ID

10101

Description

Documentation form for quality assurance in German Health Care by the institute forapplied quality Improvement and Research in Health Care (Aqua), https://www.aqua-institut.de/en/home. Internal Aqua form version: PNEU Specification 2015 V02

Link

https://www.aqua-institut.de/en/home

Keywords

Versions (2)
  1. 11/23/14 11/23/14 - Julian Varghese
  2. 3/28/15 3/28/15 - Sarah Schulze Sünninghausen
Uploaded on

March 28, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Quality assurance Community-Acquired Pneumonia (AQUA)

German English

Quality assurance Community-Acquired Pneumonia (AQUA)

1 forms  
Test
Description

Test

Admission
Description

Admission

Admission from inpatient care facility
Description

Admission from inpatient care facility

Data type

boolean

Admission from other hospital or inpatient rehabilitation facility
Description

Admission from other hospital or inpatient rehabilitation facility

Data type

boolean

chronic bed rest
Description

chronic bed rest

Data type

boolean

Alias
UMLS CUI-1
C0004910
at admission invasive mechanical ventilation
Description

at admission invasive mechanical ventilation

Data type

boolean

Alias
UMLS CUI-1
C1868981
disorientation
Description

disorientation

Data type

integer

Alias
UMLS CUI-1
C0233407
spontaneous breathing frequency (1 / min)
Description

spontaneous breathing frequency (1 / min)

Data type

integer

Measurement units
  • 1/min
1/min
not determined spontaneous respiratory rate
Description

not determined spontaneous respiratory rate

Data type

integer

Systolic blood pressure (in mmHg)
Description

Systolic blood pressure (in mmHg)

Data type

integer

Measurement units
  • mmHg
Alias
UMLS CUI-1
C0871470
mmHg
Diastolic blood pressure (in mmHg)
Description

Diastolic blood pressure (in mmHg)

Data type

integer

Measurement units
  • mmHg
Alias
UMLS CUI-1
C0428883
mmHg
acute symptoms
Description

acute symptoms

Data type

boolean

Fresh infiltrate in chest X-ray
Description

Fresh infiltrate in chest X-ray

Data type

boolean

Alias
UMLS CUI-1
C2073654
Exclusion of severe immunosuppression
Description

Exclusion of severe immunosuppression

Data type

boolean

Alias
UMLS CUI-1
C1373218
last hospital stay is more than 28 days ago
Description

last hospital stay is more than 28 days ago

Data type

boolean

Date of the first blood gas analysis or pulse oximetry
Description

Date of the first blood gas analysis or pulse oximetry

Data type

integer

Alias
UMLS CUI-1
C0005800
UMLS CUI-2
C0034108
initial antimicrobial therapy
Description

initial antimicrobial therapy

Data type

integer

Alias
UMLS CUI-1
C0443071
Course
Description

Course

Beginning of the mobilization
Description

Beginning of the mobilization

Data type

integer

Alias
UMLS CUI-1
C0300926
Follow-up of C-reactive protein or procalcitonin concentration within the first 5 days (= 120 h) of stay
Description

Follow-up of C-reactive protein or procalcitonin concentration within the first 5 days (= 120 h) of stay

Data type

boolean

Alias
UMLS CUI-1
C0201657
UMLS CUI-2
C1535922
Decrease of C-reactive protein or procalcitonin concentration within the first 5 days of stay
Description

Decrease of C-reactive protein or procalcitonin concentration within the first 5 days of stay

Data type

boolean

Alias
UMLS CUI-1
C0877451
Review of the diagnostic or therapeutic procedure
Description

Review of the diagnostic or therapeutic procedure

Data type

boolean

Alias
UMLS CUI-1
C1522577
mechanical ventilation
Description

mechanical ventilation

Data type

integer

Alias
UMLS CUI-1
C0199470
Duration (in hours)
Description

Duration (in hours)

Data type

integer

Measurement units
  • hours
Alias
UMLS CUI-1
C2926735
hours
Ventilation with positive end-expiratory pressure of min. 5 cm water column
Description

Ventilation with positive end-expiratory pressure of min. 5 cm water column

Data type

boolean

Alias
UMLS CUI-1
C2065089
Has been documented that (due to the severity of the underlying disease) assessed the pneumonia episode as terminal manifestation of a chronic disease and thus the control of symptoms was defined as the primary goal of therapy or during the course?
Description

Has been documented that due to the severity of the underlying disease assessed the pneumonia episode as terminal manifestation of a chronic disease and thus the control of symptoms was defined as the primary goal of therapy or during the course?

