Download Spine SCOAP: Variable and Outcomes Definitions

Spine SCOAP: Variable and Outcomes Definitions
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Appendix 2: SCOAP Outcomes
Variable
Event without Intervention: Atrial arrhythmia requiring treatment
Event without Intervention: CVA/stroke Event without Intervention: C. difficile infection
Event without Intervention: Dysphagia, if cervical procedure
Event without Intervention: Fall with injury requiring surgery
Event without Intervention: Hoarseness, if cervical procedure
Event without Intervention: Unplanned ICU stay/readmit to ICU Event without Intervention: Myocardial infarction/ Cardiac arrest Event without Intervention: New neurologic deficit
Event without Intervention: Paralysis (Partial)
Event without Intervention: Paralysis (Complete)
SCOAP Definition
Indicate whether the patient had a new onset of atrial fibrillation/flutter (AF) requiring treatment. Does not include recurrence of
AF which had been present preoperatively.
Stroke/Cerebral Vascular Accident (CVA): Patient develops an embolic, thrombotic, or hemorrhagic vascular accident or stroke with motor, sensory, or cognitive dysfunction (for example, hemiplegia, hemiparesis, aphasia, sensory deficit, impaired memory) that persists for 24 or more hours.
c‐Difficile infection only if there is laboratory confirmation of infection
Indicate yes if patient is diagnosed with dysphagia following this cervical spine procedure. Dysphagia is the medical term for the symptom of difficulty in swallowing.
Patient death or serious disability associated with a fall while being cared for in a healthcare facility
Indicate yes if patient is diagnosed with hoarseness following this cervical spine procedure. Hoarseness is an abnormal deep, harsh voice.
An unplanned ICU stay refers to any ICU stay that was not planned prior to the surgery, e.g. for some surgeries, the normal progression after surgery is to move from the PACU to ICU for at least a short stay
An acute myocardial infarction or cardiac arrest. Cardiac arrest occurs when the heart stops beating. Resumption of heart beat would require an intervention with CPR or defibrillator. A physician diagnosis of myocardial infarction or cardiac arrest is sufficient for indicating "yes" for this question. Myocardial infarction can be indicated by one of the following:
♦ Documentation of ECG changes indicative of acute MI (one or more of the following):
o ST elevation > 1 mm in two or more contiguous leads
o New left bundle branch
o New q‐wave in two of more contiguous leads
♦ New elevation in troponin greater than 3 times upper level of the reference range in the setting of suspected myocardial ischemia.
Enter “Yes” if the patient's chart states the patient has a new neurologic deficit AND the neurologic deficit was not present preoperatively.
Indicate if the patient suffered impairment or loss of voluntary muscle function or of sensation (sensory paralysis) in a part or area of the body.
y
Indicate if the patient suffered paralysis characterized by a complete loss of motor function.
May not be reproduced without prior consent.
Work Product of the Surgical Care and Outcomes Assessment Program (SCOAP), Foundation for Health Care Quality
Revised: June, 2014
Page 1 of 4
Variable
Event without Intervention: Renal insufficiency&/or renal failure
SCOAP Definition
Event without Intervention: UTI requiring treatment
Enter “Yes” if the patient's chart states the patient has a urinary tract infection, the infection is being treated AND the infection was not present preoperatively.
Enter “Yes” if the patient's chart states the patient has urinary retention, the urinary retention is being treated AND the urinary retention was not present preoperatively.
Event without Intervention: Urinary retention
A condition in which the kidneys fail to filter impurities from the blood. Acute or worsening renal failure results in one or more of the following:1) Increase of serum creatinine to > 2.0 and two times most recent preoperative creatinine level; 2) new requirement for dialysis postoperatively.
Event without Intervention: Pneumonia requiring treatment
Pneumonia: Enter “Yes” if the patient's chart states the patient has pneumonia, the pneumonia is being treated AND the pneumonia was not present preoperatively.
Event without Intervention: Other significant events
Event with Reoperative Intervention: Irrigation and Debridement for infection
If a postop event is significant to this admission and is not listed elsewhere, describe
If the patient had a procedure or surgical operation because of infection select "Yes". If an infection was not the reason for the I&D, select "No".
If the patient had a procedure or operation to repair the dura as a result of the index surgery select "Yes". If the patient did not have a procedure, select "No". The dura is the outermost of the three layers of the meninges surrounding the spinal cord. Event with Reoperative Intervention: Dural Repair
Event with Reoperative Intervention: Implant Revision
Event with Reoperative Intervention: Repair Vascular Injury
Event with Reoperative Intervention: Repair Esophageal Injury
Event with Reoperative Intervention: Reoperation for Iatrogenic Instability
Event with Reoperative Intervention: Reoperation for wrong level surgery
Event with Reoperative Intervention: Reoperation for cement leakage
Event with Reoperative Intervention: Other surgical operations
If the patient had a procedure or surgical operation for implant revision, select "Yes". If the patient did not have an implant revision, select "No".
If the patient had a procedure or surgical operation to repair a vascular injury, select "Yes". If the patient did not have a procedure to repair a vascular injury, select "No".
