NSQIP Data dictionary - onetomapanalytics/Meta_Data GitHub Wiki
NSQIP data dictionary
| Position # | Variable Name | Data Type | Variable Label | Variable Definition | Variable Options at Entry | Comments | **** |
|---|---|---|---|---|---|---|---|
| 1 | CaseID | Num | Case Identification Number | Each case or record in the database has a unique CaseID number | |||
| 2 | SEX | Char | Gender | Gender | Male/ Female | NUll = Unknown | |
| 3 | RACE_NEW | Char | New Race | Race | American Indian or Alaska Native; Asian; Black or African American; Native Hawaiian or Pacific Islander; Unknown/Not Reported; White | NULL = No Response | |
| 4 | ETHNICITY_HISPANIC | Char | Ethnicity Hispanic Ethnicity Hispanic Yes; No; Unknown | NUll = No Response | |||
| 5 | PRNCPTX | Char | Principal operative procedure CPT code description | The principal operative procedure is the most complex of all the procedures performed by the primary operating team during the trip to the operating room. Additional procedures requiring separate CPT codes and/or concurrent procedures will be entered separately in the “Other Procedures” or “Concurrent Procedures” categories. | |||
| 6 | CPT | Char | CPT | The CPT code of the principal operative procedure | |||
| 7 | WORKRVU | Num | Work Relative Value Unit | Work Relative Value Unit | -99 = Unknown | ||
| 8 | INOUT | Char | Inpatient/outpatient | The hospital’s definition of inpatient and outpatient status | Outpatient; Inpatient | NUll = Unknown | |
| 9 | TRANST | Char | Transfer status | The patient's transfer status which includes the following options: Admitted directly from home (Includes patients arriving from another hospital's emergency department); If the patient was transferred from another facility and was considered an inpatient at that facility Acute Care Hospital; VA Acute Care Hospital; Chronic Care Facility; and VA Chronic Care Facility are acceptable. If the kind of facility could not be determined ‘Other’ is entered | From acute care hospital inpatient; Not transferred (admitted from home); Nursing homeLabs to Operation Chronic careLabs to Operation Intermediate care; Outside emergency department; Transfer from other; Unknown | NULL = No Response; Definition change in 2009 | |
| 10 | Age | Char | Age of patient with patients over 89 coded as 90+ | Age of patient with patients over 89 coded as 90+. No patients under 15 are included. | -99 = Unknown | ||
| 11 | AdmYR | Num | Year of Admission | Year of admission to the hospital | -99 = Unknown | ||
| 12 | AdmSYR | Num | Year of Admission to Surgery | Year of admission to the surgical service | Historical variable; no longer used | ||
| 13 | OperYR | Num | Year of Operation | Year the surgical procedure is performed | -99 = Unknown | ||
| 14 | DISCHDEST | Char | Discharge Destination | Designate whether the patient was discharged to home or to another type of facility. Choose the patient’s discharge destination from the following selections: (1) Skilled care not home (e.g. transitional care unit; subacute hospital; ventilator bed; skilled nursing home); (2) Unskilled facility not home (e.g. nursing home or assisted facility-if not patient’s home preoperatively); (3) Facility which was home (e.g. return to a chronic care; unskilled facility; or assisted living-which was the patient’s home preoperatively); (4) Home; (5) Separate acute care (e.g. transfer to another acute care facility); (6) Rehab; (7) Expired; (8) Unknown | Skilled Care Not Home; Unskilled Facility Not Home; Facility Which was Home; Home; Separate Acute Care; Rehab; Expired; Unknown | NULL = No Response. Variable added in 2011 | |
| 15 ANESTHES | Char | Principal anesthesia technique | The type of anesthesia administered during the principal operative procedure as reported by the anesthesia provider.The technique employed may be found on the anesthesia record. General anesthesia should take precedence over all other forms of anesthesia. MAC should be chosen for MAC with or without Local; If the patient is given a regional/spinal or epidural and MAC; MAC anesthesia would take precedence; Anesthesia providers would include: anesthesiologists; anesthesia fellows; anesthesia residents; Certified Registered Nurse Anesthetists and Certified Registered Nurse Anesthetist; students. If IV sedation is provided by a nurse you may utilize the medical record. | Epidural; General; Local; Monitored Anesthesia care (MAC) / IV Sedation; None; Other; Regional; Spinal; Unknown | NUll = No Response Definition; revised or clarified in 2011. Definition revised or clarified in 2014 | ||
| 16 | ATTEND | Char | Level of Residency Supervision | Highest level of supervision provided by the attending staff surgeon for the case. Attending alone: Staff practitioner performed the procedure; resident not present; Attending in OR: Staff practitioner is scrubbed and present in the procedure/operating room; Attending in OR Suite: Staff practitioner is present in the procedural/surgical suite and available for consultation; Attending Not Present but Available: Staff practitioner is not present but immediately available on campus | Attending & Resident in OR; Attending Alone; Attending Not Present but Available | NUll = Unknown; Definition change in 2009. Classic variable; no longer used | |
| 17 | SURGSPEC | Char | Surgical Specialty | The surgical specialty area that best characterizes the principal operative procedure. Surgeon’s self-declared specialty; If a surgeon is privileged to perform cases within multiple specialties (regardless of board certification) the service line/specialty most closely related to the principal operative procedure would be assigned; If a Surgeon is “Board Certified” in both Vascular Surgery and General; Surgery and performs an appendectomy the surgeon’s specialty should be designated as general surgery; but if he/she performs a vascular bypass; it should be designated as vascular | Cardiac Surgery; General Surgery; Gynecology; Neurosurgery; Orthopedics; Otolaryngology (ENT); Plastics; Thoracic; Urology; Vascular; Interventional Radiologist | Definition revised or clarified in 2013 | |
| 18 | ELECTSURG | Char | Elective Surgery | "YES" is entered if the patient is brought to the hospital or facility for a scheduled (elective) surgery from their home or normal living situation on the day that the procedure is performed. ENTER NO (Exclude) FOR the following: patients who are inpatient at an acute care hospital (example: patient transferred from another acute care hospital to your hospital for surgery); patients who are transferred from an ED; patients who are transferred from a clinic; patients who undergo an emergent/urgent surgical case; patients admitted to the hospital on the day(s) prior to a scheduled procedure for any reason (e.g. cardiac or pulmonary workup or "tuning"; bowel cleanout; TPN; hydration; anticoagulation reversal etc.); ENTER YES (Include) FOR the following: patients staying with friends or family or in a local hotel because of logistics (example: patient lives 50 miles from the hospital and stays in a hotel across from the hospital the night before their scheduled (elective) surgery); patients who come from their present "home" (which may include patients whose home is a nursing home; assisted care facility; prison or other nonhospital institution). The intent is to identify a relatively homogeneous group of patients who are well enough to come from home to allow for more meaningful comparative analyses. | Yes; No; Unknown | NUll = No Response. Variable added in 2011 | |
| 19 | HEIGHT | Num | Height | The patient’s most recent height documented in the medical record in inches (in) within the 30 days prior to the principal operative procedure or at the time the patient is being considered a candidate for surgery | -99 = Unknown; Definition revised or clarified in 2013 | ||
| 20 | WEIGHT | Num | Weight | The patient’s most recent weight documented in the medical record in pounds (lbs.) within the 30 days prior to the principal operative procedure or at the time the patient is being considered a candidate for surgery | -99 = Unknown; Definition revised or clarified in 2013 | ||
| 21 | DIABETES | Char | Diabetes mellitus with oral agents or insulin | The treatment regimen of the patient’s chronic long-term management (> 2 weeks). Diabetes mellitus is a metabolic disorder of the pancreas whereby the individual requires daily dosages of exogenous parenteral insulin or a noninsulin anti-diabetic agent to prevent a hyperglycemia/metabolic acidosis. Patients with Insulin resistance (e.g. polycystic ovarian syndrome) that routinely take anti-diabetic agents are included. Patients who prescribed oral or insulin treatment and are noncompliant are included. Patients whose diabetes are controlled by diet alone are not included. No: no diagnosis of diabetes or diabetes controlled by diet alone. Non-Insulin: a diagnosis of diabetes requiring therapy with a non-insulin anti-diabetic agent (such as oral agents or other noninsulin agents). Insulin: a diagnosis of diabetes requiring daily insulin therapy. Note:If the patient requires treatment with both non-insulin and insulin; assign insulin. | INSULIN; NO; NON-INSULIN | NUll = Unknown; Definition change in 2009. Definition revised or clarified in 2010. Definition revised or clarified in 2014 | |
| 22 | SMOKE | Char | Current smoker within one year | If the patient has smoked cigarettes in the year prior to admission for surgery "YES" entered. Patients who smoke cigars or pipes or use chewing tobacco are not included. Patients who smoke mechanical/electronic cigarettes are not included | Yes; No | NUll = Unknown; Definition revised or clarified in 2014 | |
| 23 | PACKS | Num | Pack-years of smoking | If the patient has ever been a smoker; the total number of pack/years of smoking for this patient is provided. Pack-years are defined as the number of packs of cigarettes smoked per day times the number of years the patient has smoked. If the patient has never been a smoker; “0” is entered. If pack-years are > 200; 200 is entered. If smoking history cannot be determined; “--99” is entered. The possible range for number of pack-years is 0 to 200. If the chart documents differing values for pack year cigarette history or ranges for either packs per day or number of years patient has smoked; the highest value is documented. | -99 = Unknown. Classic variable; no longer used | ||
| 24 | ETOH | Char | ETOH > 2 drinks/day in 2 wks before admission | "YES" is entered if 2 drinks per day in the two weeks prior to admission: The patient admits to drinking >2 ounces of hard liquor or > two 12 oz. cans of beer or > two 6 oz. glasses of wine per day in the two weeks prior to admission. If the patient is a binge drinker; the numbers of drinks during the binge are divided by seven days and then the definition is applied. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 25 | DYSPNEA | Char | Dyspnea | Dyspnea may be symptomatic of numerous disorders that interfere with adequate ventilation or perfusion of the blood with oxygen and is defined as difficult; painful or labored breathing. The intent of this variable is to capture the usual or typical level of dyspnea (patient’s baseline); within the 30-days prior to surgery. The intent is not to include patients solely because of an acute respiratory condition leading to intubation prior to surgery; but rather to reflect a chronic disease state. Characterize the patient's dyspnea status when they were in their usual state of health; prior to the onset of the acute illness; within the 30 days prior to surgery. (1) No dyspnea; (2) Dyspnea upon moderate exertion (for example-is unable to climb one flight of stairs without shortness of breath); (3) Dyspnea at rest (for example: cannot complete a sentence without needing to take a breath). Note: Acute pre-op dyspnea associated with the acute illness will be captured through other variables like pre-op vent dependence; emergency status or ASA Class. The previous requirement that the patient has to themselves state that they are symptomatic has been removed: not all patients are able to verbalize this symptomatology. | AT REST; MODERATE EXERTION; No | NUll = Unknown. Definition revised or clarified in 2011 | |
| 26 | DNR | Char | Do not resuscitate (DNR) status | If the patient has had a Do-Not-Resuscitate (DNR) order written in the physician’s order sheet of the patient’s chart and it has been signed or cosigned by an attending physician; enter “YES”. There must be active DNR order at the time the patient is going to the OR. However; if the DNR order; as defined above; was rescinded immediately prior to surgery; in order to operate on the patient; enter “YES”. Answer “NO” if DNR discussions are documented in the progress note; but no official DNR order has been written in the physician order sheet or if the attending physician has not signed the official order. Also answer “NO” if the patient is admitted as a DNR from a nursing home; as there must be a new DNR order written and signed/co-signed by a hospital attending physician. Advanced Directives are not DNR orders. | Yes; No | NUll = Unknown. Definition revised or clarified in 2011. Classic variable; no longer used | |
| 27 | FNSTATUS1 | Char | Functional health status Prior to Current Illness | Independent | Historical variable; no longer used | ||
| 28 | FNSTATUS2 | Char | Functional health status Prior to Surgery | This variable focuses on the patient's abilities to perform activities of daily living (ADLs) in the 30 days prior to surgery. Activities of daily living are defined as ‘the activities usually performed in the course of a normal day in a person’s life’. ADLs include: bathing; feeding; dressing; toileting; and mobility. The best functional status demonstrated by the patient within the 30 days prior to surgery is reported. Report the level of functional health status as defined by the following criteria: (1) Independent: The patient does not require assistance from another person for any activities of daily living. This includes a person who is able to function independently with prosthetics; equipment; or devices. (2) Partially dependent: The patient requires some assistance from another person for activities of daily living. This includes a person who utilizes prosthetics; equipment; or devices but still requires some assistance from another person for ADLs. (3) Totally dependent: The patient requires total assistance for all activities of daily living. (4) Unknown: If unable to ascertain the functional status prior to surgery; report as unknown. All patients with psychiatric illnesses should be evaluated for their ability to function with or without assistance with ADLs just as the non-psychiatric patient. For instance if a patient with schizophrenia is able to care for him/herself without the assistance of nursing care; he/she is considered independent. If there is a change in the patients functional status (i.e. improvement to worsening) within the 30 days prior to surgery; report the patient’s best functional status. | Independent; Partially Dependent; Totally Dependent; Unknown | NUll = No Response. Definition revised or clarified in 2010 | |
| 29 | VENTILAT | Char | Ventilator dependent | "YES" is entered if a preoperative patient required ventilator-assisted respiration at any time during the 48 hours preceding surgery. This does not include the treatment of sleep apnea with CPAP. | Yes; No | NUll = Unknown | |
