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ID

44101

Description

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

Link

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

Keywords

  1. 12/22/14 12/22/14 - Julian Varghese
  2. 12/23/14 12/23/14 - Julian Varghese
  3. 9/5/19 9/5/19 - Julian Varghese
  4. 9/20/21 9/20/21 -
Copyright Holder

IQTIG

Uploaded on

September 20, 2021

DOI

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License

Creative Commons BY-NC 3.0

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    Quality assurance Heart Surgery - Surgery (AQUA)

    Quality assurance Heart Surgery - Surgery (AQUA)

    Operation - Basic documentation
    Description

    Operation - Basic documentation

    Number of surgical procedure at this stay?
    Description

    wievielter Eingriff während dieses Aufenthaltes?

    Data type

    string

    Alias
    UMLS CUI-1
    C2114712
    Operation Date (DD.MM.YY)
    Description

    OP-Datum

    Data type

    date

    Alias
    UMLS CUI-1
    C3258210
    Procedure codes
    Description

    Operation

    Data type

    integer

    Alias
    UMLS CUI-1
    C1550373
    Categories of applied procedures
    Description

    Categories of applied procedures

    Coronary artery bypass surgery
    Description

    Koronarchirurgie

    Data type

    integer

    Alias
    UMLS CUI-1
    C0010055
    Aortic valve surgery
    Description

    Aortenklappenchirurgie

    Data type

    integer

    Alias
    UMLS CUI-1
    C0003506
    other Operation
    Description

    sonstige OP

    Data type

    integer

    Leading procedure code of other operation
    Description

    Führender OPS-Kode der sonstigen OP

    Data type

    integer

    Urgency type of that procedure
    Description

    Dringlichkeit

    Data type

    integer

    Alias
    UMLS CUI-1
    C2188401
    Nitrates (preoperative) - i. v.
    Description

    Nitrate (präoperativ)

    Data type

    integer

    Alias
    UMLS CUI-1
    C0028125
    Troponin positive (preoperative)
    Description

    Troponin positiv (präoperativ)

    Data type

    integer

    Alias
    UMLS CUI-1
    C1096316
    Inotropic agent applied (preoperative) - i. v.
    Description

    Inotrope (präoperativ)

    Data type

    integer

    Alias
    UMLS CUI-1
    C0304509
    (preoperative) Mechanical circulatory support
    Description

    (präoperativ) mechanische Kreislaufunterstützung

    Data type

    integer

    Alias
    UMLS CUI-1
    C3274791
    Wound contamination classifcation of procedure (according to CDC definition)
    Description

    Wundkontaminationsklassifikation

    Data type

    integer

    Alias
    UMLS CUI-1
    C1629491
    Surgical approach (w/o Heart Lung Machine)
    Description

    OP-Vorgehen

    Data type

    integer

    Alias
    UMLS CUI-1
    C0018830
    Surgical access way
    Description

    Zugang

    Data type

    integer

    Alias
    UMLS CUI-1
    C0587266
    Procedure Duration (in minutes)
    Description

    OP-Zeit

    Data type

    integer

    Measurement units
    • Minuten
    Alias
    UMLS CUI-1
    C1442476
    Minuten
    Cardiopulmonary bypass time(in Minuten)
    Description

    Bypasszeit

    Data type

    integer

    Measurement units
    • Minuten
    Alias
    UMLS CUI-1
    C0429123
    Minuten
    bypass time unknown
    Description

    Bypasszeit unbekannt

    Data type

    integer

    Aortic clamp time (in minutes)
    Description

    Aortenabklemmzeit

    Data type

    integer

    Measurement units
    • Minuten
    Alias
    UMLS CUI-1-1
    C0003483
    UMLS CUI-1-2
    C1718394
    Minuten
    Aortic clamp time unknown
    Description

    Aortenabklemmzeit unbekannt

    Data type

    integer

    Coronary Surgery
    Description

    Coronary Surgery

    Number of grafts
    Description

    Anzahl der Grafts

    Data type

    string

    Alias
    UMLS CUI-1
    C1260596
    Type of graft
    Description

    Type of graft

    Vein graft
    Description

    Vene

    Data type

    integer

    Alias
    UMLS CUI-1
    C0440766
    Left internal thoracic artery
    Description

