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Case Study Pre-op Variables SQAN October 29, 2013 Answer& Rational Preoperative Risk Assessment Chapter 4 • Only preoperative information can be utilized to assign preoperative variables; unless otherwise specified by the definition. • Exception: In the scenario where an urgent or emergent surgery is performed and the situation does not allow for complete preoperative documentation of a history and physical (H&P), information from the H&P, which was dictated postoperatively but within 48 hours of the Principal Operative Procedure, may be utilized to assign preoperative variables. Such documentation must describe the patient’s previous medical history. Information derived solely as a result of the Principal Operative Procedure or established during the postoperative timeframe may not be utilized, unless a particular variable specifically allows it. Height Answer: 175 cm Criteria: Report the patient’s most recent height documented in the medical record in either inches (in) or centimeters (cm), within the 30 days prior to the principal operative procedure or at the time the patient is being considered a candidate for surgery. Clinical Support Answer: Per Chapter 4, postoperative information may only be utilized in an urgent/emergent surgery where there is no time to complete a pre-op H&P due to the emergent nature of the case. As the case was emergent, you may utilize the postoperative height, as long as the H&P was dictated post-op with 48 hours of the principal operative procedure. Response % Response Count 175 cm (documented post op) 60 % 15 blank 40 % 10 n =25 Weight Answer: Pre Op weight Criteria: Report the patient’s most recent weight documented in the medical record in either pounds (lbs.) or kilograms (kg), within the 30 days prior to the principal operative procedure or at the time the patient is being considered a candidate for surgery Verified by Clinical Support. Given the fact that there is preop documentation available for this emergency case, the dietician documentation which occurred postoperative should not be utilized to assign the pre-operative weight Response % Response Count 75 kg (post op) 56 % 14 90 – 91 kg (pre op) 36 % 9 Blank 8% 2 n =25 Points to Clarify at your site • Source of truth, where do you consistently go for verification of variables if there is inconsistency with documentation. • In the case of an emergency, if there is an approximate weight pre op and an accurate weight post op (within 48 hours), what weight do you use? Dyspnea Answer: NO Criteria: Characterize pt’s dyspnea status when in their usual state of health, within 30 days prior to operative procedure or time considered a surgical candidate. Documentation: The Emergency visit notes describe SOB at rest. This is not the pt’s usual state of health. Pt previously healthy and is active. Response % Response Count At rest 20 % 5 No 80 % 20 n= 25 Functional Health Status: Answer: Independent Criteria: Report the best functional status demonstrated by the patient, within the 30 days prior to the principal operative procedure or at the time the patient is being considered a candidate for surgery Documentation: Due to persistent weakness in left arm requires help from wife for meal prep and medication prep. Medication and meal prep are not considered ADL’s. ADLs include: bathing, feeding, dressing, toileting, and mobility Response % Response Count Independent 56 % 14 Partially Dependent 36 % 9 Unknown 8% 1 n= 25 Hypertension Answer: Yes Criteria: The diagnosis of HTN must be documented in the patient’s medical record and the condition is severe enough that it requires antihypertensive medication, within 30 days prior to the principal operative procedure or at the time the patient is being considered as a candidate for surgery. The patient must have been receiving or required long-term treatment of their chronic hypertension for > 2 weeks. Documentation: Pt has a documented history of hypertension and is on Lisinopril (ace inhibitor) Response % Response Count Yes 96 % 24 No 4% 1 n= 25 Open Wound with or without infection Answer: No Criteria: Preoperative evidence of a documented open wound at the time of the principal operative procedure. Scenarios to clarify: Do not assign to -A scabbed over wound with or without drainage -A minor wound small enough to be covered by a Band-Aid (break in skin) Documentation: “ small skin tear right forearm. Edges sl. red, no drainage” Response % Response Count Yes 8% 2 No 92 % 23 n= 25 Steroid Use for Chronic Condition Answer: No Criteria: Patient has required the regular administration of oral or parenteral corticosteroid medications or immunosuppressant medications, for a chronic medical condition, within the 30 days prior to the principal operative procedure, or at the time the patient is being considered as a candidate for surgery. A one-time pulse, limited short course, or a taper of less than 10 days duration would not qualify. Long-interval injections of long-acting agents (e.g., monthly) that are part of an ongoing regimen would qualify. Documentation: Meds: Lisinopril 10 mg. po daily, Zoladex q 12 weeks SC –last does 7/01/12, Coumadin 2.5 mg po daily, Digoxin 0.125 mg po daily. Response % Response Count Yes 4% 1 No 96 % 24 n= 25 > 10% Loss of Body Weight Answer: No Criteria: A greater than 10% decrease in body weight in the six month interval immediately preceding the principal operative procedure manifested by: -serial weights in the chart -reported by the patient -evidence by change in clothing size -severe cachexia Documentation: ED pre op note: “ N-V-D X 2 days with a 5 lb weight loss” (not 10% loss) Dietician note POD # 1: Pt lost approx 15 kg since Jan. unintentionally Clinical Support: Given the fact that there is preop documentation available for this emergency case, the dietician documentation which occurred postoperative should not be utilized to assign the preoperative risk factor of > 10% Loss of Body Weight in the 6 Months Prior to Surgery. Response % Response Count Yes 52 % 13 No 48 % 12 n= 25 Bleeding Disorder Answer: YES. Criteria: Documented diagnosis of a chronic/persistent hematologic disorder or the administration of medication (anticoagulants, antiplatelet agents, thrombin inhibitors, thrombolytic agent) that interferes with blood clotting. Scenarios to clarify: -If there is no documentation of discontinuation of medication, answer “Yes” for bleeding disorder. Coumadin stop time is 4 days pre-op. Documentation: “the patient takes Coumadin 2.5mg daily for A Fib”. Response % Response Count Yes 76 % 19 No 24 % 6 n= 25 Sepsis within 48 Hours Prior to Surgery Answer: Septic Shock Criteria: Report the most significant level (A, B, or C) using the criteria below: Septic shock is more severe than sepsis. Sepsis is more severe than SIRS. Criteria must be noted within 48 hours prior to the principal operative procedure: Documentation: Temp 39, HR 130, RR 32. Purulence in the operative site, seropurulent fluid present intra-op. “wife states pt has had intermittent confusion for several hours.” Response % Response Count Sepsis 36% 9 Septic Shock 64 % 16 n= 25 Report if patient has at least two of the following: Temp >38 C or <36 C HR >90 bpm RR > 20/min WBC > 12,000 or < 4,000 Anion gap acidosis of either >16 or >12 depending on lab calculation • SIRS: – – – – – • Sepsis: Report if patient meets SIRS criteria as above AND meets scenario 1 or 2: – Scenario 1: X • Positive blood culture X • Clinical documentation of purulence or positive culture from any site for which there is correlating physician documentation that the site is thought to be the acute cause of the septic picture – • Scenario 2: Suspected preoperative clinical condition of infection which leads to the surgical procedure. The findings during the operation must confirm the suspected diagnosis and ONE OR MORE of the following: • Confirmed ischemic / infarcted bowel • Purulence in the operative site • Enteric Contents in the operative site • Positive intraoperative cultures Septic Shock: Report if the patient meets both SIRS and Sepsis criteria as above AND: – Has documented organ and /or circulatory dysfunction. • Examples of organ dysfunction include: oliguria, acute alteration in mental status, acute respiratory distress • Examples of circulatory dysfunction include: hypotension, requirement of inotropic or vasopressor agents. Summary of Pre-Op Risk Assessment Pre-Op Risk Factors Correct Answer Correct Responses Height 175 cm 15/25 Weight 90 – 91 kg 9/25 Diabetes Mellitus No 25/25 Current Smoker Yes 25/25 Dyspnea No 20/25 Functional Status Independent 15/25 Vent Dependant No 25/25 History of Severe COPD No 25/25 Ascites w/in 30 days prior No 25/25 CHF w/in 30 days