| 30 | HXCOPD | Char | History of severe COPD | COPD [emphysema and/or chronic bronchitis/bronchiectasis/ bronchiolitis obliterans organizing pneumonia (BOOP)] is a progressive disease that makes it hard to breathe. ‘Progressive’ means the disease gets worse over time. “COPD can cause coughing that produces large amounts of mucus . . .; wheezing; shortness of breath; chest tightness; and other symptoms” (National Heart Lung and Blood Institute; 2010). Medical record must document that there is a historical or current diagnosis of COPD AND at least one of the following: within the 30 days prior to the principal operative procedure or at the time the patient is being considered as a candidate for surgery: Functional disability from COPD (e.g. dyspnea; inability to perform ADLs) Or Requires chronic bronchodilator therapy with oral or inhaled agents or other medication specifically targeted to this disease Or Hospitalization in the past for treatment of COPD Or An FEV1 of <75% of predicted on a prior pulmonary function test (PFT). Patients whose only pulmonary disease is asthma; an acute and chronic inflammatory disease of the airways resulting in bronchospasm are not included. Patients with diffuse interstitial fibrosis; sarcoidosis; or silicosis are not included. Notes: Utilize post bronchodilator values if available | Yes; No | NUll = Unknown; Definition revised or clarified in July 2013. Definition revised or clarified in 2014 | |
| 31 | CPNEUMON | Char | Current pneumonia | "YES" is entered if the patient has a new pneumonia or recently diagnosed pneumonia and on current antibiotic treatment at the time the patient is brought to the OR. Patients with pneumonia must meet criteria from both Radiology and Signs/Symptoms/Laboratory sections listed as follows: Radiology: One definitive chest radiological exam (x-ray or CT)* with at least one of the following: New or progressive and persistent infiltrate; Consolidation or opacity; Cavitation. Note: In patients with underlying pulmonary or cardiac disease (e.g. respiratory distress syndrome; bronchopulmonary dysplasia; pulmonary edema; or chronic obstructive pulmonary disease); two or more serial chest radiological exams (xray or CT) are required. (Serial radiological exams should be taken no less than 12 hours apart; but not more than 7 days apart. The occurrence should be assigned on the date the patient first met all of the criteria of the definition (i.e if the patient meets all PNA criteria on the day of the first xray; assign this date to the occurrence. Do not assign the date of the occurrence to when the second serial xray was performed). Signs/Symptoms/Laboratory: FOR ANY PATIENT; at least one of the following: Fever (>38 C or >100.4 F) with no other recognized cause; Leukopenia (<4000 WBC/mm3) or leukocytosis(≥12000 WBC/mm3). For adults ≥ 70 years old; altered mental status with no other recognized cause. And at least one of the following: 5% Bronchoalveolar lavage (BAL)Labs to Operationobtained cells contain intracellular bacteria on direct microscopic exam (e.g.; Gram stain); Positive growth in blood culture not related to another source of infection; Positive growth in culture of pleural fluid; Positive quantitative culture from minimally contaminated lower respiratory tract (LRT) specimen (e.g. BAL or protected specimen brushing) OR At least two of the following: New onset of purulent sputum; or change in character of sputum; or increased respiratory secretions; or increased suctioning requirements; New onset or worsening cough; or dyspnea; or tachypnea; Rales or rhonchi; Worsening gas exchange (e.g. O2 desaturations (e.g.; PaO2/FiO2 ≤ 240); increased oxygen requirements; or increased ventilator demand) | Yes; No | Definition revised or clarified in 2010. NULL=Unknown. Classic variable; no longer used | |
| 32 | ASCITES | Char | Ascites | "YES" is entered for patients with the presence of fluid accumulation in the peritoneal cavity noted on physical examination; abdominal ultrasound; or abdominal CT/MRI within 30 days prior to the operation. Documentation should state either active or a history of liver disease (for example; jaundice; encephalopathy; hepatomegaly; portal hypertension; liver failure; or spider telangiectasia). Minimal or trace ascites would not qualify; however; malignant ascites (exclusive of liver disease) due to extensive cancer would qualify. | Yes; No | Definition revised or clarified in 2010. NULL=Unknown | |
| 33 | ESOVAR | Char | Esophageal varices | "YES" is entered for patients with esophageal varices present preoperatively and documented on an EGD or CT scan performed within 6 months prior to the surgical procedure. Esophageal varices are engorged collateral veins in the esophagus that bypass a scarred liver to carry portal blood to the superior vena cava. A sustained increase in portal pressure results in esophageal varices that are most frequently demonstrated by direct visualization at esophagoscopy. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 34 | HXCHF | Char | Congestive heart failure (CHF) in 30 days before surgery | "YES" is entered in patients with congestive heart failure. Congestive heart failure is the inability of the heart to pump a sufficient quantity of blood to meet the metabolic needs of the body or can do so only at increased ventricular filling pressure. Only newly diagnosed CHF within the previous 30 days or a diagnosis of chronic CHF with new signs or symptoms in the 30 days prior to surgery fulfills this definition. Common manifestations are: Abnormal limitation in exercise tolerance due to dyspnea or fatigue; Orthopnea (dyspnea on lying supine); Paroxysmal nocturnal dyspnea (PND-awakening from sleep with dyspnea); Increased jugular venous pressure; Pulmonary rales on physical examination; Cardiomegaly; Pulmonary vascular engorgement. Pulmonary edema. Newly diagnosed CHF or a diagnosis of chronic CHF with current signs or symptoms in the 30 days prior to the principal operative procedure or at the time the patient is being considered as a candidate for surgery. Diagnosis in the medical record should be noted as congestive heart failure (CHF). The following updates starts from July 2014: Patients with documentation which indicates that pulmonary edema is not an exacerbation of CHF would not be assigned. Notes: Common CHF manifestations may include: Abnormal limitation in exercise tolerance due to dyspnea or fatigue; Orthopnea (dyspnea when lying supine); Paroxysmal nocturnal dyspnea (PND-awakening from sleep with dyspnea); Increased jugular venous pressure (JVP); Pulmonary rales on physical examination; Cardiomegaly; Pulmonary vascular engorgement; Pulmonary edema in the setting of chronic CHF | Yes; No | NUll = Unknown; Definition revised or clarified in 2014 | |
| 35 | HXMI | Char | History of myocardial infarction 6 mos prior to surgery | "Yes" is entered for patients with a history of a non-Q wave or a Q wave infarct in the six months prior to surgery as diagnosed in the patient’s medical record. | Yes; No | Classic variable; no longer used | |
| 36 | PRVPCI | Char | Previous PCI | "YES" is entered for patient who have undergone percutaneous coronary intervention (PCI) at any time (including any attempted PCI). This includes either balloon dilatation or stent placement. This does not include valvuloplasty procedures. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 37 | PRVPCS | Char | Previous cardiac surgery | "YES" is entered if the patient has had any major cardiac surgical procedures (performed either as an ‘off-pump’ repair or utilizing cardiopulmonary bypass). This includes coronary artery bypass graft surgery; valve replacement or repair; repair of atrial or ventricular septal defects; great thoracic vessel repair; cardiac transplant; left ventricular aneurysmectomy; insertion of left ventricular assist devices (LVAD); etc. Not include are pacemaker insertions or automatic implantable cardioverter defibrillator (AICD) insertions. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 38 | HXANGINA | Char | History of angina in 1 month before surgery | "YES" is entered if patient reports pain or discomfort between the diaphragm and the mandible resulting from myocardial ischemia. Typically angina is a dull; diffuse (fist-sized or larger) substernal chest discomfort precipitated by exertion or emotion and relieved by rest or nitroglycerine. Radiation to the arms and shoulders often occurs; and occasionally to the neck; jaw (mandible; not maxilla); or interscapular region. For patients on anti-anginal medications; ‘YES’ is entered only if the patient has had angina at any time within one month prior to surgery. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 39 | HYPERMED | Char | Hypertension requiring medication | Hypertension (HTN) is the term used to describe high blood pressure. Blood pressure is a measurement of the force against the walls of your arteries as your heart pumps blood through your body. High blood pressure (hypertension) is when your blood pressure is 140/90 mmHg or above most of the time.” The diagnosis of HTN must be documented in the patient’s medical record and the condition is severe enough that it requires antihypertensive medication; within 30 days prior to the principal operative procedure or at the time the patient is being considered as a candidate for surgery. The patient must have been receiving or required long-term treatment of their chronic hypertension for > 2 weeks. | Yes; No | NUll = Unknown. Definition revised or clarified in July 2013 | |
| 40 | HXPVD | Char | History of revascularization/amputation for periph. vascular disease | "YES" is entered for a patient with any type of angioplasty (including stent placement) or revascularization procedure for atherosclerotic peripheral vascular disease (PVD) (e.g.; aorta-femoral; femoral-femoral; femoral-popliteal) or a patient who has had any type of amputation procedure for PVD (e.g.; toe amputations; transmetatarsal amputations; below the knee or above the knee amputations). Patients who have had amputation for trauma or a resection of abdominal aortic aneurysms should not be included. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 41 | RESTPAIN | Char | Rest pain/gangrene | "YES" is entered for a patient with rest pain or Gangrene. Rest pain is a more severe form of ischemic pain due to occlusive disease; which occurs at rest and is manifested as a severe; unrelenting pain aggravated by elevation and often preventing sleep. Gangrene is a marked skin discoloration and disruption indicative of death and decay of tissues in the extremities due to severe and prolonged ischemia. Patients included with ischemic ulceration and/or tissue loss related to peripheral vascular disease. Fournier’s gangrene are not included. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 42 | RENAFAIL | Char | Acute renal failure (pre-op) | A clinical condition associated with rapid decline of kidney function. The intent of this variable is to capture the situation where the patient’s renal function has demonstrated compromise within 24 hours prior to surgery. Patient must meet ONE of the following scenarios (A or B) within 24 hours prior to the principal operative procedure: A. An increase in BUN based on two measurements and two creatinine (Cr) results above 3mg/dl. There must be at minimum two measurements per lab value; the most recent of which must be within 24 hours prior to the start of the principal operative procedure; the second must be within 90 days of the principal operative procedure. B. The surgeon or attending physician has documented Acute Renal Failure in the medical record and the patient demonstrates ONE of the following: (1) An increase in BUN based on at least two measurements; the most recent of which must be within 24 hours prior to the start of the principal operative procedure; the second must be within 90 days of the principal operative procedure and one creatinine above 3mg/dl; which must be within 24 hours prior to the start of the principal operative procedure. (2) Two creatinine results above 3mg/dl; the most recent of which must be within 24 hours prior to the start of the principal operative procedure; the second must be within 90 days of the principal operative procedure and one abnormal BUN (based on your hospital’s reference range for BUN); which must be within 24 hours prior to the start of the principal operative procedure. | Yes; No | NUll = Unknown. Definition revised or clarified in 2013 | |
| 43 | DIALYSIS | Char | Currently on dialysis (pre-op) | "YES" is entered if the patient has acute or chronic renal failure requiring treatment with peritoneal dialysis; hemodialysis; hemofiltration; hemodiafiltration; or ultrafiltration within 2 weeks prior to the principal operative procedure. The medical record must document that such a treat was indicated. | Yes; No | NUll = Unknown | |
| 44 | IMPSENS | Char | Impaired sensorium | "YES" is entered if patient is acutely confused and/or delirious and responds to verbal and/or mild tactile stimulation. Patients is noted to have developed an impaired sensorium if they have mental status changes; and/or delirium in the context of the current illness. Patients with chronic or long-standing mental status changes secondary to chronic mental illness (e.g.; schizophrenia) or chronic dementing illnesses (e.g.; multi-infarct dementia; senile dementia of the Alzheimer's type) are not included. This assessment of the patient’s mental status is within 48 hours prior to the surgical procedure. Example: A patient is admitted to the orthopedics service after a fall with a fractured hip. The patient is also noted to be dehydrated and febrile. He is disoriented to place and time and seems confused. His family reports that he has been oriented and alert prior to the fall. This patient has an impaired sensorium on the basis of his confusion and disorientation. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 45 | COMA | Char | Coma >24 hours | "YES" is entered if patient is unconscious; or postures to painful stimuli; or is unresponsive to all stimuli entering surgery. This does not include drug-induced coma. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 46 | HEMI | Char | Hemiplegia | "YES" is entered if patient has sustained acute or chronic neuromuscular injury resulting in total or partial paralysis or paresis (weakness) of one side of the body. ‘YES’ is entered if the patient has hemiplegia/hemiparesis (that has not recovered or been rehabilitated) upon arrival to the OR. "YES" is entered if there is hemiplegia or hemiparesis associated with a CVA/Stroke also. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 47 | HXTIA | Char | History of transient ischemic attacks (TIA) | "YES" is entered if patient has transient ischemic attacks (TIAs). TIAs are focal neurologic deficits (e.g. numbness of an arm or amaurosis fugax) of sudden onset and brief duration (usually <30 minutes) that usually reflects dysfunction in a cerebral vascular distribution. These attacks may be recurrent and at times may precede a stroke. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 48 | CVA | Char | CVA/Stroke with neurological deficit | "YES" is entered if patient has a history of a cerebrovascular accident (embolic; thrombotic; or hemorrhagic) with persistent residual motor; sensory; or cognitive dysfunction. (e.g.; hemiplegia; hemiparesis; aphasia; sensory deficit; impaired memory). If the neurological deficit is hemiplegia/hemiparesis; ‘YES’ is entered to Hemiplegia/Hemiparesis in addition to CVA/Stroke. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 49 | CVANO | Char | CVA/Stroke with no neurological deficit | "YES" is entered if the patient has a history of a cerebrovascular accident (embolic; thrombotic; or hemorrhagic); but no current residual neurologic dysfunction or deficit. | Yes; No | NUll = Unknown. Definition revised or clarified in 2010. Classic variable; no longer used | |
