Michigan STS Data Managers Meeting August 11, 2016 Boyne Mountain - - PowerPoint PPT Presentation

Michigan STS Data Managers Meeting

August 11, 2016 Boyne Mountain Resort Up North, MI

 Present SM in a slightly different format to promote

“The Big Picture” scenario.

 Ex

Expose e Ne Newer DM r DM’s to to Instructio ional Clin linical Scen cenarios…30 30% o

• f o
• ur D

DM’s hav ave l les ess than an 1 1 year year of ex exper erien

• ence. Some h

e hav ave no no OR ex OR exposure.

 Help to achieve statewide consensus by promoting

discussion and exchange.

• Reading the Scenario is necessary as the

format has changed from previous survey’s.

 Thank You to those

that responded!!

• Please provide feedback regarding

this format in your evaluations!

• Rather than multiple scenarios, all questions

are based on a single scenario to mimic chart abstraction.

A 66 yo homeless male presents to the ER @ 8:00 pm. with unrelenting chest pain unlike any he has ever experienced before. He is hypotensive (BP in 70's), diaphoretic, ashen, agitated, and is demonstrating non- specific EKG changes. Unable to obtain an accurate H&P, and suspecting ACS, the patient is given ASA and Plavix, the STEMI team is notified, and he is taken directly to the Cath Lab. Imaging reveals normal coronary arteries, but identifies a 6 cm. ascending aorta, severe AI, "Severe" LV dysfunction, and pericardial tamponade. Further hemodynamic instability ensues, requiring intubation, and pericardiocentesis. Inotropes are started with no improvement in hemodynamics. The patient is immediately taken to the OR @ 9:15 pm. with a diagnosis of Aortic Dissection. Once on CPB, the surgeon discovers that the dissection originates in the ascending aorta, and extends past the aortic arch. The operation involves replacing the aortic valve with a 21mm bioprosthetic device sewn into a synthetic graft, attached distally at the Hemi-Arch, and re-implantation of the coronary ostia.

Patien ent S Scena enario

Part 1

Questi tion 1 n 1 Selec ections ns:

Prior MI = Yes (<=6 hrs.); Risk Factor's = Thoracic Dz; Pre-Op Meds = ASA + ADP Inhibitor + Inotropes; Cardiac Presentation at Surgery = STEMI. Prior MI = No; Risk Factor's = Thoracic Aorta Dz; Pre- Op Meds = ADP Inhibitor + Inotropes; Cardiac Presentation at Surgery = Other. Prior MI = Yes (<=6 hrs.); Risk Factor's = Unknown; Pre-Op Meds = ADP Inhibitor + Inotropes; Cardiac Presentation at Surgery = NSTEMI.

Poi

• ints to

s to Con

• nsider

er

Did the Patient have an MI?

 What are his Risk Factor’s?

What Pre-Op Meds were administered? What is the Presentation at Surgery?

Poi

• ints to

s to Con

• nsider

er

Did the Patient have an MI?

 What are his Risk Factor’s?

What Pre-Op Meds were administered? What is the Presentation at Surgery?

• No Cardiac Biomarker documentation
• “Non-Specific” EKG only
• No prior history available

Point nts t to Cons nsider er

 Did the Patient have an MI?  What are his Risk Factor’s?  What Pre-Op Meds were administered?  What is the Presentation at Surgery?

• Thoracic Dz. is only documented Risk Factor
• Documented: ASA, ADP Inhibitor, Inotropes
• NSTEMI, STEMI, Other

A patient presents for valve surgery with CHF, and no pain. Code other since the field is intended to capture cardiac presentation.

Tra raining M Manual E Exa xamples f for r “Other” r”

Patient does not need to be in active CHF to use “Other” as the cardiac presentation answer!

Survey s y says ays….. ..