If the patient had a procedure or surgical operation to repair an esophageal injury, select "Yes". If the patient did not have a procedure to repair an esophageal injury, select "No".
If the patient had a procedure or surgical operation because of iatrogenic instability, select "Yes". If the patient did not have a procedure to extend the fusion because of iatrogenic instability, select "No". Iatrogenic instability refers to instability resulting from the index procedure.
If the patient had a procedure or surgical operation because the wrong spinal level was operated on in the index surgery, select "Yes". If the patient did not have a procedure to extend the fusion because the wrong spinal level was operated on in the index surgery, select "No". If the patient had a reoperation because of cement leakage, select "Yes". If the patient did not have a reoperation because of cement leakage select "No". If the patient had another surgical operation(s) that is not listed, describe.
May not be reproduced without prior consent.
Work Product of the Surgical Care and Outcomes Assessment Program (SCOAP), Foundation for Health Care Quality
Revised: June, 2014
Page 2 of 4
Variable
Event with Intervention: Tracheal reintubation
Event with Intervention: NG tube placed postop (non‐routine)
Event with Intervention: Tracheostomy
Event with Intervention: Percutaneous drainage
SCOAP Definition
The patient has to be reintubated following the procedure because of respiratory or other issues. Unplanned Intubation for Respiratory/Cardiac Failure: Patient required placement of an endotracheal tube and mechanical or assisted ventilation because of the onset of respiratory or cardiac failure manifested by severe respiratory distress, hypoxia, hypercarbia, or respiratory acidosis. In patients who were intubated for their surgery, unplanned intubation occurs after they have been extubated after surgery. In patients who were not intubated during surgery, intubation at any time after their surgery is considered unplanned.
(Non‐routine) NG tube replacement following the abdominal procedure because of loss of initial NG tube function or other issues,
Tracheostomy performed perioperatively or postoperatively because of loss of airway, chronic ventilator support or other issues
Indicate if the patient had a percutaneous drain placed or had percutaneous aspiration performed due to abscess, fluid collection or other issues. In percutaneous drainage, physicians use imaging guidance to place a thin needle or tube to remove or drain infected fluid (abscess) from an area of the body such as the chest, abdomen or pelvis.
Event with Intervention: Anticoagulation therapy for presumed/confirmed DVT: /
Use of Anticoagulation therapy for presumed/confirmed DVT (Deep Vein Thrombosis)
/
Event with Intervention: Anticoagulation therapy for presumed/confirmed PE
Use of Anticoagulation therapy for presumed/confirmed PE (Pulmonary Embolism)
Event with Intervention: Antibiotic for presumed/confirmed infection:
Event with Intervention: Wound reopened/debridement
Use of antibiotic for presumed/confirmed infection
Summary Clinical Outcomes: Discharge disposition: Home
Summary Clinical Outcomes: Discharge disposition: Death
Location patient was discharged to from the hospital.
If patient expired in hospital, location would be recorded as “death”.
If patient expired prior to discharge from hospital, define when event occurred.
Indicate if the patient experienced any of the listed events during the first 30 post‐op days. Select all that apply and note if the event occurred during the index hospitalization or after discharge from the index hospitalization. Include only events that were unplanned and occurred after the index procedure. Evaluate 30 post‐op days only. (Not applicable if death in the O.R.)
Summary Clinical Outcomes: Any post‐operative event with or without interventions
Patient Reported Outcomes: NRS Scores at 30‐90 days, 1 and 2 years postoperative
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Indicate whether the surgical wound was re‐opened or debrided (removal of a patient's dead, damaged, or infected tissue).
Indicate the Numeric Rating Scale (NRS) score for Neck or Back Pain that was recorded for the patient within 30‐90 days, and 1‐ and 2‐years of the procedure.
y
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May not be reproduced without prior consent.
Work Product of the Surgical Care and Outcomes Assessment Program (SCOAP), Foundation for Health Care Quality
Revised: June, 2014
Page 3 of 4
Variable
Patient Reported Outcomes: NDI/ODI Scores at 30‐90 days, 1 and 2 years postoperative
Patient Reported Outcomes: Readmission
Patient Reported Outcomes: Reoperation
Patient Reported Outcomes: Work status
Patient Reported Outcomes: Recurrent Spine Symptoms
SCOAP Definition
If patient had a cervical procedure, indicate if an NDI (Neck Disability Index) score was recorded for the patient within 30‐90 days, and 1‐ and 2‐years of the procedure. If patient had a lumbar procedure, indicate if an ODI (Oswestry Disability Index) score was recorded for the patient within 30‐90 days of the procedure. Indicate if within 30 days of the procedure that the patient was readmitted to an acute care hospital. Indicate if the patient had a surgical procedure that was necessary because of complications or occurrences related to the index procedure. This would not apply to a staged reoperation.
Indicate if within 30 days of the procedure the patient has been medically released to return to work or if the information is not available.
If patient had a cervical procedure, indicate if they had dysphagia or hoarseness. If patient had a lumbar procedure, indicate if they had had retrograde ejaculation or infertility.
May not be reproduced without prior consent.
Work Product of the Surgical Care and Outcomes Assessment Program (SCOAP), Foundation for Health Care Quality
Revised: June, 2014
Page 4 of 4