prior No 25/25 HTN Requiring meds Yes 24/25 Acute Renal Failure No 25/25 Currently on dialysis No 25/25 Con’t Summary of Pre-Op Risk Assessments Pre-Op Risk Factors Correct Answer Correct Responses Disseminated Cancer No 25/25 Steroid use for Chronic Condition No 24/25 10% loss of body weight 6 months prior to surgery No 12/25 Bleeding Disorder Preop Transfusions (RBC w/in 72 hrs prior to surgery start time) Open Wound with or without infection Yes 19/25 No 25/25 No 23/25 Septic Shock Yes 16/25 In/Out Patient Status Inpatient 25/25 Elective Surgery No 25/25 Origin Status Not Transferred (admitted from home) 25/25 OR Related Variables Principle Operative Procedure CPT Code What was the CPT code of the Principle Operative Procedure? Response % Response Count 44060 4% 1 44690 4% 1 44950 4% 1 44960 80 % 20 49060 correct 4% 1 n= 25 Principle CPT code: Answer & Rationale Intra operative findings: Perforated retrocecal appendix with extensive retropertioneal abscess involving the right kidney and extending along the right paracolic gutter to the level of Morrison’s pouch. Description RVU 44060 Sigmoid Myotomy (deleted code) 0 44690 Code does not exist 0 44950 Appendectomy 10.6 44960 Appendectomy for ruptured appendicitis with abscess or generalized peritonitis 14.5 Drainage of retroperitoneal abscess; open 18.53 49060 correct Other Procedures This is site specific for what other procedures you capture. • 44960 Appendectomy for ruptured appendix with abscess or generalized peritonitis. • 49000 Exploratory Laparotomy **NSQIP recently announced that they will soon be capturing secondary CPT codes to add to risk adjustment. No announcement on dates.** Wound Classification Answer: Dirty Definition: Wound classification determines the level of contamination of the surgical wound by estimating the bacterial load at the surgical site at the time of the principal operative procedure. -Dirty/Infected: Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation. Examples of “Dirty/Infected” cases include excision and drainage of abscess, perforated bowel, peritonitis, ruptured appendix, gangrenous gallbladder. Documentation: A large amount of seropurulent fluid was present. Retrocecally a perforated appendix was encountered. In the retroperitoneum there was an extensive abscess encountered Dirty (correct) Response % Response Count 100 % 25 n= 25 Post Operative Occurrences Pneumonia Answer: Pneumonia assigned on 07/07 , also PATOS Documentation: – Pre-op (All on 07/06) • CXR on 07/06 in ED shows new infiltrate LLL • Temp 39, SOB at rest, scattered rhonchi • Cough with new onset of green sputum • Pt on 2L oxygen – Post op (All on 07/07) • Temp: 38.5 overnight, RR 24 • wheezes with bibasilar rhonchi, • CXR on 07/07 shows no change in LLL consolidation, new consolidation to RLL. • Pt continues to cough greenish sputum • Pt on 4 L oxygen. • WBC = 15 Pneumonia Criteria: The case must meet Radiology (A) criteria AND ONE of the following TWO Signs/Symptoms/Laboratory (B) scenarios as listed below within the 30 days after the principal operative procedure. The criteria should be linked by a period of continuous symptomatology. – A. Radiology: • ONE definitive chest radiological exam (CT or Xray) with at least ONE of the following: – New or progressive and persistent infiltrate – Consolidation or opacity – Cavitation • *Note: In patients with underlying pulmonary or cardiac desease, two or more radiological exams are required. The two exams should both confirm the diagnosis or the first exam should serve as a baseline exam which allows the second exam to establish the definitive new diagnosis Pneumonia B. Signs/Symptoms/Laboratory X • Scenario #1 – At least ONE of the following » Fever >38 with no other recognized cause » Leukopenia <4000 WBC or leukocytosis >12000 WBC » For adults > 70 years old, altered mental status with no other recognized cause X – AND at least ONE of the following X » 5% Bronchoalveolar lavage (BAL) – obtained cells contain intracellular bacteria on direct microscopic exam (e.g., Gram stain) X » Positive growth in blood culture not related to another source of infection X » Positive growth in culture of pleural fluid X » Positive quantitative culture from minimally contaminated lower respiratory tract (LRT) specimen (E.g. BAL or protected specimen brushing) Pneumonia B. Signs/Symptoms/Laboratory • Scenario #2 – At least