| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | postop occurrence | 0;1 | FREE TEXT | This is the name of a occurrence encountered postoperatively. If there are no occurrences, this field should be left blank. 'NONE' will not be accepted. | ||
| .05 | outcome to date | 0;6 | SET OF CODES | U:UNRESOLVED I:IMPROVED D:DEATH W:WORSE | This is the code corresponding to the outcome of this postoperative occurrence. | |
| 2 | date comp noted | 0;7 | DATE-TIME | This is the date that this postoperative occurrence was noted in the patient's record. | ||
| 3 | treatment instituted | 2;1 | FREE TEXT | This is descriptive information about the treatment instituted as a result of this occurrence. | ||
| 4 | occurrence comments | 1;0 | WORD-PROCESSING | These are comments about this postoperative occurrence. | ||
| 5 | occurrence category(+) | 0;2 | POINTER | 136.5 | This is the name of the category in which this occurrence may be grouped. It should be entered for all occurrences and will be used by Surgery Central Office for reporting needs. | |
| 6 | icd diagnosis code | 0;3 | POINTER | 80 | If the occurrence entered does not fit in any of the predefined categories, an ICD Diagnosis Code must be entered. | |
| 7 | sepsis category | 0;4 | SET OF CODES | 1:SIRS 2:SEPSIS 3:SEPTIC SHOCK | Definition Revised (2014): 2. Sepsis is the systemic response to infection. Answer YES if both of the following criteria are met: Clinical documentation of infection (such as wound with purulent drainage, ruptured bowel with free air, etc.); a positive culture from any site thought to be causative; or specialized laboratory evidence of causative infection (such as viral DNA in blood). AND the presence of two or more of the following systemic responses: Temperature > 38 degrees C or < 36 degrees C HR > 90 beats/minute RR > 20 breaths /minute or PaCO2 < 32 mmHg WBC > 12,000 cell/mm3, < 4,000cells/mm3, or > 10% immature neutrophils ("bands") 3. Severe Sepsis/Septic Shock: Sepsis is considered severe when it is associated with organ and/or circulatory dysfunction. Terminology such as Severe Sepsis/Septic Shock/Refractory Septic Shock/Refractory Septic Shock and Multiple Organ Dysfunction Syndrome (MODS) all fall into this category. Answer YES if the definition of SEPSIS is present AND there is documented organ and/or circulatory dysfunction defined by one or more of the following: - Areas of acutely mottled skin not related to peripheral vascular disease - Capillary refilling requires three seconds or longer not related to peripheral vascular disease - Urine output <0.5 mL/kg for at least one hour, or renal replacement therapy - Lactate >2 mmol/L - Abrupt change in mental status - Abnormal EEG findings - Platelet count < 100,000 platelets/mL - Disseminated intravascular coagulation (DIC) - Acute lung injury or acute respiratory distress syndrome (ARDS) - New cardiac dysfunction as defined by ECHO or direct measurement of the cardiac index - An arterial systolic blood pressure (SBP) of =90 mm Hg or a mean arterial pressure (MAP) =70 mm Hg for at least 1 hour despite adequate fluid resuscitation, adequate intravascular volume status, or the need for vasopressors to maintain SBP >=90 mm Hg or MAP >=70 mm Hg. For the patient that had sepsis preoperatively, continuation of the preoperatively identified signs postoperatively would not be reported as a new postoperative sepsis. Worsening of the preope- ratively identified signs would be reported as a new postoperative sepsis. | |