| 50 | TUMORCNS | Char | Tumor involving CNS | "YES" is entered if patient has a space-occupying tumor of the brain or spinal cord; which may be benign (e.g.; meningiomas; ependymoma; oligodendroglioma) or primary (e.g.; astrocytoma; glioma; glioblastoma multiform) or secondary malignancies (e.g.; metastatic lung; breast; malignant melanoma). Other tumors that may involve the CNS include lymphomas and sarcomas. "YES" is entered even if the tumor was not treated. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 51 | Para | Char | Paraplegia | "YES" is entered if the patient has sustained acute or chronic neuromuscular injury resulting in total or partial paralysis or paresis (weakness) of the lower extremities. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 52 | QUAD | Char | Quadriplegia | "YES" is entered if the patient has sustained acute or chronic neuromuscular injury resulting in total or partial paralysis or paresis (weakness) of all four extremities. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 53 | DISCANCR | Char | Disseminated cancer | "YES" is entered for patients who have a primary cancer that has metastasized or disseminated to a major organ AND the patient also meets AT LEAST ONE of the following criteria: The patient has received active treatment for the cancer within one year of their ACS NSQIP assessed procedure surgery date. If the ACS NSQIP assessed surgical procedure is the treatment for the metastatic cancer; assign disseminated cancer to the case. The extent of disease is first appreciated at the time of the surgical procedure in question. The patient has elected not to receive treatment for the metastatic disease; but such treatment was indicated. The patient’s metastatic cancer has been deemed untreatable. Information is obtained within 30 days following the principal operative procedure indicating disseminated cancer was present at the time of the principal operative procedure. The following are reported as Disseminated Cancer:Acute Lymphocytic Leukemia (ALL); Acute Myelogenous Leukemia (AML); and Stage IV Lymphoma A patient with primary breast cancer with positive nodes in the axilla; liver metastases and is also receiving chemotherapy at the time of the assessed ACS NSQIP surgical procedure; A patient with colon cancer with liver metastasis and/or peritoneal seeding with tumor; who received their last dose of chemotherapy and radiation therapy 2 months prior to their ACS NSQIP assessed procedure; A patient with preoperative Stage III colon cancer is admitted for a colectomy. Upon entering the abdomen the surgeon identifies cancer which has spread to the surrounding organs; A patient with a history of Stage IV Lymphoma who received their second round of chemotherapy two months prior to surgery; Cancer treatments include not only chemotherapy and radiation therapy; but also surgery and hormone therapy; Patient undergoes mastectomy for breast cancer and a CT on postop day 22 reveals a metastatic lesion on the liver. | Yes; No | NUll = Unknown; Definition revised or clarified in 2014 | |
| 54 | WNDINF | Char | Open wound/wound infection | Preoperative evidence of a documented open wound at the time of the principal operative procedure. An open wound is a breach in the integrity of the skin or separation of skin edges and includes open surgical wounds; with or without cellulitis or purulent exudate. This does not include osteomyelitis or localized abscesses. Assign Yes to: Open drains should be considered an open wound: (e.g. Penrose drains); Open wounds currently undergoing dressing changes or with negative pressure wound devices (e.g.; wound vacs); Any abnormal passageway leading from an internal organ (e.g. intestinal tract) to the surface of the body / skin. (e.g. enterocutaneous fistula [ECF]). Assign No to: An ostomy would not be considered an open wound; A scabbed over wound with or without drainage; A Band-Aid over an open sore (break in skin); Oral sores; A tracheostomy would not be considered an open wound | Yes; No | NUll = Unknown. Definition revised or clarified in 2011 | |
| 55 | STEROID | Char | Steroid use for chronic condition | Patient has required the regular administration of oral or parenteral corticosteroid (e.g. Prednisone; Decadron) medications or immunosuppressant medications; within the 30 days prior to the principal operative procedure or at the time the patient is being considered as a candidate for surgery; for a chronic medical condition (e.g. COPD; asthma; rheumatologic disease; rheumatoid arthritis; inflammatory bowel disease). A one-time pulse; limited short course; or a taper of less than 10 days duration would not qualify. Do not include topical corticosteroids applied to the skin or corticosteroids administered by inhalation or rectally. Do not include patients who only receive short course steroids (duration 10 days or less) in the 30 days prior to surgery. | Yes; No | NUll = Unknown. Definition revised or clarified in 2011 | |
| 56 | WTLOSS | Char | >10% loss body weight in last 6 months | "YES" is entered for patients with a greater than 10% decrease in body weight in the six month interval immediately preceding surgery as manifested by serial weights in the chart; as reported by the patient; or as evidenced by change in clothing size or severe cachexia. Patients who have intentionally lost weight as part of a weight reduction program do not qualify. | Yes; No | NUll = Unknown | |
| 57 | BLEEDDIS | Char | Bleeding disorders | "YES" is entered for patients with any chronic; persistent; active condition that places the patient at risk for excessive bleeding (e.g.; vitamin K deficiency; hemophilia; thrombocytopenia; chronic anticoagulation therapy that has not been discontinued prior to surgery). "YES" is entered for patient with Active heparin-induced thrombocytopenia (HIT); and patients who has a past medical history of thrombocytopenia and a low platelet count (below your hospital’s normal reference range) at the time of the principal operative procedure . The following cases are not included : Patient on chronic aspirin therapy; Patient on Nonsteroidal Anti-inflammatory Drugs (NSAIDs); When medications are prescribed for prophylactic use; for the principal operative procedure only; Patient with a history of HIT in the past which is not deemed active. | Yes; No | NUll = Unknown. Definition revised or clarified in 2014 | |
| 58 | TRANSFUS | Char | Preop Transfusion of >= 1 unit of whole/packed RBCs in 72 hours prior to surgery | Preoperative loss of blood necessitating any transfusion (minimum of 1 unit) of whole blood/packed red cells transfused during the 72 hours prior to surgery start time; including any blood transfused in the emergency room. If greater than 200 units; enter 200 units. | Yes; No | NUll = Unknown | |
| 59 | CHEMO | Char | Chemotherapy for malignancy in <= 30 days pre-op | "YES" entered if the patient had any chemotherapy treatment for cancer in the 30 days prior to surgery. Chemotherapy may include but is not restricted to oral and parenteral treatment with chemotherapeutic agents for malignancies such as colon; breast; lung; head and neck; and gastrointestinal solid tumors as well as lymphatic and hematopoietic malignancies such as lymphomas; leukemia; and multiple myeloma. Patient is not included if treatment consists solely of hormonal therapy. Chemotherapy treatment must be for malignancy. | Yes; No | NUll = Unknown. Definition revised or clarified in 2010. Classic variable;no longer used | |
| 60 | RADIO | Char | Radiotherapy for malignancy in last 90 days | "YES" entered if the patient had any radiotherapy treatment for cancer in the 90 days prior to surgery. Count If the patient had radiation seeds implanted and the implantation was within 90 days prior to the operation. | Yes; No | NUll = Unknown. Classic variable; no longer used | |
| 61 | PRSEPIS | Char | Systemic Sepsis | Sepsis is a vast clinical entity that takes a variety of forms. The spectrum of disorders spans from relatively mild physiologic abnormalities to septic shock. The most significant level is reported using the following criteria: SIRS (Systemic Inflammatory Response Syndrome): SIRS is a widespread inflammatory response to a variety of severe clinical insults. This syndrome is clinically recognized by the presence of two or more of the following within the same time frame: Temp >38 degrees C or <36 degrees C HR >90 bpm RR >20 breaths/min or PaCO2 <32 mmHg(<4.3 kPa) WBC >12000 cell/mm3; <4000 cells/mm3; or >10% immature (band) forms. Anion gap acidosis: this is defined by either: [Na + K] – [CL + HCO3 (or serum CO2]. If this number is greater than 16; then an anion gap acidosis is present. Na – [CL + HCO3 (or serum CO2]. If this number is greater than 12; then An anion gap acidosis is present. If anion gap lab values are performed at your facilities lab; ascertain which formula is utilized and follow guideline criteria. Sepsis: Sepsis is the systemic response to infection. Report this variable if the patient has clinical signs and symptoms of SIRS listed above and meets either A or B: A. One of the following: Positive blood culture; Clinical documentation of purulence or positive culture from any site for which there is documentation noting the site as the acute case of sepsis. B. Suspected pre-operative clinical condition of infection or bowel infarction; which leads to the surgical procedure. The findings during the Principal Operative Procedure must confirm this suspected diagnosis with one or more of the following: Confirmed infarcted bowel requiring resection; purulence in the operative site; enteric contents in the operative site; or positive intra-operative cultures. Septic Shock: Report this variable if the patient has sepsis AND documented organ and/or circulatory dysfunction. Examples of organ dysfunction include: oliguria; acute alteration in mental status; acute respiratory distress. Examples of circulatory dysfunction include: hypotension; requirement of inotropic or vasopressor agents. The presence of pneumatosis along with the presence of SIRS is assigned | SIRS; Sepsis; Septic Shock; None | NUll = Unknown. Definition revised or clarified in 2011. Definition revised or clarified in 2014 | |
| 62 | Pregnancy | Char | Pregnancy | "YES" entered if pregnant. Pregnancy is determined by one of the following: Administration of a blood or urine pregnancy test with a positive result. Visualization of the fetus by ultrasound. Indication of fetal heart rate by ultrasound or fetal heart monitoring. Pregnancy takes approximately 40 weeks between the time of the last menstrual cycle and delivery. | Yes; No | NUll = Not applicable or not documented because variable was added in July 2006. Classic variable; no longer used | |
| 63 | PrOper30 | Char | Prior Operation within 30 days | "YES" entered if the patient has had any major surgical procedure performed within 30 days prior to the assessed operation that would meet the following NSQIP criteria: Operation was performed utilizing general; spinal; or epidural anesthesia or operation performed included any of the following: carotid endarterectomy; inguinal hernia repair; parathyroidectomy; thyroidectomy; breast lumpectomy; or endovascular AAA repair Operation was not listed on the NSQIP CPT Exclusion list. Also included are any transplant procedures or trauma procedures if performed within 30 days prior to the assessed operation. | Yes; No | NUll = Not applicable or not documented because variable was added in July 2006. Classic variable; no longer used | |
| 64 | DPRNA | Num | Days from Na Preoperative Labs to Operation | Days from Na Preoperative Labs to Operation | -99 = Lab value not obtained or Unknown | ||
| 65 | DPRBUN | Num | Days from BUN Preoperative Labs to Operation | Days from BUN Preoperative Labs to Operation | -99 = Lab value not obtained or Unknown | ||
| 66 | DPRCREAT | Num | Days from Creatinine Preoperative Labs to Operation | Days from Creatinine Preoperative Labs to Operation | -99 = Lab value not obtained or Unknown | ||
| 67 | DPRALBUM | Num | Days from Albumin Preoperative Labs to Operation | Days from Albumin Preoperative Labs to Operation | -99 = Lab value not obtained or Unknown | ||
| 68 | DPRBILI | Num | Days from Bilirubin Preoperative Labs to Operation | Days from Bilirubin Preoperative Labs to Operation | -99 = Lab value not obtained or Unknown | ||
| 69 | DPRSGOT | Num | Days from SGOT Preoperative Labs to Operation | Days from SGOT Preoperative Labs to Operation | -99 = Lab value not obtained or Unknown | ||
| 70 | DPRALKPH | Num | Days from ALKPHOS Preoperative Labs to Operation | Days from ALKPHOS Preoperative Labs to Operation | -99 = Lab value not obtained or Unknown | ||
| 71 | DPRWBC | Num | Days from WBC Preoperative Labs to Operation | Days from WBC Preoperative Labs to Operation | -99 = Lab value not obtained or Unknown | ||
| 72 | DPRHCT | Num | Days from HCT Preoperative Labs to Operation | Days from HCT Preoperative Labs to Operation | -99 = Lab value not obtained or Unknown | ||
| 73 | DPRPLATE | Num | Days from PlateCount Preoperative Labs to Operation | Days from PlateCount Preoperative Labs to Operation | -99 = Lab value not obtained or Unknown | ||
| 74 | DPRPTT | Num | Days from PTT Preoperative Labs to Operation | Days from PTT Preoperative Labs to Operation | -99 = Lab value not obtained or Unknown | ||
| 75 | DPRPT | Num | Days from PT Preoperative Labs to Operation | Days from PT Preoperative Labs to Operation | -99 = Lab value not obtained or Unknown | ||
| 76 | DPRINR | Num | Days from INR Preoperative Labs to Operation | Days from INR Preoperative Labs to Operation | -99 = Lab value not obtained or Unknown | ||
| 77 | PRSODM | Num | Pre-operative serum sodium | Pre-operative serum sodium | -99 = Lab value not obtained or Unknown | ||
| 78 | PRBUN | Num | Pre-operative BUN | Pre-operative BUN | -99 = Lab value not obtained or Unknown | ||
| 79 | PRCREAT | Num | Pre-operative serum creatinine | Pre-operative serum creatinine | -99 = Lab value not obtained or Unknown | ||
| 80 | PRALBUM | Num | Pre-operative serum albumin | Pre-operative serum albumin | -99 = Lab value not obtained or Unknown | ||
| 81 | PRBILI | Num | Pre-operative total bilirubin | Pre-operative total bilirubin | -99 = Lab value not obtained or Unknown | ||
| 82 | PRSGOT | Num | Pre-operative SGOT | Pre-operative SGOT | -99 = Lab value not obtained or Unknown | ||
| 83 | PRALKPH | Num | Pre-operative alkaline phosphatase | Pre-operative alkaline phosphatase | -99 = Lab value not obtained or Unknown | ||
| 84 | PRWBC | Num | Pre-operative WBC | Pre-operative WBC | -99 = Lab value not obtained or Unknown | ||
| 85 | PRHCT | Num | Pre-operative hematocrit | Pre-operative hematocrit | -99 = Lab value not obtained or Unknown | ||
| 86 | PRPLATE | Num | Pre-operative platelet count | Pre-operative platelet count | -99 = Lab value not obtained or Unknown | ||
| 87 | PRPTT | Num | Pre-operative PTT | Pre-operative PTT | -99 = Lab value not obtained or Unknown | ||
| 88 | PRINR | Num | Pre-operative International Normalized Ratio (INR) of PT values | Pre-operative International Normalized Ratio (INR) of PT values | -99 = Lab value not obtained or Unknown | ||
| 89 | PRPT | Num | Pre-operative PT | Pre-operative PT | -99 = Lab value not obtained or Unknown | ||
| 90 | OTHERPROC1 | Char | Other Procedure 1 | An additional surgical procedure performed by the same surgical team; under the same anesthetic which has a CPT® code different from that of the Principal Operative Procedure. Report ALL additional procedures/CPT® codes for this OR visit. The followings are not included: Imaging procedures such as x ray or CT scan; Intubation; Central line placement. | NULL = No Procedure. Definition revised or clarified in 2014 | ||
| 91 | OTHERCPT1 | Char | Other CPT Code 1 | CPT Code | NUll = No Procedure | ||
| 92 | OTHERWRVU1 | Num | Other Work Relative Value Unit 1 | Other Work Relative Value Unit 1 | -99 = No Procedure/Unknown | ||
| 93 | OTHERPROC2 | Char | Other Procedure 2 | See 'Other Procedure 1' | NUll = No Procedure | ||
| 94 | OTHERCPT2 | Char | Other CPT Code 2 | CPT Code | NUll = No Procedure | ||
| 95 | OTHERWRVU2 | Num | Other Work Relative Value Unit 2 | Other Work Relative Value Unit 2 | -99 = No Procedure/Unknown | ||
| 96 | OTHERPROC3 | Char | Other Procedure 3 | See 'Other Procedure 1' | NUll = No Procedure | ||
| 97 | OTHERCPT3 | Char | Other CPT Code 3 | CPT Code | NUll = No Procedure | ||
| 98 | OTHERWRVU3 | Num | Other Work Relative Value Unit 3 | Other Work Relative Value Unit 3 | -99 = No Procedure/Unknown | ||
| -99 | OTHERPROC4 | Char | Other Procedure 4 | See 'Other Procedure 1' | NUll = No Procedure | ||
| 100 | OTHERCPT4 | Char | Other CPT Code 4 | CPT Code | NUll = No Procedure | ||
| 101 | OTHERWRVU4 | Num | Other Work Relative Value Unit 4 | Other Work Relative Value Unit 4 | -99 = No Procedure/Unknown | ||
| 102 | OTHERPROC5 | Char | Other Procedure 5 | See 'Other Procedure 1' | NUll = No Procedure | ||
