Operating Theatres Phase 2 – Anaesthetic Record Data Standards Theatres Phase 2 Anaesth… · Users may wish to augment code 98 – “Other (specify)” with a free text field

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Operating Theatres Phase 2 –

Anaesthetic Record

Data Standards

December 2008

National Clinical Dataset Development Programme (NCDDP) Support Team Information Services Area 74A Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Tel: 0131 275 7066 Email to: [email protected] Website: http://www.clinicaldatasets.scot.nhs.uk/

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Operating Theatre Phase 2 Anaesthetic Record Data Standards 2

Overview & Background ............................................................................................... 4 Overview 4 Operating Theatres (phase 2) – Anaesthetic Record Data standards............................................. 6 Background to NCDDP .................................................................................................................... 6 Generic Data Standards................................................................................................................... 7 Clinical Terminology......................................................................................................................... 7 Date Recording ................................................................................................................................ 7

Published Data Standards ............................................................................................ 9 Generic and Previously Consulted................................................................................................... 9 Data Standards under Development.............................................................................................. 11 Data Standards Currently Undergoing Change Control ................................................................ 11

1. General Information.................................................................................................. 12 1.1 Indication for Procedure................................................................................................ 12 1.2 Anaesthesia Phase....................................................................................................... 13 2.1 Anaesthetic Alerts......................................................................................................... 14 2.2 Availability of Previous Anaesthetic Record ................................................................. 17 2.3 New York Heart Association Functional Classification................................................. 17 2.4 Airway Assessment Criteria and Findings .................................................................... 18 2.5 Factors Affecting Airway............................................................................................... 19 2.6 Dentition state............................................................................................................... 20 2.7 Venous Thromboembolism Assessment Risk .............................................................. 20 2.8 Patient Risk Factors for Venous Thromboembolism .................................................... 21 2.9 Surgical Risk Factors for Venous Thromboembolism .................................................. 22

3. Preoperative Preparation ........................................................................................ 24 3.1 Type of Last Oral Intake ............................................................................................... 24 3.2 Fasting Instruction Adherence...................................................................................... 25 3.3 Fasting Instruction Non-Adherence Reason................................................................. 25 3.4 Surgical Side Marking(s) Presence .............................................................................. 26 3.5 Type of Prophylaxis for Venous Thromboembolism..................................................... 26 3.6 Number of Units of Blood Cross-matched.................................................................... 27 3.7 Transfusion Compatibility Test Type ............................................................................ 28

4. Anaesthesia ................................................................................................................ 29 4.1 Anaesthesia and/or Sedation Type(s) .......................................................................... 30 4.2 Vascular Access ........................................................................................................... 31 4.3 Airway Maintenance Equipment Type(s)...................................................................... 32 4.4 Laryngeal Mask Airway Size......................................................................................... 33 4.5 Oxygen Mask Size ....................................................................................................... 33 4.6 Nasal Cannula Size ...................................................................................................... 33 4.7 Cormack-Lehane Score................................................................................................ 34 4.8 Intubation Attempts....................................................................................................... 34 4.9 Intubation Achieved ...................................................................................................... 35 4.10 Intubation Aids used ..................................................................................................... 35 4.11 Airway Management Aids ............................................................................................. 36 4.12 Endotracheal Tube Type .............................................................................................. 36 4.13 Endotracheal Tube Size ............................................................................................... 37 4.14 Throat Pack Use ........................................................................................................... 37 4.15 Position Supporting Equipment Type(s) ....................................................................... 37 4.16 Eye Protection Type ..................................................................................................... 38 4.17 Nasopharyngeal Airway Size........................................................................................ 39 4.18 Anaesthetic Ventilation Type ........................................................................................ 39


4.19 Mode of Assisted Ventilation ........................................................................................ 40 4.20 Ventilator Setting .......................................................................................................... 40 4.21 Ventilator Adjuvant........................................................................................................ 41 4.22 Analgesia Method ......................................................................................................... 41 4.23 Humidification Used...................................................................................................... 42 4.24 Type of Humidification .................................................................................................. 43 4.25 Blood Product(s) ........................................................................................................... 43 4.26 Number of Units of Blood Product(s) Transfused......................................................... 44 4.27 Autologous Red Cells ................................................................................................... 44 4.28 Volume of Autologous Red Cells Transfused............................................................... 44 4.29 Type of Warmer(s) Used .............................................................................................. 45 4.30 Anaesthetic Monitoring ................................................................................................. 45 4.31 Tidal Volume................................................................................................................. 47 4.32 Oxygen Administration.................................................................................................. 47 4.33 Fractional Inspired Oxygen Concentration ................................................................... 48 4.34 End Tidal Carbon Dioxide – (EtCO2) ........................................................................... 48 4.35 Inspiratory Flow Time ................................................................................................... 48 4.36 Inspiratory Pause Time................................................................................................. 49 4.37 Expiratory Time............................................................................................................. 49 4.38 Peak Airway Pressure .................................................................................................. 50 4.39 Peak Inspiratory Pressure ............................................................................................ 50 4.40 Continuous Positive Airway Pressure (CPAP) ............................................................. 50 4.41 Positive End Expiratory Pressure ................................................................................. 51 4.42 I:E Ratio (Inspiratory Time to Expiratory Time) ............................................................ 51 4.43 Inhaled Agents Concentration ...................................................................................... 51 4.44 Mean Arterial Pressure (MAP)...................................................................................... 52 4.45 Central Venous Pressure (CVP)................................................................................... 52 4.46 Cardiac Output.............................................................................................................. 52 4.47 Urine Output Volume .................................................................................................... 53 4.48 Blood Loss Volume....................................................................................................... 53 4.49 Bispectral Index ............................................................................................................ 54 4.50 Entropy TM ..................................................................................................................... 54

5. Surgical Factors......................................................................................................... 55 5.1 Operative Procedure Name.......................................................................................... 55 5.2 Surgical Position of Patient........................................................................................... 56 5.3 Surgical Approach/Access............................................................................................ 57 5.4 Type of Diathermy ........................................................................................................ 58

6. Recovery................................................................................................................... 58 6.1 Oxygen Administered ................................................................................................... 58 6.2 Anaesthesia Complications .......................................................................................... 59

Appendix 1 - Working Group ...................................................................................... 60 Membership of the Operating Theatres (phase 2) Working Group................................................ 60

Appendix 2 - Consultation Distribution List .............................................................. 61

Appendix 3 – Operating Theatre (phase 2) Anaesthesia Record - Change Control Data Items......................................................................................... 63


Overview & Background Overview The Operating Theatres Phase 2 Data Standards were developed to support the work of the National Theatres Procurement and National Theatres Implementation Group. Following the development and approval of the Operating Theatres Phase 1 Data Standards (these are available in the Health and Social Care Data Dictionary), which supported the process of service development as, described in ‘Building a Health Service Fit for the Future’, a working group was established in 2007. The Phase 2 data standards ensure a national approach to the collection of clinical and non-clinical data items relating to the anaesthetic record. The data standards for Operating Theatres Phase 2 will ensure a national approach in the collection of clinically relevant data items recorded in a wide variety of settings. A Clinical Working Group was established in November 2007 to progress this work, supported by the National Clinical Dataset Programme (NCDDP) Support Team in Information Services (ISD). For the purpose of these data standards, the term ‘theatres’ as used in the title broadly encompasses any operating environment where interventional procedures codeable in Office of Population Censuses & Surveys 4th Revision (OPCS4) take place.

The Operating Theatres (phase 2) – Anaesthetic Record data standards will:

To agree a national approach to recording of Operating Theatre data, ensuring consistency in the way data is recorded regardless of the clinical system in use.

To monitor specific clinical activity in the continuous Operating Theatre management process.

To develop a structure of clarity and consistency around Anaesthetic Record Reporting, that covers the entirety of service provision in Operating Theatres.

It is important to understand that these are data standards, not a dataset. This means that the individual data items included in this document need not all be recorded together in clinical systems but, where it is considered appropriate to record a particular data item as part of a person’s care record, it should be recorded in accordance with the nationally agreed standard. The data standards contain data items from Generic Data Standards and other Clinical Datasets, which have previously been developed through the NCDDP and are freely available in the Clinical Datasets section of the web-based Health and Social Care Data Dictionary. Feedback was sought from the wider clinical community in order to ensure that these data standards are fit for purpose. We invited all interested organisations and individuals to take part in the consultation by completing a Consultation Response Form. Comments on all or any part of the document were welcomed.

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Some background information on the NCDDP and the dataset development can be found below. If you have any further queries, please go to our website or contact [email protected].

http://www.show.scot.nhs.uk/clinicaldatasets/

mailto:[email protected]


Operating Theatres (phase 2) – Anaesthetic Record Data standards The membership of the Operating Theatres Phase 2 Data Standards Working Group is shown in Appendix 1. This group agreed the inclusion of individual data items using the following criteria:

• Is the data item required by all those involved in the running of operating theatres?

• Is the data item of benefit for the overall healthcare of patients?

• Is the data item one, which is likely to be shared amongst health care professionals?

Once consultation was complete the Data Standards were submitted to the NCDDP Programme Board for formal approval as a national standard. Now approved the Operating Theatres Phase 2 Data Standards are freely and widely available through publication in the Health and Social Care Data Dictionary. Where possible the data standards are UK compatible. It is expected that the Operating Theatres Phase 2 Data Standards will be implemented within existing and emerging national clinical information systems and commercially procured national products, as well as being available to commercial developers to ensure the ability of their systems to support national information requirements. Background to NCDDP The National Clinical Dataset Development Programme (NCDDP) supports clinicians to develop sets of interoperable national data standards to facilitate the implementation of the integrated care records across NHS Scotland.

These standards will: • Support direct patient care, by reflecting current best practice guidance • Facilitate effective communication between health care professionals • Improve data quality and support secondary data requirements where possible

including data to support clinical governance • Be freely and widely available through publication in the web based Health & Social

Care Data Dictionary • Incorporate agreed national clinical definitions and implement national terminology • Be UK compatible where possible The Chief Medical Officer established the programme in 2003 to support clinicians developing national clinical data standards, initially to support the national priority areas. These standards are an essential element of the Electronic Health Record, a central aim of the National e-Health Strategy. More information can be found on our website.


http://www.show.scot.nhs.uk/clinicaldatasets/


Generic Data Standards Data standards which are relevant to all patients and are used across specialties, disciplines and settings have already been developed by wider Generic Data Standards clinical working groups and approved as national data standards for NHS Scotland. The Operating Theatre (phase 2) – Anaesthetic Record Data Standards working group identified several generic data items as appropriate for inclusion in their standards. These data items are indicated next to the data item name and definition, which are listed in this document for information. The full detail of these existing standards are published on the web based Health and Social Care Data Dictionary. Clinical Terminology The strategic standard for clinical terminology in NHS Scotland is SNOMED-Clinical Terms. This means that clinical information systems will record clinical data using this international standard. It is intended that the NCDDP Support Team will develop recommended SNOMED CT specifications as part of the data standards and datasets it supports. This work will be commenced once SNOMED CT tools become available. Date Recording It is good record-keeping practice always to identify the date of recording of any clinical information. It is expected that all clinical information systems should include ‘date stamping’ as standard functionality. In many clinical situations, the date of an event, investigation, etc. is required for clinical purposes and should be visible to the health care professional (it will be seen that dates and times appear quite prominently in the Operating Theatres Data Standards). It is important to note that the date of an event may not be the same as the date on which the data are entered onto the system. In these instances the system must allow the health care professional to enter whichever date is appropriate. These issues must be addressed during system specification and development. The date format for storage and management within a system should conform to the 1Government Data Standards Catalogue format: CCYY-MM-DD. However, this does not preclude entry or display of data on the user interface using the traditional DD-MM-CCYY format. An example of a date & time in correct format is: 1997-07-16T19:20:30+01:00 (CCYY-MM-DDThh:mm:ssTZD). It is recommended that a time should always be recorded with the appropriate date and not on its own; however, it may not be necessary to display the date along with the time. This is of particular importance where any calculations or analyses are likely to be performed. Automated times recorded by IT systems should include all elements of the time, i.e. hours, minutes and seconds, and are expected to be actual. Where times are entered manually, it is likely that only the hours and minutes will be required, although in some circumstances only hours may be required. Time, or any element of the time (hours, minutes or seconds) may be actual or estimated. In some circumstances only an actual time may be acceptable, whilst in others an estimated time may be allowed. In the latter situation, it may be necessary to


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identify whether the time recorded is actual or estimated. Times identified as actual may be used in calculations and analyses. Times marked as estimated should be treated with caution and the implications of undertaking any calculations or analyses should be considered in the particular context within which the time is recorded or to be made subsequent use of. Where an estimated time is allowed, the appropriate degree of verification detail required should be decided, again dependent on the context in which it is recorded and how the time is to be used. 1Government Data Standards Catalogue 1. All times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00. 2. Values of any element less than 10 should be entered with a zero in the first position. 3. All times for UK transactions/events will be assumed to be GMT. 4. Systems should record whether the time is Coordinated Universal Time or British Summer Time in the “Time zone designator”. This will allow time elapsed to be calculated correctly, for example for A&E waiting times.