| 8 | cpb status | 0;5 | SET OF CODES | 0:None 1:On-bypass 2:Off-bypass | Definition Revised (2014): Indicate the CPB status if the patient underwent a repeat operation on the heart after the patient had left the operating room from the initial operation and within current hospitalization or within 30 days of the initial operation. Indicate the one appropriate response: None - no repeat cardiac surgical procedure post-operatively within 30 days of initial operation. On-bypass - patient underwent a repeat cardiac surgical procedure utilizing CPB. Off-bypass - patient underwent a repeat cardiac surgical procedure not utilizing CPB. | |
| 9 | stroke/cva duration | 0;8 | SET OF CODES | 1:NO SYMPTOMS 2:<24 HOURS 3:24-72 HOURS 4:>72 HOURS | VASQIP Definitions (2011): Indicate if the patient developed a new neurologic deficit with onset immediately post-operatively or occurring within the 30 days after surgery. Neurologic deficits are defined as an embolic, thrombotic, or hemorrhagic vascular accident or stroke with motor, sensory, or cognitive dysfunction (e.g., hemiplegia,hemiparesis, aphasia, sensory deficit, impaired memory). Indicate the duration as follows: 1) no symptoms 2) symptomatic duration less than 24 hours 3) symptomatic duration of 24-72 hours 4) symptomatic duration >72 hours | |
| 10 | indwelling urethral catheter | 0;9 | SET OF CODES | 1:YES, IN PLACE 2:YES, REMOVED 3:NO, IN PLACE 4:NO, REMOVED 5:NO CATHETER | VASQIP Definition (2014): This indicates that the patient had an indwelling urinary catheter in place at the time of, or removed within 48 hours of, specimen collection or the onset of signs or symptoms. | |
| 11 | uti sign/symptoms urg/freq/dys | 0;10 | SET OF CODES | Y:HAS URGENCY, FREQUENCY, OR DYSURIA WITH NO OTHER RECOGNIZED CAUSE N:DOES NOT HAVE URGENCY, FREQUENCY OR DYSURIA | VASQIP Definition (2014): This indicates the patient complains of urinary urgency or urinary frequency or dysuria. | |
| 12 | uti signs/symptoms fever | 0;11 | SET OF CODES | Y:FEVER > 38C AT THE TIME OF CULTURE OR ONSET OF SYMPTOMS N:NO FEVER > 38C AT THE TIME OF CULTURE OR ONSET OF SIGNS OR SYMPTOMS | VASQIP Definition (2014): This indicates the patient has a fever >38C at the time of culture or onset of signs or symptoms. | |
| 13 | uti signs/symptoms tenderness | 0;12 | SET OF CODES | Y:SUPRAPUBIC, COSTOVERTEBRAL ANGLE PAIN N:NO SUPRAPUBIC TENDERNESS, COSTOVERTEBRAL ANGLE PAIN | VASQIP Definition (2014): This indicates the patient has suprapubic tenderness or costovertebral angle pain or tenderness. | |
| 14 | uti culture | 0;13 | SET OF CODES | 1:POS CULTURE >10E5, 1-2 SPECIES 2:POS CULTURE 10E3-10E5, 1-2 SPECIES DIPSTICK(+), PYURIA, OR GRAM (+) | VASQIP Definition (2014): This indicates that 1. The patient has a positive urine culture, that is, >10^5 colony- forming units (CFU)/ml with no more than 2 species of microor- ganisms OR 2. The patient has a positive urine culture of >10^3 and <10^5 colony forming units (CFU)/mL with no more than 2 species of microorganisms AND one of the following three items: a. Positive dipstick for leukocyte esterase and/ or nitrate; b. Pyuria (urine specimen with >10 white blood cell [WBC]/mm3 of unspun urine or > 3 WBC high-power field of spun urine); c. Microorganisms seen on Gram's stain of unspun urine | |
| 15 | postop device type | 0;14 | SET OF CODES | 1:IABP 2:VAD 3:TAH 4:ECMO 5:MULTIPLE DEVICES | VASQIP Definition (2014): Indicate the patient required post-op placement of a new IABP, VAD, TAH, ECMO, or MULTIPLE DEVICES for circulatory support within 30 days post-operatively. Please choose the device from the following list. 1. IABP 2. VAD 3. TAH 4. ECMO 5. MULTIPLE DEVICES |
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