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SCOTTISH STROKE CARE AUDIT
DATA INFORMATION: How to collect and enter
data on the standard forms
Table of Contents
CASE ASCERTAINMENT ...................................................................................................................5
DATA QUALITY ...................................................................................................................................7
DATA ENTRY........................................................................................................................................7
STANDARD INPATIENT FORM.........................................................................................................8
1
PERSONAL...................................................................................................................................8
1.1 ADDRESS LABEL .........................................................................................................................8
1.2 CHI NO. – PATIENT IDENTIFICATION FIELD ...............................................................................8
1.2.1
In addition ........................................................................................................................9
1.3 PATIENT IDENTIFICATION FIELD .................................................................................................9
1.3.1
In addition ........................................................................................................................9
1.4 PATIENT’S SURNAME ..................................................................................................................9
1.4.1
In addition ........................................................................................................................9
1.5 PATIENT’S FORENAME ................................................................................................................9
1.5.1
In addition.......................................................................................................................10
1.6 HELP TEXT FOR PATIENT’S SEX ..................................................................................................10
1.7 PATIENT’S TITLE .......................................................................................................................10
1.8 DATE OF BIRTH .........................................................................................................................10
1.9 PATIENT’S ADDRESS .................................................................................................................10
1.10
PATIENT’S TELEPHONE NUMBER .........................................................................................10
1.11
PATIENT’S POSTCODE ..........................................................................................................10
1.11.1 Postcode Sector ..............................................................................................................10
1.11.2 Postcode Unit .................................................................................................................11
2
NEXT OF KIN/ GP.....................................................................................................................11
2.1 NAME OF NEXT OF KIN .............................................................................................................11
2.2 TELEPHONE NUMBER OF NEXT OF KIN ......................................................................................11
2.3 RELATIONSHIP OF NEXT OF KIN ................................................................................................11
2.4 GP INFORMATION .....................................................................................................................11
2.4.1
GP List............................................................................................................................11
2.4.2
How to order GP List .....................................................................................................12
2.4.3
GP Initials ......................................................................................................................12
2.4.4
GP Surname....................................................................................................................12
2.4.5
GP Post Code .................................................................................................................12
2.4.6
GP Telephone .................................................................................................................12
2.4.7
In addition ......................................................................................................................12
3
CARE ...........................................................................................................................................12
3.1 DATE OF ASSESSMENT ..............................................................................................................13
3.1.1
Caution ...........................................................................................................................13
3.1.2
In addition ......................................................................................................................13
3.2 TIME OF ASSESSMENT ...............................................................................................................14
3.2.1
In addition ......................................................................................................................14
3.3 RESPONSIBLE CONSULTANT (CLINICIAN) .................................................................................14
3.3.1
In addition ......................................................................................................................14
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3.4 SEEN AS ....................................................................................................................................14
3.5 UNIT .........................................................................................................................................14
3.5.1
In addition ......................................................................................................................14
3.6 DATE ADMITTED.......................................................................................................................14
3.6.1
In addition ......................................................................................................................15
3.7 TIME ADMITTED .......................................................................................................................15
3.7.1
In addition ......................................................................................................................15
3.8 ADMITTED FROM ......................................................................................................................15
3.8.1
In addition ......................................................................................................................15
3.9 DATE DISCHARGED ...................................................................................................................17
3.9.1
In addition ......................................................................................................................17
3.10
DISCHARGED TO ...................................................................................................................17
3.10.1 In addition ......................................................................................................................17
4
FINAL DIAGNOSIS AND STATUS.........................................................................................17
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
5
CEREBRAL: STROKE..................................................................................................................17
CEREBRAL: TRANSIENT ISCHAEMIC ATTACK ...........................................................................17
CEREBRAL: SUB-ARACHNOID HAEMORRHAGE .........................................................................17
EYE: RETINAL ARTERY OCCULSION .........................................................................................18
EYE: TRANSIENT MONOCULAR BLINDNESS ..............................................................................18
OTHER: POSSIBLE CEREBROVASCULAR ....................................................................................18
OTHER: POSSIBLE CEREBROVASCULAR DETAILS......................................................................18
OTHER: DEFINITE NON-CEREBROVASCULAR............................................................................18
OTHER: DEFINITE NON-CEREBROVASCULAR DETAILS .............................................................18
END DATA COLLECTION .......................................................................................................18
DATE END DATA COLLECTION..............................................................................................19
INITIAL ASSESSMENT ............................................................................................................19
5.1 DATE OF FIRST SYMPTOMS .......................................................................................................19
5.1.1
In addition ......................................................................................................................19
5.2 CAN THE PATIENT LIFT BOTH ARMS OFF THE BED? ....................................................................19
5.2.1
In addition ......................................................................................................................19
5.3 WAS THE PATIENT INDEPENDENT IN ADL BEFORE EVENT?.......................................................20
5.4 ABLE TO WALK WITHOUT HELP FROM OTHER PERSON? .............................................................20
5.4.1
In addition ......................................................................................................................20
5.5 WAS PATIENT LIVING ALONE AT THE TIME OF EVENT? ..............................................................20
5.5.1
In addition ......................................................................................................................20
5.6 CURRENT AF CONFIRMED ON ECG?.........................................................................................20
5.6.1