Prio rior M MI = = Yes RF RF’s = = Th Thorac acic c Dz Dz Meds = = ASA+ADP+Inotr

• trop
• pes

Card rd Pre resent = = STEM EMI Prio rior M MI = = No RF RF’s = = Th Thorac acic c Dz Dz Meds = = ADP+Inotr

• trop
• pes

Card Pres esen ent = Other er Prio rior M MI =Y =Yes RF’s = = U Unknow

• wn

Meds = = ADP+Inotr

• trop
• pes

Car ard Present = NSTE NSTEMI

Questi tion

• n 2 Selec

ections ns:

Previous Cardiac Intervention = Yes, Other Cardiac, Other; Heart Failure w/in 2 wks. = No; Cardiogenic Shock = Yes; Aortic Disease = Yes, Symptomatic, Hemodynamics Unstable. Previous Cardiac Intervention = Yes, Other Cardiac, Other; Heart Failure w/in 2 wks. = Yes, NYHA IV; Cardiogenic Shock = Yes; Aortic Disease = Yes, Location = Ascending. Previous Cardiac Intervention = No; Heart Failure w/in 2

• wks. = No, Cardiogenic Shock = Yes; Aortic Disease = Yes,

Lesion Type = Dissection.

Point nts t to Cons nsider er

Were there Previous Cardiac Interventions? Was there Heart Failure w/in 2 weeks? Was the Patient in Cardiogenic Shock? Aortic Disease: Presentation, Location, and Lesion Type?

• No documented Previous Interventions other than

Pericardiocentesis in Cath Lab.

Previous us C Cardiac I c Inter erven entions ns

• Pericardiocentesis is not a listed option for (#805) except for

Other Cardiac (not listed).

Cardi diac T Tampon ponade de

Point nts t to Cons nsider er

Were there Previous Cardiac Interventions? Was there Heart Failure w/in 2 weeks? Was the Patient in Cardiogenic Shock? Aortic Disease: Presentation, Location, and Lesion Type?

• Pericardiocentesis = Gray Area
• No consensus at the National level
• What is the Michigan consensus?

?

Heart F Failur ure e w/in 2 n 2 week eks

Point nts t to Cons nsider er

Were there Previous Cardiac Interventions? Was there Heart Failure w/in 2 weeks? Was the Patient in Cardiogenic Shock? Aortic Disease: Presentation, Location, and Lesion Type?

?

• Based on scenario,the patient does not fit the clinical

picture of HF

• No physician documented HF

Cardi diog

• genic S

Shoc

• ck
• Sustained hypotension (BP 70’s)
• Inotropic support required.

Point nts t to Cons nsider er

Were there Previous Cardiac Interventions? Was there Heart Failure w/in 2 weeks? Was the Patient in Cardiogenic Shock? Aortic Disease: Presentation, Location, and Lesion Type?

?

• Meets the clinical definition of Cardiogenic

Shock

Ao Aort rtic D Dise isease

• Presenta

ntati tion

• n (most severe): Pain, hypotension, inotropes =

Symptomatic, Hemodynamically Unstable.

• Loc
• cati

tion

• n (Choose all that apply): Where is the lesion present?

Ascending Aorta, Aortic Arch.

• Lesion T

Type pe: : Dissection Tim imin ing: Acute Dis Dissectio ion T Type pe: : Stanford “Type A” ak aka: a: DeBakey “Type I”

Point nts t to Cons nsider er

Were there Previous Cardiac Interventions? Was there Heart Failure w/in 2 weeks? Was the Patient in Cardiogenic Shock? Aortic Disease: Presentation, Location, and Lesion Type?

?

Prev ev Card In Inter =Yes es, Other er Card Other er HF HF = = No Cardi dio

• Shock

k =Yes Aortic ic Dz Dz = Yes, Sympt ptom

• matic

Prev ev Card In Inter =Yes es, Other er Card Other er HF HF = = Yes ess Cardi dio

• Shock

k =No Aortic ic Dz Dz = Yes es, Ascen cending Prev ev Card rd Inter r =No HF HF = = No Cardi dio

• Shock

k =Yes Aortic ic Dz Dz = Yes, Dissection

Questi tion

• n 3 Selec

ections ns:

Aortic Valve Etiology = Primary Aortic Disease, Aortic Dissection; Aortic Valve Procedure Performed = Root Replacement w/ Valved Conduit; Aortic Procedure Location = Root, Ascending, and Hemi-Arch. Aortic Valve Etiology = Primary Aortic Disease, Aortic Dissection; Aortic Valve Procedure Performed = AVR and major root reconstruction with a valved conduit; Aortic Procedure Location = Root and Ascending. Aortic Valve Etiology = Primary Aortic Disease, Atherosclerotic Aneurysm; Aortic Valve Procedure Performed = AVR and insertion of non-valved conduit in a supra-coronary position; Aortic Procedure Location = Ascending and Hemi-Arch.