| 103 | OTHERCPT5 | Char | Other CPT Code 5 | CPT Code | NUll = No Procedure | ||
| 104 | OTHERWRVU5 | Num | Other Work Relative Value Unit 5 | Other Work Relative Value Unit 5 | -99 = No Procedure/Unknown | ||
| 105 | OTHERPROC6 | Char | Other Procedure 6 | See 'Other Procedure 1' | NUll = No Procedure | ||
| 106 | OTHERCPT6 | Char | Other CPT Code 6 | CPT Code | NUll = No Procedure | ||
| 107 | OTHERWRVU6 | Num | Other Work Relative Value Unit 6 | Other Work Relative Value Unit 6 | -99 = No Procedure/Unknown | ||
| 108 | OTHERPROC7 | Char | Other Procedure 7 | See 'Other Procedure 1' | NUll = No Procedure | ||
| 109 | OTHERCPT7 | Char | Other CPT Code 7 | CPT Code | NUll = No Procedure | ||
| 110 | OTHERWRVU7 | Num | Other Work Relative Value Unit 7 | Other Work Relative Value Unit 7 | -99 = No Procedure/Unknown | ||
| 111 | OTHERPROC8 | Char | Other Procedure 8 | See 'Other Procedure 1' | NUll = No Procedure | ||
| 112 | OTHERCPT8 | Char | Other CPT Code 8 | CPT Code | NUll = No Procedure | ||
| 113 | OTHERWRVU8 | Num | Other Work Relative Value Unit 8 | Other Work Relative Value Unit 8 | -99 = No Procedure/Unknown | ||
| 114 | OTHERPROC9 | Char | Other Procedure 9 | See 'Other Procedure 1' | NUll = No Procedure | ||
| 115 | OTHERCPT9 | Char | Other CPT Code 9 | CPT Code | NUll = No Procedure | ||
| 116 | OTHERWRVU9 | Num | Other Work Relative Value Unit 9 | Other Work Relative Value Unit 9 | -99 = No Procedure/Unknown | ||
| 117 | OTHERPROC10 | Char | Other Procedure 10 | See 'Other Procedure 1' | NUll = No Procedure | ||
| 118 | OTHERCPT10 | Char | Other CPT Code 10 | CPT Code | NUll = No Procedure | ||
| 119 | OTHERWRVU10 | Num | Other Work Relative Value Unit 10 | Other Work Relative Value Unit 10 | -99 = No Procedure/Unknown | ||
| 120 | CONCURR1 | Char | Concurrent Procedure 1 | An additional operative procedure performed by a different surgical team or surgeon (e.g.; under direction of a different surgical attending) and under the same anesthetic which have CPT codes different from that of the Principal Operative Procedure (for example; Coronary Artery Bypass Graft procedure on a patient who is also undergoing a Carotid Endarterectomy). Certain CPT codes can be billed for a patient more than one time reflecting repeated performance of a particular procedure. In such cases the codes could be considered different. The followings are not included: Imaging procedures such as x ray or CT scan; Intubation; Central line placement | NULL = No Procedure. Definition revised or clarified in 2011 | ||
| 121 | CONCPT1 | Char | Concurrent CPT 1 | Concurrent CPT 2 | NUll = No Procedure | ||
| 122 | CONWRVU1 | Num | Concurrent Work Relative Value Unit 1 | Concurrent Work Relative Value Unit 2 | -99 = No Procedure/Unknown | ||
| 123 | CONCURR2 | Char | Concurrent Procedure 2 | Concurrent Procedure 3 | NUll = No Procedure | ||
| 124 | CONCPT2 | Char | Concurrent CPT 2 | Concurrent CPT 3 | NUll = No Procedure | ||
| 125 | CONWRVU2 | Num | Concurrent Work Relative Value Unit 2 | Concurrent Work Relative Value Unit 3 | -99 = No Procedure/Unknown | ||
| 126 | CONCURR3 | Char | Concurrent Procedure 3 | Concurrent Procedure 4 | NUll = No Procedure | ||
| 127 | CONCPT3 | Char | Concurrent CPT 3 | Concurrent CPT 4 | NUll = No Procedure | ||
| 128 | CONWRVU3 | Num | Concurrent Work Relative Value Unit 3 | Concurrent Work Relative Value Unit 4 | -99 = No Procedure/Unknown | ||
| 129 | CONCURR4 | Char | Concurrent Procedure 4 | Concurrent Procedure 5 | NUll = No Procedure | ||
| 130 | CONCPT4 | Char | Concurrent CPT 4 | Concurrent CPT 5 | NUll = No Procedure | ||
| 131 | CONWRVU4 | Num | Concurrent Work Relative Value Unit 4 | Concurrent Work Relative Value Unit 5 | -99 = No Procedure/Unknown | ||
| 132 | CONCURR5 | Char | Concurrent Procedure 5 | Concurrent Procedure 6 | NUll = No Procedure | ||
| 133 | CONCPT5 | Char | Concurrent CPT 5 | Concurrent CPT 6 | NUll = No Procedure | ||
| 134 | CONWRVU5 | Num | Concurrent Work Relative Value Unit 5 | Concurrent Work Relative Value Unit 6 | -99 = No Procedure/Unknown | ||
| 135 | CONCURR6 | Char | Concurrent Procedure 6 | Concurrent Procedure 7 | NUll = No Procedure | ||
| 136 | CONCPT6 | Char | Concurrent CPT 6 | Concurrent CPT 7 | NUll = No Procedure | ||
| 137 | CONWRVU6 | Num | Concurrent Work Relative Value Unit 6 | Concurrent Work Relative Value Unit 7 | -99 = No Procedure/Unknown | ||
| 138 | CONCURR7 | Char | Concurrent Procedure 7 | Concurrent Procedure 8 | NUll = No Procedure | ||
| 139 | CONCPT7 | Char | Concurrent CPT 7 | Concurrent CPT 8 | NUll = No Procedure | ||
| 140 | CONWRVU7 | Num | Concurrent Work Relative Value Unit 7 | Concurrent Work Relative Value Unit 8 | -99 = No Procedure/Unknown | ||
| 141 | CONCURR8 | Char | Concurrent Procedure 8 | Concurrent Procedure 9 | NUll = No Procedure | ||
| 142 | CONCPT8 | Char | Concurrent CPT 8 | Concurrent CPT 9 | NUll = No Procedure | ||
| 143 | CONWRVU8 | Num | Concurrent Work Relative Value Unit 8 | Concurrent Work Relative Value Unit 9 | -99 = No Procedure/Unknown | ||
| 144 | CONCURR9 | Char | Concurrent Procedure 9 | Concurrent Procedure 10 | NUll = No Procedure | ||
| 145 | CONCPT9 | Char | Concurrent CPT 9 | Concurrent CPT 10 | NUll = No Procedure | ||
| 146 | CONWRVU9 | Num | Concurrent Work Relative Value Unit 9 | Concurrent Work Relative Value Unit 10 | -99 = No Procedure/Unknown | ||
| 147 | CONCURR10 | Char | Concurrent Procedure 10 | Concurrent Procedure 11 | NUll = No Procedure | ||
| 148 | CONCPT10 | Char | Concurrent CPT 10 | Concurrent CPT 11 | NUll = No Procedure | ||
| 149 | CONWRVU10 | Num | Concurrent Work Relative Value Unit 10 | Concurrent Work Relative Value Unit 11 | -99 = No Procedure/Unknown | ||
| 150 | OPNOTE | Char | Surgeon who dictated the operative note | Surgeon who dictated the operative note | Attending; Resident; Not Available | Historical variable; no longer used | |
| 151 | PGY | Num | Highest Level of Resident Surgeon | Report the highest Post-Graduate Year (PGY) of the resident(s) who scrubbed for the surgical procedure. Choose from 1 – 10. Enter ‘0’ if there is no resident scrubbed on the surgical procedure. | 0-10 | -99 = Unknown. Classic variable; no longer used | |
| 152 | EMERGNCY | Char | Emergency case | Emergency Case: An emergency case is usually performed within a short interval of time between patient diagnosis or the onset of related preoperative symptomatology. It is implied that the patient’s well-being and outcome is potentially threatened by unnecessary delay and the patient’s status could deteriorate unpredictably or rapidly. The NSQIP Principal Operative Procedure must be performed during the hospital admission for the diagnosis. Patients who are discharged after diagnosis and return for an elective; semi-elective; or urgent procedure related to the diagnosis would not be considered to have had an emergent case. The intent is to identify a patient population with heightened surgical risk due to an ongoing acute process that is currently having a negative impact on the patients’ health and for which continued; potentially rapid deterioration could occur. The increased risk might be partly due to the fact that the procedure is being performed with limited preoperative preparation time and the surgical team does not necessarily have the ability to optimize the patient’s status. The emergency case variable distinguishes between urgent/semi-elective/elective cases and true emergent surgeries. Urgent/semielective cases are not considered emergencies. Assign 'YES' if the surgeon and/or anesthesiologist report the case as emergent. | Yes; No | NUll = Unknown. Definition revised or clarified in 2011 | |
| 153 | WNDCLAS | Char | Wound classification | Wound classification should be assigned based on the primary principal procedure being performed. Wound class is not assigned based on an 'other' or 'concurrent' procedure. This variable indicates whether the primary surgeon has classified the wound as: (1) Clean: An uninfected operative wound in which no inflammation is encountered and the respiratory; alimentary; genital or uninfected urinary tract is not entered. In addition clean wounds are primarily closed and if necessary drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria. Examples of "Clean" cases include mastectomy; vascular bypass graft; exploratory laparotomy; hernia repair; thyroidectomy; total hip or knee replacement; total hip replacements for avascular necrosis; removal of 'old' hardware without evidence of infection. Note: Placement of any drain at the time of surgery does not change the classification of the wound. (2) Clean/Contaminated: An operative wound in which the respiratory; alimentary; genital; or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically operations involving the biliary tract; appendix; vagina; and oropharynx are included in this category; provided no evidence of infection or major break in technique is encountered. Examples of "Clean/Contaminated" cases include cholecystectomy; colectomy; colostomy reversals; roux-en-Y; laryngectomy; small bowel resection; transurethral resection of the prostate; Whipple pancreaticoduodenectomy. (3) Contaminated: Open; fresh; accidental wounds. In addition operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract and incisions in which acute nonpurulent inflammation is encountered including necrotic tissue without evidence of purulent drainage (e.g. dry gangrene) are included in this category. Examples of "Contaminated" cases include appendectomy for inflamed appendicitis; bile spillage during cholecystectomy or open cardiac massage. Open surgical wounds returning to the OR. Examples of major break in sterile technique include but are not limited to non-sterile equipment or debris found in the operative field. (4) Dirty/Infected: Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation. Examples of "Dirty/Infected" cases include excision and drainage of abscess; perforated bowel; peritonitis; ruptured appendix. Wound Class for Non-Skin Incision Surgeries (Natural Orifice): assign the wound classification based on which orifice was entered. Example: appendectomy performed via the vagina would at minimum be a clean/contaminated wound class. Multiple surgical procedures performed with different incision sites = Assign wound classification based on the Principal Operative Procedure being reviewed in NSQIP. Revision: January 1 2012 ACS 4-24 NSQIP Example: Principal Operative Procedure: Carotid Endarterectomy (clean) Other Procedure: I & D of an infected right big toe (dirty/infected). The wound class assigned to this case would be clean. Multiple surgical procedures performed through one incision (same operative space) = Assign wound classification based on the assessment of the overall operative space. Example: Principal Operative Procedure: Lysis of adhesions (clean) Other Procedure: cholecystectomy with gross bile spillage (contaminated). The wound class would be contaminated; as the spillage is in the same operative space as the Principal Operative Procedure. | 1-Clean/ 2-Clean/Contaminated / 3-Contaminated / 4-Dirty/Infected | NULL = Unknown. Definition revised or clarified in 2011 | |
| 154 | ASACLAS | Char | ASA classification | The American Society of Anesthesiology (ASA) Physical Status Classification of the patient’s present physical condition on a scale from 1-5 as it appears on the anesthesia record. The classifications are as follows: ASA 1Labs to OperationNormal healthy patient ASA 2Labs to OperationPatient with mild systemic disease ASA 3Labs to OperationPatient with severe systemic disease ASA 4Labs to OperationPatient with severe systemic disease that is a constant threat to life ASA 5Labs to OperationMoribund patient who is not expected to survive without the operation. | 1-No Disturb; 2-Mild Disturb; 3-Severe Disturb; 4-Life Threat;5-Moribund;None assigned | NUll= Unknown | |
| 155 | AIRTRA | Char | Airway trauma | The code corresponding to trauma resulting from the endotracheal intubation process is entered. | None; Lip laceration or hematoma; Tooth chipped loosened or lost; Tongue laceration or hematoma; Pharyngeal laceration; Laryngeal laceration; Failure to intubate | Historical variable; no longer used | |
| 156 | MALLAMP | Num | Mallampati scale | The Mallampati classification relates tongue size to pharyngeal size. This test is performed with the patient in sitting position; the head held in a neutral position; the mouth wide open and the tongue protruding to the maximum. The subsequent classification is assigned based upon the pharyngeal structures that are visible: Class I – visualization of the soft palate; fauces; uvula; and anterior and posterior pillars. Class II – visualization of the soft palate; fauces; and uvula. Class III – visualization of the soft palate and the base of the uvula. Class IV – soft palate is not visible at all. | 1; 2; 3; 4 | Historical variable; no longer used | |
| 157 | MORTPROB | Num | Estimated Probability of Mortality | Probability of mortality is developed for general and vascular surgical cases based on a logistic regresion analysis using the patient's preopeartive characteristics as the independent or predictive variables. Only general and vascular cases used in the logistic regression analysis will have the associated probabilities of mortality. | System missing = case was not included in the logistic regression analysis | ||
| 158 | MORBPROB | Num | Estimated Probability of Morbidity | Probability of morbidity is developed for general and vascular surgical cases based on a logistic regresion analysis using the patient's preopeartive characteristics as the independent or predictive variables. Only the general and vascular cases used in the logistic regression analysis will have the associated probabilities of morbidity. | System missing = case was not included in the logistic regression analysis | ||
| 159 | RBC | Num | Number of RBC units given intraoperative | The number of packed or whole red blood cells given during the operative procedure as it appears on the anesthesia record. The amount of blood reinfused from the cell saver is also noted. For a cell saver; every 500 cc’s of fluid will equal 1 unit of packed cells. If there is less than 250 cc of fluid; 0 is entered. | Historical variable; no longer used | ||
| 160 | ANESURG | Num | Duration from Anesthsia start to Surgery start | Duration from Anesthsia start to Surgery start in minutes | -99 = Unknown. classic variable; no longer used | ||
| 161 | SURGANE | Num | Duration from Surgery stop to Anesthia Stop | Duration from Surgery stop to Anesthia Stop in minutes | |||
| 162 | DPATRM | Num | Duration patient is in Room | Duration patient is in Room in minutes | -99 = Unknown | ||
| 163 | ANETIME | Num | Duration of Anesthesia Duration | of Anesthesia in minutes | -99 = Unknown. Classic variable; no longer used | ||
| 164 | OPTIME | Num | Total operation time | Total operation time in minutes | -99 = Unknown. | ||
| 165 | TYPEINTOC | Char | Type of Intraoperative Occurrence | One of the three following intraoperative occurrences can be selected. Cardiac Arrest Requiring CPR is defined as the absence of cardiac rhythm or presence of chaotic cardiac rhythm that results in loss of consciousness requiring the initiation of any component of basic and/or advanced cardiac life support. Patients with automatic implantable cardioverter defibrillator that fire but the patient has no loss of consciousness should be excluded. Myocardial Infarction is defined as a new transmural acute myocardial infarction occurring during surgery as manifested by nnew Q-waves on ECG. Unplanned Intubation for Respirator/Cardiac Failure is defined as a patient requiring placement of an endotracheal tube or other similar breathing tube [Laryngeal Mask Airway (LMA); nasotracheal tube; etc] and ventilator support which was not intended or planned. | Cardiac Arrest Requiring CPR; Myocardial Infarction; Unplanned Intubation | NULL = None of the three occurred. Classic variable; no longer used | |
| 166 | SDISDT | Num | Year discharged/transferred from surgical service | Year discharged/transferred from surgical service | Historical variable; no longer used | ||