ONE of the following » Fever >38 with no other recognized cause » Leukopenia <4000 WBC or leukocytosis >12000 WBC » For adults > 70 years old, altered mental status with no other recognized cause – AND at least TWO of the following » New onset of purulent sputum, or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements » New onset or worsening cough, or dyspnea, or tachypnea » Rales (crackles) or rhonchi » Worsening gas exchange (e.g. 02 desaturations), increased oxygen requirements, or increased ventilator demand Pneumonia PATOS Definition: Evidence/suspicion of active pneumonia noted at the time the patient enters the OR, or intraoperatively. Criteria: The case must meet the following criteria, A AND B below: A. Pneumonia is assigned as a postoperative occurrence AND B. Preoperative data are highly suggestive or suspicious of pneumonia • PATOS criteria are frequently less stringent than criteria for an analogous preoperative risk factor or postoperative occurrence. This means at times PATOS can be assigned to a postoperative occurrence despite the fact that criteria for a preoperative risk factor may not be met. Pneumonia PNA Response % Response Count Yes (correct) 76% 19 No 24 % 6 n= 25 PATOS Response % Response Count Yes (correct) 84 % 16 No 26 % 5 n= 19 Date Response % Response Count 07/07 (correct) 89 % 17 07/06 11 % 2 n= 19 Clinical Support Answer for Pneumonia • Clinical Support Answer: • Based on the information provided, you would be able to assign pneumonia to the case. The patient has 2 CXRs which meet the criteria, temp, rhonci, and increased 02 requirement. Urinary Tract Infection Answer: No Documentation: there is documentation of signs and symptoms along with a positive urine culture that support a diagnosis of UTI. There is a lack of post -op urine culture or post op signs and symptoms to assign post -operatively. Response % Response Count Yes with PATOS 16 % 4 No (correct) 84 % 21 n= 25 UTI Criteria • • Must be noted within 30 days after the principal operative procedure AND patient must meet ONE of the following A OR B below: A: ONE of the following six criteria: fever (>38oC or 100.4o F) urgency frequency dysuria suprapubic tenderness costovertebral angle pain or tenderness AND X A urine culture of > 100,000 colonies/ml urine with no more than two species of organisms UTI Criteria • Must be noted within 30 days after the principal operative procedure AND patient must meet ONE of the following A OR B below: • B: TWO of the following six criteria: fever (>38oC or 100.4o F) X urgency X frequency X dysuria X suprapubic tenderness X costovertebral angle pain or tenderness AND • At least one of the following: • • • • Dipstick test positive for leukocyte esterase and/or nitrate Pyuria (>10 WBCs/mm3 or > 3 WBC/hpf of unspun urine) Organisms seen on Gram stain of unspun urine Two urine cultures with repeated isolation of the same uropathogen with >100,000 colonies/ml urine in non-voided specimen Urine culture with < 100,000 colonies/ml urine of single uropathogen in patient being treated with appropriate antimicrobial therapy Physician's diagnosis Physician institutes appropriate antimicrobial therapy • • • Intra- / Postop Mycardial Infarction Answer: Yes Criteria: An acute myocardial infarction must be noted intraoperatively OR within 30 days after the principal operative procedure AND one of the following three scenarios (A or B or C) below: A. Documentation of ECG changes indicative of acute MI B. New elevation in troponin greater than three times upper level of the reference range in the setting of suspected myocardial ischemia C. Physician diagnosis of myocardial infarction Documentation: Clinical Findings: Cardiology states EKG reveals a ST elevation indicative of an acute myocardial infarction. Response % Response Count Yes (correct) Date: 07/08 96 % 24 No 4% 1 n= 25 Sepsis / Septic Shock Answer: Septic Shock, also assign PATOS Documentation: Pre-op: -Temp 39, HR 130, RR 32. -“wife states pt has had intermittent confusion for several hours.” Post-op: -WBC 15, Temp 38.5, RR24, HR 94 -abscess and purulence documented in OR report -intermittent confusion and agitation Sepsis / Septic Shock Criteria: Report the most significant level using the criteria below: Septic shock is more severe than sepsis. Criteria must be noted within 30 days after the principal operative procedure. Report this