    ITA links

    Data type

    integer

    Alias
    UMLS CUI-1
    C0841999
    Left internal thoracic artery
    Description

    ITA rechts

    Data type

    integer

    Alias
    UMLS CUI-1
    C0842000
    Radial artery
    Description

    A. radialis

    Data type

    integer

    Alias
    UMLS CUI-1
    C0842001
    other Grafts
    Description

    sonstige Grafts

    Data type

    integer

    (Number of) central coronal anastomosis
    Description

    zentrale Anastomose(n)

    Data type

    integer

    Measurement units
    • Anzahl
    Alias
    UMLS CUI-1-1
    C1265611
    UMLS CUI-1-2
    C2825209
    Anzahl
    (Number of) peripheral anastomosis, using arterial graft
    Description

    periphere Anastomose(n), arterieller Graft

    Data type

    integer

    Measurement units
    • Anzahl
    Anzahl
    (Number of) peripheral anastomosis, using vein graft
    Description

    periphere Anastomose(n), venöser Graft

    Data type

    integer

    Measurement units
    • Anzahl
    Anzahl
    Treated coronary arteries
    Description

    Treated coronary arteries

    LAD and/or branches
    Description

    LAD und / oder Äste

    Data type

    integer

    Alias
    UMLS CUI-1
    C0226032
    RCA and/or branches
    Description

    RCA und / oder Äste

    Data type

    integer

    Alias
    UMLS CUI-1
    C0447064
    RCX and/or branches
    Description

    RCX und / oder branches

    Data type

    integer

    Aortic valve surgery
    Description

    Aortic valve surgery

    Aortic stenosis
    Description

    Stenose

    Data type

    integer

    Alias
    UMLS CUI-1
    C0003507
    Aortic valve insufficiency
    Description

    Insuffizienz

    Data type

    integer

    Alias
    UMLS CUI-1
    C0003504
    Procedure on heart valve
    Description

    Klappeneingriff

    Data type

    integer

    Alias
    UMLS CUI-1
    C1292963
    Type of valve prosthesis
    Description

    Ventil- bzw. Ringtyp

    Data type

    integer

    Alias
    UMLS CUI-1
    C0449518
    Diameter of artificial valve (in mm)
    Description

    Durchmesser

    Data type

    integer

    Measurement units
    • mm
    Alias
    UMLS CUI-1-1
    C1301886
    UMLS CUI-1-2
    C3873910
    mm
    intraprocedural complications
    Description

    intraprozedurale Komplikationen

    Data type

    integer

    Alias
    UMLS CUI-1
    C0021890
    Device micplacement
    Description

    Device-Fehlpositionierung

    Data type

    integer

    Alias
    UMLS CUI-1
    C0274325
    Coronary ostium stenosis
    Description

    Koronarostienverschluss

    Data type

    integer

    Alias
    UMLS CUI-1
    C0345120
    Aortic dissection
    Description

    Aortendissektion

    Data type

    integer

    Alias
    UMLS CUI-1
    C0340643
    Rupture of fibrous ring of heart
    Description

    Annulus-Ruptur

    Data type

    integer

    Alias
    UMLS CUI-1-1
    C3203359
    UMLS CUI-1-2
    C0504005
    Pericardial tamponade
    Description

    Perikardtamponade

    Data type

    integer

    Alias
    UMLS CUI-1
    C0007177
    Left ventricular decompensation
    Description

    LV-Dekompensation

    Data type

    integer

    Alias
    UMLS CUI-1
    C0023212
    Cerebral embolism
    Description

    Hirnembolie

    Data type

    integer

    Alias
    UMLS CUI-1
    C0007780
    Aortic Valve Insufficiency (>= 2. degree)
    Description

    Aortenregurgitation > = 2. Grades

    Data type

    integer

    Cardiac Arrhythmia
    Description

    Rhythmusstörungen

    Data type

    integer

    Alias
    UMLS CUI-1
    C0003811
    Device-Embolization
    Description

    Device-Embolisation

    Data type

    integer

    Alias
    UMLS CUI-1
    C3830526
    Reason for catheteral intervention (instead of open coronary surgery)
    Description

    Reason for catheteral intervention (instead of open coronary surgery)