In addition ......................................................................................................................20
5.7 CAN THE PATIENT TALK? ..........................................................................................................20
5.7.1
In addition ......................................................................................................................21
5.8 ON ASPIRIN AT ONSET?.............................................................................................................21
5.9 ARE THEY ORIENTED IN TIME, PLACE AND PERSON?..................................................................21
5.10
ON WARFARIN AT ONSET? ...................................................................................................21
5.11
SWALLOW SCREENING RECORDED?......................................................................................21
5.12
DATE SWALLOWING ASSESSED .............................................................................................21
5.12.1 In addition ......................................................................................................................21
6
INPATIENT MANAGEMENT ...................................................................................................22
6.1 WAS THE PATIENT MANAGED IN AN ACUTE STROKE UNIT (SU)? ..............................................22
6.1.1
In addition ......................................................................................................................22
6.2 ACUTE STROKE UNIT ENTRY DATE? ........................................................................................22
6.3 ACUTE STROKE UNIT EXIT DATE?............................................................................................22
6.4 ACUTE STROKE UNIT CONSULTANT .........................................................................................22
6.5 WAS THE PATIENT MANAGED IN A REHAB STROKE UNIT?.........................................................22
6.6 REHAB STROKE UNIT ENTRY DATE? ........................................................................................22
6.7 REHAB STROKE UNIT EXIT DATE?............................................................................................23
6.8 REHAB STROKE UNIT CONSULTANT .........................................................................................23
6.9 WAS THE PATIENT MANAGED IN A REHAB UNIT?......................................................................23
6.10
REHAB UNIT ENTRY DATE? .................................................................................................23
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6.11
REHAB UNIT EXIT DATE? ....................................................................................................23
6.12
REHAB UNIT CONSULTANT ..................................................................................................23
6.13
WHETHER ASPIRIN GIVEN IN HOSPITAL? ..............................................................................23
6.14
DATE ASPIRIN STARTED? .....................................................................................................23
6.14.1 In addition ......................................................................................................................24
6.15
FINAL DISCHARGE FROM HOSPITAL ON ASPIRIN?.................................................................24
6.16
FINAL DISCHARGE FROM HOSPITAL ON CLOPIDOGREL (PLAVIX)? .......................................24
6.17
FINAL DISCHARGE FROM HOSPITAL ON DIPYRIDAMOLE (PERSANTIN)? ...............................24
6.18
FINAL DISCHARGE FROM HOSPITAL ON WARFARIN?............................................................24
6.19
FINAL DISCHARGE FROM HOSPITAL ON AN ACE INHIBITOR? ...............................................24
6.20
FINAL DISCHARGE FROM HOSPITAL ON A DIURETIC? ...........................................................24
6.21
FINAL DISCHARGE FROM HOSPITAL ON ANOTHER ANTIHYPERTENSIVE?..............................24
6.22
FINAL DISCHARGE FROM HOSPITAL ON A STATIN?...............................................................24
6.23
BARTHEL – SCORES TAKEN AT TIMES OF YOUR CHOOSING .................................................24
6.23.1 In addition ......................................................................................................................25
6.24
BARTHEL DATES ..................................................................................................................25
6.25
BARTHEL SCORING SYSTEM .................................................................................................25
6.25.1 In addition ......................................................................................................................25
6.26
FIM – SCORES TAKEN AT TIMES OF YOUR CHOOSING .........................................................26
6.26.1 In addition ......................................................................................................................26
6.27
FIM DATES ..........................................................................................................................26
6.28
MODIFIED RANKIN SCORE ...................................................................................................26
6.28.1 In addition ......................................................................................................................26
6.29
MODIFIED RANKIN SCORE DATE..........................................................................................26
7
FINAL CLASSIFICATION ........................................................................................................27
7.1 CT DONE?.................................................................................................................................27
7.2 CT DATE ...................................................................................................................................27
7.3 MRI DONE? ..............................................................................................................................27
7.4 MRI DATE.................................................................................................................................27
7.5 EVIDENCE OF NEW HAEMORRHAGE ON SCAN? ..........................................................................27
7.6 POST-MORTEM PERFORMED ......................................................................................................27
7.7 EVIDENCE OF NEW HAEMORRHAGE ON PM? .............................................................................27
7.8 FINAL SYNDROME CLASSIFICATION ..........................................................................................27
7.9 ICD 10 FINAL DIAGNOSIS ........................................................................................................27
7.9.1
In addition ......................................................................................................................27
8
ADDITIONAL COMMONLY USED FIELDS........................................................................28
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
FAMILY HISTORY OF PREMATURE VASCULAR DISEASE? ............................................................28
PREVIOUS STROKE ....................................................................................................................28
PREVIOUS TIA ..........................................................................................................................28
DIABETES ..................................................................................................................................28
WEEKLY ALCOHOL INTAKE ......................................................................................................28
DIASTOLIC BLOOD PRESSURE AT ADMISSION/DISCHARGE ........................................................28
SYSTOLIC BLOOD PRESSURE AT ADMISSION/DISCHARGE ..........................................................28
WAS THE PATIENT MANAGED IN AN INTEGRATED STROKE UNIT?.............................................29
STANDARD OUTPATIENT FORM ..................................................................................................29
1
PERSONAL.................................................................................................................................29
2
NEXT OF KIN/ GP.....................................................................................................................29
3
CARE ...........................................................................................................................................29
4
FINAL DIAGNOSIS AND STATUS.........................................................................................29
5
OUTPATIENT SERVICE DATA ..............................................................................................29
5.1
5.2
DATE OF REFERRAL...................................................................................................................30
FROM GP? ................................................................................................................................30
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5.3
5.4
6
DATE REFERRAL RECEIVED .......................................................................................................30
DATE OF FIRST APPOINTMENT OFFERED ....................................................................................30
OUTPATIENT CLINICAL ASSESSMENT.............................................................................30
6.1 DATE OF MOST RECENT TIA/STROKE (OR BEST ESTIMATE) ........................................................30
6.2 SIDE OF BRAIN/EYE LESION .......................................................................................................30
6.3 BLOOD PRESSURE......................................................................................................................30
6.3.1
Systolic Blood Pressure ..................................................................................................30
6.3.2
Diastolic Blood Pressure................................................................................................31
6.4 KNOWN HISTORY OF ATRIAL FIBRILLATION?.............................................................................31
7
DATA TO AUDIT USE OF SECONDARY PREVENTIVE DRUGS ...................................31