Published Data Standards Generic and Previously Consulted The following table contains data standards that have already been consulted on previously and are published on the data dictionary. They serve to give an example of the data standards that can be used when implementing a specific system. Additional data standards are available in the Health and Social Care Data Dictionary. Person Demographic(s) Symptom Presence (Symptom) Patient Identification Symptom Presence (Nausea & Vomiting) Address (BS7666) Symptom Management (Pain) CHI Number Symptom Severity (Breathlessness) Health Record Identifier Assessment(s), Examination(s) and Investigation(s) Name Element Position Assessment Name {Core Nursing Assessment} Person Current Gender Assessment Tool Name (Pain) Person Family Name Procedure (Clinical Imaging) Type Person Given Name Procedure Person Initials Finding(s) and Result(s) Person Preferred Forename Fluid Type(s) Person Title Height Postcode Weight Preferred Language Heart Rate Preferred Name Pulse Rate Arterial Previous Person Family Name Pulse Rhythm UK Telephone number Pulse Volume Unique Person Identifier Systolic Blood Pressure Interpretation Assistance Indicator Diastolic Blood Pressure Preferred Communication Method Temperature (General Body) Carer(s), Care Professional(s), Team(s), Service(s) Organisation(s) or Sector(s)

Body Mass Index

Associated Professional Analgesia Breakthrough Doses – Days in a Week Associated Professional Identifier Analgesia Breakthrough Doses – Number in 24 Hours Associated Professional Role ASA status Associated Professional Employing Organisation Type

Assessment Score/Result

Associated Professional Employing Organisation Name

Oxygen Saturation

Associated Person QRS Amplitude (ECG) Result Associated Person Role Electrocardiography (Rhythm) Abnormal Results Associated Person Relationship to client/patient RR Interval (ECG) Result Associated Professional Group Q Waves (Pathological) (ECG) Result Referring Specialty QRS Duration (ECG) Result Location Code P Wave (ECG) Result Socio-Environmental Detail(s) PR Interval (ECG) Result Lifestyle QT Interval (ECG) Result Current Tobacco and Nicotine Consumption Status ST Segment (ECG) Result Current Substance Misuse Status ST Segment Height of Elevation / Depression (ECG) Current Alcohol Drinking Status T Wave (ECG) Result Person Name Status Electrocardiography (Investigation) Person Name Suffix Electrocardiography Results {CHD} Clinical / Care Process Exercise Tolerance Test (Investigation) Problem(s) and Issue(s) Reason for not Exercise Tolerance Test Exercise Tolerance Test Results {CHD} Exercise Tolerance Test Result


Echocardiogram Results Medication and Device(s) Pregnancy Status Antibiotic Prophylaxis (pre-operative) Glasgow Coma Scale – Best Motor Response Medication Dosage Echocardiography (Investigation) Medication or Device Name Glasgow Coma Scale – Eye Opening Specific Medication Record Reason for No Echocardiography Date and Time Reason for No Electrocardiography Date and Time Glasgow Coma Scale – Verbal Response Date of Admission Conscious Level Date of Assessment (Assessment Tool Name) Procedure (Interventional Radiology) Complications Date of First Assessment Procedure (Clinical Imaging) Complications Date of Last Intervention Imaging Modality Duration (Descriptive) Diagnosis Time of Day/Night Asthma Laboratory Data Standards Cardiac Arrest Investigation/Test Name Certainty of Diagnosis Specimen Type Diabetes Mellitus Laboratory Specimen Number Diabetes Mellitus Type Units (Investigation/Test) Diabetes Related Conditions Full Blood Count Diagnosis {Heart Failure} Group Name Diagnosis Neurovascular Reason for investigation/Test Request Heart Failure {ACS} Reference Range Limit: Lower Hypertension Reference Range Limit: Upper Initial Diagnosis {ACS} Reference Range Flag Previous Angina Microorganism Detection Result Underlying Cause of Death Infection Risk Status Care Planning, Management and Outcome(s) Laboratory Report Status Food Components of Meal Phase 1 Biochemistry Investigations/Tests NCEPOD category Microorganism Name (Microorganism) Treatment(s) and Intervention(s) Antimicrobial Agent Anaesthetic/Sedation Administration Result (Investigation Test Name) Anaesthetic/Sedation Supervision Sensitivity: Interpretive Anaesthetic/Sedation Supervision (Administration) Sensitivity: Numeric Care Journey and Encounter Infection Risk Status Reason Specific Medication Not Prescribed Date of Laboratory Processes and Procedures Reason Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Not Given

Generic Consent Standards

Admitted/Transfer from - Location


Data Standards under Development The following data standards are currently under development and impact on Operating Theatres (phase 2) – Anaesthetic Record Critical Operative State Operative Stage Ventilated Pre-operative Hospital Area Diagnosis

Data Standards Currently Undergoing Change Control Modifying the existing item, which is displayed in the Health and Social Care Data Dictionary, has produced the following data standards. Its adoption will mean that change control is required to the existing items. Please refer to Appendix 3 – Operating Theatres (phase 2) – Proposed Change Control Data Items for a comparison of the existing and proposed data standard. Dates and Times of Theatre Processes and Operative Procedures Associated Professional Role Associated Professional Grade Respiratory Rate Type of Prophylaxis for Venous Thromboembolism Anaesthesia and/or Sedation Type Route of Administration

The following Data items are applicable to Operating Theatres – Anaesthetic Record but are undergoing change control via the Cardiac Surgery & Percutaneous Cardiac Interventions Data Standards Development. Admission Type Referral Source Method of Referral


1. General Information Data Item Number Indication for Procedure 1.1 Anaesthesia Phase 1.2

1.1 Indication for Procedure Definition: The clinical indication for the procedure. Format: Characters (Specific term in SNOMED Clinical Terms (SCT) / ICD 10 for specific diagnosis) Field length: 255 Codes and values: Code Value Explanatory Notes 00 None No indicative diagnosis has

been made SNOMED Clinical Terms specific Code

SNOMED Clinical Term(s) (SCT) for specific indication

ICD 10 Specific Code

ICD version 10 specific term(s) for specific indication

98 Other (please specify) 99 Not known

Related data item: Date and Time

Diagnosis Operative Procedure Name

Recording Guidance: In the future this data standard should be recorded using SNOMED-CT (SCT) using an appropriate browser however as an interim solution ICD-10 taxonomy should be used. IT systems should allow for multiple recording of this item. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings.


1.2 Anaesthesia Phase Definition: The phase of anaesthesia management. Format: Characters Field length: 2 Codes and values: Code Value Explanatory Note 01 Preoperative 02 Induction This phase commences when the

anaesthetist starts interventions and assumes continuing responsibility for the patient.

03 Maintenance 04 Recovery 05 Post Operative

Related data items: Anaesthesia Complications Operative Stage


2. Preoperative Assessment Data Item Number Anaesthetic Alerts 2.1

Availability of Previous Anaesthetic Record 2.2

New York Heart Association Functional Classification 2.3

Airway Assessment Findings 2.4

Factors Affecting Airway 2.5

Dentition State 2.6

Venous Thromboembolism Risk 2.7

Patient Risk Factors for Venous Thromboembolism 2.8

Surgical Rick Factors for Venous Thromboembolism 2.9

2.1 Anaesthetic Alerts Definition: A record of the presence or history of condition(s) and/or other factor(s) that may affect the provision of the anaesthetic process or procedure.

Format: Characters

Field length: 3

Codes and values: Codes Values Sub

codes Sub values Explanatory Notes

00 None 01 Adverse reactions

A Malignant Hyperpyrexia 02 Hereditary Anaesthetic Reactions B Suxamethonium (Scoline)

Apnoea

03 Religious Belief precluding the use of blood transfusion

This would include Jehovah’s Witnesses.

04 Anaesthesia Complications

A Over the counter medication B Prescription medication

05 Medication

C Complementary or Alternative Medication

A Cardiac Pacemaker B Implantable Defibrillator C Internal Pacing Wires D Cardiac Valve Prosthesis E Orthopaedic Prosthesis F Plate in Skull G Metal Clips H Shunts J Stents K Respiratory support device

06 Biomedical Devices

L Aneurysm Clip


A Hypertension B Unstable Angina C Heart Failure D Transient Ischaemic Attacks E Recent Myocardial Infarction Within the last six

months F Arrhythmias G Percutaneous Coronary

Intervention

H Aortic Stenosis

07 Cardiovascular

J Significant Valvular Disorder

A Chronic Obstructive Pulmonary Disease

B Emphysema C

Asthma The severity of asthma relevant to anaesthesia delivery

08 Respiratory

D Obstructive Sleep Apnoea A Tracheostomy 09 Airway Z Other (specify)

10 Gastro-intestinal A Gastro-oesophageal reflux 11 Genitourinary A Renal Insufficiency

A Epilepsy B Cerebrovascular Incident C Transient Ischaemic Attack D Motor Neurone Disease

12 Neurological

E Spinal Injury A Haemoglobinopathies 13 Haematological B Coagulation Disorder

A Hepatitis B B Hepatitis C C Human Immunodeficiency Virus D Acquired Immune Deficiency

Syndrome

E Meticillin Resistant Staphylococcus Aureus

Methicillin Resistant Staphylococcus Aureus

F Creutzfeldt-Jacob Disease G Severe Acute Respiratory

Syndrome (SARS)

H E-Coli J Vancomycin-resistant

enterococcus

K Clostridium difficile

14 High Risk Infectious Disease

Z Other (specify) A Diabetes mellitus B Adrenal Suppression C Hypothyroidism

15 Endocrinology

D Hyperthyroidism

16 Congenital Abnormalities

17 Hereditary conditions A Porphyria This list exclude


B Neuromuscular Disorders Malignant Hyperpyrexia and Suxamethonium Apnoea as they are captured in Value 02 “Hereditary Anaesthetic Reactions”

A Rheumatoid Arthritis B Ankylosing spondylitis C Musculodystrophy

18 Musculo-skeletal

D Scoliosis

19 Patient’s advanced directives

A Obese patient B Smoker C Excessive Alcohol

Consumption

20 Personal and Social Factor

D Substance Misuse

21 Patient with Incapacity A Limited Communication B Limited Comprehension

22 Learning Disability Issues

C Autism

A 1st Trimester of Pregnancy B 2nd Trimester of Pregnancy

23 Pregnancy

C 3rd Trimester of Pregnancy

Attribute:

Person(s) Affected Patient Family

Attribute: Course Acute Chronic Related Data Items: Medication & Device Name

Diagnosis Date and Time

Recording guidance: IT systems should allow for multiple recording of this item. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings.

The Attribute “Person(s) Affected” further clarifies who has been affected by the recorded condition, and is of particular relevance to Code 02 “Hereditary Anaesthetic Reactions” and 16 “Hereditary conditions”. Therefore it is advised that they are recorded in conjunction.


2.2 Availability of Previous Anaesthetic Record Definition: A record of the availability of the patient’s prior anaesthetic record. Format: Characters Field length: 2 Codes and values: Code Value 01 None known to exist 02 Exist but not available 03 Available

Related data item: Anaesthesia and/or Sedation Type

Anaesthetic/Sedation Administration Anaesthetic/Sedation, Supervision (Administration) Anaesthesia Complications Anaesthetic Alerts Date and Time

Recording guidance: IT systems should allow for multiple recording of this item. 2.3 New York Heart Association Functional Classification Common Name (s): NYHA Functional Classification Source: The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994:253-256. Definition: The category of the functional capacity of the patient’s cardiac status, based on clinical severity and prognosis. Format: Characters Field Length: 2 Codes and values: Code Value Explanatory Notes 01 Class I Patients with cardiac disease but without resulting limitation of physical activity.

Ordinary physical activity does not cause undue fatigue, palpitation, dyspnoea, or anginal pain

02 Class II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnoea, or anginal pain

03 Class III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnoea, or anginal pain.

04 Class IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.


Attributes Optimised Not Optimised

Related data items: Assessment Name Assessment Tool Name Assessment Result/Score Date & Time 2.4 Airway Assessment Criteria and Findings Definition: The criteria and findings of an airway assessment. Format: Character Field Length: 3 Codes and values: Code Value Sub

Codes Sub Values Explanatory Notes

A Not Restricted Inter incisor gap: The distance between the upper and lower incisors with the mouth fully open. < 3.8 cm predicts difficult airway. Normal is >4.6 cm

01 Mouth opening

B Restricted A Class I visualization of the

soft palate, fauces, uvula, and both anterior and posterior pillars

B Class II Visualization of the soft palate, fauces, and uvula

C Class III Visualization of the soft palate and the base of the uvula

02 Mallampati score

D Class IV - the soft palate is not visible at all

A Grade I : > 35° Normal extent of movement (>35 degrees)

B Grade II : 22°-34° Restricted C Grade III : 12°-21° Restricted

03 Atlanto-Occipital joint extension

D Grade IV: < 12° Restricted A Normal >3 finger breadths/6

cm The distance from the mentum to the thyroid notch while the patient’s neck is fully extended.

04 Thyromental distance

B Decreased <3 finger breadths/6 cm

05 Sternomental distance

A Normal >12 cm The distance from the suprasternal notch to the mentum measured with the head fully extended on the neck with the mouth closed.


B Decreased <12 cm A Lower incisors anterior to

upper Incisors (G)

Patient is asked to protrude his/her lower incisors as far as possible.

06 Mandible protrusion

B Lower incisors not anterior to upper incisors NG

Related Data items: Date and Time Factors Affecting Airway Recording guidance: IT systems should allow for multiple recording of this item. 2.5 Factors Affecting Airway Definition: Any factors that may contribute towards a difficult airway. Format: Characters Field Length: 3 Codes and values: Codes Values Sub

codeSub values Explanation

00 None 01 Dentition

A Internal Factors 02 Obstruction and/or Distortion of airway

B External Factors A Short Thick Neck B Large Tongue To include

macroglossia; hyperplasia; glossoptossis

C High arched narrow palate D Macrocephalus This would include

patient with associated Hydrocephalus

E Microcephalus F Enlarged Epiglottis G Cleft Palate H Cleft Lip J Prognathism

03 Anatomical disproportion / malformation

K Retrognathia

A Temporomandibular joint Limitation of Normal Function

To include restricted opening and translocation.

B Cervical Spine Limitation of Movement

To include fused and hemivertebrae, resulting in limitation of neck movement.