    Alias
    UMLS CUI-1-1
    C0566251
    UMLS CUI-1-2
    C1532338
    Age
    Description

    Alter

    Data type

    boolean

    Frailty
    Description

    Frailty

    Data type

    boolean

    High risk
    Description

    Hochrisiko

    Data type

    boolean

    Prognosis-limiting comorbidity
    Description

    Prognose-limitierende Zweiterkrankung

    Data type

    boolean

    Patient's wish
    Description

    Patientenwunsch

    Data type

    boolean

    Porcelain aorta
    Description

    Porzellan-Aorta

    Data type

    boolean

    Malignant tumor (without curative treatment )
    Description

    Malignom (nicht kurativ behandelt)

    Data type

    boolean

    other
    Description

    sonstige

    Data type

    boolean

    X-Ray Exposure Time (in minutes)
    Description

    Durchleuchtungszeit

    Data type

    integer

    Measurement units
    • Minuten
    Alias
    UMLS CUI-1
    C2348485
    Minuten
    Dose Area product (cGy)* cm²)
    Description

    Flächendosisprodukt

    Data type

    integer

    Measurement units
    • (cGy)* cm²
    (cGy)* cm²
    unknown dose area product
    Description

    Flächendosisprodukt nicht bekannt

    Data type

    integer

    X-ray contrast media dose (in ml)
    Description

    Kontrastmittelmenge

    Data type

    integer

    Measurement units
    • ml
    Alias
    UMLS CUI [1,1]
    C0009924
    UMLS CUI [1,2]
    C0178602
    ml
    Conversion of procedure
    Description

    Konversion

    Data type

    integer

    Alias
    UMLS CUI-1
    C0444785
    Vascular complication
    Description

    vaskuläre Komplikation

    Data type

    integer

    Alias
    UMLS CUI-1
    C1112391

    Similar models

    Quality assurance Heart Surgery - Surgery (AQUA)