7.1 AT TIME OF EVENT ....................................................................................................................31
7.1.1
Aspirin ............................................................................................................................31
7.1.2
Dipyridamole (Perstatin/Asasantin) ...............................................................................31
7.1.3
Clopidogrel.....................................................................................................................31
7.1.4
Warfarin .........................................................................................................................31
7.1.5
ACE Inhibitor .................................................................................................................31
7.1.6
Diuretic...........................................................................................................................31
7.1.7
Other antihypertensive....................................................................................................31
7.1.8
Statin / lipid lowering agent ...........................................................................................31
7.1.9
None................................................................................................................................32
7.2 AT TIME OF FIRST ASSESSMENT .................................................................................................32
7.2.1
Aspirin ............................................................................................................................32
7.2.2
Dipyridamole (Perstatin/Asasantin) ...............................................................................32
7.2.3
Clopidogrel.....................................................................................................................32
7.2.4
Warfarin .........................................................................................................................32
7.2.5
ACE Inhibitor .................................................................................................................32
7.2.6
Diuretic...........................................................................................................................32
7.2.7
Other antihypertensive....................................................................................................32
7.2.8
Statin / lipid lowering agent ...........................................................................................32
7.2.9
None................................................................................................................................32
7.3 RECOMMENDED FOLLOWING NV ASSESSMENT .........................................................................32
7.3.1
Aspirin ............................................................................................................................32
7.3.2
Dipyridamole (Perstatin/Asasantin) ...............................................................................33
7.3.3
Clopidogrel.....................................................................................................................33
7.3.4
Warfarin .........................................................................................................................33
7.3.5
ACE Inhibitor .................................................................................................................33
7.3.6
Diuretic...........................................................................................................................33
7.3.7
Other antihypertensive....................................................................................................33
7.3.8
Statin / lipid lowering agent ...........................................................................................33
7.3.9
None................................................................................................................................33
7.4 PATIENT KNOWN NOT TO TOLERATE .........................................................................................33
7.4.1
Aspirin ............................................................................................................................33
7.4.2
Dipyridamole (Perstatin/Asasantin) ...............................................................................34
7.4.3
Clopidogrel.....................................................................................................................34
7.4.4
Warfarin .........................................................................................................................34
7.4.5
ACE Inhibitor .................................................................................................................34
7.4.6
Diuretic...........................................................................................................................34
7.4.7
Other antihypertensive....................................................................................................34
7.4.8
Statin / lipid lowering agent ...........................................................................................34
8
BRAIN IMAGING AND FINAL CLASSIFICATION ..............................................................34
8.1
8.2
8.3
8.4
8.5
9
CT DATE ...................................................................................................................................34
MRI DONE? ..............................................................................................................................34
MRI DATE.................................................................................................................................34
EVIDENCE OF NEW HAEMORRHAGE ON SCAN? ..........................................................................34
ICD 10 FINAL DIAGNOSIS ........................................................................................................35
CARDIAC INVESTIGATIONS .................................................................................................35
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9.1
9.2
9.3
9.4
9.5
9.6
10
DATA TO AUDIT CAROTID INTERVENTION SERVICE ...................................................36
10.1
10.2
10.3
10.4
10.5
10.6
10.7
10.8
10.9
10.10
10.11
10.12
10.13
10.14
10.15
10.16
10.17
10.18
10.19
10.20
10.21
10.22
10.23
10.24
11
ECG SINCE EVENT AVAILABLE?................................................................................................35
AF ON ECG? ............................................................................................................................35
LVH ON ECG? .........................................................................................................................35
ECHOCARDIOGRAM PERFORMED? .............................................................................................35
DATE OF FIRST ECHOCARDIOGRAM ...........................................................................................35
LVH ON ECHO?.........................................................................................................................35
CAROTID DUPLEX EXAMINATION PERFORMED? ...................................................................36
DATE OF FIRST DUPLEX?......................................................................................................36
SECOND CAROTID DUPLEX PERFORMED?.............................................................................36
DATE OF SECOND DUPLEX?..................................................................................................36
MR ANGIOGRAPHY PERFORMED? ........................................................................................36
DATE OF MR ANGIOGRAPHY? .............................................................................................36
CT ANGIOGRAPHY PERFORMED? .........................................................................................36
DATE OF CT ANGIOGRAPHY? ..............................................................................................36
CONVENTIONAL ANGIOGRAPHY PERFORMED? ....................................................................36
DATE OF ANGIOGRAPHY? ....................................................................................................36
REFERRED TO VASCULAR SURGEONS/INTERVENTIONAL RADIOLOGIST?...............................36
DATE REFERRED? .................................................................................................................37
IF NOT REFERRED, WHY? ......................................................................................................37
IF REFERRED – INTERVENTION CONSIDERED?.......................................................................37
SEEN BY SURGEON / RADIOLOGIST? .....................................................................................37
DATE SEEN...........................................................................................................................37
INTERVENTION PERFORMED? ...............................................................................................37
DATE OF PROCEDURE ...........................................................................................................37
IF YES, SIDE .........................................................................................................................37
STROKE WITHIN 30 DAYS OF INTERVENTION? ......................................................................38
OTHER COMPLICATION(S) OF INTERVENTION? .....................................................................38
OTHER COMPLICATION(S) OF INTERVENTION, PLEASE SPECIFY? ..........................................38
REVIEWED IN NV CLINIC?....................................................................................................38
DATE REVIEWED ..................................................................................................................38
CAROTID IMAGING RESULTS ..............................................................................................38
11.1
11.2
ICA % STENOSIS ON FIRST DUPLEX LEFT? ..........................................................................38
ICA % STENOSIS ON FIRST DUPLEX RIGHT? ........................................................................39
Several notes before we get started:
As you read through the help notes there will be reference to the SMR Data
Manual which refers to version 1.3; issued November 2000. Copies of the
SMR Data Manual can be downloaded from the ISD website at
www.isdscotland.org .