04 Joint Dysmobility

C Cervical Instability

98 Other (specify)


Related data items: Anaesthetic Alerts

Airway Assessment Criteria and Findings Recording guidance: IT systems should allow for multiple recording of this item. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings. 2.6 Dentition state Definition: The condition of the patient’s teeth. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Normal 02 Edentulous 03 Missing tooth/teeth 04 Loose tooth/teeth 05 Dentures 06 Caps 07 Crowns 08 Dental caries 09 Protruding incisors 10 Mal-aligned dentition 11 Veneers

Further information: Dentition may be represented using the Common Tooth Notation. The teeth are numbered in each individual quadrant, as the patient would view them. Upper Right Quadrant Upper Left Quadrant Lower Right Quadrant Lower Left Quadrant Recording Guidance: IT systems should allow for multiple recording of this item. 2.7 Venous Thromboembolism Assessment Risk Source: Derived from SIGN 62: Prophylaxis for Venous Thromboembolism, NHS and Lanarkshire and NHS Greater Glasgow and Clyde VTE assessment chart. Common Names: VTE Assessment Findings Definition: The findings of a risk assessment for venous thromboembolism.


Format: Characters Field Length: 2 Codes and Values: Code Value 01 Low risk 02 Moderate risk 03 High risk

Related Data Items: Indication for Operation

Operative Procedure Name Reason Operative Procedure Not Performed

Patient Risk Factors for Venous Thromboembolism Surgical Risk Factors for Venous Thromboembolism Type of Prophylaxis for Venous Thromboembolism 2.8 Patient Risk Factors for Venous Thromboembolism Source: Derived from SIGN 62: Prophylaxis for Venous Thromboembolism, NHS and Lanarkshire and NHS Greater Glasgow and Clyde VTE assessment chart. Definition: A record of the patient factors, which increase the risk for venous thromboembolism. Format: Characters Field Length: 3 Codes and Values: Code Value Sub

code Sub Value Explanatory Notes

00 None 01 Age >40 years 02 Obesity (body Mass

Index >= 30kg/m2)

A Recent Stroke B Inflammatory Bowel

Disease

C Nephrotic Syndrome D Polycythaemia E Paraproteinaemia F Bechet’s Disease G Paroxysmal Nocturnal

haemoglobinuria

H Ischaemic Heart Disease; CCF;

J Myeloproliferative disorders

03 Thrombotic States

K Sepsis 04 Chronic Obstructive

Pulmonary Disease This would also include

Chronic Obstructive Airway Disease


05 Varicose veins 06 Previous Venous

Thromboembolism

A Low coagulation inhibitors

Antithrombin; Protein C or S

B Activated Protein C resistance

E.g. Factor V Leiden

07 Thrombophilias

C High coagulation factors (I, II, VIII, IX, XI)

08 Pregnancy 09 Post partum

A Bed rest >72hours B Plaster cast

10 Immobility

C Paralysis 11 Prolonged Travel

A Acute Trauma B Acute Illness

12 Hospitalisation

C Surgery 13 Malignancy 14 Administration of

Anaesthesia

A Oral Combined Contraceptives

B Hormone Replacement Therapy

C Raloxifene D Tamoxifen

15 Hormone Therapy

E High-dose progestogens

98 Other (specify) Related data items: Date & Time

Operative Procedure Name Operative Stage Diagnosis Venous Thromboembolism Assessment Risk Surgical Risk Factors for Venous Thromboembolism

Type of Prophylaxis for Venous Thromboembolism

Recording guidance: IT systems should allow for multiple recording of this item. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings. 2.9 Surgical Risk Factors for Venous Thromboembolism Source: Modified from SIGN 62 – Prophylaxis for Venous Thromboembolism, NHS and Lanarkshire and NHS Greater Glasgow and Clyde VTE assessment chart. Definition: A record of the surgical risk factors which contribute to venous thromboembolism. Format: Characters


Field Length: 3 Codes and Values: Code Value Sub

Code Sub Value Explanatory Notes

00 None

A Major Joint replacement

B Surgery for fractured neck of femur

01 Orthopaedic Surgery

C Major Trauma e.g. lower limb fractures

This would include patients undergoing major (total knee or hip) replacement or other elective major orthopaedic surgery.

A Thoracotomy or abdominal surgery involving mid-line laparotomy

B Intraperitoneal laparoscopic surgery

02 General / Gynaecological Surgery

C Total Abdominal hysterectomy; including laparoscopic assisted

This would include procedures exceeding 30 minutes.

03 Urological Surgery This would include patient undergoing major or open urological procedures or TURP.

04 Vascular Surgery This would include patients undergoing peripheral vascular and varicose vein surgery. Also patients with critical Limb ischaemia.

05 Head and Neck Surgery

98 Other (specify)

Related data items: Date & Time

Operative Procedure Name Operative Stage Diagnosis Venous Thromboembolism Assessment Risk Patient Risk Factors for Venous Thromboembolism

Type of Prophylaxis for Venous Thromboembolism Recording guidance: IT systems should allow for multiple recording of t his item. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings.


3. Preoperative Preparation Data Item Number Type of Last Oral Intake 3.1

Fasting Instruction Adherence 3.2

Reason Fasting Instruction Non Adherence 3.3

Surgical Side Marking(s) Presence 3.4

Type of Prophylaxis for Venous Thromboembolism

3.5

Number of Units of Blood Cross-matched 3.6

Transfusion Compatibility Test Type 3.7

3.1 Type of Last Oral Intake Source: Royal College of Nursing, Perioperative fasting in adults and children, November 2005, http://www.rcn.org.uk/__data/assets/pdf_file/0009/78678/002800.pdf Definition: The physical form of the last oral intake. Format: Characters Field Length: 2 Codes and Values: Code Value Explanatory Notes 00 None 01 Solids Includes milk, sweets and chewing gum 02 Clear Fluids Includes all transparent fluids, such as water, fruit squash,

carbonated beverages, tea or coffee without milk. 98 Other (specify) 99 Not Known

Related Data Item: Date and Time,

Fasting Instruction Adherence Reason Fasting Instruction Non Adherence

Recording Guidance: IT systems should allow for multiple recording of this item. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings.

http://www.rcn.org.uk/__data/assets/pdf_file/0009/78678/002800.pdf


3.2 Fasting Instruction Adherence Definition: An indication of whether the fasting instructions were adhered to. Format: Characters Field Length: 2 Codes and Values: Code Value Explanatory Notes 00 No 01 Yes 96 Not Applicable e.g. patient not requested to fast 99 Not Known

Related Data Items: Type of Last Oral Intake

Fasting Instruction Non-Adherence Reason Date and Time

3.3 Fasting Instruction Non-Adherence Reason Definition: The reason fasting instructions were not adhered to. Format: Characters Field Length: 3 Codes and Values: Code Value Sub

Codes Sub Values

A Patient Non-compliance 01 Non-compliance B Staff Non-compliance

02 Wrong Instruction Given 03 Counter Instruction 96 Not Applicable 99 Not Known

Related Data Item: Type of Last Oral Intake

Fasting Instruction Adherence Recording guidance: IT systems should allow for multiple recording of this item.


3.4 Surgical Side Marking(s) Presence Definition: An indication of the presence of surgical side marking(s). Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 96 Not Applicable

Related Data Items: Anatomical Site

Operative Procedure Name Date and Time

3.5 Type of Prophylaxis for Venous Thromboembolism Source: Derived from SIGN Guideline 62, Prophylaxis for Venous Thromboembolism Common Name (s): Antithrombotic; DVT prophylaxis, Pulmonary embolism prophylaxis Definition: The pharmacological and/or mechanical measures taken to prevent thrombosis. Format: Characters Field Length: 3 Codes and values: Code Value Sub

codes Sub code Explanatory Notes

00 None A Full leg Graduated

Elastic Compression Stockings

01

Mechanical

B Half leg Graduated Elastic Compression Stockings

Includes Anti-embolism stockings; antithrombosis stockings; Elastic Support Hose; Jobst Stockings; Surgical Hose; TEDS; Thrombo-guard; White hose; Thrombosis stockings


C Intermittent Pneumatic Compression

Includes DVT boots; Flotron / Flotron DVT system; Impulse Pump; Plexipulse; Sequential Compression device; Sequential TEDS; Venodyne boots; Mechanical Foot Pump

A Anti-platelet Medication B Low molecular weight

Heparin

C Un-fractionated heparin D Heparinoids E Hirudins F Pentasaccharides G Dextrans

02 Pharmacological

H Oral Anticoagulants Including Warfarin, Coumarins and others.

98 Other (specify) Attributes

Status Actual Planned / Proposed

Related data items: Medication & Device Name

Medication Dosage Route of Administration Anatomical Site Operative Stage Date and Time

Recording guidance: IT systems should allow for multiple recording of this item. Users may wish to augment code 98 – “other (specify)” with a free text field for recording other findings. 3.6 Number of Units of Blood Cross-matched Definition: The number of units of blood cross-matched for transfusion. Format: Numeric (nnn) Field Length: 3 Codes and values: N/A Related data items: Date & Time

Dates and Times of Laboratory Processes and Procedures Laboratory Report Status Transfusion Compatibility Test Type Blood Product(s)


Number of Units of Blood(s) Transfused Laboratory Specimen Number Specimen Type Reason for Investigation/Test Request

3.7 Transfusion Compatibility Test Type Definition: The type of compatibility tests requested for transfusion products. Format: Character Field Length: 2 Codes and values: Code Value 00 None 01 Group & Save 02 Cross Match

Related data items: Dates and Time Number of Units of Blood Cross-matched Blood Product(s) Number of Units of Blood Product(s) Transfused

Laboratory Report Status Laboratory Specimen Number Dates and Times of Laboratory Processes and Procedures

Recording guidance: IT systems should allow for multiple recording of this item.


4. Anaesthesia Data Item Number Anaesthesia and/or Sedation Type 4.1 Vascular Access 4.2 Airway Maintenance Equipment Type 4.3 Laryngeal Mask Airway Size 4.4 Oxygen Mask Size 4.5 Nasal Cannula Size 4.6 Cormack-Lehane Score 4.7 Intubation Attempts 4.8 Intubation Achieved 4.9 Intubation Aids Used 4.10 Airway Management Aids 4.11 Endotracheal Tube Type 4.12 Endotracheal Tube Size 4.13 Throat Pack Used 4.14 Position Supporting Equipment Type(s) 4.15 Eye Protection type 4.16 Nasopharyngeal Airway Size 4.17 Oropharyngeal Airway Size 4.18 Anaesthetic Ventilation Type 4.19 Mode of Assisted Ventilation 4.20 Ventilator Setting 4.21 Ventilator Adjuvant 4.22 Analgesia Method 4.23 Humidification Used 4.24 Type of Humidification 4.25 Blood Product(s) 4.26 Units of Blood Product(s) Transfused 4.27 Type of Warmer(s) 4.28 Anaesthetic Monitoring 4.29 Tidal Volume 4.30 Respiratory Rate 4.31 Oxygen Quantity 4.32 Fractional Inspired Oxygen Concentration 4.33 End Tidal Carbon Dioxide (EtCO2) 4.34 Inspiratory Flow Time 4.35 Inspiratory Pause Time 4.36 Expiratory Time 4.37 Peak Airway Pressure 4.38 Peak Inspiratory Pressure 4.39 Continuous Positive Airway Pressure (CPAP) 4.40 Positive End Expiratory Pressure 4.41 I:E Ratio (Inspiratory Time to Expiratory Time) 4.42 Inhaled Agents Concentration 4.43 Mean Arterial Pressure (MAP) 4.44 Central Venous Pressure (CVP) 4.45 Cardiac Output 4.46 Urine Output Volume 4.47 Blood Loss Volume 4.48 Bispectral Index 4.49 Entropy 4.50


4.1 Anaesthesia and/or Sedation Type(s) Definition: The types of anaesthesia and/or sedation. Format: Characters Field length: 3 Codes and values: Code Value Sub

code Sub value Explanatory Notes

00 None 01 General Anaesthesia

A Spinal B Epidural C Plexus Includes all nerve blocks

02 Regional Anaesthesia

D Intravenous 03 Local Anaesthesia Should include all topical, infiltrated,

instillation of local anaesthetics at the surgical site.

A Patient Controlled

B Target Controlled

04 Sedation

Z Other (specify)

98 Other (specify) Attributes

Status Planned Performed

Related data items: Availability of Previous Anaesthesia Record

Anaesthesia Complications Anaesthetic Alerts Medication and Device Name Medication Dosage Vascular Access Anatomical Site Route of Administration Date and Time



4.2 Vascular Access Definition: Types of vascular access. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Peripheral Venous 02 Central Venous 03 Arterial 04 Cardiopulmonary By-pass Venous

Cannulation 05 Cardiopulmonary By-pass Arterial Cannulation 06 Umbilical Venous Cannulation 07 Umbilical Arterial Cannulation 08 Pulmonary Artery Cannulation 09 Intra-osseous

Attribute

Laterality Left Right

Status Planned Actual

Related data items: Medication and Device Name

Medication and Device Code Anatomical Site Route of Administration Anaesthesia and/or Sedation Type Date & Time


4.3 Airway Maintenance Equipment Type(s) Definition: The type of medical devices for maintaining the patient’s airway. Format: Characters Field Length: 2 Codes and Values:

Attribute


Related data items: Laryngeal Mask Airway Size Oxygen Mask Size Nasal Cannula Size

Endotracheal Tube Type Endotracheal Tube Size Nasopharyngeal Airway Size Airway Management Aids Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings.

