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 of o our 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.
Thank You to those that responded!! Reading the Scenario is necessary as the format has changed from previous survey’s. Rather than multiple scenarios, all questions are based on a single scenario to mimic chart abstraction. Please provide feedback regarding this format in your evaluations!
Patien ent S Scena enario Part 1 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.
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 oints to s to Con onsider 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 oints to s to Con onsider er Did the Patient have an MI? No Cardiac Biomarker documentation “Non-Specific” EKG only No prior history available What are his Risk Factor’s? What Pre-Op Meds were administered? What is the Presentation at Surgery?
Point nts t to Cons nsider er Did the Patient have an MI? What are his Risk Factor’s? Thoracic Dz. is only documented Risk Factor What Pre-Op Meds were administered? Documented: ASA, ADP Inhibitor, Inotropes What is the Presentation at Surgery? NSTEMI, STEMI, Other
Tra raining M Manual E Exa xamples f for r “Other” r” A patient presents for valve surgery with CHF, and no pain. Code other since the field is intended to capture cardiac presentation. 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 = = No Prio rior M MI = = Yes Prio rior M MI =Y =Yes RF RF’s = = Th Thorac acic c Dz Dz RF RF’s = = Th Thorac acic c Dz Dz RF’s = = U Unknow own Meds = = ASA+ADP+Inotr otrop opes Meds = = ADP+Inotr otrop opes Meds = = ADP+Inotr otrop opes Card Pres esen ent = Other er Card rd Pre resent = = STEM EMI Car ard Present = NSTE NSTEMI
Questi tion on 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? No documented Previous Interventions other than Pericardiocentesis in Cath Lab. Was there Heart Failure w/in 2 weeks? Was the Patient in Cardiogenic Shock? Aortic Disease: Presentation, Location, and Lesion Type?
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? Based on scenario,the patient does not fit the clinical picture of HF No physician documented HF Was the Patient in Cardiogenic Shock? Aortic Disease: Presentation, Location, and Lesion Type?
Cardi diog ogenic S Shoc ock 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? Meets the clinical definition of Cardiogenic Shock Aortic Disease: Presentation, Location, and Lesion Type?
Ao Aort rtic D Dise isease Presenta ntati tion on (most severe): Pain, hypotension, inotropes = Symptomatic, Hemodynamically Unstable. Loc ocati tion on (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 Prev ev Card In Inter =Yes es, Other er Card Other er Prev ev Card rd Inter r =No HF = HF = No HF HF = = Yes ess HF HF = = No Cardi dio o Shock k =Yes Cardi dio o Shock k =No Cardi dio o Shock k =Yes Aortic ic Dz Dz = Yes, Sympt ptom omatic Aortic ic Dz Dz = Yes es, Ascen cending Aortic ic Dz Dz = Yes, Dissection
Questi tion on 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 Prim rimary ry A Aort rtic ic Dis Disease, , Aort rtic ic Dis Dissectio ion Aortic Valve Procedure Aortic Procedure Location
Aortic V c Valve P Proced cedur ures es Coro ronarie ies I Intact “Bentall” AVR • AVR AVR • • Valved conduit • Non-valved graft Root Reconstruction • • (commercial or custom) in supra-coronary Valved conduit • Re-implant coronaries • position
Point nts t to Cons nsider er Aortic Valve Etiology Prim Primary ry Aort rtic D Dis isease, A Aort rtic D Dis issection Aortic Valve Procedure The operation includes AVR, Root + Ascending Aorta Replacement, Re-implantation of Coronary Ostia = Ben Bentall Aortic Procedure Location 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
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