .. 62 COARCTATION OF THE 62 COR TRIATRIATUM .. 62 62 DOUBLE OUTLET RIGHT VENTRICLE .. 62 EBSTEIN S ANOMALY .. 62 HYPOPLASTIC LEFT HEART SYNDROME .. 62 INTERRUPTED AORTIC ARCH .. 62 PATENT DUCTUS ARTERIOSUS.

10 63 SHONE S COMPLEX .. 63 TETRALOGY OF FALLOT .. 63 TRANSPOSITION OF THE GREAT VESSELS .. 63 TRUNCUS ARTERIOSUS .. 63 VENTRICULAR SEPTAL DEFECT .. 63 CONGESTIVE HEART FAILURE (CHF) TIME OF MOST RECENT EPISODE .. 63 CONGESTIVE HEART FAILURE (CHF) TYPE .. 64 ELEVATED PULMONARY VASCULAR RESISTANCE AND PULMONARY HYPERTENSION .. 65 HISTORY OF ANGINA WITHIN 1 MONTH OF THE DATE OF THE ANESTHESIA START TIME .. 65 HISTORY OF MYOCARDIAL INFARCTION .. 65 HISTORY OF PREVIOUS PERCUTANEOUS CORONARY INTERVENTION .. 66 HYPERTENSION REQUIRING MEDICATION .. 67 LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION .. 67 RIGHT VENTRICULAR FAILURE.