Code Value Sub Code

Sub Value Explanatory Note

00 None 01 Anaesthetic Mask 02 Laryngeal Mask Airway 03 Endotracheal Tube 04 Oropharyngeal Airway 05 Nasopharyngeal Airway 06 Nasal Cannula 07 Nasal Mask (Dental)

A Variable performance

For example, Hudson Mask

08 Oxygen Mask

B Fixed performance

For example. Venturi

98 Other (specify)


4.4 Laryngeal Mask Airway Size Definition: The size of the laryngeal mask airway. Format: Numeric (n.n) Field Length: 3 Codes and Values: N/A Related data items: Airway Maintenance Equipment Type Recording guidance: IT systems should allow for multiple recording of this item. 4.5 Oxygen Mask Size Definition: The size of the oxygen mask. Format: Characters Field Length: 2 Codes and Values:

Related data items: Airway Maintenance Equipment Type 4.6 Nasal Cannula Size Definition: The size of the nasal cannula. Format: Characters Field Length: 2 Codes and Values:

Related data items: Airway Maintenance Equipment Type

Code Value 01 Adult 02 Paediatric

Code Value 01 Adult 02 Paediatric 03 Neonatal 04 Infant 05 Premature


4.7 Cormack-Lehane Score

Source: Derived from Modified Cormack-Lehane scoring system; S. M Yentis, D. J. H Lee (1998) Evaluation of an improved scoring system for the grading of direct laryngoscopy. Anaesthesia 53 (11), 1041–1044 Definition: A record of the view during laryngoscopy. Format: Characters Field Length: 3 Codes and Values: Code Value Sub

code Sub Value Explanatory Notes

01 Grade I Complete glottis visible A Grade II a Partial view of the glottis 02 Grade II B Grade II b Only arytenoids seen

03 Grade III Epiglottis seen, but not glottis

04 Grade IV neither epiglottis nor glottis seen Related data items: Factors Affecting Airway

Airway Assessment Criteria and Findings Intubation Attempts Intubation Achieved Intubation Aids

4.8 Intubation Attempts Common Names: Number of Intubation Attempts Definition: The number of attempts to achieve intubation. Format: Characters Field Length: 2 Codes and Values: Code Value 01 1 02 2 03 >2

Related data items: Rapid Sequence Intubation Performed

Intubation Achieved Intubation Aids Used Comack-Lehane Score


4.9 Intubation Achieved Definition: An indication of whether intubation was successful. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes


Intubation Attempts Intubation Aids Used Comack-Lehane Score

4.10 Intubation Aids used Definition: The type of medical device used to aid intubation of the patient, in addition to or instead of a laryngoscope. Format: Characters Field Length: 2 Codes and Values: Code Value 00 None 01 Introducer 02 Bougie 03 Intubating Laryngeal Mask Airway 04 Fibre-optic Laryngoscope 05 Bronchoscope 98 Other (specify)


Intubation Attempts Intubation Achieved Comack-Lehane Grade

Recording guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings. IT systems should allow for multiple recording of this item.


4.11 Airway Management Aids Definition: The type of airway management aids used. Format: Characters Field Length: 2 Codes and Values: Code Value 00 None 01 Endobronchial Blocker 02 Endotracheal Ventilation Catheter 98 Other (specify)

Related Data Items: Airway Maintenance Equipment Type

Endotracheal Tube Type Recording guidance: IT systems should allow for multiple recording of this item. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings. 4.12 Endotracheal Tube Type Definition: The type of endotracheal tube. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Non-reinforced 02 Reinforced 03 Laser Resistant 04 Cuffed 05 Uncuffed 06 Double Lumen 07 Microlaryngoscope 96 Not Applicable 98 Other (specify)

Attributes

Planned Used

Related data items: Airway Maintenance Equipment Type Endotracheal Tube Size Recording guidance: IT systems should allow for multiple recording of this item. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings.


4.13 Endotracheal Tube Size Definition: The internal diameter of the endotracheal tube in millimetres (mm). Format: Numeric (n.n) Field Length: 3 Codes and Values: N/A Related data items: Endotracheal Tube Type Airway Maintenance Equipment Type Recording guidance: IT systems should allow for multiple recording of this item. 4.14 Throat Pack Use Definition: An indication of whether a throat pack was used Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 99 Not Known

Related data items: Endotracheal Tube Type Endotracheal Tube Size

Operative Procedure Name 4.15 Position Supporting Equipment Type(s) Definition: The type(s) of supporting equipment for maintaining the position of the patient. Format: Characters Field Length: 3 Codes and Values: Code Value Sub

Code Sub Values

00 None A Positioning Strapping 01 Safety Strapping B Supporting Strapping

02 Axillary Roll 03 Pillows 04 Prone Support 05 Mattress A Air mattress


B Vacuum mattress C Gel mattress D Fluid mattress

06 Arm Board 07 Arm Rest 08 Leg Rest 09 Ankle Rest 10 Heel Rest 11 Head Ring 12 Sandbag 13 Padding 14 Head frame 98 Other (specify)

Attribute


Related data items: Operative Procedure Name

Anatomical Site Surgical Position of Patient

Recording guidance: IT systems should allow for multiple recording of this item. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings. 4.16 Eye Protection Type Definition: The type(s) of protection for the eye(s). Format: Characters Field Length: 2 Codes and Values: Code Value Explanatory Note 00 None 01 Taped Closed 02 Padded This would include gel eye

pads or gel patches 03 Emollient/Ointment 04 Goggles 98 Other (specify)



4.17 Nasopharyngeal Airway Size Definition: The diameter of the nasopharyngeal airway device in millimetres (mm). Format: Characters Field Length: 2 Codes and Values: Codes Values 01 9 02 8.5 03 8 04 7.5 05 7 06 6.5 07 6 08 5.5 09 5 10 4.5 11 4 12 3.5 13 3 14 2.5 15 2 98 Other (specify)

Recording guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings. Related data Item: Airway Maintenance Equipment Type 4.18 Anaesthetic Ventilation Type Definition: The type of ventilation during anaesthesia. Format: Characters Field Length: 2 Codes and Values: Code Value Explanatory Notes 01 Spontaneous 02 Assisted 98 Not Applicable This would include By-Pass and ECMO (Extra-

Corporeal Membrane Oxygenation) Patients Related data items: Mode of Assisted Ventilation Ventilator Setting Ventilator Adjuvant

Operative Stage Anaesthetic Monitoring


4.19 Mode of Assisted Ventilation Definition: A record of the predominant mode of assisted ventilation. Format: Characters Field Length: 3 Codes and Values: Code Value Sub

Code Sub Value

A Normal Frequency Positive Pressure Ventilation

B High Frequency Positive Pressure Ventilation

C Jet Entrainment

01 Intermittent Positive Pressure Ventilation

D Hand or Manual 02 Mixed Mode 98 Other (specify) 99 Not Known

Attribute


Related data items: Operative stage

Anaesthetic Ventilation Type Ventilator Setting Ventilator Adjuvant Anaesthetic Monitoring

Recording guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings. IT systems should allow for multiple recording of this item.

4.20 Ventilator Setting Definition: A record of the ventilator settings. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Fractional Inspired Oxygen Concentration 02 Tidal Volume 03 Respiratory Rate 04 I:E Ratio (Inspiratory Time: Expiratory Time ) 05 Inspiratory Flow Time 06 Inspiratory Pause Time 07 Expiratory Time 08 Peak Inspiratory Pressure


09 CPAP (Continuous Positive Airway Pressure Value)10 PEEP (Positive End Expiratory Pressure)

Related data items: Date & Time

Anaesthetic Ventilation Type Ventilator Adjuvant Mode of Assisted Ventilation

Recording Guidance: IT systems should allow for multiple recording of this item.

4.21 Ventilator Adjuvant Definition: A record of the additional ventilator functions used during the procedure. Format: Characters Field Length: 2 Codes and Values: Code Value 00 None 01 Positive End Expiratory Pressure 02 Continuous Positive Airway Pressure 03 Negative Pressure 98 Other (specify)

Related data items: Anaesthetic Ventilation Type

Mode of Assisted Ventilation Ventilator Setting

Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings. IT systems should allow for multiple recording of this item. 4.22 Analgesia Method Definition: The method of pain relief. Format: Characters Field Length: 2 Codes and Values: Code Value Explanatory Notes 00 None 01 Intermittent Administration 02 Continuous Infusion

Analgesics given by various routes of administration

03 Patient Controlled Analgesia 04 Continuous Epidural 05 Patient Controlled Epidural Analgesia (PCEA) 06 Nerve Blocks


07 Plexus Infusions 08 Transcutaneous Electrical Nerve Stimulation (TENS) 09 Acupuncture 10 Gaseous (Nitrous Oxide) 98 Other (specify) 99 Not Known

Attribute:

Status Planned Administered

Related data items: Route of Administration

Vascular Access Medication and Device Name Medication Dosage Operative Stage Anaesthesia Phase

Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings. IT systems should allow for multiple recording of this item. 4.23 Humidification Used Definition: A record of whether humidification was used. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 96 Not Applicable

Related data items: Duration

Airway Maintenance Equipment Type Oxygen Administered Type of Humidification


4.24 Type of Humidification Definition: The type of humidification. Format: Characters Field Length: 3 Codes and Values: Codes Values Sub

codesSub values

00 None 01 Heat Moisture Exchange

A Cold B Ultrasonic

02

Nebulised

C Heated 96 Not Applicable 98 Other (specify) 99 Not Known Related data items: Airway Maintenance Equipment Type

Oxygen Administered Humidification Used

4.25 Blood Product(s) Definition: The type of blood product(s) for transfusion. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Red Blood Cells 02 Platelets 03 Plasma (Fresh Frozen Plasma) 04 Cryoprecipitate 05 Coagulation factor concentrates 06 Human Albumin 07 Human Immunoglobulin 98 Other (specify)

Attributes: Administered Cross-Matched Ordered Planned/Proposed Related Data Item: Date and Time

Number of Units of Blood Cross-Matched Number of Units of Blood Product(s) Transfused


Transfusion Compatibility Test Type Location

Recording Guidance: IT systems should allow for multiple recording of this item. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings. 4.26 Number of Units of Blood Product(s) Transfused Source: NHS Quality Improvement Scotland, Clinical Standards: Blood Transfusion, September 2006. Definition: The units of red cell preparations transfused. Format: Numeric (nnn) Field Length: 3 Codes and Values: N/A Related data items: Blood Product(s)

Transfusion Compatibility Test Type Number of Units of Blood Cross-Matched

Further information: This does not include circumstance where the volumes of blood used are less than a single unit and it is expected that this will be recorded in millilitres as a separate data item, for example, infants and children. 4.27 Autologous Red Cells Definition: A record of whether autologous red cells (or cell salvage products) were transfused. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes

Related data items: Volume of Autologous Red Cells Transfused 4.28 Volume of Autologous Red Cells Transfused Definition: The volume of autologous red cells transfused in millilitres (ml). Format: Numeric (nnn)


Field Length: 3 Codes and Values: N/A Related data items: Autologous Red Cells 4.29 Type of Warmer(s) Used Definition: The type(s) of warmer(s). Format: Characters Field Length: 2 Codes and Values: Code Value 00 None 01 Air 02 Fluid 03 Mattress 98 Other (specify)

Related data items: Anatomical Site

Anaesthesia Phase Operative Stage

Recording guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings. IT systems should allow for multiple recording of this item. 4.30 Anaesthetic Monitoring Definition: A list of patient monitoring used. Format: Characters Field Length: 3 Codes and Values: Code Value Sub

codeSub value Explanatory Notes

01 Observation To denote whether patient is being directly or indirectly observed by an appropriate clinician.

02 Heart Rate 03 Arterial Blood Pressure A Non-invasive arterial

blood pressure


B Invasive arterial blood pressure

04 Central Venous Pressure 05 Mean Arterial Pressure 06 Cardiac Output 07 ECG 08 Oxygen Saturation 09 Respiratory rate 10 Tidal Volume 11 End Tidal CO2 12 Fractional Inspired Oxygen

Concentration Positive End Expiratory

Pressure

13 Peak Airway Pressure 14 Inhaled Agents Concentration 15 Neuro-muscular monitoring 16 Temperature

17 Urine Output 18 Blood Loss

A Auditory Evoked Potential (AEPs)

B Bispectral Index (BIS) C Entropy TM

19 Brain Activity/Depth of Anaesthesia

Z Other (specify) 98 Other (specify) 99 Not Known


Date & Time of Theatre Processes and Operative Procedures Operative Stage Anaesthesia Phase Tidal Volume Fractional Inspired Oxygen Concentration End Tidal Carbon Dioxide – (EtCO2) Inspiratory Flow Time Inspiratory Pause Time Expiratory Time Peak Airway Pressure Peak Inspiratory Pressure Continuous Positive Airway Pressure (CPAP) Positive End Expiratory Pressure I:E Ratio (Inspired Time to Expiratory Time Inhaled Agents Concentration Mean Arterial Pressure Central Venous Pressure Cardiac Output Urine Output Volume Blood Loss Volume Bispectral Index Entropy TM


Recording guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings. IT systems should allow for multiple recording of this item. 4.31 Tidal Volume Definition: The tidal volume expressed in millilitres (ml). Format: Numeric (nnn) Field Length: 3 Codes and Values: N/A Attributes

Origin Measured Set

Related data items: Ventilator Setting

Anaesthetic Monitoring 4.32 Oxygen Administration Definition: The quantity of oxygen administered to the patient, recorded in litres per minute or delivered as a percentage. Format: Numeric (nnn) Field Length: 3 Codes and Values: N/A Related data items: Duration

Airway Maintenance Equipment Type Oxygen Administered Operative Stage Anaesthesia Phase


4.33 Fractional Inspired Oxygen Concentration Definition: The value of inspired oxygen concentration, as a percentage. Format: Numeric (nnn) Field Length: 3 Codes and Values: N/A Attribute

Origin Measured Set

Related data items: Ventilator Setting Anaesthetic Monitoring Oxygen Administration Recording guidance: Fractional Inspired Oxygen Concentration can be represented either as a fraction or percentage but should be stored as a percentage. 4.34 End Tidal Carbon Dioxide – (EtCO2) Definition: The value of the carbon dioxide tension at the end of expiration, as measured as a percentage, in anaesthesia systems. Format: Numeric (nnn.n) Field Length: 5 Codes and Values: N/A Related data items: Anaesthetic Monitoring

Mode of Assisted Ventilation Operative Stage

4.35 Inspiratory Flow Time Definition: The inspiratory flow time set in seconds. Format: Numeric (n.n) Field Length: 3 Codes and Values: N/A Related data items: Ventilator Setting,

I :E Ratio (Inspiratory Time to Expiratory Time) Expiratory Time


Recording guidance: It is accepted that the flow time may actually be calculated by the ventilator rather than directly set. 4.36 Inspiratory Pause Time Definition: The inspiratory pause time set in seconds Format: Numeric (n.n) Field Length: 3 Codes and Values: N/A Related data items: Ventilator Setting,

I :E Ratio (Inspiratory Time to Expiratory Time), Expiratory Time

Recording guidance: It is accepted that the pause time may actually be calculated by the ventilator rather than directly set. 4.37 Expiratory Time Definition: The expiratory time set in seconds. Format: Numeric (n.n) Field Length: 3 Codes and Values: N/A Related data items: Ventilator Setting,

I:E Ratio (Inspiratory Time to Expiratory Time) Inspiratory Flow Time Inspiratory Pause Time

Recording guidance: It is accepted that the expiratory time may actually be calculated by the ventilator rather than directly set.