    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Operation - Basic documentation
    wievielter Eingriff während dieses Aufenthaltes?
    Item
    Number of surgical procedure at this stay?
    string
    C2114712 (UMLS CUI-1)
    OP-Datum
    Item
    Operation Date (DD.MM.YY)
    date
    C3258210 (UMLS CUI-1)
    Operation
    Item
    Procedure codes
    integer
    C1550373 (UMLS CUI-1)
    Item Group
    Categories of applied procedures
    Item
    Coronary artery bypass surgery
    integer
    C0010055 (UMLS CUI-1)
    Code List
    Coronary artery bypass surgery
    CL Item
     (0)
    CL Item
     (1)
    Item
    Aortic valve surgery
    integer
    C0003506 (UMLS CUI-1)
    Code List
    Aortic valve surgery
    CL Item
     (0)
    CL Item
     (1)
    CL Item
     (2)
    CL Item
     (3)
    Item
    other Operation
    integer
    Code List
    other Operation
    CL Item
     (0)
    CL Item
     (1)
    Führender OPS-Kode der sonstigen OP
    Item
    Leading procedure code of other operation
    integer
    Item
    Urgency type of that procedure
    integer
    C2188401 (UMLS CUI-1)
    Code List
    Urgency type of that procedure
    CL Item
     (1)
    CL Item
     (2)
    CL Item
     (3)
    CL Item
     (4)
    Item
    Nitrates (preoperative) - i. v.
    integer
    C0028125 (UMLS CUI-1)
    Code List
    Nitrates (preoperative) - i. v.
    CL Item
     (0)
    CL Item
     (1)
    Item
    Troponin positive (preoperative)
    integer
    C1096316 (UMLS CUI-1)
    Code List
    Troponin positive (preoperative)
    CL Item
     (0)
    CL Item
     (1)
    Item
    Inotropic agent applied (preoperative) - i. v.
    integer
    C0304509 (UMLS CUI-1)
    Code List
    Inotropic agent applied (preoperative) - i. v.
    CL Item
     (0)
    CL Item
     (1)
    Item
    (preoperative) Mechanical circulatory support
    integer
    C3274791 (UMLS CUI-1)
    Code List
    (preoperative) Mechanical circulatory support
    CL Item
     (0)
    CL Item
     (1)
    CL Item
     (2)
    Item
    Wound contamination classifcation of procedure (according to CDC definition)
    integer
    C1629491 (UMLS CUI-1)
    Code List
    Wound contamination classifcation of procedure (according to CDC definition)
    CL Item
     (1)
    CL Item
     (2)
    CL Item
     (3)
    CL Item
     (4)
    Item
    Surgical approach (w/o Heart Lung Machine)
    integer
    C0018830 (UMLS CUI-1)
    Code List
    Surgical approach (w/o Heart Lung Machine)
    CL Item
     (1)
    CL Item
     (2)
    CL Item
     (3)
    Item
    Surgical access way
    integer
    C0587266 (UMLS CUI-1)
    Code List
    Surgical access way
    CL Item
     (1)
    CL Item
     (9)
    OP-Zeit
    Item
    Procedure Duration (in minutes)
    integer
    C1442476 (UMLS CUI-1)
    Bypasszeit
    Item
    Cardiopulmonary bypass time(in Minuten)
    integer
    C0429123 (UMLS CUI-1)
    Item
    bypass time unknown
    integer
    Code List
    bypass time unknown
    CL Item
     (1)
    Aortenabklemmzeit
    Item
    Aortic clamp time (in minutes)
    integer
    C0003483 (UMLS CUI-1-1)
    C1718394 (UMLS CUI-1-2)
    Item
    Aortic clamp time unknown
    integer
    Code List
    Aortic clamp time unknown
    CL Item
     (1)
    Item Group
    Coronary Surgery
    Anzahl der Grafts
    Item
    Number of grafts
    string
    C1260596 (UMLS CUI-1)
    Item Group
    Type of graft
    Item
    Vein graft
    integer
    C0440766 (UMLS CUI-1)
    Code List
    Vein graft
    CL Item
     (1)
    Item
    Left internal thoracic artery
    integer
    C0841999 (UMLS CUI-1)
    Code List
    Left internal thoracic artery
    CL Item
     (1)
    Item
    Left internal thoracic artery
    integer
    C0842000 (UMLS CUI-1)
    Code List
    Left internal thoracic artery
    CL Item
     (1)
    Item
    Radial artery
    integer
    C0842001 (UMLS CUI-1)
    Code List
    Radial artery
    CL Item
     (1)
    Item
    other Grafts
    integer
    Code List
    other Grafts
    CL Item
     (1)
    zentrale Anastomose(n)
    Item
    (Number of) central coronal anastomosis
    integer
    C1265611 (UMLS CUI-1-1)
    C2825209 (UMLS CUI-1-2)
    periphere Anastomose(n), arterieller Graft
    Item
    (Number of) peripheral anastomosis, using arterial graft
    integer
    periphere Anastomose(n), venöser Graft
    Item
    (Number of) peripheral anastomosis, using vein graft
    integer
    Item Group
    Treated coronary arteries
    Item
    LAD and/or branches
    integer
    C0226032 (UMLS CUI-1)
    Code List