As you fill out the forms and enter the data create a decision list and keep it
by your computer for future reference. A decision list is a list of problems you
find as you fill out the forms and the decisions you made on how to handle
them. The creation of the decision list should mean that over time you handle
problematic data consistently.
In addition instructions on how to use the SSCAS software can be found in
the Software User Notes. This document is meant to help you understand
what should be entered for each field.
Case Ascertainment
Before you get started filling out the forms it is important to think about how
you are going to try and ‘capture’ every stroke patient admitted into the
hospital. The value of the audit will be greater, and the results more easily
04 February 2004
5
interpreted if all, or at least the vast majority, of patients admitted (or
assessed) at the participating hospitals are included in the register. Thus an
effective system to identify eligible cases needs to be developed. The best
method, or more likely combination of methods, will vary depending on local
circumstances.
Before you start the audit a decision will need to be made about whether it will
include just those patients which are admitted to the hospital (i.e. stay
overnight) or in addition those attending outpatient clinics and/or the Accident
and Emergency department. Different systems of ascertainment will be
required for each.
Here are some suggestions of methods you might use to find as many
patients as possible:
1. Regular scrutiny of Casualty books or registers. Many departments keep a
register of all attendees which includes a provisional diagnosis.
Unfortunately these diagnoses are often vague or incorrect so that
considerable commitment is required to chase up the cases which were
admitted with, for example "collapse" to establish whether the patient had
a stroke or TIA.
2. Admissions to a Medical Assessment ward. Increasingly, hospitals are
organising themselves so that all emergency medical admissions pass
through an admission ward. Here the patients will undergo an initial
assessment with investigations. The admission book of such a ward or a
daily phone call to the nurse in charge will often identify cases of stroke. In
many hospitals this system would detect almost all admitted cases.
3. Scrutiny of Ward books - many wards keep a register of admission and
discharges. In our experience they may not be complete and the
diagnoses, which are entered on admission may be inaccurate. However,
they may be useful to ensure completeness of ascertainment.
4. CT scan records - some radiology departments keep records of X Ray
requests and reports issued. In many these may be electronic and allow
patients to be identified in whom a CT brain was requested because of a
provisional diagnosis of stroke or TIA, or where a stroke lesion was
identified on the scan. In the latter case the patient may not have been
admitted with a recent stroke so that the scan data may be misleading. No
hospital that we know of manages to obtain CT brain scans in ALL stroke
patients (some die too quickly or are too ill) so that this method has to be
used in conjunction with others. Over reliance on this method could distort
a hospital'
s performance with respect to CT scan rate. (see standards).
5. Notification of cases - in hospitals with a stroke service or team it is
reasonable to have a single point of referral. This can provide a very
efficient method of ascertainment since one is notified of cases rather than
having to seek them out. Thus one could stipulate that any patient with a
stroke or TIA who is not admitted directly to any stroke service or unit
should be referred as soon as possible. If the service then provides useful
input into the patient’s care then this will encourage referral of all cases.
Referral could be by:
04 February 2004
6
a) A standard referral form made available on all wards to be
completed and posted or FAXed to a secretary
b) Telephone call to a specified extension (with an answerphone
facility) or bleep
c) By email
6. A "bucket" system. It can be useful to have containers into which people
can simply put a piece of paper with the details of eligible patients. This
might be on one’s desk, a secretary’s desk or on a ward. When one has
seen a ward referral or has taken a phone call about a suitable patient one
simply puts that information onto a card and into a bucket which is
regularly sorted through.
7. Discharge summaries - since each admission should generate a discharge
summary this represents a reasonably "fool proof" method of
ascertainment although since it is "retrospective" data collection may not
be complete. Thus the person responsible for maintaining the system
would encourage their colleagues producing discharge summaries for
different clinical teams to copy those with a stroke/TIA diagnosis to them.
One could also capture discharge summaries if these are routinely sent of
a coding department.
8. Routinely collected data. Each completed consultant episode should
generate a SMR01 form which will be entered into the hospitals'Patient
Administration System and then forwarded electronically to the Information
and Statistics Division. The SMR01 contains patient identifiers,
demographics and diagnostic codes. Unfortunately several weeks may
elapse before episodes are coded and the data entered and sent to ISD.
Thus this system may be useful to check completeness of ascertainment
but is probably not the ideal method. Also diagnostic coding is often
inaccurate unless clinicians are closely involved in the process. This might
mean that cases would have to be checked by cross-reference to medical
records.
9. Teamwork is essential if case ascertainment is to be both efficient and
complete. Senior medical staff, stroke co-ordinators, nursing and therapy
staff and those working in coding and radiology should all be involved. In
general the more people who know and support the audit at the hospital
the easier it will be to find the patients.
Data Quality
Having high quality data is the key to a good audit.
Data Entry
In developing SSCAS we have tried to minimise the amount of data needed
and also focused on those data which are easily and reliably collected. Data
could be collected using one or more of the following methods:
1. Extraction from unstructured case records. Much of the data will be found
in the medical or nursing record. However extracting the data is likely to be
time consuming and some data will not be easily available. Also some
04 February 2004
7
pieces of information may have to be deduced if not specifically recorded.
This may influence the validity of data collection.
2. Clerking proformas and integrated care pathways. Questions referring to
specific aspects of the minimum data set can be included within routine
documentation. This will make data easier to extract and probably more
valid. Proformas have been shown to improve recording of information so
that the introduction of SSCAS might be used to stimulate the move
towards this system of documentation.
3. A SSCAS data collection form might be completed during admission or at
the time of dictating a discharge summary. *
4. Structured Discharge summary - the discharge summary could be
structured so that essential data items for the SSCAS are included and
easily extracted. *
*Although using information from the Discharge summary as a method of data
collection precludes SSCAS being used to produce a discharge summary.
Standard Inpatient Form
Although not everyone will be using this version of the form, a discussion of
each of the sections should help you collect the basic patient dataset. Each
field has the help text given and additional information below.