4.38 Peak Airway Pressure Definition: The peak airway pressure measured during the inspiratory phase, in centimetres of water (cmH20). Format: Numeric (nnn) Field Length: 3 Codes and Values: N/A Related data items: Anaesthetic Monitoring


4.39 Peak Inspiratory Pressure Definition: The value for peak inspiratory pressure set in centimetres of water (cmH20). Format: Numeric (nnn) Field Length: 3 Codes and Values: N/A Related data items: Ventilator Setting Mode of Assisted Ventilation 4.40 Continuous Positive Airway Pressure (CPAP) Definition: A value for continuous positive airway pressure expressed in centimetres of water (cmH20). Format: Numeric (nn) Field Length: 2 Codes and Values: N/A Attribute Set Observed Related data items: Ventilator Setting Mode of Assisted Ventilation


4.41 Positive End Expiratory Pressure Definition: The positive end expiratory pressure set in centimetres of water (cmH20). Format: Numeric (nn) Field Length: 2 Codes and Values: N/A Related data items: Ventilator Setting Mode of Assisted ventilation 4.42 I:E Ratio (Inspiratory Time to Expiratory Time) Definition: The ratio of inspired time to expired time. Format: Numeric (nn.n:nn.n) Field Length: 9 Codes and Values: N/A Related data items: Ventilator Setting

Inspiratory Flow Time Expiratory Time

4.43 Inhaled Agents Concentration Definition: The concentration of inhalational agents, expressed as a percentage. Format: Numeric (nn.n) Field Length: 4 Codes and Values: N/A Attribute: 01 Measured within Fresh Gas Flow 02 Measured as a Fractional Inspired Concentration 03 Calculated as a Minimum Alveolar Concentration (MAC) 04 Measured as an End Tidal Concentration 05 Measured as an Mean Circuit Concentration

Related data items: Anaesthetic Monitoring

Mode of Assisted Ventilation Operative Stage Medication or Device Name Medication Dosage


4.44 Mean Arterial Pressure (MAP) Common Name (s): Mean blood pressure Definition: The Mean Arterial Pressure (measured in millimetres of mercury). Format: Numeric (nnn) Field Length: 3 Codes and values: N/A Attribute

Origin Estimated Measured

Related data items: Systolic blood pressure

Diastolic blood pressure Date & Time

Recording guidance: It is suggested that the attribute “origin” should be recorded in association with every value noted. 4.45 Central Venous Pressure (CVP) Definition: A record of the central venous pressure, measured in millimeters of mercury (mmHg). Format: Numeric (nn.n) Field Length: 4 Codes and Values: N/A Related data items: Anaesthetic Monitoring


4.46 Cardiac Output Definition: A record of the cardiac output measured as litres per minute (L/min). Format: Numeric (nn.nn) Field Length: 5 Codes and Values: N/A Related data items: Anaesthetic Monitoring

Mode of Assisted Ventilation Operative Stage Anatomical Site


4.47 Urine Output Volume Definition: The volume of urine output, measured in millilitres (ml). Format: Numeric (nnnn) Field Length: 4 Codes and Values: N/A Related data items: Duration

Date and Time Anaesthetic Monitoring

4.48 Blood Loss Volume Definition: The total volume of blood loss in millilitres (ml). Format: Numeric (nnnnn) Field Length: 5 Codes and Values: N/A Attribute

Origin Estimated Measured

Related data items: Date and Time

Anaesthetic Monitoring Further Information: It is generally agreed that the total volume of blood loss is measured by estimating volume of blood absorbed by weighing surgical materials such as swabs etc and that collected by suction directly from the patient.


4.49 Bispectral Index Definition: A record of the patient’s Bispectral Index value. Format: Numeric (nnn) Field Length: 3 Codes and Values: N/A Related data items: Anaesthetic Monitoring


Further information: A value is unique to that patient on the occasion that it is measured. The range would be 0 – 100. 4.50 Entropy TM Source: GE Healthcare Finland Oy Definition: A record of 3 figures (parameters) generated from the application of the proprietary General Electric (GE) Entropy Algorithm for measurement of the effects of certain anaesthetic agents on the patient's central nervous system during general anaesthesia. Format: Numeric Field Length: 3 Codes and Values: N/A Related data items: Anaesthetic Monitoring



5. Surgical Factors Data Item Number Operative Procedure Name 5.1 Surgical Position of Patient 5.2 Surgical Approach/Access 5.3 Type of Diathermy 5.4

5.1 Operative Procedure Name Definition: The name of the procedure. Format: Specific term for SNOMED Clinical Terms (SCT) / OPCS Classification of Interventions and Procedures v.4 Field length: 255 Codes and Values: Code Value SCT Specific codes SNOMED CT specific term(s) for specific procedure OPCS 4 specific code OPCS 4 specific term for a specific procedure 96 Not applicable 98 Other (specify) 99 Not known

Attribute:

Laterality Left Right Bilateral Midline

Attribute:

Status Actual Proposed/Planned

Related data item: Operative Procedure Performed Indicator

Reason Operative Procedure Not Performed NCEPOD Category Management Intent

Recording Guidance: In the future this data standard should be applied using a completed list of the SNOMED-CT (SCT) codes via an appropriate browser; however as an interim solution OPCS 4 codes should be used. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings.


5.2 Surgical Position of Patient Common Names: Positioning of patient Definition: The position of the patient during the procedure. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Supine 02 Lateral 03 Lateral tilt 04 Lateral decubitus 05 Prone 06 Trendelenburg 07 Reverse Trendelenburg 08 Lithotomy 09 Semi/low Lithotomy 10 Jack Knife 11 Sitting 98 Other (please specify) 99 Not Known

Attribute:

Laterality Left Right Midline Bilateral

Related data items: Operative Procedure Name

Position Supporting Equipment Type(s) Anatomical Site Operative Procedure Stage



5.3 Surgical Approach/Access Common Names: Surgical Access Definition: The surgical approach/access used for the procedure. Format: Characters Field Length: 3 Codes and Values: Code Value Sub

Code Sub Value

01 Closed 02 Percutaneous

A Minimal Access Endoscopic

03 Endoscopic

B Open Port Endoscopic 04 Endoscopic converted to open 05 Open 98 Other (please specify)

Attribute:



Imaging Modality Indication for Procedure Operative Procedure Name



5.4 Type of Diathermy Definition: The type of diathermy used. Format: Characters Field Length: 2 Codes and Values: Code Value 00 None 01 Unipolar 02 Bipolar

Related data items: Operative Stage Operative Procedure Name Recording guidance: IT systems should allow for multiple recording of this item.

6. Recovery Data Item Number Oxygen Administered 6.1 Anaesthesia Complications 6.2

6.1 Oxygen Administered Definition: A record of whether oxygen was administered. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes

Related data items: Duration

Airway Equipment Used Oxygen Administration Humidification Used Type of Humidification Operative Stage


6.2 Anaesthesia Complications Definition: The problems or issues encountered by the patient during episodes of anaesthesia. Format: Characters Field length: 2 Codes and values: Code Value Explanatory Notes 01 Airway Complication e.g. Tooth Damage; Mucosal

Laceration; sore throat; dislocated mandible; retropharyngeal dissection; Mucosal inflammation; Ulceration and Excoriation of nose Laryngeal Malfunction; aspiration; glottic, subglottic or tracheal oedema and stenosis; vocal chord granuloma

02 Breathing complication E.g. Laryngospasm

03 Circulation complication E.g. Hypotension, Tachycardia,

04 Adverse Reactions

05 Neurological complication e.g. Paralysis, Cauda Equina Syndrome; Post Dural Puncture Headache

06 Death

98 Other (specify)

Attributes:

Temporal Context Previous Current


Availability of Previous Anaesthetic Record Medication and Device Name Anaesthesia Phase Diagnosis Date and Time

Recording guidance: IT systems should allow for multiple recording of this item. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings


Appendix 1 - Working Group Membership of the Operating Theatres (phase 2) Working Group Name Position Organisation Colin Howie Consultant Orthopaedic

Surgeon NHS Lothian

Dr Alan Hope Consultant Anaesthetist NHS Greater Glasgow & Clyde Dr Cliff Barthram Consultant Anaesthetist &

Joint eHealth Clinical Lead NHS Tayside

Dr Donald MacLean Consultant Anaesthetist NHS Lanarkshire Dr Heather Hosie Consultant Anaesthetist NHS Greater Glasgow & Clyde Dr Jagannathan Sundaresan

Clinical Advisor NHS NSS – Information Services Division

Dr Jane Burns Consultant Anaesthetist, Acting Associate Medical Director

NHS Lanarkshire

Dr Peter Curry (Chair) Consultant Anaesthetist NHS Fife Hazel Borland Head of Clinical

Governance and Patient Safety Unit

NHS QIS

Janette Owens Depute Director of Nursing NHS Fife John McGarva Consultant ENT Surgeon NHS Forth Valley Karen (Catherine) Boylan Theatre Manager Golden

Jubilee Hospital National Waiting Time Centre Special Health Board - Golden Jubilee

Leigh Brown Information Manager NHS NSS – Information Services Division

Peter Stonebridge Consultant NHS Tayside Professor John Davies Director Centre for Applied

Social Psychology University of Strathclyde

Adebusola Debora King Data Standards and Terminology Development Officer

NHS NSS – Information Services Division


Appendix 2 - Consultation Distribution List Chief Executives Medical Directors Directors of Public Health Chief Medical Officer Chief Nursing Officer National Advisory Committees Managed Clinical Networks (MCNs) NCDDP Stakeholders • Clinical eHealth Leads • Electronic Clinical Communications Implementation (ECCI) • Health & Social Care Information Centre, Datasets Development Programme

(England) • Health Delivery Directorate: Improvement and Support Team • Improving Mental Health Information Programme • Information Services Division, NSS • Information Standards Group • National Resource Centre for Ethnic Minority Health • NHS Education for Scotland • NHS Health Scotland • NHS Quality Improvement Scotland (QIS) • NHS24 • NMAHP e-Health Leads

o AHP o Acute Nursing o Community Nursing Network (CNNet) o Midwives

• Open Scotland Information Age Framework (OSIAF) • Royal College of General Practitioners (Scotland) • Royal College of Nursing (Scotland) • Royal College of Physicians • Royal College of Physicians, London • Royal College of Physicians and Surgeons Glasgow • Royal College of Surgeons • Royal College of Surgeons, Edinburgh • Royal College of Surgeons, England • Royal College of Psychiatrists • Scottish Clinical Information Management Practice (SCIMP) • Scottish eHealth Nursing Forum • Scottish Government Delivery Unit • Scottish Government Data Standards Branch • Scottish Government Department of Health and Wellbeing • Scottish Government Health Department • UK Data Standards Forum


• Voluntary Health Scotland Operating Theatre (phase 2) Anaesthetic Record Specific • Association of Anaesthetist of Great Britain & Ireland • Association of Peri-operative Practice (incorporating National Association of

Theatre Nurses) • British Association of Day Surgery • College of Operating Department Practitioners (incorporating Association of

Operating Department Practitioners) • Do once and Share Theatre project • Interfaith Council • International Organisation for Terminology in Anaesthesia • National Theatre System Procurement Team • National Theatres Implementation Group • NHS QIS – Clinical Governance and Patient Safety Unit • Royal College of Anaesthetists • Royal College of Anaesthetists – Scottish Advisory Board • Royal College of Surgeons of Edinburgh - Patient Safety Board • Scottish Association of Mental Health • Scottish Audit of Surgical Mortality • Scottish Consortium of Learning Disabilities • Scottish Consumer Council • Scottish Patient Safety Alliance (inc Scottish Patient Safety Programme) • Scottish Patient Safety Research Network • SGHD IM&T Infrastructure Group • The Health Foundation • World Alliance for Patient safety NCDDP Reference & Working Groups


Appendix 3 – Operating Theatre (phase 2) Anaesthesia Record - Change Control Data Items

Associated Professional Role

Summary of Changes Create a generic standard applicable to all specialties. Values were reworded to reflect this change and values 14 and 15 were added.