Data type

boolean

Discharge
Description

Discharge

Hostpital discharge date (DD.MM.YYYY)
Description

Hostpital discharge date (DD.MM.YYYY)

Data type

date

Alias
UMLS CUI-1
C2710998
Discharge diagnosis
Description

Discharge diagnosis

Data type

integer

Alias
UMLS CUI-1
C0011900
Reason for Discharge
Description

Reason for Discharge

Data type

integer

Alias
UMLS CUI-1
C3164834
Analysis of clinical stability criteria against dismissal
Description

Analysis of clinical stability criteria against dismissal

disorientation
Description

disorientation

Data type

integer

Alias
UMLS CUI-1
C0233407
stable oral and / or enteral intake of food
Description

stable oral and / or enteral intake of food

Data type

boolean

Alias
UMLS CUI-1
C0086311
spontaneous respiratory rate
Description

spontaneous respiratory rate

Data type

integer

Alias
UMLS CUI-1
C0425486
heart rate
Description

heart rate

Data type

integer

Alias
UMLS CUI-1
C0018810
temperature
Description

temperature

Data type

integer

Alias
UMLS CUI-1
C0005903
oxygen saturation
Description

oxygen saturation

Data type

integer

Alias
UMLS CUI-1
C0523807
Systolic blood pressure
Description

Systolic blood pressure

Data type

integer

Alias
UMLS CUI-1
C0871470
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Similar models