| 167 | HDISDT | Num | Hospital discharge Year | Hospital discharge Year | -99 = Unknown | ||
| 168 | YRDEATH | Num | Year of death | Year of death | -99 = Patient alive at 30 days. Notes: include death >30days of procedure | ||
| 169 | TOTHLOS | Num | Length of total hospital stay | Length of total hospital stay | |||
| 170 | AdmQtr | Num | Quarter of Admission | Quarter of Admission | 1; 2; 3; 4 | -99 = Unknown | |
| 171 | HtoODay | Num | Days from Hospital Admission to Operation | Days from Hospital Admission to Operation | -99 = Unknown | ||
| 172 | StoODay | Num | Days from Surgical Admission to Operation | Days from Surgical Admission to Operation | Historical variable; no longer used | ||
| 173 | TOTSLOS | Num | Length of total surgical stay | Length of total surgical stay | Classic variable; no longer used | ||
| 174 | NSUPINFEC | Num | Number of Wound Occurrences | Number of Superficial Wound Occurrences | |||
| 175 | SUPINFEC | Char | Superficial surgical site infection | Superficial incisional SSI is an infection that occurs within 30 days after the operation and the infection involves only skin or subcutaneous tissue of the incision and at least one of the following: Purulent drainage with or without laboratory confirmation from the superficial incision. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision. At least one of the following signs or symptoms of infection: pain or tenderness; localized swelling; redness; or heat AND superficial incision is deliberately opened by the surgeon; unless incision is culture-negative or the physician documented NO infection and does not further treat the patient. Diagnosis of superficial incisional SSI by the surgeon or attending physician. Do not report the following conditions as SSI: Stitch abscess (minimal inflammation and discharge confined to the points of suture penetration). Infected burn wound. Incisional SSI that extends into the fascial and muscle layers (see deep incisional SSI). Diagnosis of superficial vaginitis after vaginal surgery. Diagnosis of superficial oral thrush after oral surgery. Notes: See SSI Guidance Table for additional information. Only SSIs at the incision site of the principal operative procedure should be assessed. Incision sites for “other” or “concurrent” procedures; if they are in distinctly different anatomical sites should not be assessed. If there is question as to whether or not an incision site was an integral portion of the principal operative procedure; include this site in your SSI assessment. Please note: a single principal operative procedure can have more than one incision. Criteria will be assigned when modifying terms such as “possible”; “probable”; “evolving”; “highly suspicious” or “suggestive” are used to describe an infection; in conjunction with otherwise meeting criteria. Can be assigned multiple times within the 30 day postop period each time criteria is met (reference the chart above). A Gram Stain result is not considered a culture and cannot be utilized as criterion to assign this postoperative occurrence | No Complication; Superficial Incisional SSI | Definition revised or clarified in 2014 | |
| 176 | SSSIPATOS | Char | Superficial Incisional SSI PATOS | Evidence/suspicion of an active superficial infection (e.g.; skin / subcutaneous) noted at the time the patient enters the OR or intraoperatively for the principal operative procedure. The case must meet the following criteria; A AND B: A. Superficial Incisional SSI is assigned as a postoperative occurrence; AND B. Evidence or suspicion of a superficial infection found at the intended surgical site. This must be noted preoperatively or found intraoperatively at the surgical site and may include an open wound; cellulitis (erythema; tenderness AND swelling); or wound infection.'Yes' is entered if a postop superficial infection is assigned; Intraoperatively during the surgical “time out”; cellulitis is noted at the intended surgical site prior to incision. 'No' is entered if a superficial SSI has not been assigned as a postop occurrence. Notes: If a Superficial Incisional SSI is assigned as a postoperative occurrence; only Superficial Incisional SSI PATOS can be assigned if the patient meets criteria for Superficial Incisional PATOS [Cannot assign Deep Incisional or Organ/Space PATOS unless the corresponding postoperative occurrence is assigned]; PATOS criteria are frequently less stringent than criteria for a preoperative risk factor or postoperative occurrence. This means at times PATOS can be assigned to a postoperative occurrence despite the fact that criteria for a preoperative risk factor may not be met. | Yes; No | NUll = No response; Variable added in 2011. Definition revised or clarified in 2014 | |
| 177 | DSUPINFEC | Num | Days from Operation until Superficial Incisional SSI Complication | Days from Operation until Superficial Incisional SSI Complication | -99 = Patient did not experience this complication at or before 30 days post operation | ||
| 178 | NWNDINFD | Num | Number of Deep Incisional SSI Occurrences | Number of Deep Incisional SSI Occurrences | |||
| 179 | WNDINFD | Char | Occurrences Deep Incisional SSI | Deep Incision SSI is an infection that occurs within 30 days after the operation and the infection appears to be related to the operation and infection involved deep soft tissues (e.g.; fascial and muscle layers) of the incision and at least one of the following: Purulent drainage from the deep incision but not from the organ/space component of the surgical site. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (> 38 C); localized pain; or tenderness; unless site is culture-negative. An abscess or other evidence of infection involving the deep incision is found on direct examination; during reoperation; or by histopathologic or radiologic examination. Diagnosis of a deep incision SSI by a surgeon or attending physician. Infection that involves both superficial and deep incision sites is reported as deep incisional SSI; Organ/space SSI that drains through the incision is reported as a deep incisional SSI; Diagnosis of vaginitis in association with purulent drainage (i.e. from the cuff) after vaginal surgery is reported as a deep incisional SSI; Diagnosis of pharyngitis in association with purulent drainage after oral surgery is reported as a deep incisional SSI. Those which refer to superficial SSI variable for further clarification regarding superficial vaginitis and pharyngitis are not included. Notes: See SSI Guidance Table for additional information. Only an SSI at the incision site of the principal operative procedure should only be assessed. Incision sites for “other” or “concurrent” procedures; if they are in distinctly different anatomical sites should not be assessed. If there is question as to whether or not an incision site was an integral portion of the principal operative procedure; include this site in your SSI assessment. | Deep Incisional SSI; No Complication | Definition revised or clarified in 2014 | |
| 180 | DSSIPATOS | Char | Deep Incisional SSI PATOS | Evidence/suspicion of an active deep layer infection (e.g.; muscle and fascial layers) noted at the time the patient enters the OR or intraoperatively for the principal operative procedure. The case must meet the following criteria: A.Deep Incisional SSI is assigned as a postoperative occurrence AND B. Evidence or suspicion of a deep infection (e.g.; muscle and fascial layers) found at the intended surgical site. This must be noted preoperatively or found intraoperatively at the surgical site and may include an open wound; cellulitis (erythema; tenderness AND swelling); or wound infection. The followings are not included: Deep incisional SSI has not been assigned as a postop occurrence; Iatrogenic injuries that occur during the principal operative procedure with no other evidence of infection. Notes: If a Deep Incisional SSI is assigned as a postoperative occurrence; thenLabs to Operation- only Deep Incisional SSI PATOS can be assigned if the patient meets criteria for Deep Incisional SSI PATOS [Cannot assign Superficial or Organ/Space PATOS (unless there is an organ/space infection draining through the incision which is assigned as a Deep Incisional SSI)]. PATOS criteria are frequently less stringent than criteria for a preoperative risk factor or postoperative occurrence. This means at times PATOS can be assigned to a postoperative occurrence despite the fact that criteria for a preoperative risk factor may not be met. In instances where criteria for deep SSI was met due to an intraoperative event (e.g. iatrogenic injury) PATOS would not be assigned | Yes; No | NUll = No response. Variable added in 2011. Definition revised or clarified in 2014 | |
| 181 | DWNDINFD | Num | Days from Operation until Deep Incisional SSI Complication | Days from Operation until Deep Incisional SSI Complication | -99 = Patient did not experience this complication at or before 30 days post operation | ||
| 182 | NORGSPCSSI | Num | Number of Organ/Space SSI Occurrences | Number of Organ/Space SSI Occurrences | |||
| 183 | ORGSPCSSI | Char | Occurrences Organ Space SSI | Organ/Space SSI is an infection that occurs within 30 days after the operation and the infection appears to be related to the operation and the infection involves any part of the anatomy (e.g.; organs or spaces); other than the incision; which was opened or manipulated during an operation and at least one of the following: Purulent drainage from a drain that is placed through a stab wound into the organ/space. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space. An abscess or other evidence of infection involving the organ/space that is found on direct examination; during reoperation; or by histopathologic or radiologic examination. Diagnosis of an organ/space SSI by a surgeon or attending physician. The followings are considered organ/space SSI: Anastomotic leaks involving the GI tract or which involve enteric contents; Anastomotic leaks involving the GU tract which involve evidence of an active infection (e.g. elevated WBC/fever attributed to the leak; diagnosis by physician; collection or leak is culture positive); Injury to intestine (e.g. enterotomy; iatrogenic injury) which results in a postoperative leak of enteric contents into the abdomen. The followings are not considered as O/S SSI: Report an organ/space SSI that drains through the incision as a deep incisional SSI; Fistulas alone; unless they independently meet the other criteria listed above; Anastomotic leaks involving vasculature (e.g. lower extremity bypass); unless one of the 4 criteria above is met; Anastomotic leaks involving the GU tract; which does not meet criteria above; C diff in isolation. Notes: Only SSIs at the incision site of the principal operative procedure should be assessed. Incision sites for “other” or “concurrent” procedures that are in distinctly different anatomical sites should not be assessed. If there is question as to whether or not an incision site was an integral portion of the principal operative procedure; then include this site in your SSI assessment. Criteria will be assigned when modifying terms such as “possible”; “probable”; “evolving”; “highly suspicious” or “suggestive” are used to describe an infection; in conjunction with otherwise meeting criteria. Can be assigned multiple times within the 30 day postop period each time criteria is met. A Gram Stain result is not considered a culture and cannot be utilized as criterion to assign this post-operative occurrence. | Organ/Space SSI; No Complication | Definition revised or clarified in 2014 | |
| 184 | OSSIPATOS | Char | Organ/Space SSI PATOS | Evidence/suspicion of an active organ/space infection noted at the time the patient enters the OR or intraoperatively for the principal operative procedure. The case must meet the following criteria: A. Organ/space SSI is assigned as a postoperative occurrence AND B. Evidence or suspicion of an abscess or other infection involving the organ or space manipulated during the operation. This must be noted preoperatively or found intraoperatively in the surgical space. The followings are not reported as O/S SSI PATOs: Organ/Space SSI has not been assigned as a postop occurrence; Enterotomies or iatrogenic injuries that occur during the principal operative procedure with no other evidence of infection. Notes: If an Organ/Space SSI is assigned as a postoperative occurrence—only Organ/Space SSI PATOS can be assigned if the patient meets criteria for Organ/Space SSI PATOS [Cannot assign Superficial or Deep PATOS]. Exception: If an Organ/Space SSI that drains through the incision is assigned as a deep incisional SSI; PATOS can be assigned if the patient meets criteria for Organ/Space SSI PATOS. PATOS criteria are frequently less stringent than criteria for a preoperative risk factor or postoperative occurrence. This means at times PATOS can be assigned to a postoperative occurrence despite the fact that criteria for a preoperative risk factor may not be met. In instances where criteria for Organ/Space SSI was met due to an intraoperative event (e.g. enterotomy; iatrogenic injury) PATOS would not be assigned | Yes; No | NUll = No response. Variable added in 2011. Definition revised or clarified in 2014 | |
| 185 | DORGSPCSSI | Num | Days from Operation until Organ/Space SSI Complication | Days from Operation until Organ/Space SSI Complication | ; 99 = Patient did not experience this complication at or before 30 days post operation | ||
| 186 | NDEHIS | Num | Number of Wound Disruption Occurrences | Number of Wound Disruption Occurrences | |||
| 187 | DEHIS | Char | Occurrences Wound Disrupt | The spontaneous reopening of a previously surgically closed wound that occurs within 30 days after the principal operative procedure AND one of the following criteria: A. Abdominal site: refers primarily to loss of the integrity of fascial closure (or whatever closure was performed in the absence of fascial closure) OR B. Other Surgical Sites: there must be a total breakdown of the surgical closure compromising the integrity of the procedure. The followings are considered as wound disruption: Tissue flap coverage where the surgical incisions; which were closed; have lost the integrity of closure; Above the knee amputation wound which spontaneously opens exposing the bone. Patients who has an ostomy with a small separation around it are not included.Notes:Can be assigned multiple times within the 30 day postop period each time criteria is met; If a wound is closed in a subsequent procedure within the 30 day postop | Wound Disruption; No Complication | Definition revised or clarified in 2011. Defintion revised or clarified in 2014 | |
| 188 | DDEHIS | Num | Days from Operation until Wound Disruption Complication | Days from Operation until Wound Disruption Complication | 99 = Patient did not experience this complication at or before 30 days post operation | ||
| 189 | NOUPNEUMO | Num | Number of Pneumonia Occurrences | Number of Pneumonia Occurrences | |||