1 Personal
Although the form is not explicitly divided into these sections, this is how they
are entered.
1.1 Address label
This section is designed for the data collector to place the hospital generated
patient label on the inpatient form. Pages of these labels should be in the
patient notes. Each hospital should have the same information on the label, if
yours does not, be sure to write the missing parts on the form to facilitate data
entry.
1.2 Chi No. – Patient Identification Field
Accurate patient identification is crucial to achieving accurate figures. This is
because patients may return to the same hospital, may move to a different
hospital catchment, or may be referred from one hospital to another. We may
wish to link across units and avoid counting any patient more than once. Many
different identification systems are in use. We have experienced many
problems in the past with systems which use supposedly unique identifiers but
where an individual patient has more than one number. Matching patients
across different systems is often difficult.
The NHS in Scotland has recognised these problems. Community Health
Index ('
CHI'
) numbers are being introduced, giving a patient a unique, national
reference number '
from the cradle to the grave'
. This blessing could not have
arrived at a better time for our system. We recommend using CHI numbers as
patient reference numbers. Where CHI numbers are not immediately available
users may use another number, or the system can be asked to generate a
04 February 2004
8
unique number, for temporary use. When a CHI number becomes available,
that can be used to replace the temporary number.
Similar steps are being taken in other parts of the UK. In England, '
new NHS'
numbers are being introduced to fulfil the same function as CHI numbers.
These will be acceptable to the system which is designed to cope with
patients from any origin required.
1.2.1 In addition
Whatever number you decide to use for the patient identification number
please be consistent. If you are unable to obtain the Patient’s CHI number
from the patient’s notes on a regular basis please choose another more easily
obtainable number.
1.3 Patient Identification Field
Current hospital (provider unit) case reference for patient. This is not required
by the system. It is offered for convenience only to help identifying the
patient within the hospital (provider unit). It will be needed to extract data from
a hospital system (usually Patient Administration System, or PAS).
Where Chi number is used for case reference and patient identifier, and PAS
linkage is not required, this is certainly redundant.
1.3.1 In addition
If you have an individual tracking system for SSCAS this is a good place to
record this information. Or you can use other important hospital identification
information, for example the X-ray department patient identifier.
1.4 Patient’s Surname
Patient'
s surname or family name is mandatory for the system.
From the SMR Data Manual: "The surname of a person represents that part of
the name of a person which indicates the family group of which the person is
part."
When recording names be aware of different conventions for order for parts of
the name used in different cultures. This is particularly confusing as people
from cultures which normally give the family name first, such as Chinese
cultures, are perfectly aware of the difference and may give their name in
reverse order to conform to our standard, but may not.
1.4.1 In addition
As has been explained in the software instructions in some cultures people
are given only one name. If you come across this situation decide on a
system for recording these patients add it to your decision list and stick to it.
1.5 Patient’s Forename
Patient'
s forename or given name is mandatory for the system. From the
SMR Data Manual: "The first forename of a person represents that part of the
04 February 2004
9
name of a person which, after the surname, is the principal identifier of a
person."
When recording names be aware of different conventions for order for parts of
the name used in different cultures. This is particularly confusing as people
from cultures which normally give the family name first, such as Chinese
cultures, are perfectly aware of the difference and may give their name in
reverse order to conform to our standard, but may not.
1.5.1 In addition
As has been explained in the software instructions in some cultures people
are given only one name. If you come across this situation decide on a
system for recording these patients add it to your decision list and stick to it.
1.6 Help Text for Patient’s Sex
Patient'
s sex or gender is mandatory for the system. Sex is entered as M or F.
There is no coding, and there is no way of saying '
don’t know.'
1.7 Patient’s Title
This is the patient'
s title of address e.g. Mr. Standard abbreviations should
always be used: Mr, Mrs, Miss, Ms, Prof, Dr, etc.
1.8 Date of Birth
Date of birth is mandatory for the system.
1.9 Patient’s Address
Patient address should only be stored where it is specifically required. To aid
entry, case (capitalisation) is checked automatically.
SMR Data Manual: "A patient'
s usual address is the address at which (s)he
currently lives and which the patient states is his/her current address."
1.10 Patient’s Telephone Number
Telephone number should only be stored where it is specifically required. To
aid entry, a default STD code can be set in Site Settings. Any number not
starting with a 0 will then have the default STD code attached at the
beginning. Where this is not possible (non-UK or no clear default STD), not
specifying a default STD will result in no changes being made to numbers
entered.
1.11 Patient’s Postcode
Postcode is a mandatory field and must be filled in.
1.11.1 Postcode Sector
Postcode sector is that part of the patient'
s postcode excluding the last two
characters (the '
Unit'
) from their usual address. Strictly the postcode sector as
described here comprises Area, District and Sector (see
http://www.ex.ac.uk/cimt/resource/postcode.htm). Storage of postcode sector
04 February 2004
10
alone is not considered to compromise patient confidentiality as it is too
imprecise to be used to identify individuals. The postcode sector can be used
to establish Deprivation scores in Scotland using the Carstairs index.
SMR Data Manual: "The postcode is a basic unit for identifying geographic
locations. A postcode is associated with each address in the UK. A postcode
has two component parts. Part one of the postcode is known as the
OUTCODE, and part two is known as the INCODE”. Patient address is
defined above.
1.11.2 Postcode Unit
Postcode unit is the last two characters of the Postcode from the patient'
s
usual address. Storage of sector (the rest of the postcode) alone is not
considered to compromise patient confidentiality as it is too imprecise to be
used to identify individuals. The unit, however, can be used in conjunction
with the sector to identify individuals with reasonable (or in this case
unacceptable) accuracy. The unit should not be stored unless there is a
genuine need.
SMR Data Manual: "The postcode is a basic unit for identifying geographic
locations. A postcode is associated with each address in the UK. A postcode
has two component parts. Part one of the postcode is known as the
OUTCODE, and part two is known as the INCODE”. Patient address is
defined above.