    LAD and/or branches
    CL Item
     (1)
    Item
    RCA and/or branches
    integer
    C0447064 (UMLS CUI-1)
    Code List
    RCA and/or branches
    CL Item
     (1)
    Item
    RCX and/or branches
    integer
    Code List
    RCX and/or branches
    CL Item
     (1)
    Item Group
    Aortic valve surgery
    Item
    Aortic stenosis
    integer
    C0003507 (UMLS CUI-1)
    Code List
    Aortic stenosis
    CL Item
     (0)
    CL Item
     (1)
    Item
    Aortic valve insufficiency
    integer
    C0003504 (UMLS CUI-1)
    Code List
    Aortic valve insufficiency
    CL Item
     (0)
    CL Item
     (1)
    Item
    Procedure on heart valve
    integer
    C1292963 (UMLS CUI-1)
    Code List
    Procedure on heart valve
    CL Item
     (1)
    CL Item
     (2)
    CL Item
     (9)
    Item
    Type of valve prosthesis
    integer
    C0449518 (UMLS CUI-1)
    Code List
    Type of valve prosthesis
    CL Item
     (1103)
    CL Item
     (1104)
    CL Item
     (1105)
    CL Item
     (1106)
    CL Item
     (1188)
    CL Item
     (1201)
    CL Item
     (1202)
    CL Item
     (1203)
    CL Item
     (1204)
    CL Item
     (1205)
    CL Item
     (1206)
    CL Item
     (1207)
    CL Item
     (1208)
    CL Item
     (1209)
    CL Item
     (1210)
    CL Item
     (1211)
    CL Item
     (1212)
    CL Item
     (1213)
    CL Item
     (1288)
    CL Item
     (1388)
    Durchmesser
    Item
    Diameter of artificial valve (in mm)
    integer
    C1301886 (UMLS CUI-1-1)
    C3873910 (UMLS CUI-1-2)
    Item
    intraprocedural complications
    integer
    C0021890 (UMLS CUI-1)
    Code List
    intraprocedural complications
    CL Item
     (0)
    CL Item
     (1)
    Item
    Device micplacement
    integer
    C0274325 (UMLS CUI-1)
    Code List
    Device micplacement
    CL Item
     (1)
    Item
    Coronary ostium stenosis
    integer
    C0345120 (UMLS CUI-1)
    Code List
    Coronary ostium stenosis
    CL Item
     (1)
    Item
    Aortic dissection
    integer
    C0340643 (UMLS CUI-1)
    Code List
    Aortic dissection
    CL Item
     (1)
    Item
    Rupture of fibrous ring of heart
    integer
    C3203359 (UMLS CUI-1-1)
    C0504005 (UMLS CUI-1-2)
    Code List
    Rupture of fibrous ring of heart
    CL Item
     (1)
    Item
    Pericardial tamponade
    integer
    C0007177 (UMLS CUI-1)
    Code List
    Pericardial tamponade
    CL Item
     (1)
    Item
    Left ventricular decompensation
    integer
    C0023212 (UMLS CUI-1)
    Code List
    Left ventricular decompensation
    CL Item
     (1)
    Item
    Cerebral embolism
    integer
    C0007780 (UMLS CUI-1)
    Code List
    Cerebral embolism
    CL Item
     (1)
    Item
    Aortic Valve Insufficiency (>= 2. degree)
    integer
    Code List
    Aortic Valve Insufficiency (>= 2. degree)
    CL Item
     (1)
    Item
    Cardiac Arrhythmia
    integer
    C0003811 (UMLS CUI-1)
    Code List
    Cardiac Arrhythmia
    CL Item
     (1)
    Item
    Device-Embolization
    integer
    C3830526 (UMLS CUI-1)
    Code List
    Device-Embolization
    CL Item
     (1)
    Item Group
    Reason for catheteral intervention (instead of open coronary surgery)
    C0566251 (UMLS CUI-1-1)
    C1532338 (UMLS CUI-1-2)
    Alter
    Item
    Age
    boolean
    Frailty
    Item
    Frailty
    boolean
    Hochrisiko
    Item
    High risk
    boolean
    Prognose-limitierende Zweiterkrankung
    Item
    Prognosis-limiting comorbidity
    boolean
    Patientenwunsch
    Item
    Patient's wish
    boolean
    Porzellan-Aorta
    Item
    Porcelain aorta
    boolean
    Malignom (nicht kurativ behandelt)
    Item
    Malignant tumor (without curative treatment )
    boolean
    sonstige
    Item
    other
    boolean
    Durchleuchtungszeit
    Item
    X-Ray Exposure Time (in minutes)
    integer
    C2348485 (UMLS CUI-1)
    Flächendosisprodukt
    Item
    Dose Area product (cGy)* cm²)
    integer
    Item
    unknown dose area product
    integer
    Code List
    unknown dose area product
    CL Item
     (1)
    Kontrastmittelmenge
    Item
    X-ray contrast media dose (in ml)
    integer
    C0009924 (UMLS CUI [1,1])
    C0178602 (UMLS CUI [1,2])
    Item
    Conversion of procedure
    integer
    C0444785 (UMLS CUI-1)
    Code List
    Conversion of procedure
    CL Item
     (0)
    CL Item
     (1)
    CL Item
     (2)
    CL Item
     (3)
    Item
    Vascular complication
    integer
    C1112391 (UMLS CUI-1)
    Code List
    Vascular complication
    CL Item
     (1)

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