| 190 | OUPNEUMO | Char | Enter "Yes" if the patient has pneumonia meeting the definition below. Patients with pneumonia must meet criteria from both Radiology and Signs/Symptoms/Laboratory sections listed as follows: Radiology: One definitive chest radiological exam (x-ray or CT)* with at least one of the following: New or progressive and persistent infiltrate; Consolidation or opacity; Cavitatio. Note: In patients with underlying pulmonary or cardiac disease (e.g. respiratory distress syndrome; bronchopulmonary dysplasia; pulmonary edema; or chronic obstructive pulmonary disease); two or more serial chest radiological exams (xray or CT) are required. (Serial radiological exams should be taken no less than 12 hours apart but not more than 7 days apart. The occurrence should be assigned on the date the patient first met all of the criteria of the definition (i.e; if the patient meets all PNA criteria on the day of the first xray; assign this date to the occurrence. Do not assign the date of the occurrence to when the second serial xray was performed). Pneumonia; No Complication Definition revised or clarified in 2010. Signs/Symptoms/Laboratory: FOR ANY PATIENT; at least one of the following: Fever (>38 C or >100.4 F) with no other recognized cause; Leukopenia (<4000 WBC/mm3) or leukocytosis( ≥12000 WBC/mm3). For adults ≥ 70 years old; altered mental status with no other recognized cause and at least one of the following: 5% Bronchoalveolar lavage (BAL) obtained cells contain intracellular bacteria on direct microscopic exam (e.g.; Gram stain); Positive growth in blood culture not related to another source of infection; Positive growth in culture of pleural fluid; Positive quantitative culture from minimally contaminated lower respiratory tract (LRT) specimen (e.g. BAL or protected specimen brushing) OR at least two of the following: New onset of purulent sputum or change in character of sputum; or increased respiratory secretions; or increased suctioning requirements; New onset or worsening cough; or dyspnea; or tachypnea; Rales or rhonchi; Worsening gas exchange (e.g. O2 desaturations (e.g.; PaO2/FiO2 ≤ 240);increased oxygen requirements; or increased ventilator demand). | Pneumonia; No Complication | Definition revised or clarified in 2010 | ||
| 191 | PNAPATOS | Char | Pneumonia PATOS | Evidence/suspicion of active pneumonia noted at the time the patient enters the OR or intraoperatively for the principal operative procedure. The case must meet the following criteria: A. Pneumonia is assigned as a postoperative occurrence AND B. Preoperative data are highly suggestive or suspicious of pneumonia. The following are included: Preoperative physician diagnosis of pneumonia on the day of surgery; Preoperative diagnosis of pneumonia (day of surgery or prior) with patient undergoing treatment at time of surgery; Preoperative X-ray results stating pneumonia and patient being treated at time of surgery; Patient being treated for pneumonia at the time of surgery. Patients with pneumonia has not been assigned as a postop occurrence are not included. Notes: PATOS criteria are frequently less stringent than criteria for a preoperative risk factor or postoperative occurrence. This means at times PATOS can be assigned to a postoperative occurrence despite the fact that criteria for a preoperative risk factor may not be met. | Yes; No | NUll = No response. Variable added in 2011. Definition revised or clarified in 2014 | |
| 192 | DOUPNEUMO | Num | Days from Operation until Pneumonia Complication | Days from Operation until Pneumonia Complication | 99 = Patient did not experience this complication at or before 30 days post operation | ||
| 193 | NREINTUB | Num | Number of Unplanned Intubation Occurrences | Number of Unplanned Intubation Occurrences | |||
| 194 | REINTUB | Char | Occurrences Unplanned Intubation | Patient required placement of an endotracheal tube or other similar breathing tube [Laryngeal Mask Airway (LMA); nasotracheal tube; etc] and ventilator support intraoperatively or within 30 days following surgery which was not intended or planned. The variable intent is to capture all cause unplanned intubations; including but not limited to unplanned intubations for refractory hypotension; cardiac arrest; inability to protect airway. Accidental self extubations requiring reintubation would be assigned. Emergency tracheostomy would be assigned. Patients with a chronic/long-term tracheostomy who are on and off the ventilator would not be assigned; unless the tracheostomy tube itself is removed and the patient requires reintubation (endotracheal or a new tracheostomy tube) or an emergency tracheostomy. Patients undergoing time off the ventilator during weaning trials and who fail the trail and are placed back on the ventilator would not be assigned. Intubations for an unplanned return to the OR would not be assigned; as the intubation is planned; it is the return to the OR which is unplanned. In patients who were intubated for a return to the OR for a surgical procedure unplanned intubation occurs after they have been extubated after surgery. In patients who were not intubated for a return to the OR; intubation at any time after their surgery is complete is considered unplanned. Intraoperative conversion from local or MAC anesthesia to general anesthesia; during the Principal Operative Procedure; with placement of a breathing tube and ventilator support; secondary to the patient not tolerating local or MAC anesthesia; in the absence of an emergency; would not be assigned. If patients required placement of an endotracheal tube or other similar breathing tube and refused placement of the tube would not be assigned | Unplanned Intubation; No Complication | Definition revised or clarified in 2011. Definition revised or clarified in 2014 | |
| 195 | DREINTUB | Num | Days from Operation until Unplanned Intubation Complication | Days from Operation until Unplanned Intubation Complication | 99 = Patient did not experience this complication at or before 30 days post operation | ||
| 196 | NPULEMBOL | Num | Number of Pulmonary Embolism Occurrences | Number of Pulmonary Embolism Occurrences | |||
| 197 | PULEMBOL | Char | Occurrences Pulmonary Embolism | Lodging of a blood clot in the pulmonary artery with subsequent obstruction of blood supply to the lung parenchyma. The blood clots usually originate from the deep leg veins or the pelvic venous system. The identification of a new blood clot in a pulmonary artery causing obstruction (complete or partial) of the blood supply to the lungs. However; since there are not always preoperative studies proving that a clot or thrombus was not present preoperatively; the technical specification of the variable requires only a “new diagnosis”- in other words the clot or thrombus was not previously known. A pulmonary embolism must be noted within 30 days after the principal operative procedure AND the following criteria; A AND B below: A. New diagnosis of a new blood clot in a pulmonary artery AND B. The patient has a V-Q scan interpreted as high probability of pulmonary embolism or a positive CT exam; TEE; pulmonary arteriogram; CT angiogram; or any other definitive imaging modality (including direct pathology examination such as autopsy | Pulmonary Embolism; No Complication | Definition revised or clarified in 2013 | |
| 198 | DPULEMBOL | Num | Days from Operation until Pulmonary | Embolism Complication | Days from Operation until Pulmonary Embolism Complication | -99 = Patient did not experience this complication at or before 30 days post operation | |
| 199 | NFAILWEAN | Num | Number of On Ventilator > 48 Hours Occurrences | Number of On Ventilator > 48 Hours Occurrences | |||
| 200 | FAILWEAN | Char | Occurrences Ventilator > 48Hours | Total duration of ventilator-assisted respirations during postoperative hospitalization was greater than 48 hours. This can occur at any time during the 30-day period postoperatively. This time assessment is CUMULATIVE; not necessarily consecutive. Ventilator-assisted respirations can be via endotracheal tube; nasotracheal tube; or tracheostomy tube. | On Ventilator greater than 48 Hours; No Complication | ||
| 201 | VENTPATOS | Char | On Ventilator > 48 Hours PATOS | To identify patients who are intubated and receiving mechanical ventilator support upon entering the operating room for the principal operative procedure OR requires an unplanned intubation intraoperatively prior to the initiation of anesthesia for the principal operative procedure. The case must meet the following criteria: A. On the Ventilator > 48 Hours is assigned as a postoperative occurrence AND B. One of the following scenarios (1 or 2): (1.) The patient is intubated and receiving mechanical ventilator support upon entering the operating room OR (2.) The patient requires an unplanned intubation intraoperatively prior to the initiation of anesthesia for the principal operative procedure. The followings are not included: CPAP; BiPAP; etc. Patients who required intubation and ventilator support at some point prior to the principal operative procedure; but who are not intubated and receiving ventilator support prior to the initiation of anesthesia for the principal operative procedure. | Yes; No | NUll = No response; Variable added in 2011. Definition revised or clarified in 2014 | |
| 202 | DFAILWEAN | Num | Days from Operation until On Ventilator >48 Hours Complication | Days from Operation until On Ventilator > 48 Hours Complication | 99 = Patient did not experience this complication at or before 30 days post operation | ||
| 203 | NRENAINSF | Num | Number of Progressive Renal Insufficiency Occurrences | Number of Progressive Renal Insufficiency Occurrences | |||
| 204 | RENAINSF | Char | Occurrences Progressive Renal Insufficiency | The reduced capacity of the kidney to perform its function as evidenced by a rise in creatinine of >2 mg/dl from preoperative value; but with no requirement for dialysis within 30 days of the operation. | Progressive Renal Insufficiency; No Complication | ||
| 205 | DRENAINSF | Num | Days from Operation until Progressive Renal Insufficiency Complication | Days from Operation until Progressive Renal Insufficiency Complication | -99 = Patient did not experience this complication at or before 30 days post operation | ||
| 206 | NOPRENAFL | Num | Number of Acute Renal Failure Occurrences | Number of Acute Renal Failure Occurrences | |||
| 207 | OPRENAFL | Char | Occurrences Acute Renal Fail | A patient who did not require dialysis preoperatively; worsening of renal dysfunction postoperatively requiring hemodialysis; peritoneal dialysis; hemofiltration; hemodiafiltration; or ultrafiltration. If the patient refuses a recommendation for dialysis; you would answer ‘Yes’to this variable because the patient required dialysis ; Hemodialysis; peritoneal dialysis; hemofiltration; hemodiafiltration; or ultrafiltration all qualify Placement of a dialysis catheter is indicative of the need for dialysis; if used within 48 hours of placement would not be assinged. Notes: The preoperative creatinine level that should be utilized when assigning the postoperative occurrence of "progressive renal insufficiency" should be taken closest to the surgery start time; but no greater than 90 days prior to surgery. | Acute Renal Failure; No Complication | Definition revised or clarified in 2011. Defintion revised or clarified in 2014 | |
| 208 | DOPRENAFL | Num | Days from Operation until Acute Renal Failure Complication | Days from Operation until Acute Renal Failure Complication | -99 = Patient did not experience this complication at or before 30 days post operation | ||
| 209 | NURNINFEC | Num | Number of Urinary Tract infection Occurrences | Number of Urinary Tract infection Occurrences | |||
| 210 | URNINFEC | Char | Occurrences Urinary Tract Infection | An infection in the urinary tract (kidneys; ureters; bladder; and urethra). Must be noted within 30 days after the principal operative procedure AND patient must meet ONE of the following: A: ONE of the following six criteria: fever (>38oC or 100.4o F); urgency; frequency; dysuria; suprapubic tenderness; costovertebral angle pain or tenderness AND; A urine culture of > 100;000 colonies/ml urine with no more than two species of organisms. Signs and symptoms should be reported within 72 hours prior to a urine culture being sent or 24 hours after the culture was sent. OR B: TWO of the following six criteria: fever (>38o C or 100.4o F); urgency; frequency; dysuria; suprapubic tenderness; costovertebral angle pain or tenderness AND At least one of the following: Dipstick test positive for leukocyte esterase and/or nitrate; Pyuria (>10 WBCs/mm3 or > 3 WBC/hpf of unspun urine); Organisms seen on Gram stain of unspun urine; Two urine cultures with repeated isolation of the same uropathogen with >100;000 colonies/ml urine in non-voided specimen. Signs and symptoms should be reported within 72 hours prior to a urine culture being sent or 24 hours after the culture was sent. Urine culture with < 100000 colonies/ml urine of single uropathogen in patient being treated with appropriate antimicrobial therapy. Signs and symptoms should be reported within 72 hours prior to a urine culture being sent or 24 hours after the culture was sent. Physician's diagnosis. Physician institutes appropriate antimicrobial therapy | Urinary Tract Infection; No Complication | Definition revised or clarified in 2013;. Definition revised or clarified in 2014 | |
| 211 | UTIPATOS | Char | UTI PATOS | Evidence/suspicion of an active urinary tract infection noted at the time the patient enters the OR or intraoperatively for the principal operative procedure. The case must meet the following criteria: A. A Urinary Tract Infection (UTI) is assigned as a postoperative occurrence AND B. One of the following scenarios (1 or 2):1. Preoperative evidence of a symptomatic UTI that had not started treatment or is currently undergoing treatment OR 2. Preoperative evidence was highly suggestive or suspicious of a UTI (symptomatic or asymptomatic) at the time of surgery. PATOs is assigned if results from a sterile urine culture obtained at the start of the principal operative can be utilized for evidence. Notes: PATOS criteria are frequently less stringent than criteria for a preoperative risk factor or postoperative occurrence. This means at times PATOS can be assigned to a postoperative occurrence despite the fact that criteria for a preoperative risk factor may not be met. | Yes; No | NUll = No response. Variable added in 2011. Definition revised or clarified in 2014 | |
| 212 | DURNINFEC | Num | Days from Operation until Urinary Tract Infection Complication | Days from Operation until Urinary Tract Infection Complication | -99 = Patient did not experience this complication at or before 30 days post operation | ||
| 213 NCNSCVA | Num | Number of Stroke/CVA Occurrences | Number of Stroke/CVA Occurrences | ||||
| 214 | CNSCVA | Char | CVA/Stroke with neurological deficit | Patient develops an embolic; thrombotic; or hemorrhagic vascular accident or stroke with motor; sensory; or cognitive dysfunction (e.g.; hemiplegia; hemiparesis; aphasia; sensory deficit; impaired memory) that persists for 24 or more hours. If a specific time frame for the dysfunction is not documented in the medical record; but there is a diagnosis of a stroke; assign the occurrence; unless documentation specifically states that the motor; sensory; or cognitive dysfunction resolved. | Stroke/CVA; No Complication | Definition revised or clarified in 2010 | |
| 215 | DCNSCVA | Num | Days from Operation until Stroke/CVA Complication | Days from Operation until Stroke/CVA Complication | -99 = Patient did not experience this complication at or before 30 days post operation | ||
| 216 | NCNSCOMA | Num | Number of Coma > 24 Hours Occurrences | Number of Coma > 24 Hours Occurrences | Classic variable; no longer used | ||
| 217 | CNSCOMA | Char | Coma >24 hours | Patient is unconscious or postures to painful stimuli or is unresponsive to all stimuli (exclude transient disorientation or psychosis) for greater than 24 hours. Drug-induced coma (e.g. Propofol drips) are not entered within 30 days of the operation. | Coma greater than 24 hours; No Complication | Classic variable; no longer used | |
| 218 | DCNSCOMA | Num | Days from Operation until Coma > 24 Hours Complication | Days from Operation until Coma > 24 Hours Complication | -99 = Patient did not experience this complication at or before 30 days post operation. Classic variable; no longer used | ||
| 219 | NNEURODEF | Num | Number of Peripheral Nerve Injury Occurrences | Number of Peripheral Nerve Injury Occurrences | Classic variable; no longer used | ||
| 220 | NEURODEF | Char | Peripheral Nerve Injury | Peripheral nerve damage may result from damage to the nerve fibers; cell body; or myelin sheath during surgery. Peripheral nerve injuries which result in motor deficits to the cervical plexus; brachial plexus; ulnar plexus; lumbar-sacral plexus (sciatic nerve); peroneal nerve; and/or the femoral nerve should be included. | Peripheral nerve injury ; No Complication | Classic variable; no longer used | |
