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Terminology

Frequently asked about specific fields from the anesthestic record.

Over the years we have developed and refined very detailed interfaces for many systems, including Epic and Cerner anesthesia modules.

Patient

Last Name

Type: String
Description: Patient’s last name

First Name

Type: String
Description: Patient’s first name

Middle Name

Type: String
Description: Patient’s middle name

Date of Birth

Type: Date
Format: YYYYMMDD
Description: Patient’s date of birth

Gender

Type: String
Values: M, F, U (M = Male, F = Female, U = Unknown)
Description: Patient’s gender

Medical Record Number

Type: String
Description: Patient’s ID number associated with their entire medical record, and not specific to any single hospital visit/admission.

Encounter Number

Type: String
Description: Patient’s ID number associated with a single hospital visit/admission. An Encounter Number may also be referred to as a Visit Number or Account Number. Importantly, the Encounter Number is barcoded on the patient’s wrist band and is used to identify the patient’s current admission.

Place of Service Code

Type: String
Values: IP, AMB (IP = Inpatient, AMB = Ambulatory)
Description: This specifies the type of entity where service(s) were rendered. Commonly coded as a value of “21”, “22” or “24”. QCDRs require this information to be submitted with their quality data.

ASA Status with Emergency

Type: String
Values: 1, 1E, 2, 2E, 3, 3E, 4, 4E, 5, 5E, 6.
Description: Identifies severity of the patient’s clinical condition.

Primary Anesthetic

Type: String
Values: GENERAL, MAC, SPINAL, REGIONAL, EPIDURAL, LABOR_EPIDURAL, TOPICAL
Description: This is the primary type of anesthetic used for the procedure. Even if multiple techniques were used, only one should be selected for this field. Typically when Regional is used in cobmination with General, a “General” anesthetic will be selected.

Care Team

Surgeon NPI

Type: Numeric
Description: The 10-digit number assigned to the surgeon of record.

Anesthesia Provider(s) NPI

Type: Numeric
Description: The 10-digit number assigned to the anesthesia provider.

Anesthesia Provider(s) Type

Type: String
Values: Physician, CRNA
Description: The type of provider corresponding to the NPI provided above.

Times/Locations

Date of Service

Type: Date
Description: The data on which anesthesia service began and equivalent to the Anesthesia Start Date.

OR Location

Type: String
Description: Name of the anesthetizing location. For example, “OR 1” or “Cath Lab 1”.

Scheduled Start

Type: Timestamp
Description: Date and Time the patient was told the case would start.

Anesthesia Start 

Type: Timestamp
Description: Date and Time the patient arrives to the operating room.

Anesthesia Ready 

Type: Timestamp
Description: Date and Time the patient has been induced, vascular access obtained, and any regional or neuraxial procedures have been completed. It’s the time the anesthesia team typically allows the surgical team to begin their positioning and prepping of the patient for start of procedure.

Surgery Start 

Type: Timestamp
Description: Date and Time incision is made or the procedure begins.

Surgery End 

Type: Timestamp
Description: Date and Time surgery is complete.

PACU/ICU Arrival 

Type: Timestamp
Description: Date and Time the patient arrives to the either PACU or ICU. If the patient does not “transfer” physcially to another location following anesthesia, this is the time a handoff to another team occurs, in which the new team is responsible for monitoring the patient followin anesthesia.

Anesthesia End 

Type: Timestamp
Description: Date and Time the continuous anesthetic care as ended.

Process

Transfer location

Type: String
Values: PACU, ICU
Description: The patient’s area of treatment following their anesthetic. This is used to code certain CMS measures which distinguish if patients are transferred to the PACU or ICU. We also visualize this information in our Population Health charts to help you better understand the acuity of your patients and the effects that may have on average efficiency times.

PACU Pain Score

Type: String
Values: 0-10, Unknown
Description: The patient’s pain score in the PACU within 15 minutes of arrival. If patient is sedated or otherwise unable to report a score, a value of “unknown” may be reported.

Hypothermia (Temp <35.5 C)

Type: Numeric
Description: A temperature of <35.5 degrees centigrade in the immediate postoperative period within 15 minutes of arrival in PACU.

Handoff Protocol Used

Type: Boolean
Description: Percentage of patients, regardless of age, who undergo a procedure under anesthesia who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible care team or team member.

The key handoff elements that must be included in the transfer of care protocol or checklist include:

  • Identification of patient, key family member(s) or patient surrogate
  • Identification of responsible practitioner (primary service)
  • Discussion of pertinent medical history
  • Discussion of the surgical/procedure course (procedure, reason for surgery, procedure 
performed)
  • Intraoperative anesthetic management and issue/concerns to include things such as airway, hemodynamic, narcotic, sedation level and paralytic management and 
intravenous fluids/blood products and urine output during the procedure
  • Expectations/Plans for the early post-procedure period to include things such as the anticipated course (anticipatory guidance), complications, need for laboratory or ECG and medication administration.
  • Opportunity for questions and acknowledgement of understanding of report from the receiving team.

Surgical Safety Checklist Used

Type: Boolean
Description: Percentage of patients, regardless of age, who undergo a surgical procedure under anesthesia who have documentation that all applicable safety checks from the World Health Organization (WHO) Surgical Safety Checklist (or other surgical checklist that includes the applicable safety checks for the specific procedure) were performed before induction of anesthesia.