Existing Proposed Changes Formal Name: Associated Professional Role Associated Professional Role {Maternity} Associated Professional Role {Mental Health} Associated Professional Role {Operating Theatres} Associated Professional Role {Radiology} Associated Professional Role {Support Needs}

Formal Name: Associated Professional Source: Modified from “Anaesthetic record set”, Royal College of Anaesthetist, 1996 Definition: An indication of the particular role(s) carried out by each professional. Format: Characters Field Length: 3 Codes and values:

Code Value Sub code Sub value Explanatory Notes A Episode Clinician responsible

for a patient's healthcare during an episode

01 Responsible Clinician

B Procedure Clinician responsible for a patient's healthcare during the procedure








02 Main operator

Clinician actually performing the procedure

03 Surgical first assistant (First operating assistant)

An individual who assists the operating surgeon in performing the procedure

04 Assistant surgeon (Additional operating assistant)

Any other individual (in addition to the first assistant) who assist the operating surgeon/clinician in performing the procedure

05 Supervising clinician

The clinician supervising the procedure

A Medical practitioner

06 Main anaesthetist B Non

medical practitioner

Clinician who actually administered anaesthesia / sedation

Clinician assisting the main anaesthetist in the administration of anaesthesia / sedation

A Medical practitioner

07 Assistant anaesthetist

B Non medical practitioner

08 Supervising Anaesthetist


Anaesthetist supervising the anaesthetic procedure

09 Anaesthetic assistant

Non-medical person assisting the anaesthetist/s in the administration of anaesthesia / sedation. E.g. Operating Department Practitioners

10 Scrub practitioner

Registered practitioner responsible for the preparation and handling of instrumentation, swabs, needles etc during a surgical procedure

11 Circulating practitioner

Practitioner assisting the scrub practitioner

12 Recovery room practitioner

Registered practitioner responsible for care of patient during recovery from procedure

13 Radiographer

14 Decision Maker The clinician who makes the decision to operate.

15 Assessor A Clinician who performs an anaesthetic assessment or part of it prior to intervention/surgery.


16 Named / Lead Clinician

17 Discharging Clinician

18 Counsellor

19 Accepting/admitting clinician

20 Referring/transferring clinician

21 Key worker

22 Clinician vetting referral

23 Justifying clinician

24 Report Authorising Clinician

25 Reporting Clinician

26 Perfusionist

98 Other – (please specify)

Includes medical and nursing students, medical trainees, medical representatives, AHP trainees or any other observers.

99 Not Known

Related data items: Associated Professional Recording guidance: IT systems should allow for multiple recording of this item


Associated Professional Grade Summary of Changes Create a generic standard applicable to entirety of NHS. Existing Proposed Formal Name: Associated Professional Grade (Most Senior Operating Surgeon) {Cancer} Definition: The clinical grade of the most senior clinician participating in the operation. Format: Characters Field length: 2 Codes and values:

Code Value 01 Consultant 02 Staff Grade/Associate Specialist 03 Specialist Registrar 04 Senior House Officer / House Officer

96 Not Applicable 99 Not Known

Related Data Items: Associated Professional Recording Guidance: IT systems should allow for the recording of more than one Associated Professional Grade (Most Senior Operating Surgeon) {Cancer}.

Formal Name: Associated Professional Grade Definition: The clinical grade of the associated professional. Format: Characters Field length: 3 Codes and values:

Code Value Sub Codes

Sub Values

A Art Therapist Entry Level B Art Therapist

01 AHP - Arts Therapist

C Highly Specialist Art Therapist 02 AHP - Music Therapist A Music Therapist - Grade To Be

Advised A Clinical Support Worker Dietetics B Clinical Support Worker Higher Level

Dietetics C Dietitian - Band 4 Post Descriptor To

Be Advised D Dietitian E Specialist Dietitian F Specialist Dietitian Higher Level

03 AHP - Dietitians

G Dietitian Consultant A Orthoptist 04 AHP - Orthoptists

B Specialist Orthoptist


Associated Professional Grade {Operating Theatres} Definition: The grade of the associated professional in the operating theatre. Format: Characters Field length: 2 Codes and values:

Code Value Explanatory Notes

01 Consultant 02 Associate Specialist 03 Staff Grade 04 Specialist Run Through Training Number of Years

variable (ST!, ST2, ST3 etc.)

05 Fixed Term Specialist Training 1 FTST1 06 Fixed Term Specialist Training 2 FTST2 07 Specialist Registrar Year 1 – 4 08 Senior House Officer 09 Foundation Year 2 (Senior House

Officer 1)

10 Foundation Year 1 (Pre-Registration House Officer)

11 Nurse: Bands 2-8 12 Operating Department Practitioner 13 Operating Department Assistant 14 Physicians Assistant – Anaesthesia 15 Surgical Practitioner 98 Other

Attributes:

C Highly Specialist Orthoptist D Orthoptist Consultant A Clinical Support Worker Occupational

Therapy (Occupational therapy) B Clinical Support Worker Occupational

Therapy Higher Level/ Occupational Therapy Technician

C Occupational Therapy Technician Higher Level

D Occupational Therapist E Specialist Occupational Therapist F Highly Specialist Occupational

Therapist

04 AHP - Occupational Therapy

G Occupational Therapist Consultant A Clinical Support Worker Orthotist B Clinical Support Worker Higher Level

Orthotist Technician C Orthotist Technician Higher Level D Orthotist E Specialist Orthotist F Specialist Orthotist Higher Level

05 AHP - Orthotists

G Orthotist Consultant A Clinical Support Worker Prosthetist B Clinical Support Worker Higher Level

Prosthetist Technician C Prosthetist Technician Higher Level D Prosthetist E Specialist Prosthetist F Specialist Prosthetist Higher Level

06 AHP - Prosthetists

G Prosthetist Consultant A Clinical Support Worker Podiatry B Clinical Support Worker Podiatry

Higher Level/Podiatry Technician C Podiatry Technician Higher Level D Podiatrist E Specialist Podiatrist

07 AHP - Podiatry

F Highly Specialist Podiatrist


Associated Professional status: Permanent Locum Temporary Agency Bank Further Information Specialist Programme also known as Specialist Run Through Training, will replace Specialist Registrar year 1-4and Senior House Officer from August 2007. Fixed Term Specialist Training 1 and Fixed Term Specialist Training 2 will be grades in parallel to run through training from August 2007.

G Consultant Podiatric Surgeon A Clinical Support Worker Physiotherapy B Clinical Support Worker Higher

Level/Physiotherapy Technician C Physiotherapy Technician Higher

Level D Physiotherapist E Specialist Physiotherapist F Highly Specialist Physiotherapist

08 AHP - Physiotherapy

G Consultant Physiotherapist A Clinical Support Worker Radiography B Clinical Support Worker Radiography

Higher Level C Assistant Practitioner Radiography D Radiographer E Specialist Radiographer F Highly Specialist Radiographer

09 AHP - Radiography

G Consultant Radiographer Sonographer A Clinical Support Worker Speech And

Language Therapy B Clinical Support Worker Speech And

Language Therapy Higher Level C Speech And Language Therapy

Assistant/Associate Practitioner D Speech And Language Therapist E Specialist Speech And Language

Therapist F Highly Specialist Speech And

Language Therapist

10 AHP - Speech and Language Therapy

G Consultant Speech And Language Therapist

A Multi-Skilled Support Worker - Grade To Be Advised

B Multi-Skilled Support Worker Higher Level

C AHP Practice Education Facilitator

11 AHP - Multi Skilled/Therapies

D AHP Consultant


A Administrative Assistant - Finance B Administrative Assistant Higher Level -

Finance C Administrative Officer - Finance D Administrative Officer Higher Level -

Finance E Administrative Manager - Finance F Administrative Manager Higher Level -

Finance

12 Administrative Services - Finance

G Head Of Finance A Administrative Assistant - Hr B Administrative Assistant Higher Level -

Hr C Administrative Officer - Hr D Administrative Officer Higher Level -

Hr E Administrative Manager - Hr F Administrative Manager Higher Level -

Hr

13 Administrative Services - Human Resources

G Head Of Personnel A Administrative Assistant - Office

Services B Administrative Assistant Higher Level -

Office Services C Administrative Officer - Office Services

14 Administrative Services - Office Services

D Administrative Officer Higher Level - Office Services

A Administrative Assistant - Patient Services

B Administrative Assistant Higher Level - Patient Services

C Administrative Officer - Patient Services

D Administrative Officer Higher Level - Patient Services

15 Administrative Services - Patient Services

E Administrative Manager - Patient Services


F Administrative Manager Higher Level - Patient Services

G Head Of Patient Services A Administrative Assistant - Information

Systems/Technology B Administrative Assistant Higher Level -

Information Systems/Technology C Administrative Officer - Information

Systems/Technology D Administrative Officer Higher Level -

Information Systems/Technology E Administrative Manager - Information

Systems/Technology F Administrative Manager Higher Level -

Information Systems/Technology

16 Administrative Services - Information Systems/Technology

G Head Of Information Systems/Technology

A Administrative Assistant - General/Management Services

B Administrative Assistant Higher Level - General/Management Services

C Administrative Officer - General/Management Services

D Administrative Officer Higher Level - General/Management Services

E Administrative Manager - General/Management Services

F Administrative Manager Higher Level - General/Management Services

17 Administrative Services - General/Management Services

G Head Of Service - General/Management Services

A Ambulance Technician Trainee - Band 2 Retained

B Ambulance Auxiliary C Ambulance Technician Trainee -

ACA/ORA Retained

18 Emergency Services - Ambulance

D Ambulance Technician Trainee - Band 3 Retained


E Ambulance Technician F Leading Ambulance Technician G Ambulance Paramedic H Leading Ambulance Paramedic J Community Paramedic K Sort Team Leader/Risk And Resilience L Ambulance Area Service Manager A Patient Transport Service Driver B Patient Transport Service Ambulance

Care Assistant Trainee - Driver Retained

C Patient Transport Service Ambulance Care Assistant

19 Emergency Services - Ambulance - Patient Transport Service

D Ambulance Care Assistant Urgent Tier A Patient Transport Service Leading

Ambulance Care Assistant B EMDC Call Taker C PTS Day Control D EMDC Dispatcher E EMDC Supervisor

20 Emergency Services - Ambulance - EMDC/Control

F EMDC Officer/Shift Manager 21 Emergency Services -

Ambulance - Training A Ambulance Training Officer/Manager

A Assistant Chief Administrative Dental Officer

B Assistant Clinical Director C Assistant Prescribing Adviser D Associate Specialist E Chief Administrative Dental Officer F Clinical Director G Clinical Medical Officer H Consultant J Dental Advisor (NSS only) K Dental Officer

22 General Medical Service

L Director of Public Health


M Fixed Term Specialist Training Appointment

N Foundation Year 1 P Foundation Year 2 Q General Practitioner (GP) Principal R General Practitioner (GP) Registrar S General Professional Trainee – Dental T Hospital Practitioner U Limited Specialist V Locum Appointment Service W Locum Appointment Training X Medical Director Y Part time Dental Practitioner AA Part time Medical Practitioner AB Prescribing Advisor AC Registrar AD Salaried GDP AE Salaried GP AF Senior Clinical Medical Officer AG Senior Dental Officer AH Senior House Officer AJ Senior Registrar AK Specialist Registrar AL Specialty Registrar AM Staff Grade (pre-2008) AN Staff Grade (post 2008) A Clinical Physiology Technician B Clinical Physiology Specialist

Technician C Clinical Physiology Higher Specialist

Technician

23 Health Science Services - Clinical Physiology

D Clinical Physiology Head Of Service A Biomedical Support Worker Entry

Level 24 Health Science Services -

Biomedical Sciences B Biomedical Support Worker


C Biomedical Support Worker Higher Level

D Biomedical Technician E Biomedical Scientist F Specialist Biomedical Scientist G Biomedical Laboratory Section

Manager H Biomedical Scientist Head Of Service A Clinical Technology Support

Technician Higher Level B Clinical Technology Technician C Clinical Technology Specialist

Technician D Clinical Technology Higher Specialist

Technician

25 Health Science Services - Clinical Technology

E Clinical Technology Head Of Service A Clinical Assistant B Support Technician C Clinical Scientist Trainee D Clinical Scientist

26 Health Science Services - Clinical Sciences

E Principal/Consultant/Head Of Service Clinical Scientist

27 Health Science Services - Other Healthcare Science

A Other Specialist Technician

A Theatre Services Support Technician Higher Level

B Theatre Services Technician C Theatre Services Specialist Technician

28 Medical and Dental Support - Theatre Services

D Theatre Services Higher Specialist Technician

A Dental Healthcare Assistant B Dental Healthcare Assistant Higher

Level C Dental Nurse D Specialist Dental Nurse

29 Medical and Dental Support - Dental Nurse

E Higher Specialist Dental Nurse 30 Medical and Dental A Dental Services Technician


B Dental Services Specialist Technician C Dental Services Higher Specialist

Technician

Support - Dental Technician

D Dental Services Head Of Service A Oral Health Practitioner B Oral Health Practitioner Specialist

31 Medical and Dental Support - Oral Health C Oral Health Higher Specialist

Practitioner A General (Acute) Healthcare Assistant B General (Acute) Healthcare Assistant

Higher Level C General (Acute) Nursery Nurse D General (Acute) Registered Nurse E General (Acute) Specialist Nurse F General (Acute) Higher Specialist

Nurse

32 Nursing / Midwifery (General Acute)

G General (Acute) Nurse Consultant A Care Of The Elderly Healthcare

Assistant B Care Of The Elderly Healthcare

Assistant Higher Level C Care Of The Elderly - Band 4 Post

Descriptor To Be Advised D Care Of The Elderly Registered Nurse E Care Of The Elderly Specialist Nurse F Care Of The Elderly Higher Specialist