variable if the patient meets SIRS criteria (A) AND meets the most significant level of criterion (B-Sepsis OR C-Septic Shock) below: A.Five Clinical Signs of SIRS (need two). Plus must met either scenario 1, 2 or 3. X Scenario 1: One of the following: X a. Positive blood culture X b. Clinical documentation of purulence or positive culture from any site for which there is correlating physician documentation that the site was thought to be the acute cause of the septic picture OR Scenario 2: -The patient must meet SIRS criteria within 48 hours after the Principal Operative Procedure AND one of the following findings during the Principal Operative Procedure: a. Confirmed ischemic/infarcted bowel (for instance requiring resection) b. Purulence in the operative site c. Enteric contents in the operative site d. Positive intraoperative culture Sepsis / Septic Shock Septic Shock: Report this variable if the patient meets both of the followings: 1. Sepsis criteria (B) above AND 2. Has documented organ and/or circulatory dysfunction. -Examples of organ dysfunction include: oliguria, acute alteration in mental status, acute respiratory distress. -Examples of circulatory dysfunction include: hypotension, requirement of inotropic or vasopressor agents. Sepsis Immediately Post op Response % Response Count Sepsis 28 % 7 Septic Shock (correct) 28 % 7 Blank 44 % 11 n= 25 PATOS Response % Response Count Yes (correct) 93 % 13 No 7% 1 n= 14 Date Response % Response Count 07/06 21.5 % 3 57 % 8 21.5 % 3 07/07 (Correct) 07/08 n= 14 Sepsis at Neverland Hospital Answer: No Documentation: SIRS over the “next 10 days” after D/C on 7/12 HR >90; WBC 22.3; Temp 39.0. Criteria: Report the most significant level using the criteria below: Septic shock is more severe than sepsis. Criteria must be noted within 30 days after the principal operative procedure. Report this variable if the patient meets SIRS criteria (A) AND meets the most significant level of criterion (B-Sepsis OR C-Septic Shock) below: Five Clinical Signs of SIRS (need two). Plus must met either scenario 1, 2 or 3. X Scenario 1: One of the following: X a. Positive blood culture X b. Clinical documentation of purulence or positive culture from any site for which there is correlating physician documentation that the site was thought to be the acute cause of the septic picture Sepsis at Neverland Hospital X Scenario 2: X -The patient must meet SIRS criteria within 48 hours after the Principal Operative Procedure AND one of the following findings during the Principal Operative Procedure: a. Confirmed ischemic/infarcted bowel (for instance requiring resection) b. Purulence in the operative site c. Enteric contents in the operative site d. Positive intraoperative culture X Scenario 3: X -The patient must meet SIRS criteria within 48 hours before or after a subsequent reopeartion the AND one of the following findings during thesubsequent operation: a. Confirmed ischemic/infarcted bowel (for instance requiring resection) b. Purulence in the operative site c. Enteric contents in the operative site d. Positive intraoperative culture Clinical Support Answer for Sepsis at Neverland Hospital Clinical Support Answer: In this instance, the patient would meet criteria to assign postoperative Sepsis if the SIRS criteria [WBC (18.5) & temp (38.7)] were within 48 hours prior to or 48 hours after the reoperation for the intrabdominal abscess. If you are unable to determine if the patient met SIRS criteria were within 48 hours prior to or 48 hours after the reoperation for the intrabdominal abscess, as there is documentation of pus and SIRS criteria there would also need to be clinical documentation from the physician correlating that the abscess was thought to be the acute cause of the septic picture. If you need additional clarification regarding the information received from the outside office, we would recommend following up with your Surgeon Champion or the Surgeon who performed the case. Sepsis at Neverland Hospital Response % Response Count Sepsis 40 % 10 Blank correct 60 % 15 n= 25 PATOS Response % Response Count Yes 40 % 4 No 60 % 6 n= 10 Date Response % Response Count 07/16 100 % 10/10 n= 10 Wound Occurrence Immediately post op Answer: No occurrence Documentation: The abdomen was closed with a VAC dressing and the plan was made to return the patient to the operating room within 48 hours for