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Release Notes:
Data Element
Version 2010A1

Data Element Name: Perioperative Death
Collected For: SCIP-Card-2, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-4, SCIP-Inf-7,
Definition:The patient expired during the timeframe from surgical incision through discharge from the post anesthesia care/recovery area.
Note:
For this data element, the timeframe for Perioperative Death is from surgical incision through discharge from the post anesthesia care/recovery area.
Suggested Data Collection Question:Is there documentation that the patient expired during the timeframe from surgical incision through discharge from the post anesthesia care/recovery area?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y    (Yes)   There is documentation that the patient expired during the timeframe from surgical incision through discharge from the post anesthesia care/recovery area.

N   (No)   There is no documentation that the patient expired during the timeframe from surgical incision through discharge from the post anesthesia/recovery area or unable to determine from medical record documentation.

Notes for Abstraction:Examples:
  • The patient expired while undergoing vascular surgery (repair of aneurysm); select “Yes.”
  • The patient died while in the post anesthesia care/recovery area; select “Yes.”
  • A discharge order from the post anesthesia care/recovery area was written for a surgery patient at 11:05 a.m. and at 11:17 a.m. the patient developed a complication and ultimately expired. The order for discharge was written, but the patient did not leave the recovery area; select “No.”
  • The patient was not discharged from the post anesthesia care/recovery area, developed a complication and then expired; select “Yes.”
  • The patient was discharged from the post anesthesia care/recovery area and on the way to the floor, developed complications and expired; select “No.”
  • To determine when the end of the perioperative period occurred for patients discharged from surgery and admitted to the Post Anesthesia Care Unit (PACU): The end of the perioperative period occurs when the patient is discharged from the PACU.
  • To determine when the end of the perioperative period occurred for patients discharged from surgery and admitted to locations other than the PACU (e.g., ICU):
    • The recovery period would end a maximum of six hours after arrival to the recovery area unless the anesthesiologist signs off before the six hours has elapsed.
    • If the anesthesiologist signs off before the patient enters the non-PACU recovery area, allow up to six hours for the recovery period.
      Examples:
      -The anesthesiologist signed off at 08:45. The patient arrived in ICU for recovery at 09:00. The post anesthesia care/recovery area period would end a maximum of six hours later or 15:00. Select “Yes” if the patient expired before 15:00.
      -The patient arrived in the ICU for recovery at 23:00 on 01-04-2008. After allowing six hours for the recovery period, the recovery end time would be 05:00 on 01-05-2008. Select “Yes” if the patient expired before 05:00 on 01-05-2008.
Suggested Data Sources:
  • Anesthesia record
  • Consultation notes
  • Nursing notes
  • Progress notes
  • Operative report
  • PACU/recovery room record
  • Operating room record
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
  • None
  • None

Perioperative Death
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)