Nurse

33 Nursing / Midwifery (Care of the Elderly)

G Care Of The Elderly Nurse Consultant A Paediatrics Healthcare Assistant B Paediatrics Healthcare Assistant

Higher Level C Paediatrics Nursery Nurse D Paediatrics Registered Nurse E Paediatrics Specialist Nurse F Paediatrics Higher Specialist Nurse

34 Nursing / Midwifery (Paediatrics)

G Paediatrics Nurse Consultant 35 Nursing / Midwifery (Mental A Mental Health Healthcare Assistant


B Mental Health Healthcare Assistant Higher Level

C Mental Health Nurse Associate Practitioner

D Mental Health Registered Nurse E Mental Health Specialist Nurse F Mental Health Higher Specialist Nurse

Health)

G Mental Health Nurse Consultant A Learning Disabilities Healthcare

Assistant B Learning Disabilities Healthcare

Assistant Higher Level C Learning Disabilities - Band 4 Post

Descriptor To Be Advised D Learning Disabilities Registered Nurse E Learning Disabilities Specialist Nurse F Learning Disabilities Higher Specialist

Nurse

36 Nursing / Midwifery (Learning Disabilities)

G Learning Disabilities Nurse Consultant A Midwifery Healthcare Assistant B Midwifery Healthcare Assistant Higher

Level C Midwifery Nursery Nurse/Maternity

Care Assistant D Midwifery Registered Midwife E Midwifery Specialist Midwife F Midwifery Higher Specialist Midwife

37 Nursing / Midwifery (Midwifery)

G Midwifery Midwife Consultant A Nurse – Occupational Health B Community Services Healthcare

Assistant C Community Services Healthcare

Assistant Higher Level D Community Services Nurse Associate

Practitioner

38 Nursing/Midwifery (Occupational Health)

E Community Services Registered Nurse/Midwife


F Community Services Nurse Specialist G Community Services Nurse Higher

Specialist H Community Services Nurse Consultant A Nurse Adviser (NHS 24)/Nurse

Adviser Team Leader B Nurse Adviser (NHS 24) Team

Manager C Senior Nurse/Clinical Services

Manager D Senior Nurse E Associate Director of Nursing/Senior

Service Manager

39 Nursing / Midwifery (NHS24)

F Senior Service Manager A Evening Nurse Assistant B Evening Nurse Assistant Higher Level C Family Planning Nurse Assistant D Family Planning Nurse Assistant

Higher Level E Registered Family Planning Nurse F Specialist Family Planning Nurse G Higher Specialist Family Planning

Nurse H School Nurse Assistant J School Nurse Assistant Higher Level K School Nurse Associate Practitioner L Registered School Nurse M Specialist School Nurse N Higher Specialist School Nurse P Treatment Room Nurse Assistant Q Treatment Room Nurse Assistant

Higher Level R Registered Treatment Room Nurse S Specialist Treatment Room Nurse T Higher Specialist Treatment Room

Nurse

40 Nursing / Midwifery (Community Nursing)

U Public Health Nurse/Midwife Assistant


V Public Health Nurse/Midwife Assistant Higher Level

W Registered Public Health Nurse/Midwife

X Specialist Public Health Nurse/Midwife Y Higher Specialist Public Health

Nurse/Midwife AA Public Health Nurse Consultant AB Community Services District Nurse AC Community Services District Nurse

Manager AD Community Services Health Visitor AE Community Services Health Visitor

Manager AF Modern Matron Community AG Specialist Community Nurse AH Higher Specialist Community Nurse AJ Community Services Combined Duty

Nurse - Grade To Be Advised A Donor Carer B Donor Carer Drivers C Donor Carer Apheresis/Whole Blood

41 Nursing/Midwifery (Blood Transfusion Service)

D Senior Donor Carer A Nurse Bank Healthcare Assistant B Nurse Bank Healthcare Assistant

Higher Level C Nurse Bank Associate Practitioner D Nurse Bank Registered Nurse/Midwife E Nurse Bank Specialist Nurse/Midwife

42 Nursing/Midwifery (Nurse Bank)

F Nurse Bank Higher Specialist Nurse/Midwife

A Healthcare Assistant Training & Administration

B Healthcare Assistant Higher Level Training & Administration

43 Nursing/Midwifery (Training & Administration)

C Associate Practitioner Training & Administration


D Registered Nurse Training & Administration

E Specialist Nurse Training & Administration

F Higher Specialist Nurse Training & Administration

G Nurse Consultant Training & Administration

A Clinical Support Worker Higher Level Psychology

B Assistant Clinical Psychologist C Assistant Clinical Psychologist Higher

Level D Trainee Clinical Psychologist E Specialist Clinical Psychologist F Highly Specialist/Consultant Clinical

Psychologist

44 Clinical Psychology/Therapy/Counselling

G Consultant Clinical Psychologist Head Of Service

A Play Assistant B Play Assistant Higher Level C Play Specialist D Play Specialist Higher Level

45 Play Specialist

E Play Specialist Manager A Optometrist Entry Level B Optometrist C Optometrist Specialist D Optometrist Principal

46 Optometrist

E Optometrist Consultant Head Of Service

A Pharmacy Assistant B Pharmacy Assistant Higher

Level/Pharmacy Tech Entry Level C Pharmacy Technician D Pharmacy Technician Higher Level

47 Pharmacy

E Clinical Pharmacist/Specialist Pharmacy Tech Team Leader


F Specialist Clinical Pharmacist G Highly Specialist Clinical Pharmacist H Pharmacist Head Of Service A Genetic Counsellor Specialist

Technician B Genetic Counsellor Higher Specialist

Technician

48 Genetic Counselling

C Genetic Counsellor Consultant 49 Personal and Social Care -

Social Work A Social Worker

A Sexual Health Advisor 50 Personal and Social Care - Sexual Health

B Sexual Health Advisory Service Manager Community

A Health Improvement Officer B Health Improvement Practitioner C Health Improvement Practitioner

Specialist D Health Improvement Practitioner

Advanced E Health Improvement Principal

51 Personal and Social Care - Health Promotion

F Health Improvement Consultant A Hotel Services Assistant B Hotel Services Assistant Higher Level C Hotel Services Supervisor D Hotel Services - Band 4 Post

Descriptor To Be Advised

52 Support Services - Hotel Services

E Hotel Services Manager A CSSD/TSSU/HSDU Support Worker

Soft Packs B CSSD/TSSU/HSDU Support Worker

Full Range C CSSD/TSSU/HSDU Supervisor D Assistant Manager

CSSD/TSSU/HSDU E Manager CSSD/TSSU/HSDU

53 Support Services - Sterile Services

F Manager Higher Level CSSD/TSSU/HSDU


A General Services Assistant B General Services Assistant Higher

Level C General Services Supervisor D General Services Supervisor Higher

Level E General Services Manager

54 Support Services - General Services

F General Services Manager Higher Level

A Catering Assistant B Catering Assistant Higher Level C Catering Supervisor D Catering Supervisor Higher Level E Catering Manager F Catering Manager Higher Level G Domestic Assistant H Domestic Assistant Higher Level J Domestic Supervisor K Domestic Supervisor Higher Level L Domestic Manager M Domestic Manager Higher Level N Laundry Assistant P Laundry Assistant Higher Level Q Laundry Supervisor R Laundry Manager S Laundry Manager Higher Level T Linen Room/Sewing Room Assistant U Linen Room/Sewing Room Assistant

Higher Level V Linen Room/Sewing Room Supervisor W Linen Room Supervisor Higher Level X Linen Room/Sewing Room Manager Y Linen Room/Sewing Room Manager

Higher Level

55 Support Services - Hotel Services

AA Assistant Linen Services Manager 56 Support Services - General A Security Assistant


B Security Assistant Higher Level C Security Supervisor D Security Supervisor Higher Level E Security Manager F Security Manager Higher Level G Stores Assistant H Stores Assistant Higher Level J Stores Supervisor K Stores Supervisor Higher Level L Stores Manager M Stores Manager Higher Level N Stores Manager Specialist P Head Of Stores Q Stoker R Stoker Higher Level S Stoker Supervisor T Stoker Supervisor Higher Level U Stoker Manager V Stoker Manager Higher Level W Porter X Porter Higher Level Y Portering Supervisor AA Portering Supervisor Higher Level AB Portering Manager AC Portering Manager Higher Level AD Grounds Assistant AE Grounds Assistant Higher Level AF Grounds Supervisor AG Grounds Supervisor Higher Level AH Grounds Manager AJ Grounds Manager Higher Level AK Driver AL Driver Higher Level AM Driver Supervisor AN Driver Supervisor Higher Level

Services

AP Transport Manager


AQ Transport Manager Higher Level A Maintenance Support Worker B Maintenance Support Worker Higher

Level C Maintenance Craft worker D Maintenance Supervisor/Multi-Skilled

Maintenance Tech/ Maintenance Planning Officer

E Specialist Maintenance/Planning Officer

F Maintenance/Planning Manager G Estates Manager H Estates Manager Higher Level I Estates Manager Higher Level J Head Of Estates K Head Of Estates L Director Of Estates M Maintenance Support Worker

Engineering N Maintenance Support Worker Higher

Level Engineering P Maintenance Craft worker

Engineering Q Maintenance Supervisor/Multi-Skill

Maintenance Tech/ Maintenance Planning Off Engineering

R Specialist Maintenance/Planning Officer Engineering

S Maintenance/Planning Manager Engineering

T Estates Manager Engineering U Maintenance Support Worker Building V Maintenance Support Worker Higher

Level Building

57 Support Services - Maintenance and Estates

W Maintenance Craft worker Building


X Maintenance Supervisor /Multi-Skill Maintenance Tech/ Maintenance Planning Off Building

Y Specialist Maintenance/Planning Officer Building

AA Maintenance/Planning Manager Building

AB Estates Manager Building A Assistant Chaplain B Chaplain

58 Support Services - Chaplaincy C Chaplain Manager

98 Other (specify) 99 Not known

Attributes: Associated Professional Status Permanent Locum Temporary Agency Bank

Further Information: Specialist Programme also known as Specialist Run-Through Training, replaced Specialist Registrar year 1-4and Senior House Officer from August 2007. Fixed Term Specialist Training 1 and Fixed Term Specialist Training 2 will be grades in parallel to run through training from August 2007.


Dates and Times of Theatre Processes and Operative Procedures Summary of Changes Addition of new values to the reference table in further information to allow recording of key time points in

patient’s care pathway within the operating theatres of other areas that impact on theatres utilisation. Existing Proposed Formal Name: Dates and Times of Theatre Processes and Operative Procedures Main Source of Standard: Government Data Standards Catalogue Definition: The combined date and time at which a specified component of theatre processes and operative procedures occurs. Format: Characters (CCYY-MM-DDThh:mm:ssTZD) Field Length: 25 Further Information: The National Theatres Project has identified the following times, during theatre processes and operative procedures, as being appropriate to be recorded.

Time patient sent for

The time that the theatre team sent the request for the patient to be brought to the operating theatre department

Time patient arrived in theatre premises

The time that the patient actually arrived in the operating theatre premises

Time into anaesthetic room

The time at which the patient was brought into the anaesthetic room

Start time of The time of start of the anaesthetic procedure

Formal Name: Dates and Times of Theatre Processes and Operative Procedures Main source of standard: Government Data Standards Catalogue Definition: The combined date and time of specific components of theatre processes and operative procedures. Format: Characters (CCYY-MM-DDT hh:mm:ss TZD) Field length: 25 Codes and values: N/A Attributes Planned Actual Related Data Items: Location Associated Person Associated Professional Further Information: The National Theatres Project and Operating Theatre Phase 2 Working Group has identified the following times, during theatre processes and operative procedures, as being appropriate to be recorded with reference to the National Theatres Project, Final Report and Technical Appendix, November 2006.


anaesthesia where this takes place either in the operating theatre or in the anaesthetic room

Time into theatre The time at which the patient is transferred from the anaesthetic room into theatre

Start time of procedure

The time of commencement of the procedure regardless of whether an anaesthetic is given or not. This should be ‘knife to skin’ or equivalent.

Finish time of procedure

The time at which the procedure was finished and any dressings applied.

Time Patient entered recovery

The time at which the patient was transferred into the recovery area.

Time patient ready to leave recovery

The time at which the patient was assessed as meeting the discharge criteria of the recovery room

Time patient actually left recovery

The time at which the patient actually left the recovery room

An example of a date & time in correct format is: 1997-07-16T19:20:30+01:00 (CCYY-MM-DDThh:mm:ssTZD)

Date & time of decision to proceed to intervention

The time when the decision to perform the procedure was taken.

Proposed date of procedure The preferred time for the procedure to take place as suggested by the specialty responsible for carrying out the procedure.

Planned Date & Time of procedure

The scheduled start time (and Date) for the proposed procedure.

Target date & time of operation

A record of the nearest date and time at which, the operative procedure should be completed with reference to the National Waiting Time Standards.

Call for admission A record of the date and time at which the patient is requested to attend for admission.

Patient presented for admission

A record of when the patient arrives at the premises.

Ready for theatre A record of the time when all required preoperative preparations in the ward have been completed. Explanatory Note: What constitutes preoperative preparations will vary locally, and between specialities, patients and the urgency of treatment.

Time patient sent for The time when the theatre team sent the request for the patient to be brought to the Operating Theatre or other appropriate location.

Porter dispatched The time when the porter was given instructions to transport the patient from the ward to the operating theatre premises.

Patient left ward The time when the patient actually departed from the ward.

Time patient arrived in theatre reception

The time that the patient actually arrived in the Operating Theatre reception

Patient transferred to anaesthetic room

The time when the patient entered the anaesthetic room.


