ID

6458

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 -
Uploaded on

December 23, 2014

DOI

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License

Creative Commons BY-NC 3.0 Legacy

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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
C0182440
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
C0178602
UMLS CUI-1-2
C0009924
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)
C0182440 (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
C0178602 (UMLS CUI-1-1)
C0009924 (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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