2 Next of Kin/ GP
2.1 Name of Next of Kin
Name of Next of Kin should only be stored where it is specifically required.
2.2 Telephone number of Next of Kin
Telephone number can be stored or any other convenient method of contact.
Contact details should only be stored where it is specifically required.
2.3 Relationship of Next of Kin
Relationship of Next of Kin should only be stored where it is specifically
required.
2.4 GP Information
Entering GP detail is done by selecting a patient, selecting GP and moving
through the data fields completing them.
2.4.1 GP List
List of GPs and practices currently available on the system. If you can'
t see
the list, activate the list by clicking the arrow (pointed downwards) on the right
side of the window.
You can select any one GP by scrolling to that GP and then clicking the GP.
04 February 2004
11
2.4.2 How to order GP List
You may choose the order in which GPs are listed. If you don'
t know the GP'
s
name, and are looking for a practice, you may order by postcode. If you are
uncertain of the spelling of the GP name on the system, but know the
practice, order by postcode. This will group all GPs for a practice together
(some practices share premises, so share postcodes, these will be grouped
together).
2.4.3 GP Initials
You can enter GP initials here. However it is recommended that you enter GP
data by selecting the GP from the list. This ensures that GP data is kept
consistent.
2.4.4 GP Surname
You can enter GP surname here. However it is recommended that you enter
GP data by selecting the GP from the list. This ensures that GP data is kept
consistent.
2.4.5 GP Post Code
Post Code Sector: GP postcode sector is that part of the GP'
s postcode
excluding the last two characters (the '
Unit'
). Strictly the sector as described
here comprises Area, District and Sector (see
http://www.ex.ac.uk/cimt/resource/postcode.htm). Storage of sector alone is
not considered to compromise patient confidentiality as it is too imprecise to
be used to identify individuals.
Post Code Unit: Postcode unit is the last two characters of the Postcode from
the GP'
s usual address. Storage of sector (the rest of the postcode) alone is
not considered to compromise confidentiality as it is too imprecise to be used
to identify individuals. The unit, however, can be used in conjunction with the
sector to identify individuals with reasonable (or in this case unacceptable)
accuracy. The unit should not be stored unless there is a genuine need.
2.4.6 GP Telephone
You can enter GP telephone number here. However it is recommended that
you enter GP data by selecting the GP from the list. This ensures that GP
data is kept consistent.
2.4.7 In addition
Remember the GP list needs to be updated regularly, and even the most
recent information supplied can be several months out of date. If you find that
a GP is not listed when you need to use them, please contact the Coordinating Centre.
3 Care
Once you have entered the information in the Personal section the other
sections then become available. In order to enter information into the Care
04 February 2004
12
section for the first time you must click on the ‘New Event’ button to enable
you to enter information in the provided fields.
3.1 Date of Assessment
Date of clinical examination from which baseline data (see note) for the
system has been (mainly) drawn. Thus if the data on the form has been
extracted from an admission clerking the date of that clerking should be
entered. However, if patients are prospectively assessed as part of the
registry then the date of that prospective assessment should be entered.
If the patient was due to be seen as an Outpatient, and has never attended
record the date the decision has been made to accept that the patient will
never attend. Under '
Where seen'(or '
Seen as'
) please record '
Never seen as
an Outpatient'
.
3.1.1 Caution
The "clinical examination" referred to in the above definition refers to the first
specialist examination from which clinical management is defined. This date is
used to identify event records that are the same. This is used because this
date is available no matter what type of patient (inpatient or outpatient) is
being assessed.
It is important that this date is defined consistently between different studies. If
the relevant records are recorded with different dates of assessment for
different studies, they will appear as separate events and the data cannot be
linked. This has happened with a research study running alongside an audit.
The research study re-assessed the patients, and used that date of
assessment, resulting in un-linked data for some patients.
If you are running separate studies including the same patients, please
ensure that this definition is consistently applied across all studies. Ideally,
regular communication should occur between the staff collecting data for the
separate studies to check that this is happening in individual cases.
3.1.2 In addition
For inpatients, the standard forms have a section called Initial Assessment.
The date of initial assessment recorded should be the date on which these
data are recorded (for audit purposes – see caution above). In particular this
should be the date on which the questions below are assessed:
• Can the patient talk?
• Are they orientated in time, place, and person?
• Can the patient lift both arms off the bed?
• Can the patient walk without help from another person?
(all these being in the present tense).
For outpatients, the standard forms have a section called Clinical
Assessment. The date of initial assessment recorded should be the date on
which these data are recorded (for audit purposes – see caution above). This
section may or may not include the questions above depending on local
requirements.
04 February 2004
13
3.2 Time of Assessment
Time - hour of clinical examination from which baseline data for the system
has been (mainly) drawn. This should be recorded using the 24-hour clock.
See the Date of Assessment section above for further clarifications.
3.2.1 In addition
Often this time is not available. If that is the case you need to select a
designated time that means unknown and add it to your decision list.
3.3 Responsible Consultant (Clinician)
This should be the consultant under whose care the patient was at the time of
hospital discharge. This information can be found in the Discharge Letter.
3.3.1 In addition
The consultant is selected from a drop down list provided at set-up.
Remember the consultant list needs to be updated regularly. If you find that a
consultant is not listed when you need to use them, please contact the Coordinating Centre.
3.4 Seen as
In what context was the patient seen when initially examined. This can be in a
hospital as either an Inpatient or as an Outpatient. It could also be at a GP
clinic, at home (normal place of residence) or at some other place away from
a hospital.
Never seen as an Outpatient should be used where a patient has been
referred for an event or events, but has never been seen in relation to that
event or events. Thus it can be used even if a patient has been seen for a
separate event or events. This code is intended to allow a Unit to audit the
number of referrals received, including those where the patient is never seen.