| 221 | DNEURODEF | Num | Days from Operation until Peripheral Nerve Injury Complication | Days from Operation until Peripheral Nerve Injury Complication | -99 = Patient did not experience this complication at or before 30 days post operation. Classic variable; no longer used | ||
| 222 | NCDARREST | Num | Number of Cardiac Arrest Requiring CPR Occurrences | Number of Cardiac Arrest Requiring CPR Occurrences | |||
| 223 | CDARREST | Char | Occurrences Cardiac Arrest Requiring CPR | The absence of cardiac rhythm or presence of chaotic cardiac rhythm; intraoperatively or within 30 days following surgery; which results in a cardiac arrest requiring the initiation of CPR; which includes chest compressions. Patients are included who are in a pulseless VT or Vfib in which defibrillation is performed and PEA arrests requiring chest compressions. Patient who receives open cardiac massage are included. Patients with automatic implantable cardioverter defibrillator (AICD) that fire but the patient has no loss of consciousness should be excluded. | Cardiac Arrest Requiring CPR; No Complication | Definition revised or clarified in 2011. Defintion revised or clarified in 2014 | |
| 224 | DCDARREST | Num | Days from Operation until Cardiac Arrest Requiring CPR Complication | Days from Operation until Cardiac Arrest Requiring CPR Complication | -99 = Patient did not experience this complication at or before 30 days post operation | ||
| 225 | NCDMI | Num | Number of Myocardial Infarction Occurrences | Number of Myocardial Infarction Occurrences | |||
| 226 | CDMI | Char | Occurrences Myocardial Infarction | An acute myocardial infarction which occurred intraoperatively or within 30 days following surgery as manifested by one of the following: Documentation of ECG changes indicative of acute MI (one or more of the following): ST elevation > 1 mm in two or more contiguous leads; New left bundle branch; New q-wave in two of more contiguous leads; New elevation in troponin greater than 3 times upper level of the reference range in the setting of suspected myocardial ischemia. Physician diagnosis of myocardial infarction | Myocardial Infarction; No Complication | Definition revised or clarified in 2011 | |
| 227 | DCDMI | Num | Days from Operation until Myocardial Infarction Complication | Days from Operation until Myocardial Infarction Complication | -99 = Patient did not experience this complication at or before 30 days post operation | ||
| 228 | NOTHBLEED | Num | Number of Bleeding Transfusions Occurrences | Number of Bleeding Transfusions Occurrences | |||
| 229 | OTHBLEED | Char | Occurrences Bleeding Transfusions | At least 1 unit of packed or whole red blood cells given from the surgical start time up to and including 72 hours postoperatively. If the patient receives shed blood; autologous blood; cell saver blood or pleurovac postoperatively; count this blood in terms of equivalent units. For a cell saver; every 500 ml's of fluid will equal 1 unit of packed cells. If there are less than 250 ml of cell saver; round down and report as 0 units. If there are 250 cc; or more of cell saver; round up to 1 unit. The blood may be given for any reason. If greater than 200 units; enter 200 units. Record the number of units given. Record the date the blood was initially started (intra-operatively or postoperatively). Note: Intra-operative blood to prime the by-pass pump for CABG is not shed blood and should not be included as cell-saver blood. | Transfusions/Intraop/Postop; No Complication | Definition change in 2009 | |
| 230 | DOTHBLEED | Num | Days from Operation until Bleeding Transfusions Complication | Days from Operation until Bleeding Transfusions Complication | -99 = Patient did not experience this complication at or before 30 days | ||
| 231 | NOTHGRAFL | Num | Number of Graft/Prosthesis/Flap Failure Occurrences | Number of Graft/Prosthesis/Flap Failure Occurrences | Classic variable; no longer used | ||
| 232 | OTHGRAFL | Char | Occurrences Graft/Prosthesis/FF | Mechanical failure of an extracardiac graft or prosthesis including myocutaneous flaps and skin grafts requiring return to the operating room; interventional radiology; or a balloon angioplasty within 30 days of the operation. | Graft/Prosthesis/Flap Failure; No Complication | Classic variable; no longer used | |
| 233 | DOTHGRAFL | Num | Days from Operation until Graft/Prosthesis/Flap Failure Complication | Days from Operation until Graft/Prosthesis/Flap Failure Complication | -99 = Patient did not experience this complication at or before 30 days post operation Classic | ||
| 234 | NOTHDVT | Num | Number of DVT/Thrombophlebitis Occurrences | Number of DVT/Thrombophlebitis Occurrences | |||
| 235 | OTHDVT | Char | Occurrences DVT/Thrombophlebitis | New diagnosis of blood clot or thrombus within the venous system (superficial or deep) which may be coupled with inflammation and requires treatment. Must be noted within 30 days after the principal operative procedure AND one of the following A or B below: A.New Diagnosis of a [new] venous thrombosis (superficial or deep); confirmed by a duplex; venogram; CT scan; or any other definitive imaging modality (including direct pathology examination such as autopsy) AND the patient must be treated with anticoagulation therapy and/or placement of a vena cava filter or clipping of the vena cava; or the record indicates that treatment was warranted but there was no additional appropriate treatment option available. B. As per (A) above; but the patient or decisionmaker has refused treatment. There must be documentation in the medical record of the [patient’s] refusal of treatment. The followings are included: Internal jugular (IJ) clots; Cephalic Vein clots; Portal vein clots; Patient requires therapy but refuses; Chronic venous thrombosis present preoperatively which are also noted postoperatively with evidence of new progression. The followings are not included: Chronic venous thrombosis present preoperatively which are also noted postoperatively but without evidence of new progression; If only an intravenous catheter is thrombosed and the vein is not; Arterial clots | DVT Requiring Therapy; No Complication | Definition revised or clarified in 2013. Definition revised or clarified in 2014 | |
| 236 | DOTHDVT | Num | Days from Operation until DVT/Thrombophlebitis Complication | Days from Operation until DVT/Thrombophlebitis Complication | -99 = Patient did not experience this complication at or before 30 days post operation | ||
| 237 | NOTHSYSEP | Num | Number of Sepsis Occurrences | Number of Sepsis Occurrences | |||
| 238 | OTHSYSEP | Char | Occurrences Sepsis | Sepsis is a vast clinical entity that takes a variety of forms. The spectrum of disorders spans from relatively mild physiologic abnormalities to septic shock. The intent is to capture the patient whose physiology is compromised by an ongoing infectious process after surgery. Present at the time of surgery (PATOS) modifiers prevent patients from being counted as having complications if there is significant evidence that the sepsis or septic shock outcome was under way prior to the surgery performed. Please report the most significant level using the criteria below. 1.Sepsis: Sepsis is the systemic response to infection. Report this variable if the patient has two of the following clinical signs and symptoms of SIRS: Temp >38o C (100.4 o F) or < 36 o C (96.8 o F); HR >90 bpm; RR >20 breaths/min or PaCO2 <32 mmHg(<4.3 kPa); WBC >12000 cell/mm3; <4000 cells/mm3; or >10% immature (band) forms; Anion gap acidosis: this is defined by either: [Na + K] – [Cl + HCO3 (or serum CO2)]. If this number is greater than 16; then an anion gap acidosis is present. Na – [Cl + HCO3 (or serum CO2)]. If this number is greater than 12; then an anion gap acidosis is present. If anion gap lab values are performed at your facilities lab; ascertain which formula is utilized and follow guideline criteria. And either A or B below: A. One of the following: positive blood culture; clinical documentation of purulence or positive culture from any site for which there is documentation noting the site as the acute cause of sepsis. B. The patient must meet SIRS criteria within 48 hours after the Principal Operative Procedure AND One of the following findings during the Principal Operative Procedure: Confirmed infarcted bowel requiring resection; Purulence in the operative site; Enteric contents in the operative site or Positive intra-operative cultures. Guidance: if the patient meets criteria to assign preop sepsis assign the risk factor; if the patient meets the criteria to assign postop sepsis assign the occurrence and then assess for PATOS and assign if appropriate. 2. Septic Shock: Sepsis is considered severe when it is associated with organ and/or circulatory dysfunction. Report this variable if the patient has sepsis AND documented organ and/or circulatory dysfunction. Examples of organ dysfunction include: oliguria; acute alteration in mental status; acute respiratory distress. Examples of circulatory dysfunction include: hypotension; requirement of inotropic or vasopressor agents. Septic Shock is assigned when it appears to be related to Sepsis and not a Cardiogenic or Hypovolemic etiology. Guidance: if the patient meets criteria to assign preop septic shock assign the risk factor; if the patient meets the criteria to assign postop septic shock assign the occurrence and then assess for PATOS and assign if appropriate. The presence of pneumatosis along with the presence of SIRS is reported as Sepsis. | Sepsis; No Complication | Definition revised or clarified in 2013. Definition revised or clarified in 2014 | |
| 239 | SEPSISPATOS | Char | Sepsis PATOS | Evidence is highly suggestive or suspicious of a systemic response to infection preoperatively/ intraoperatively for the principal operative procedure.The case must meet the following criteria: A. Sepsis is noted as a postoperative occurrence AND B. Preoperative/intraoperative evidence was highly suggestive or suspicious of sepsis at the time of the principal operative procedure. The preoperative sepsis variable does not need to be assigned in order to assign PATOS to a postoperative occurrence of sepsis. The followings are not included: If the record indicates that sepsis was present at some point preoperatively but fully and definitively resolved prior to the time of surgery; then PATOS should not be chosen. Injury to intestine (e.g. enterotomy; iatrogenic injury) which results in a postoperative leak of enteric contents into the abdomen. Notes: In instances where criteria for sepsis was met due to an intraoperative event (e.g. enterotomy; iatrogenic injury) PATOS would not be assigned | Yes; No | NUll = No response; Variable added in 2012. Definition revised or clarified in 2014 | |
| 240 | DOTHSYSEP | Num | Days from Operation until Sepsis Complication | Days from Operation until Sepsis Complication | -99 = Patient did not experience this complication at or before 30 days post operation | ||
| 241 | NOTHSESHOCK | Num | Number of Septic Shock Occurrences | Number of Septic Shock Occurrences | |||
| 242 | OTHSESHOCK | Char | Occurrences Septic Shock | For Sepsis and Septic Shock within 30 days of the operation; please report the most significant level using the criteria that follow. Severe Sepsis/Septic Shock: Sepsis is considered severe when it is associated with organ and/or circulatory dysfunction. Report this variable if the patient has the clinical signs and symptoms of SIRS or sepsis AND documented organ and/or circulatory dysfunction. Examples of organ dysfunction include: oliguria; acute alteration in mental status; acute respiratory distress. Examples of circulatory dysfunction include: hypotension; requirement of inotropic or vasopressor agents. For the patient that had sepsis preoperatively; worsening of any of the above signs postoperatively would be reported as a postoperative sepsis. | Septic Shock; No Complication | ||
| 243 | SEPSHOCKPATOS | Char | Septic Shock PATOS | Evidence is highly suggestive or suspicious of a systemic response to infection with organ/circulatory dysfunction preoperatively/intraoperatively for the principal operative procedure. The case must meet the following criteria: A. Septic Shock is noted as a postoperative occurrence AND B. Preoperative/intraoperative evidence was highly suggestive or suspicious of septic shock at the time of the principal operative procedure. The preoperative septic shock variable does not need to be assigned in order to assign PATOS to a postoperative occurrence of septic shock. If the record indicates that septic shock was present at some point preoperatively but fully and definitively resolved prior to the time of surgery; then PATOS should not be chosen. Injury to intestine (e.g. enterotomy; iatrogenic injury) which results in a postoperative leak of enteric contents into the abdomen. PATOS should not be chosen. | Yes; No | NUll = No response; Variable added in 2012. Definition revised or clarified in 2014 | |
| 244 | DOTHSESHOCK | Num | Days from Operation until Septic Shock Complication | Days from Operation until Septic Shock Complication | -99 = Patient did not experience this complication at or before 30 days post operation | ||
| 245 | PODIAG | Char | Post-op diagnosis (ICD 9) | The appropriate ICD-9-CM code corresponding to the condition noted as the postoperative diagnosis in the brief operative note; operative report; and/or after the return of the pathology reports are entered. | |||
| 246 | PODIAGTX | Char | Post-op Diagnosis Text | Post-op Diagnosis text | |||
| 247 | PODIAG10 | Char | Post-op diagnosis (ICD 10) | The appropriate ICD-10-CM code corresponding to the condition noted as the postoperative diagnosis in the brief operative note; operative report; and/or after the return of the pathology reports are entered. | Variable added in 2014 | ||
| 248 | PODIAGTX10 | Char | Post-op Diagnosis Text | Post-op Diagnosis text | Variable added in 2014 | ||
| 249 | RETURNOR | Char | Return to OR | Returns to the operating room within 30 days include all major surgical procedures that required the patient to be taken to the surgical operating room for intervention of any kind. “Major surgical procedures” are defined as those cases in any and all surgical subspecialties that meet Program criteria for inclusion. | Yes; No | NUll= Unknown | |
| 250 | DSDtoHD | Num | Days from Surgical Discharge (Acute Care;Discharge) to Hospital Discharge | Days from Surgical Discharge to Hospital Discharge | Historical variable; no longer used | ||
| 251 | DOpertoD | Num | Days from Operation to Death | Days from Operation to Death | -99 = Patient did not die at or before 30 days post operation. Notes: deaths within 30 days of procedure included only | ||
| 252 | DOptoDis | Num | Days from Operation to Discharge | Days from Operation to Discharge | -99 = Unknown | ||
| 253 | STILLINHOSP | Char | Still in Hospital > 30 Days | "Yes" is entered if patient has a continuous stay in the acute care setting > 30 days after the surgery. However if the patient was discharged from the acute care setting but remained in the hospital (rehab or hospice unit); then "NO" is entered since the stay in the acute care setting was no longer continuous. | Yes; No | NUll = No response; Variable added in 2011 | |
| 254 | READMISSION | Char | Readmssion | "Yes" is entered for any readmission (to the same or another hospital) for any reason within 30 days of the principal surgical procedure. The readmission has to be classified as an “inpatient” stay by the readmitting hospital or reported by the patient/family as such. | Yes; No | Historical variable; no longer used. NULL=Unknown | |
| 255 | UNPLANREADMISSION | Char | Unplanned Readmission | "Yes" is entered for any unplanned readmission (to the same or another hospital) for a post operative occurrence likely related to the principal surgical procedure within 30 days of the procedure. | Yes; No | Historical variable; no longer used. NULL=Unknown | |