Quality assurance Community-Acquired Pneumonia (AQUA)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Item Group
Admission
Aufnahme aus stationärer Pflegeeinrichtung
Item
Admission from inpatient care facility
boolean
Aufnahme aus anderem Krankenhaus oder aus stationärer Rehabilitationseinrichtung
Item
Admission from other hospital or inpatient rehabilitation facility
boolean
chronische Bettlägerigkeit
Item
chronic bed rest
boolean
C0004910 (UMLS CUI-1)
bei Aufnahme invasive maschinelle Beatmung
Item
at admission invasive mechanical ventilation
boolean
C1868981 (UMLS CUI-1)
Item
disorientation
integer
C0233407 (UMLS CUI-1)
Desorientierung
Code List
disorientation
CL Item
no (0)
CL Item
yes, pneumonia caused (1)
CL Item
yes, no pneumonia caused (2)
spontane Atemfrequenz (in 1/min)
Item
spontaneous breathing frequency (1 / min)
integer
Item
not determined spontaneous respiratory rate
integer
spontane Atemfrequenz nicht bestimmt
Code List
not determined spontaneous respiratory rate
CL Item
yes (1)
Blutdruck systolisch (in mmHg)
Item
Systolic blood pressure (in mmHg)
integer
C0871470 (UMLS CUI-1)
Blutdruck diastolisch (in mmHg)
Item
Diastolic blood pressure (in mmHg)
integer
C0428883 (UMLS CUI-1)
Akute Symptomatik
Item
acute symptoms
boolean
Frisches Infiltrat im Röntgen-Thorax
Item
Fresh infiltrate in chest X-ray
boolean
C2073654 (UMLS CUI-1)
Ausschluss schwerer Immunsupression
Item
Exclusion of severe immunosuppression
boolean
C1373218 (UMLS CUI-1)
letzter KH-Aufenthalt liegt mehr als 28 Tage zurück
Item
last hospital stay is more than 28 days ago
boolean
Item
Date of the first blood gas analysis or pulse oximetry
integer
C0005800 (UMLS CUI-1)
C0034108 (UMLS CUI-2)
Zeitpunkt der ersten Blutgasanalyse oder Pulsoxymetrie
Code List
Date of the first blood gas analysis or pulse oximetry
CL Item
no blood gas analysis or pulse oximetry (0)
CL Item
within the first 4 hours after admission (1)
CL Item
4 to less than 8 hours (2)
CL Item
8 hours and later (3)
Item
initial antimicrobial therapy
integer
C0443071 (UMLS CUI-1)
initiale antimikrobielle Therapie
Code List
initial antimicrobial therapy
CL Item
no antimicrobial therapy (0)
CL Item
within the first 4 hours after admission (1)
CL Item
4 to less than 8 hours (2)
CL Item
8 hours and späterinitiale antimicrobial therapy (3)
Item Group
Course
Item
Beginning of the mobilization
integer
C0300926 (UMLS CUI-1)
Beginn der Mobilisation
Code List
Beginning of the mobilization
CL Item
no mobilization (0)
CL Item
within the first 24 hours after admission (1)
CL Item
after 24 hours and later (2)
Verlaufskontrolle des C-reaktiven Proteins oder Procalcitoninwertes innerhalb der ersten 5 Tage (= 120 h) des Aufenthalts
Item
Follow-up of C-reactive protein or procalcitonin concentration within the first 5 days (= 120 h) of stay
boolean
C0201657 (UMLS CUI-1)
C1535922 (UMLS CUI-2)
Abfall des C-reaktiven Proteins oder Procalcitoninwertes innerhalb der ersten 5 Tage des Aufenthalts
Item
Decrease of C-reactive protein or procalcitonin concentration within the first 5 days of stay
boolean
C0877451 (UMLS CUI-1)
Überprüfung des diagnostischen oder therapeutischen Vorgehens
Item
Review of the diagnostic or therapeutic procedure
boolean
C1522577 (UMLS CUI-1)
Item
mechanical ventilation
integer
C0199470 (UMLS CUI-1)
maschinelle Beatmung
Code List
mechanical ventilation
CL Item
no (0)
CL Item
yes, only non-invasive (1)
CL Item
yes, only invasive (2)
CL Item
yes, both non-invasive and invasive (3)
Dauer (in Stunden)
Item
Duration (in hours)
integer
C2926735 (UMLS CUI-1)
Beatmung mit positivem endexspiratorischen Druck von mind. 5 cm Wassersäule
Item
Ventilation with positive end-expiratory pressure of min. 5 cm water column
boolean
C2065089 (UMLS CUI-1)
Wurde dokumentiert, dass aufgrund der Schwere der Grunderkrankung die Pneumonie-Episode als terminale Manifestation einer chronischen Krankheit eingeschätzt und damit als Therapieziel primär oder im Verlauf die Symptomkontrolle definiert wurde?
Item
Has been documented that (due to the severity of the underlying disease) assessed the pneumonia episode as terminal manifestation of a chronic disease and thus the control of symptoms was defined as the primary goal of therapy or during the course?
boolean
Item Group
Discharge
Entlassungsdatum Krankenhaus (TT.MM.JJJJ)
Item
Hostpital discharge date (DD.MM.YYYY)
date
C2710998 (UMLS CUI-1)
Entlassungsdiagnose(n)
Item
Discharge diagnosis
integer
C0011900 (UMLS CUI-1)
Item
Reason for Discharge
integer
C3164834 (UMLS CUI-1)
Entlassungsgrund
Code List
Reason for Discharge
CL Item
treatment finished as planned (1)
CL Item
transferral to nursing facility (10)
CL Item
discharge to hospice (11)
CL Item
external transferral to psychiatric treatment (13)
CL Item
treatment finished because of other reasons, postdischarge treatment is planned (14)
CL Item
treatment aborted against medical advice, postdischarge treatment is planned (15)
CL Item
internal transferral with change of DRG payment areas (17)
CL Item
treatment finished as planned, postdischarge treatment is planned (2)
CL Item
case termination (internal transferral) with change between full- and partial stationary care (22)
CL Item
discharge at the end of the year with admission in previous year (25)
CL Item
treatment finished because of other reasons (3)
CL Item
treatment aborted against medical advice (4)
CL Item
change of jurisdiction of insurer or other payer (5)
CL Item
transferral to another hospital (6)
CL Item
death (7)
CL Item
transferral to another hospital within cooperative and governmental policies  (8)
CL Item
transferral to rehabilitation facility (9)
Item Group
Analysis of clinical stability criteria against dismissal
Item
disorientation
integer
C0233407 (UMLS CUI-1)
Desorientierung
Code List
disorientation
CL Item
no (0)
CL Item
yes, pneumonia caused (1)
CL Item
yes, no pneumonia caused (2)
stabile orale und/oder enterale Nahrungsaufnahme
Item
stable oral and / or enteral intake of food
boolean
C0086311 (UMLS CUI-1)
Item
spontaneous respiratory rate
integer
C0425486 (UMLS CUI-1)
spontane Atemfrequenz
Code List
spontaneous respiratory rate
CL Item
up to 24 / min (1)
CL Item
24 / min (2)
CL Item
not determined (3)
CL Item
not determined because of long-term ventilation (4)
Item
heart rate
integer
C0018810 (UMLS CUI-1)
Herzfrequenz
Code List
heart rate
CL Item
up to 100 / min (1)
CL Item
100 / min (2)
CL Item
not determined (3)
Item
temperature
integer
C0005903 (UMLS CUI-1)
Temperatur
Code List
temperature
CL Item
maximum 37,2C (1)
CL Item
about 37,2C (2)
CL Item
not determined (3)
Item
oxygen saturation
integer
C0523807 (UMLS CUI-1)
Sauerstoffsättigung
Code List
oxygen saturation
CL Item
less than 90% (1)
CL Item
at least 90% (2)
CL Item
not determined (3)
Item
Systolic blood pressure
integer
C0871470 (UMLS CUI-1)
Blutdruck systolisch
Code List
Systolic blood pressure
CL Item
less than 90 mmHg (1)
CL Item
at least 90 mmHg (2)
CL Item
not determined (3)
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