Point nts t to Cons nsider er

Aortic Valve Etiology Aortic Valve Procedure Aortic Procedure Location

Ao Aort rtic V Valve lve E Etio iology

• Aortic Insufficiency @ Cath found to be “Severe”
• Documented Aortic Dissection

Point nts t to Cons nsider er

Aortic Valve Etiology Aortic Valve Procedure Aortic Procedure Location

• Prim

rimary ry A Aort rtic ic Dis Disease, , Aort rtic ic Dis Dissectio ion

Aortic V c Valve P Proced cedur ures es

• AVR
• Valved conduit

(commercial or custom)

• Re-implant coronaries
• AVR
• Non-valved graft

in supra-coronary position

• AVR
• Root Reconstruction
• Valved conduit

Coro ronarie ies I Intact “Bentall”

Point nts t to Cons nsider er

Aortic Valve Etiology Aortic Valve Procedure Aortic Procedure Location

• Prim

Primary ry Aort rtic D Dis isease, A Aort rtic D Dis issection

• The operation includes AVR, Root + Ascending Aorta

Replacement, Re-implantation of Coronary Ostia =

Ben Bentall

• What portions of the Aorta were involved in this procedure?
• Where did the Surgeon perform the distal anastomosis?

Aortic P c Proce cedur ure e Loca cation

Point nts t to Cons nsider er

Aortic Valve Etiology Aortic Valve Procedure Aortic Procedure Location

• Prim

Primary ry Aort rtic D Dis isease, A Aort rtic D Dis issection

• Wha

hat w was d done

• ne? The operation includes AVR, Root +

Ascending Aorta Replacement, Re-implantation of Coronary Ostia.

= Ben Bentall

• What portions of the Aorta were involved in this procedure?
• Where did the Surgeon perform the distal anastomosis?

Roo

• ot,

t, A Asce cending A Aorta ta, H Hemi-Arc rch

Etiol

• log
• gy =

= Dissecti tion

• n

Proced edure e = Benta tall Locatio ion = = Ascendin ing + + Hemi A i Arch Etiol

• log
• gy =

= Dissecti tion

• n

Procedure = AVR+ R+ Ro Root Re Reco construct ct Location = n = Root + +Ascend nding ng Etiol

• log
• gy =

= Rupture Procedur ure = AVR+ S Supra c corona nary Cond ndui uit Locatio ion = = Ascendin ing + + Hemi A i Arch

After a prolonged surgery, the patient is transferred to ICU with considerable volume overload and marginal urine output. The surgeon

• rders UF for hemoconcentration. On the morning of POD #1, the patient

is found to be unresponsive, anuric, and has lost pulses in his lower

• extremities. MRI and CT Scans reveal a CVA, "ischemic" in origin, and a

new diagnosis of an abdominal aortic dissection. Urgent TEVAR is undertaken in the Vascular OR to repair the abdominal aorta with limited

• results. On POD #2, the patient remains unresponsive and anuric with

faint pulses in only one limb. UF has been replaced with CRRT due to rising creatinine. Repeat MRI reveals a worsened neurologic condition. On POD #3, the patient's condition is further complicated with worsening lactic acidosis and evidence of ischemic bowel. Given the poor prognosis, the family elects for palliative care measures only. The patient is extubated, and expires on POD #4.

Patien ent S Scena enario

Part t 2

Questi tion

• n 4 Selec

ections ns:

Re-Op = Yes, Other Cardiac; CVA = Yes, Embolic; Renal failure = Yes, New Dialysis. Re-Op = Yes, Other Non-Cardiac; CVA = Yes, Undetermined Type; Renal failure = Yes, New Dialysis. Re-Op = Yes, Other Non-Cardiac; CVA = Yes, Hemorrhagic; Renal failure = Yes, New Dialysis. Re-Op = Yes, Other Cardiac; CVA = Yes, Undetermined Type; Renal failure = Yes, New Dialysis.

Point nts t to Cons nsider er

 What at R Re-Opera ratio ion w was perform rmed p post-opera rativ ively ly?  What t typ ype o

• f st

stroke d did the p pat atient su suffer?  Did t the p patie ient d develo lop R Renal F l Failu ilure re?