relook laparotomy and further debridement Purulence noted during 2nd OR when VAC drsg was removed documented drainage of intra-abdominal abscess on return to OR on 07/08/2013. SSI Guidance – Surgical Wound Closure (From Chapter 4, page 83): – Can assign an Organ/Space SSI: only if there is/was evidence of interval resolution of the initial finding of infection, or that the current finding was not present at the time of surgery or is clearly separate from the finding at surgery Wound Occurrence at Neverland Hospital Answer: Organ / Space SSI, also assign PATOS Documentation: -Abdominal CT showed reforming of retroperitoneal abscess. -Patient returns to the OR for a laparotomy and I& D of retroperitoneal abscess. -No documentation of drainage through the incision. -The patient's skin was closed during the second OR procedure, this would signify resolution Criteria: An infection that occurs within 30 days after the principal operative procedure AND involves any of the anatomy (e.g., organs or spaces), other than the incision, which was opened or manipulated during the operation AND at least ONE of the following: A. Purulent drainage from a drain that is placed through a stab wound into the organ/space. This does not apply to drains placed during the principal operative procedure, which are continually in place, with continual evidence of drainage/infection since the time of the principal operative procedure – B. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space – C. An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination – D. Diagnosis of an organ/space SSI by a surgeon or attending physician – PATOS and Organ Space SSI Answer from Clinical Support: From the information provided, as the patient went on to develop an abscess following closure of the surgical site, you would assign an organ/space SSI to this case. As there was an abscess noted during the principal operative procedure, you would also assign PATOS to this case. There is no documentation to show a period of wellness. Definition: Evidence/suspicion of an active organ/space infection noted at the time the patient enters the OR, or intraoperatively. Criteria: The case must meet the following criteria, A AND B below: A. Organ/space SSI is assigned as a postoperative occurrence AND B. Evidence or suspicion of an abscess or other infection involving the organ or space manipulated during the operation. This must be noted preoperatively or found intraoperatively in the surgical space. Surgical Site Infection (SSI) Organ Space SSI (correct) Deep Incisional SSI Blank Response % Response Count 84 % 21 4% 1 12 % 3 N= 25 PATOS Response % Response Count Yes (correct) 95 % 20 No 5% 1 n= 21 Date Response % Response Count 07/06; 07/07; 07/08 23 % 5 07/16 (correct) 77 % 17 n= 22 Hospital Discharge Date Answer: 07/12 Criteria: Enter the date the patient is transferred or discharged from your hospital’s acute care setting. Documentation: Discharged from initial hospital on 07/12/2013 Response % Response Count 07/12 (correct) 96% 24 07/26 4% 1 n= 25 Still in hospital >30 days Answer: No Criteria: Patient has a continuous stay in the acute care setting at your institution > 30 days after the principal operative procedure. Documentation: Discharged from initial hospital on 07/12/2013 Response % Response Count Yes 6% 2 No (Correct) 92 % 23 n= 25 Discharge Destination Answer: Separate Acute Care Criteria: Enter the date the patient is transferred or discharged from your hospital’s acute care setting. Options: Skilled care, not home (e.g., transitional care unit, subacute hospital, ventilator bed, skilled nursing home) - Unskilled facility, not home (e.g., nursing home or assisted facility-if not patient’s home preoperatively) - Facility which was home (e.g., return to a chronic care, unskilled facility, or assisted living which was the patient’s home preoperatively, prison) - Separate acute care (e.g., transfer to another acute care facility) - Rehab -Home -Unknown -Expired Documentation: Patient discharged to Neverland Hospital for Cardiac care Response % Response Count Home 4% 1 Separate Acute Care (correct) 84 % 21 Skilled Care, not home 12 % 3 n= 25 ICD.9 Intent of Variable: To capture information regarding the indication for the principal operative procedure. In some cases, this information further stratifies risk. Definition: The diagnosis code which corresponds