Start time of anaesthesia The commencement of the anaesthetic procedure whether this takes place either in the operating theatre or in the anaesthetic room

Time into Theatre

The time at which the patient is transferred from the anaesthetic room into theatre

Patient ready for surgery The time when the anaesthetist declared the patient ready for the procedure to commence.

Start of patient preparation The time when patient positioning, skin preparation, and draping commenced. Explanatory Note: This usually follows when the patient has been declared ready for surgery.

Start time of procedure The time of commencement of the procedure regardless of whether an anaesthetic is given or not. This should be ‘knife to skin’ or equivalent.

Cardiopulmonary Bypass Start Time

The time at which Bypass commences. Explanatory Note: This item should be used for multiple recordings.

Cardiopulmonary Bypass Stop Time

The time at which Bypass is stopped. Explanatory Note: This item should be used for multiple recordings.

Start of aortic cross clamp time

The time at which the ascending aorta is cross clamped. Recording Guidance: This item should be used for multiple recordings.

End of aortic cross clamp time

The time at which the ascending aorta cross clamp is removed. Recording Guidance: This item should be used for multiple recordings.

Start Time of Circulatory Arrest

The start of circulatory arrest if extra corporeal circulation is stopped whilst there is no normal circulation.


Explanatory Note: This item should be used for multiple recordings.

End Time of Circulatory Arrest

The time of re-starting extra corporeal circulation following a period of circulatory arrest. Explanatory Note: This item should be used for multiple recordings.

Start of Descending Aortic Clamp Time

The time at which the Descending Aortic is Clamped. Explanatory Note: This item should be used for multiple recordings.

End of Descending Aortic Clamp Time

The time at which the Descending Aorta Clamp is removed. Explanatory Note: This item should be used for multiple recordings.

Time Procedure Completed

The time at which the procedure was finished including the application of any required dressings, catheters, drains, drainage bags, vacuum units, etc.

Anaesthesia Delivery Finished

The time when the administration of anaesthesia was discontinued in operating/procedure room.

Time patient entered recovery

The time when the patient arrived in the recovery room/area.

Time when ready to commence next procedure

A record of the time that the operating/procedure room will be ready to commence a subsequent procedure/intervention

Care accepted by recovery staff

The time when the immediate care of the patient was transferred from the anaesthetist to the recovery staff.

Patient fit for discharge from recovery

The time when the patient was assessed and deemed fit to be discharged from the recovery room.

Ward requested to accept patient

The time when the ward was informed that the patient was ready to be discharged from the recovery area.

Time Porter requested for transfer

The time when the request was made for the porter to assist in the transfer of the patient from the recovery to the ward.


Staff arrived to collect patient

A record of the time when clinical staff arrived at the postoperative recovery room to collect the patient.

Time porter arrived to collect patient

A record of the time at when the porter arrived at the postoperative recovery room to collect the patient.

Time patient actually left recovery

The time when the patient actually left the recovery room

An example of a date & time in correct format is: 1997-07-16T19: 20:30+01:00 (CCYY-MM-DDThh: mm: ssTZD) It is recommended that a time should always be recorded with the appropriate date and not on its own; however it may not be necessary to display the date along with the time. This is of particular importance where any calculations or analyses are likely to be performed. Automated times recorded by IT systems should include all elements of the time, i.e. hours, minutes and seconds, and are expected to be actual. Where times are entered manually, it is likely that only the hours and minutes will be required. Times identified as actual may be used in calculations and analyses. Start time of procedure does not include positioning, with the exception of manipulation of fractures. Recording guidance:

1. All times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00.

2. Values of any element less than 10 should be entered with a zero in the first position.

3. All times for UK transactions/events will be assumed to be GMT.

Systems should record whether the time is Coordinated Universal Time or British Summer Time in the "Time zone designator". This will allow time elapsed to be calculated.


Type of Prophylaxis for Venous Thromboembolism Summary of Changes Existing values replaced, thereby standard is in line SIGN 62. Attributes added to allow robust use of

standard. Existing Proposed Formal Name: Deep Vein Thrombosis (DVT) Prophylaxis {Endometrial Cancer} Definition: The measures (mechanical or pharmacological) taken to prevent deep vein thrombosis following cancer surgery. Format: Characters Field Length: 2 Codes and values:

Code Value 00 No 01 Yes (including heparin) 02 Yes (not including heparin) 96 Not Applicable 98 Not Known

Further Information: Prophylactic measures for DVT for this patient group are subcutaneous low-dose standard heparin, subcutaneous low molecular weight heparin (such as enoxaparin) or heparinoid (danaparoid), graduated elasticated compression stockings, intermittent pneumatic compression or adjusted dose Warfarin. If presentation for surgery is emergency, administration of mini-heparin

Formal Name: Type of Venous Thromboembolism Source: derived from SIGN Guideline 62, Prophylaxis for Venous Thromboembolism Common Name (s): Antithrombotic; DVT prophylaxis, Pulmonary embolism prophylaxis Definition: The pharmacological and/or mechanical measures taken to prevent thrombosis. Format: Characters Field Length: 3 Codes and values:

Code Value Sub codes

Sub code Explanatory Notes

00 None 01

Mechanical A Full leg Graduated Elastic Compression Stockings

Includes Anti-embolism stockings; antithrombosis


is an acceptable form of prophylaxis.

Related data items: Medication & Device Name, Medication Dosage, Route of Administration, Anatomical Site, Operative Stage Date and Time Further information: For further information please consult the following SIGN publication: Guideline No. 62 Prophylaxis of Venous Thromboembolism

B Half leg Graduated Elastic Compression Stockings

C Intermittent Pneumatic Compression

Includes DVT boots; Flotron / Flotron DVT system; Impulse Pump; Plexipulse; Sequential Compression device; Sequential TEDS; Venodyne boots; Mechanical Foot Pump

A Anti-platelet Medication

B Low molecular weight Heparin

C Un-fractionated heparin

D Heparinoids E Hirudins F Pentasaccharides G Dextrans

02 Pharmacological

H Warfarin 98 Other (please

specify)

Attributes Actual Planned / Proposed

http://www.sign.ac.uk/guidelines/fulltext/62/index.html



Related data items: Medication & Device Name Medication Dosage Route of Administration Anatomical Site Operative Stage Date and Time Further information: -For further information please consult the following SIGN publication: Guideline No. 62 Prophylaxis of Venous Thromboembolism Recording guidance: IT systems should allow for multiple recording of this item. It may also be appropriate to record associated date(s) of administration. The information recorded from this standard should be linked with Generic Medication Standards as found in the Health and Social Care Dictionary. Users may wish to augment code 98 – “other (please specify)” with a free text field for recording other findings.




Anaesthesia and/or Sedation Type Summary of Changes Values reordered. Addition of sub values to allow for a more robust data standard. Existing Proposed Formal Name: Anaesthesia/Sedation Status Definition: A record of the type of anaesthetic and/or sedation used during the current episode of care. Format: Characters Field Length: 2 Codes and Values: (code order)

Code Value Explanatory Notes 00 Not required 01 Analgesics only 02 Sedation Only 03 Sedation and Analgesics 04 Local Anaesthetic 05 General Anaesthetic 06 Sedation and Local Anaesthetic 07 Regional Anaesthetic This includes spinal, epidural

and nerve block

Formal Name: Anaesthesia and/or Sedation Type Definition: The types of sedation and/or anaesthesia used. Format: Characters Field length: 3 Codes and values:

Code Value Sub code

Sub value Explanatory Notes

00 None 01 General

Anaesthesia

A Spinal B Epidural C Plexus Includes all nerve

blocks

02 Regional Anaesthesia

D Intravenous 03 Local Anaesthesia Should include all

topical, infiltrated, instillation of local anaesthetics at the surgical site.

04 Sedation


98 Other (please specify)

Attributes: Status Planned Performed Related data items: Anatomical Site Availability of Previous Anaesthesia Record, Anaesthesia Complications, Medication and Device Name Medication Dosage Route of Administration Date and Time Recording guidance: IT systems should allow for multiple recording of this item. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other findings.


Respiratory Rate Summary of Changes Change to definition, as it was more applicable to a description of resting respiratory rate. Existing Proposed Formal Name: Respiration Rate Common Name(s): Respiratory Rate Main Source of Standard: WHO Definition: The number of breaths per minute when the patient is at rest. Format: Numeric Field Length: 2

Definition: The number of breaths per minute. Format: Numeric Field Length: 2 Attributes Observed Set Attributes Exercise Rest Related Data Items: Anaesthetic Monitoring


Route of Administration Summary of Changes Values were reordered by frequency of use and anatomical site. Addition of value

Existing Proposed


Formal Name: Route of Administration Common names: Administration Route Definition: A description of the way in which a drug or preparation is given or used. Format: Characters Field length: 2 Codes and values:

Code Value Explanatory notes 01 Oral Administration to or by way of the

mouth. 02 Intravenous Administration within or into a vein

or veins. 03 Intra-arterial Administration within an artery or

arteries. 04 Intramuscular Administration within a muscle. 05 Subcutaneous/Subd

ermal Administration beneath the skin; hypodermic.

06 Rectal Administration to the rectum. 07 Vaginal Administration into the vagina. 08 Enteral Administration directly into the

intestines. 09 Topical Application to a particular spot on

the outer surface of the body. Local effect substance applied directly where its action is desired. Specific examples could be developed locally as sub-codes and sub-values and could include Eye

Formal Name: Route of Administration Common names: Administration Route Definition: A description of the way in which a drug or preparation is given or used. Format: Characters Field length: 2 Codes and values:

Code Value Sub codes

Sub value

Explanatory notes

A Oral Including medicines taken orally or swallowed.

01 Enteral

Z Other (specify)

Administration directly into the stomach and/or intestines. This include intra gastric delivery of drug e.g. via a naso-gastric or PEG tube

02 Intravenous Administration within or into a vein or veins.

03 Intramuscular Administration within a muscle.

04 Topical Application to skin for local effect.

05 Transdermal Administration through the dermal layer of the skin for systemic effect.

06 Subcutaneous/Subdermal

Administration beneath the skin; hypodermic.

07 Intradermal Administration within the


Drops, Ear Drops etc. 10 Respiratory

(Inhalation) Administration within the respiratory tract by inhaling orally or nasally for local or systemic effect.

11 Intrathecal Administration within the cerebrospinal fluid at any level of the cerebrospinal axis, including injection into the cerebral ventricles.

12 Sublingual Administration beneath the tongue. 13 Enteral Administration directly into the

intestines. 14 Transdermal Administration through the dermal

layer of the skin to the systemic circulation by diffusion.

15 Transmucosal Administration across the mucosa. 16 Intradermal Administration within the dermis. 17 Intraperitoneal Administration within the peritoneal

cavity. 18 Intra-articular Administration within a joint. 19 Intraventricular Administration within a ventricle. 20 Intrathoracic Administration within the thorax

(internal to the ribs); synonymous with the term endothoracic.

21 Buccal Administration directed toward the cheek, generally from within the mouth.

22 Intraocular Administration within the eye. 23 Epidural Administration upon or over the

dura mater. 24 Urethral Administration into the urethra. 98 Other, specify 99 Not known

Related data items: Medication or Device Name, Medication or Device Code, Medication Dosage

dermis. 08 Periocular 09 Peribulbar Administration around the bulb

of the eye 10 Intraocular Administration within the eye. 11 Nasal Administration to the nose;

administered by way of the nose.

12 Respiratory (Inhalation)

Administration within the respiratory tract by inhaling orally or nasally for local or systemic effect.

13 Buccal Administration directed toward the cheek, generally from within the mouth.

14 Sublingual Administration beneath the tongue.

15 Oropharyngeal Administration directly to the mouth and pharynx.

16 Intrapleural Administration within the pleura.

17 Intracardiac Administration with the heart. 18 Epidural Administration into the

epidural space within the bony spinal canal.

19 Urethral Administration into the urethra.

20 Intravisecal Administration within the bladder.

21 Rectal Administration to the rectum. 22 Vaginal Administration into the vagina. 23 Intrathecal Administration within the

cerebrospinal fluid at any level of the cerebrospinal axis.

24 Intraventricular Administration within a


Further information: A drug or preparation must be transported from the site of entry to the part of the body where its action is desired to take place (unless this is on the body surface e.g. Topical). (Ref: FDA http://www.fda.gov/cder/dsm/DRG/drg00301.htm) Recording guidance: Users may wish to augment code 98 -“Other”-specify” with a free text field for recording other Routes of Administration. This is not an exhaustive list of Routes of Administration. Appropriate codes and values should be developed locally for specific healthcare professionals, services, organisations or specialist areas.

ventricle. This specifically relates to injection within cerebral ventricles.

25 Perineural Administration surrounding a nerve or nerve plexus and trunk.

26 Intraperitoneal Administration within the peritoneal cavity.

27 Intra-arterial Administration within an artery or arteries.

28 Intra-articular Administration within a joint. 98 Other (specify) 99 Not known


Medication or Device Name, Medication or Device Code, Medication Dosage

Further information: A drug or preparation must be transported from the site of entry to the part of the body where its action is desired to take place (unless this is on the body surface e.g. Topical). (Ref: FDA http://www.fda.gov/cder/dsm/DRG/drg00301.htm) Recording guidance: Users may wish to augment code 98 -“Other”-specify” with a free text field for recording other Routes of Administration. This is not an exhaustive list of Routes of Administration. Appropriate codes and values should be developed locally for specific healthcare professionals, services, organisations or specialist areas.

http://www.fda.gov/cder/dsm/DRG/drg00301.htm

http://www.fda.gov/cder/dsm/DRG/drg00301.htm

Documents

Operating Theatres Phase 2 – Anaesthetic Record Data Standards Theatres Phase 2 Anaesth… · Users may wish to augment code 98 – “Other (specify)” with a free text field