The Imaging only option is a special option to allow compatibility with our old
register, the Lothian Stroke Register. Please ignore this option.
3.5 Unit
No Help text is provided.
3.5.1 In addition
The unit is selected from a drop down list provided at set-up, but the Units are
usually local hospitals and clinics. If you find that a unit is not listed when you
need to use them, please contact the Co-ordinating Centre.
3.6 Date Admitted
This should refer to date of arrival at the hospital rather than the date when
the decision to admit was made or the date when the patient actually entered
the ward. It is likely to be recorded in the Accident & Emergency department.
If the event concerned occurred when the patient was already in hospital for
another condition, the date of the original admission should be given. Dates of
admission prior to event can easily be identified at analysis.
04 February 2004
14
3.6.1 In addition
Please be sure to use the date of admittance to the hospital rather than the
ward, as not all stroke patients end up on the stroke ward this could cause
you to miss patients. Check the admissions book to get this information, and
also to find patients to include in the audit.
3.7 Time Admitted
This should refer to time of arrival at the hospital rather than the time when
the decision to admit was made or the time when the patient actually entered
the ward. It is likely to be recorded in the Accident & Emergency department.
3.7.1 In addition
This is admission to A&E and not the ward. Often this time is not available. If
that is the case you can select a designated time that means unknown, or you
can enter ??:?? to indicate the missing data.
3.8 Admitted From
Type of facility admitted from. Code as per SMR Data Manual Admission
/Transfer From codes. The patient'
s place of residence is required. For
instance, patients taken ill in the street should be coded as "admitted from
home". Admission /Transfer From codes have on occasions been mis-applied
here (1). Patients taken ill in the street have been incorrectly coded as
"admitted from other". Where a patient has a stroke when they are already in
hospital for another condition, code the patient'
s place of residence when
originally admitted to hospital.
3.8.1 In addition
The list of codes is not complete on the form, you have more options when
you enter this field into SSCAS. Although several of the options are unlikely
to ever be used for stroke patients, we use the complete list. Here is a full list
of all available codes:
10
11
12
13
18
19
20
21
22
23
24
28
29
30
31
32
33
Private Residence: no additional detail added
Private Residence: living alone
Private Residence: living with friends/relatives
Private Residence: (sheltered), living alone
Private Residence: other type
Private Residence: type not known
Usual place of residence: institution, no additional detail added
Usual: NHS - Nursing/Residential/Hostel/Group Home
Usual: Local Authority/Voluntary - Nursing/Residential/Hostel/Group
Home
Usual: Private - Nursing/Residential/Hostel/Group Home
Usual: NHS partnership hospital
Usual: institution - other type
Usual: institution - type not known
Temporary place of residence: no additional detail added
Temporary: Holiday accommodation
Temporary: Student accommodation
Temporary: Legal establishment, including prison
04 February 2004
15
34
35
38
39
40
41
42
43
44
45
46
47
48
49
4A
4B
4C
4D
4E
4F
4G
50
51
52
53
54
55
56
57
58
59
5A
5B
5C
5D
5E
5F
5G
60
61
62
68
69
70
Temporary: No fixed abode
Temporary: Admission of Foundling
Temporary: Other type (includes hospital residences)
Temporary: type not known
Transfer from the same Provider Unit: no additional detail added
same Provider Unit: Accident and Emergency
same Provider Unit: Surgical speciality
same Provider Unit: Medical speciality
same Provider Unit: Obstetric / Postnatal Cots
same Provider Unit: Paediatrics
same Provider Unit: Neonatal Paediatrics
same Provider Unit: GP Obstetric / Postnatal Cots
same Provider Unit: Other speciality not separately identified
same Provider Unit: speciality not known
same Provider Unit: GP other than Obstetrics
same Provider Unit: Geriatrics (except for patient on pass)
same Provider Unit: Geriatrics (patient on pass)
same Provider Unit: Psychiatry (except for patient on pass)
same Provider Unit: Psychiatry (patient on pass)
same Provider Unit: Orthopaedics
same Provider Unit: Learning disability
Transfer from other NHS Provider unit: no additional detail added
other NHS Provider unit: Accident and Emergency
other NHS Provider unit: Surgical speciality
other NHS Provider unit: Medical speciality
other NHS Provider unit: Obstetric / Postnatal Cots
other NHS Provider unit: Paediatrics
other NHS Provider unit: Neonatal Paediatrics
other NHS Provider unit: GP Obstetric / Postnatal Cots
other NHS Provider unit: Other speciality not separately identified
other NHS Provider unit: speciality not known
other NHS Provider unit: GP Non Obstetrics
other NHS Provider unit: Geriatrics (except for patient on pass)
other NHS Provider unit: Geriatrics (patient on pass)
other NHS Provider unit: Psychiatry (except for patient on pass)
other NHS Provider unit: Psychiatry (patient on pass)
other NHS Provider unit: Orthopaedics
other NHS Provider unit: Learning disability
Admission from Private Hospital or Hospice etc.: no additional detail
from Private Unit: Private Hospital
from Private Unit: Hospice
from Private Unit: Other type of location
from Private Unit: Type of location not known
Home birth
It may not always seem clear which of the above categories a patient should
be coded to. For example, what does home to district general to teaching
hospital get coded as?
The answer should be based on where the patient was living prior to the event
that is the reason they are included in the audit. So in the example if the route
04 February 2004
16
given is the path a patient takes on admission for a stroke they should be
considered admitted from home. If they were admitted say for cancer and
then had the stroke in hospital then they live in hospital prior to the event.
3.9 Date Discharged
Date discharged from hospital (alive) if relevant.
3.9.1 In addition
It is essential to be absolutely clear about what is meant when referring to
discharge in relation to Scottish hospital care as the term is used to represent
two different times.
In this case we mean '
Discharge from hospital home (to usual place of
residence) or to long term care'
. The term is intended to define the end of
hospital care. This period of care need not all be within one hospital, nor even
within one Trust or under one health board.