to the patient’s condition. Criteria: Enter the appropriate ICD code corresponding to the condition noted as the postoperative diagnosis in the brief operative note, operative report, and/or after the return of the pathology reports Response % Response Count 540: Acute appendicitis with peritoneal abscess 76 % 19 567: Perforated appendicitis and retroperitoneal abscess 8 2 16 % 4 Blank n= 25 Post-operative death >30 days Answer: No Definition: The date in which the patient expires. Documentation: No date of death recorded No (correct) Response % Response Count 100 % 25 n= 25 Readmission within 30 days of Procedure Answer: No Intent of Variable: To capture inpatient readmission(s) by midnight of POD 30 and distinguish between planned and unplanned readmissions at the time of the principal operative procedure; and to distinguish those that are likely related or unlikely related to adverse events following the principal operative procedure. Definition: Patients who were discharged from their acute hospital stay for their principal operative procedure, and subsequently readmitted as an inpatient to an acute care hospital setting. Documentation: Patient was discharged from acute care hopsital to Neverland hospital and then discharged from Neverland hospital to home Response % Response Count Yes 4% 1/25 No (correct) 96% 24/25 n= 25 Was there an unplanned return to the OR: Answer: Yes Definition: A return to the OR that was not planned at the time of the principal operative procedure. Documentation: -the first return to OR, on 07/08/2013 was for closure of the wound. This was documented as planned as the patient needed to have primary closure of the open abdominal wound that was left open intentionally during the initial operative procedure. -The second OR, on 07/16/2013, was for a laparotomy for incision and drainage of retroperitoneal abscess at the Neverland Hospital. Was there a second unplanned return to the OR: Answer: No Definition: A return to the OR that was not planned at the time of the principal operative procedure. Documentation: -the first return to OR, on 07/08/2013 was for closure of the wound. This was documented as planned as the patient needed to have primary closure of the open abdominal wound that was left open intentionally during the initial operative procedure. -The second OR, on 07/16/2013, was for a laparotomy for incision and drainage of retroperitoneal abscess at the Neverland Hospital. This was unplanned. Was there an unplanned return to the OR for a surgical procedure, within the 30 days post op period? Response % Response Count Yes (Correct) 96 % 24 No 4% 1 n= 25 Was it related? Yes (Correct) Response % Response Count 100 % 24 n= 24 Date 07/16/2013 Not asked Return to the OR CPT Code Response % Response Count 49002 4% 1 49020 16 % 4 49060 correct 72 % 18 Blank 8% 2 N= 25 CPT Description CPT Description RVU 49002 Reopening of recent laparotomy 1 49020 Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open 26.67 49060 correct Drainage of retroperitoneal abscess; open 18.53 8% 2 Blank Neverland Return to OR CPT Coding 49002 is not incorrect as this was done, but is not an accurate description of the principle operation performed on the return to OR. 49020 is not correct as this was a retroperiotneal abscess, which is more accurately reflected in code 49060. 30 day follow up • Correct Answer: No 30 day follow up would be completed. • This was not asked on the case study. Summary of Post Op Occurrences Post Op Occurrence Correct Answer Correct Responses Pneumonia Yes 19/25 Pneumonia PATOS Yes 16/19 Urinary Tract Infection No 21/25 Intra-/Postop MI Yes 24/25 Septic Shock Immediate Post op Yes 7/25 Septic Shock PATOS Yes 6/7 Sepsis at Neverland No 15/25 Organ Space SSI Yes 21/25 Organ Space PATOS Yes 20/21 Summary of OR Variables and D/C information Variable Correct Answer Correct Responses Primary CPT code 49060 (Drainage of retroperitoneal 1/25 Wound Classification Dirty 25/25 Hospital D/C Date 07/12 24/25 Discharge Destination Separate acute care 21/25 Post op Death > 30 days No 25/25 Readmission within 30 days No 24/25 Unplanned ROR Yes 24/25 Unplanned ROR Date 07/16/2013 Date not asked ROR CPT code 49060 (Drainage of retroperitoneal 18/25 30 day Follow up No abscess; open) abscess; open) Not asked Organ Space SSI CPT Code 49060 (ruptured appendectomy); 44960 (retroperitoneal abscess)