| 256 | REOPERATION | Char | Unplanned Reoperation | "Yes" is entered if the patient had an unplanned return to the operating room for a surgical procedure related to either the index or concurrent procedure performed. This return must be within the 30 day postoperative period. The return to the OR may occur at any hospital or surgical facility (i.e. your hospital or at an outside hospital). Note: This definition is not meant to capture patients who go back to the operating room within 30 days for a follow-up procedure based on the pathology results from the index or concurrent procedure. Examples: Exclude breast biopsies which return for re-excisions; insertion of port-a-caths for chemotherapy. | Yes; No | Historical variable; no longer used. NULL=Unknown | |
| 257 | REOPERATION1 | Char | Unplanned Reoperation 1 | "Yes" is entered if the patient had an unplanned return to the operating room for a surgical procedure; for any reason; within 30 days of the principal operative procedure. The return to the OR may occur at any hospital or surgical facility (i.e. your hospital or at an outside hospital). | Yes; No | NUll=No response; Variable added in 2012 | |
| 258 | RETORPODAYS | Num | Days from principal operative procedure to Unplanned Reoperation 1 | Days from principal operative procedure to Unplanned Reoperation 1 | -99 = Patient did not experience Unplanned Reoperation 1. Variable added in 2012 | ||
| 259 | REOPORCPT1 | Char | Unplanned Reoperation 1 CPT | The CPT code for Unplanned Reoperation 1 | NUll = No Response Variable added in 2012 | ||
| 260 | RETORRELATED | Char | Unplanned Reoperation 1 related to principal operative procedure | Was the return to the OR for a postoperative occurrence likely related to the principal operative procedure? “Yes” is the default answer unless it is definitively indicated that the unplanned return to the OR is not related to the principal operative procedure. | Yes; No; Unknown | NULL = No Response. Variable added in 2012. Definition revised in 2013 | |
| 261 | REOPORICD91 | Char | Unplanned Reoperation 1 ICD-9 | The ICD-9 code for Unplanned Reoperation 1 | NUll = No Response. Variable added in 2012 | ||
| 262 | REOPOR1ICD101 | Char | Unplanned Reoperation 1 ICD-10 | The ICD-10 code for Unplanned Reoperation 1 | Variable added in 2014 | ||
| 263 | REOPERATION2 | Char | Unplanned Reoperation 2 | "Yes" is entered if the patient had an unplanned return to the operating room for a surgical procedure for any reason within 30 days of the principal operative procedure. The return to the OR may occur at any hospital or surgical facility (i.e. your hospital or at an outside hospital). | Yes; No | NUll=No response; Variable added in 2012 | |
| 264 | RETOR2PODAYS | Num | Days from principal operative procedure to Unplanned Reoperation 2 | Days from principal operative procedure to Unplanned Reoperation 2 | -99 = Patient did not experience Unplanned Reoperation 2. Variable added in 2012 | ||
| 265 | REOPOR2CPT1 | Char | Unplanned Reoperation 2 CPT | The CPT code for Unplanned Reoperation 2 | NUll = No Response. Variable added in 2012 | ||
| 266 | RETOR2RELATED | Char | Was the return to the OR for a postoperative occurrence likely related to the principal operative procedure? “Yes” is the default answer unless it is definitively indicated that the unplanned return to the OR is not related to the principal operative procedure. | Yes; No; Unknown | NULL = No Response Variable. Added in 2012. Definition revised in 2013 | ||
| 267 | REOPOR2ICD91 | Char | Unplanned Reoperation 2 ICD-9 | The ICD-9 code for Unplanned Reoperation 2 | NUll = No Response. Variable added in 2012 | ||
| 268 | REOPOR2ICD101 | Char | Unplanned Reoperation 2 ICD-10 | The ICD-10 code for Unplanned Reoperation 2 | NUll = No Response. Variable added in 2014 | ||
| 269 | REOPERATION3 | Char | More than 2 unplanned reoperations | "Yes" is entered if there were more than two unplanned re-operations for a post operative occurrence likely related to the principal surgery within 30 days. | Yes; No | NUll=No response; Variable added in 2012 | |
| 270 | READMISSION1 | Char | Any Readmission 1 | "Yes" is entered if the patient had any readmission (to the same or another hospital) for any reason within 30 days of the principal surgical procedure. The readmission has to be classified as an “inpatient” stay by the readmitting hospital; or reported by the patient/family as such. | Yes; No | NUll=No response; Variable added in 2012 | |
| 271 | READMPODAYS1 | Num | Days from principal operative procedure to Any Readmission 1 | Days from principal operative procedure to Any Readmission 1 | -99 = Patient did not experience Any Readmission 1. Variable added in 2012 | ||
| 272 | UNPLANNEDREADMISSION1 | Char | Unplanned Readmission 1 | "Yes" is entered if Any Readmission 1 was unplanned at the time of the principal procedure. | Yes; No | NUll = No Response. Variable added in 2012 | |
| 273 | READMRELATED1 | Char | Unplanned Readmission 1 likely related to the principal procedure | "Yes” is entered if Unplanned Readmission 1 (to the same or another hospital) was for a postoperative occurrence likely related to the principal surgical procedure within 30 days of the procedure. | Yes; No | NUll = No Response Variable added in 2012 | |
| 274 | READMSUSPREASON1 | Char | Readmission related suspected reason 1 | The primary suspected reason for the readmission if it is likely related to the | |||
| principlal operating procedure | Superficial Incisional SSI; Deep Incisional SSI;Organ/Space SSI;Wound Disruption;Pneumonia;Unplanned Intubation;Pulmonary Embolism;On Ventilator > 48 hours;Progressive Renal Insufficiency;Acute Renal Failure;Urinary Tract Infection;CVA;Cardiac Arrest Requiring CPR;Myocardial Infarction;Bleeding Requiring Transfusion (72h of surgery start time);Vein Thrombosis Requiring Therapy;Sepsis;Septic Shock;Other (list ICD 9 code);Other (list ICD 10 code) | NUll = No Response. Variable added in 2012. Definition revised or clarified in 2014 | |||||
| 275 | READMUNRELSUSP1 | Char | Readmission unrelated suspected reason 1 | The primary suspected reason for the readmission if it is likely unrelated to the principlal operating procedure | Superficial Incisional SSI;Deep Incisional SSI;Organ/Space SSI;Wound Disruption;Pneumonia;Unplanned Intubation;Pulmonary Embolism;On Ventilator > 48 hours;Progressive Renal Insufficiency;Acute Renal Failure;Urinary Tract Infection;CVA;Cardiac Arrest Requiring CPR;Myocardial Infarction;Bleeding Requiring Transfusion (72h of surgery start time);Vein Thrombosis Requiring Therapy;Sepsis;Septic Shock;Other (list ICD 9 code);Other (list ICD 10 code) | NULL = No Response. Variable added in 2013. Definition revised or clarified in 2014 | |
| 276 | READMRELICD91 | Char | Readmission related ICD-9 code 1 | The ICD-9 code for the suspected reason if 'Other' is chosen and the readmission is likely related to the principle operating procedure | NULL = No Response. Variable added in 2012 | ||
| 277 | READMRELICD101 | Char | Readmission related ICD-10 code 1 | The ICD-10 code for the suspected reason if 'Other' is chosen and the readmission is likely related to the principle operating procedure | NULL = No Response Variable added in 2014 | ||
| 278 | READMUNRELICD91 | Char | Readmission unrelated ICD-9 code 1 | The ICD-9 code for the suspected reason if 'Other' is chosen and the readmission is likely unrelated to the principle operating procedure | NULL = No Response Variable added in 2013 | ||
| 279 | READMUNRELICD101 | Char | Readmission unrelated ICD-10 code 1 | The ICD-10 code for the suspected reason if 'Other' is chosen and the readmission is likely unrelated to the principle operating procedure | NULL = No Response. Variable added in 2014 | ||
| 280 | READMISSION2 | Char | Any Readmission 2 | See "Any Readmission 1" | Yes; No | Variable added in 2012 | |
| 281 | READMPODAYS2 | Num | Days from principal operative procedure to Any Readmission 2 | See "Days from principal operative procedure to Any Readmission 1" | -99 = Patient did not experience Any Readmission 2. Variable added in 2012 | ||
| 282 | UNPLANNEDREADMISSION2 | Char | Unplanned Readmission 2 | See "Unplanned Readmission 1" | Yes;No | NUll = No Response. Variable added in 2012 | |
| 283 | READMRELATED2 | Char | Unplanned Readmission 2 likely related to the principal procedure | See "Unplanned Readmission 1 likely related to the principal procedure" | Yes;No | NUll = No Response. Variable added in 2012 | |
| 284 | READMSUSPREASON2 | Char | Readmission related suspected reason 2 | See "Readmission related suspected reason 1" | See "Readmission related suspected reason 1" | NUll = No Response Variable added in 2012 | |
| 285 | READMUNRELSUSP2 | Char | Readmission unrelated suspected reason 2 | See "Readmission unrelated suspected reason 1" | See "Readmission unrelated suspected reason 1" | NUll = No Response Variable added in 2013 | |
| 286 | READMRELICD92 | Char | Readmission related ICD-9 code 2 | See "Readmission related ICD-9 code 1" | NUll = No Response Variable added in 2012 | ||
| 287 | READMRELICD102 | Char | Readmission related ICD-10 code 2 | See "Readmission related ICD-10 code 1" | NUll = No Response Variable added in 2014 | ||
| 288 | READMUNRELICD92 | Char | Readmission unrelated ICD-9 code 2 | See "Readmission unrelated ICD-9 code 1" | NUll = No Response Variable added in 2013 | ||
| 289 | READMUNRELICD102 | Char | Readmission unrelated ICD-10 code 2 | See "Readmission unrelated ICD-10 code 1" | NUll = No Response Variable added in 2014 | ||
| 290 | READMISSION3 | Char | Any Readmission 3 | See "Any Readmission 1" | Yes; No | Variable added in 2012 | |
| 291 | READMPODAYS3 | Num | Days from principal operative procedure to Any Readmission 3 | See "Days from principal operative procedure to Any Readmission 1" | -99 = Patient did not experience Any Readmission 3. Variable added in 2012 | ||
| 292 | UNPLANNEDREADMISSION3 | Char | Unplanned Readmission 3 | See "Unplanned Readmission 1" | Yes;No | NUll = No Response. Variable added in 2012 | |
| 293 | READMRELATED3 | Char | Unplanned Readmission 3 likely related to the principal procedure | See "Unplanned Readmission 1 likely related to the principal procedure" | Yes; No | NUll = No Response. Variable added in 2012 | |
| 294 | READMSUSPREASON3 | Char | Readmission related suspected reason 3 | See "Readmission related suspected reason 1" | See "Readmission related suspected reason 1" | NUll = No Response. Variable added in 2012 | |
| 295 | READMUNRELSUSP3 | Char | Readmission unrelated suspected reason 3 | See "Readmission unrelated suspected reason 1" | See "Readmission unrelated suspected reason 1" | NUll = No Response Variable added in 2013 | |
| 96 | READMRELICD93 | Char | Readmission related ICD-9 code 3 | See "Readmission related ICD-9 code 1" | NUll = No Response Variable added in 2012 | ||
| 297 | READMRELICD103 | Char | Readmission related ICD-10 code 3 | See "Readmission related ICD-10 code 1" | NUll = No Response Variable added in 2014 | ||
| 298 | READMUNRELICD93 | Char | Readmission unrelated ICD-9 code 3 | See "Readmission unrelated ICD-9 code 1" | NUll = No Response Variable added in 2013 | ||
| 299 | READMUNRELIC103 | Char | Readmission unrelated ICD-10 code 3 | See "Readmission unrelated ICD-10 code 1" | NUll = No Response Variable added in 2014 | ||
| 300 | READMISSION4 | Char | Any Readmission 4 | See "Any Readmission 1" | Yes; No | Variable added in 2012 | |
| 301 | READMPODAYS4 | Num | Days from principal operative procedure to Any Readmission 4 | See "Days from principal operative procedure to Any Readmission 1" | -99 = Patient did not experience Any Readmission 4. Variable added in 2012 | ||
| 302 | UNPLANNEDREADMISSION4 | Char | Unplanned Readmission 4 | See "Unplanned Readmission 1" | Yes; No | NUll = No Response Variable added in 2012 | |
| 303 | READMRELATED4 | Char | Unplanned Readmission 4 likely related to the principal procedure | See "Unplanned Readmission 1 likely related to the principal procedure" | Yes; No | NUll = No Response Variable added in 2012 | |
| 304 | READMSUSPREASON4 | Char | Readmission related suspected reason 4 | See "Readmission related suspected reason 1" | See "Readmission related suspected reason 1" | NUll = No Response Variable added in 2012 | |
| 305 | READMUNRELSUSP4 | Char | Readmission unrelated suspected reason 4 | See "Readmission unrelated suspected reason 1" | See "Readmission unrelated suspected reason 1" | NUll = No Response Variable added in 2013 | |
| 306 | READMRELICD94 | Char | Readmission related ICD-9 code 4 | See "Readmission related ICD-9 code 1" | NUll = No Response Variable added in 2012 | ||
| 307 | READMRELICD104 | Char | Readmission related ICD-10 code 4 | See "Readmission related ICD-10 code 1" | NUll = No Response Variable added in 2014 | ||
| 308 | READMUNRELICD94 | Char | Readmission unrelated ICD-9 code 4 | See "Readmission unrelated ICD-9 code 1" | NUll = No Response Variable added in 2013 | ||
| 309 | READMUNRELICD104 | Char | Readmission unrelated ICD-10 code 4 | See "Readmission unrelated ICD-10 code 1" | NUll = No Response Variable added in 2014 | ||
| 310 | READMISSION5 | Char | Any Readmission 5 | See "Any Readmission 1" | Yes; No | Variable added in 2012 | |
| 311 | READMPODAYS5 | Num | Days from principal operative procedure to Any Readmission 5 | See "Days from principal operative procedure to Any Readmission 1" | -99 = Patient did not experience Any Readmission 5. Variable added in 2012 | ||
| 312 | UNPLANNEDREADMISSION5 | Char | Unplanned Readmission 5 | See "Unplanned Readmission 1" | Yes; No | NUll = No Response. Variable added in 2012 | |
| 313 | READMRELATED5 | Char | Unplanned Readmission 5 likely related to the principal procedure | See "Unplanned Readmission 1 likely related to the principal procedure" | Yes; No | NUll = No Response Variable added in 2012 | |
| 314 | READMSUSPREASON5 | Char | Readmission related suspected reason 5 | See "Readmission related suspected reason 1" | See "Readmission related suspected reason 1" | NUll = No Response. Variable added in 2012 | |
| 315 | READMUNRELSUSP5 | Char | Readmission unrelated suspected reason 5 | See "Readmission unrelated suspected reason 1" | See "Readmission unrelated suspected reason 1" | NUll = No Response. Variable added in 2013 | |
| 316 | READMRELICD95 | Char | Readmission related ICD-9 code 5 | See "Readmission related ICD-9 code 1" | NUll = No Response Variable added in 2012 | ||
| 317 | READMRELICD105 | Char | Readmission related ICD-10 code 5 | See "Readmission related ICD-10 code 1" | NUll = No Response Variable added in 2014 | ||
| 318 | READMUNRELICD95 | Char | Readmission unrelated ICD-9 code 5 | See "Readmission unrelated ICD-9 code 1" | NUll = No Response Variable added in 2013 | ||
| 319 | READMUNRELICD105 | Char | Readmission unrelated ICD-10 code 5 | See "Readmission unrelated ICD-10 code 1" | NUll = No Response Variable added in 2014. | ||
| 320 | WOUND_CLOSURE | Char | Surgical wound closure | To classify three layers of wound closure. Code the most complete closure of any incision based on the criteria below: A. All layers of incision (deep and superficial) are fully closed by some means. Often referred to as “Incision Primarily Closed.” | All layers of incision (deep and superficial) fully closed; Only deep layers closed superficial left open; No layers of incision are surgically closed | NULL=Unknown. Variable added in 2014 | |
| 321 | PODIAG_OTHER | Char | Other postoperative occurrence(ICD 9) | Other postoperative surgical occurrences which are significant and that are not covered by other postoperative outcome criteria | NULL=Unknown Variable added in 2014 | ||
| 322 | PODIAG_OTHER10 | Char | Other postoperative occurrence(ICD 10) | Other postoperative surgical occurrences which are significant and that are not covered by other postoperative outcome criteria | NULL=Unknown. Variable added in 2014 | ||
| 323 | ANESTHES_OTHER | Char | Additional anesthesia technique | Type of anesthesia administered outside of the primary anesthesia technique as reported in medical record. | General;Epidural;Spinal;Regional;Local;Monitored Anesthesia Care/IV Sedation; Other | NULL = Unknown Variable added in 2014 |
NSQIP data dictionary