• New diagnosis of abdominal dissection requires intervention.
• TEVAR is undertaken in Vascular Lab.
• Cardiac or Non-Cardiac (Vascular) ?

TEVA TEVAR

Point nts t to Cons nsider er

 What at R Re-Opera ratio ion w was perform rmed p post-opera rativ ively ly?  What t typ ype o

• f st

stroke d did the p pat atient su suffer?  Did t the p patie ient d develo lop R Renal F l Failu ilure re?

• New diagnosis of abdominal (oops) dissection requires

intervention.

• TEVAR is undertaken in Vascular Lab.
• Cardiac or Non-Cardiac (Vascular) ?
• Embolic, Hemorrhagic, or Undetermined?

Type pes of

• f C

CVA

Po Post st-Op CVA CVA

Point nts t to Cons nsider er

 What at R Re-Opera ratio ion w was perform rmed p post-opera rativ ively ly?  What t typ ype o

• f st

stroke d did the p pat atient su suffer?  Did t the p patie ient d develo lop R Renal F l Failu ilure re?

• New diagnosis of abdominal dissection requires intervention.
• TEVAR is undertaken in Vascular Lab.
• Cardiac or Non-Cardiac (Vascular) ?
• Embolic, Hemorrhagic, or Undetermined?

Renal F l Failu lure re

Point nts t to Cons nsider er

 What at R Re-Opera ratio ion w was perform rmed p post-opera rativ ively ly?  What t typ ype o

• f st

stroke d did the p pat atient su suffer?  Did t the p patie ient d develo lop R Renal F l Failu ilure re?

• New diagnosis of abdominal dissection requires intervention.
• TEVAR is undertaken in Vascular Lab.
• Cardiac or Non-Cardiac (Vascular) ?
• Embolic, Hemorrhagic, or Undetermined?
• New requirement for postoperative dialysis
• Anuria >= 12 hours

Re ReOp=Yes es, O Other er C Card CVA = = Yes, E , Embolic ic RF RF= Y Yes Re ReOp=Yes es, O Other er NonCard CVA = A = Ye Yes, Undert rterm rmined RF RF= Y Yes Re ReOp=Yes es, O Other er NonCard CVA = = Yes, H Hemorrh rrhagic RF RF= Y Yes Re ReOp=Yes es, O Other er C Card CVA = = Yes, U Undet eter ermined ed RF RF= Y Yes

Questi tion

• n 5 Selec

ections ns:

In-Hospital Post Operative Events include: Operative, Neurologic, Renal. In-Hospital Post Operative Events include: Pulmonary, Vascular, Other. All of the above.

Point nts t to Cons nsider er

• Intervention in Vascular Lab = Operative
• Post Operative Stroke (Undetermined) = Neurologic
• Ultra Filtration and new Dialysis = Renal
• Prolonged Ventilation = Pulmonary
• Acute Limb Ischemia = Vascular
• Aortic Dissection, GI Event, MSF(?) = Other

Questi tion

• n 5 Selec

ections ns:

In-Hospital Post Operative Events include: Operative, Neurologic, Renal. In-Hospital Post Operative Events include: Pulmonary, Vascular, Other. All of the above.

Opera rativ ive Neuro rolo logic ic Re Renal al Pulmonary Vas ascu cular Other er All o

• f the A

Above

Questi tion

• n 6 Selec

ections ns:

The Mortality Cause of Death is: Cardiac The Mortality Cause of Death is: Neurologic The Mortality Cause of Death is: Vascular The Mortality Cause of Death is: Unknown The Mortality Cause of Death is: Deferred to Surgeon

Point nts t to Cons nsider er

• What was the Primary cause of death?
• What is the “most right” answer?

Questi tion

• n 6 Selec

ections ns:

The Mortality Cause of Death is: Cardiac The Mortality Cause of Death is: Neurologic The Mortality Cause of Death is: Vascular The Mortality Cause of Death is: Unknown The Mortality Cause of Death is: Deferred to Surgeon

• Use POCMA as resource, discuss case, or call Jae
• Discuss case, ask questions, then call Jae
• Per TM, the Primary cause of all PO events
• Per POCMA, the seminal event that triggered the spiral
• Vascular events occurred as a result of initial insult
• Occurred as a result of initial surgery.
• Did not cause the cascade of events that followed

Seriously, please call us!!

Neuro Vascular Cardiac Unknown Surgeon