The WHO Surgical Safety Checklist includes the following items before Induction of Anesthesia:

  • Has the patient confirmed his/her identity, site, procedure and consent?
  • Is the site marked?
  • Is the anesthesia machine and medication check complete?
  • Is the pulse oximeter on the Patient And Functioning?
  • Does the Patient have a:
    • Known Allergy?
    • Difficult Airway/Aspiration Risk?
    • Risk of >500 ml Blood Loss (7ml/kg in children)?

Outcomes

Dysrhythmia requiring intervention

Description: Arrhythmia that requires intervention with anti-arrhythmics other than anesthetics. Does not include beta blockade for cases for HR < 100.

Cardiac arrest (unplanned)

Description: Any alteration in cardiac activity requiring CPR and/or unplanned defibrillation within the first 24 hours after the completion of an anesthetic.

Unexpected death

Description: Unexpected death within 24 hours after completion of anesthesia, in-hospital death.

Stroke, CVA, or coma

Description: Unspecified cause of supratentorial neurologic dysfunction requiring evaluation or intervention. Includes TIA, hemorrhage, anoxic or metabolic coma. Symptoms occurring within 24 hours of OR end and persisting > 24 hours.

Myocardial ischemia

Description: Any scenario felt to be indicative of myocardial ischemia that requires intervention after physician evaluation.

Myocardial infarction

Description: New myocardial infarction from induction of anesthesia until 24 hours after OR end, diagnosed by troponin, CK MB or any other criteria of American College of Cardiology.

Vascular access injury

Description: An event arising from an attempt at securing vascular access (arterial, central venous, or peripheral venous) requiring intervention.

Uncontrolled HTN

Description: Uncontrolled hypertension defined as > 180 systolic or > 110 diastolic.

Aspiration

Description: Observation of gastric contents in oropharynx in unprotected airway or in LMA or ETT, suspected or confirmed.

Pneumothorax (related to anesthesia)

Description: A new onset of a pneumothorax in the perioperative period following anesthetically performed perithoracic vascular procedures.

Failed regional anesthetic

Description: Regional anesthesia intended as primary anesthetic that requires GA.

Systemic local anesthetic toxicity

Description: Any CNS or Cardiac effects following instillation of LA for regional block thought to be related to systemic LA levels.

Peripheral nerve injury following regional

Description: The new onset of peripheral nerve injury identified within 24 hours of an anesthetic in the absence of a known surgical cause.

Inadequate reversal

Description: Patient requires either manual assistance for ventilation or reintubation following paralytic secondary to inadequate reversal.

Reintubation (trial extubation)

Description: Any patient who requires tracheal re-intubation in the PACU after receiving anesthesia who had a formal trial of extubation.

Reintubation (no trial extubation)

Description: Any patient who requires tracheal re-intubation in the PACU after receiving anesthesia who did NOT have a formal trial of extubation.

Medication administration error

Description: Wrong drug or dose given requiring treatment or resulting in harm to the patient.

Adverse transfusion reaction

Description: Clinical diagnosis of definite or suspected transfusion reaction during or following transfusion of blood products confirmed by blood bank results to be possibly incompatible with patient blood. New onset of fever, chills, rash, flank pain or back pain, bloody urine, fainting or dizziness, kidney failure, delayed anemia, lung dysfunction or shock.

Anaphylaxis

Description: Immediate sensitivity response after exposure to specific antigen; results in life-threatening respiratory distress; usually followed by vascular collapse, shock, urticaria, angioedema and pruritus.

Wrong site surgery

Description: Regional block or surgery performed on incorrect site or side.

Wrong patient

Description: Incorrect patient arrives to OR or procedure room.

Difficult Airway

Description: Difficult airway equipment is brought to the room after induction and used when difficult airway is encountered unexpectedly.

Unplanned hospital admission

Description: Patient admitted to the hospital from the PACU that was originally scheduled to go home.

Unplanned ICU admission

Description: A patient admitted to the ICU within 24 hours of anesthesia care when the need for ICU care is determined after the induction of anesthesia.

Wrong surgical procedure

Description: Incorrect surgical procedure performed.

Dental trauma

Description: Unintended change in the patient’s perioperative dental status.

Visual loss

Description: Any loss of visual field or acuity following anesthesia not related periocular treatments (eye drops, ointments, or eye surgery) lasting more than 24 hours.

Malignant Hyperthermia

Description: Suspected MH following induction of general anesthesia requiring treatment with Dantrolene.

Awareness under GA

Description: Awareness under anesthesia occurs when a patient remembers events during surgery/procedure while under general anesthetic. Does not include recall of events during periods of intended intra-operative “wake-up” or sedation.

Other

Description: Mechanism for providers to add any comments/complications they may feel is necessary to report, but not available in any of the options available.

Equipment malfunction

Description: Any malfunction requiring intervention not part of routine device/machine checkout.

Fire in OR

Description: Fire in OR, not contacting patient.

Airway fire in OR

Description: Any fire in patient airway.

Corneal abrasion

Description: Any ocular surface injury requiring evaluation, follow up, or treatment.

Fall in OR

Description: Patient fall while under anesthesia care while in OR or procedure room.

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