Beware - in other circumstances discharge can be used to describe the end of
an Episode of consultant care. When a patient moves from the care of one
consultant to that of another, they are '
discharged'
. This definition is used for
Scottish Morbidity Record (SMR) data. Confusingly, it is possible, though
extremely unlikely, that a discharge can occur without changing consultant if
a patient is moved from care under one speciality to care under another and
the particular consultant is responsible for both.
3.10 Discharged to
Type of facility Discharged to. Code as per SMR Data Manual Discharge
/Transfer To codes.
3.10.1 In addition
These codes are the same the Admitted From codes. Again they are not all
listed on the form, but a complete list is given above in the Admitted From
definition.
4 Final Diagnosis and Status
When entering this section you must fill in every field. For each category
enter an Y (Yes) or an N (No). You should find the final diagnosis in the
Discharge Letter.
4.1 Cerebral: Stroke
Whether final diagnosis included stroke. (Further details may be recorded in a
Disease Classification section).
4.2 Cerebral: Transient Ischaemic Attack
Whether final diagnosis included Transient Ischaemic Attack. (Further details
may be recorded in a Disease Classification section).
4.3 Cerebral: Sub-arachnoid Haemorrhage
Whether final diagnosis included Sub-arachnoid Haemorrhage. (Further
details may be recorded in a Disease Classification section).
04 February 2004
17
4.4 Eye: Retinal Artery Occulsion
Whether final diagnosis included Retinal Artery Occlusion FAO. (Further
details may be recorded in a Disease Classification section).
We regard terms such as retinal infarction as synonymous with RAO. Any
episode of monocular visual loss (complete or partial) lasting more than 24
hours and which is presumed to be due to retinal ischaemia (not venous
occlusions) should be coded as RAO.
Retinal venous occlusions should be coded as non-cerebrovascular disease.
4.5 Eye: Transient Monocular Blindness
Whether final diagnosis included Transient Monocular Blindness (or
Amaurosis Fugax - AFx). (Further details may be recorded in a Disease
Classification section).
Amaurosis Fugax refers to any episode of monocular visual loss (complete or
partial) lasting less than 24 hours and which is presumed to be due to retinal
ischaemia (not venous occlusions).
Retinal venous occlusions should be coded as non-cerebrovascular disease.
4.6 Other: Possible Cerebrovascular
Use if presentation could have cerebrovascular cause but < 50% certain and
give details (e.g. lone vertigo).
4.7 Other: Possible Cerebrovascular Details
When final diagnosis is Possible cerebrovascular, please give details of main
problems and reasons for uncertainty.
4.8 Other: Definite Non-Cerebrovascular
Whether final diagnosis included non-cerebrovascular diagnosis. Further
details may be recorded in the text box alongside. You may record noncerebrovascular diagnoses as well as cerebrovascular for complex situations.
4.9 Other: Definite Non-Cerebrovascular Details
When final diagnosis includes non-cerebrovascular diagnoses, further details
may be recorded here.
4.10 End data collection
Select a value to end data collection for this patient. On this form the only
relevant value is probably '
Death'
. Once a value is recorded, no new data
collection will be initiated, though the system may continue to attempt to
collect data for previous requests.
Options are :
Death
Lost
- patient cannot be traced
Refused
- patient has refused further contact
Removed
- patient has been removed following a decision made by the
responsible clinician or study manager. Care must be taken when making
such decisions to ensure that they are made on a consistent basis, and that
they do not introduce unwanted bias into any study sample.
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18
4.11 Date End data collection
This is the date after which no new data collection is to be initiated.
5 Initial Assessment
When entering this section you must fill in every field. For each category
where appropriate enter an Y (Yes) or an N (No). This data can be hard to
find in the Notes. A clerking proforma that includes some of these questions
on admission can help simplify collecting this information.
5.1 Date of First Symptoms
This is the best estimate of the date of onset of the patients focal cerebral
symptoms based on all available information. If patients do not have focal
cerebral symptoms (e.g. just headache with subarachnoid or intracerebral
haemorrhage) the onset of the predominant symptom should be recorded. If a
patient has non-focal symptoms prior to development of focal cerebral
symptoms or deficits do not code the date of onset of these as the date of
stroke onset.
5.1.1 In addition
If you are having problems finding this information it is often somewhere on
admission information, e.g. this morning leg weakness, 2/7 ago sudden.
5.2 Can the patient lift both arms off the bed?
We do not stipulate that they should be able to keep them off the bed for any
specific period or lift them to the horizontal.
Should the patient be unassessable for any reason code '
NO'(abnormal).
Should the unaffected arm be completely missing, code the affected arm only.
Should the affected arm be completely missing, code on the affected leg
instead, if possible, otherwise code '
NO'
.
The field name, ARMSMOD, could be slightly confusing. The original
measurements* were made on a motor deficit scale very similar to the MRC
scale. On that scale, able to lift arms was rated better than moderate deficit
(none or mild), so ARMSMOD was an abbreviation of ARMS better than
MODerate deficit.
5.2.1 In addition
Sometimes this can be found clearly in a patient record. If not, look at the
physiotherapy notes and nursing notes. If patient is unable to feed/wash
him/herself less likely that he/she can lift both arms off the bed. In addition if
power in both arms is < 3/5 answer is No. If power in both arms is 3/5 or more
answer is Yes. In this instance power refers to the UK MRC scale with the
following grades:
Grade 0: No muscle contraction
Grade 1: Flicker of contraction
Grade 2: Some active movement
Grade 3: Active movement against gravity
Grade 4: Active movement against resistance
04 February 2004
19
Grade 5: Normal power
5.3 Was the patient independent in ADL before event?
Patients should be independent (i.e. not need help from any person) in
activities which would normally be performed everyday, i.e. walking (at least
around their house), washing, dressing and feeding (not meal preparation).
For the purposes of this classification we do not include activities which are
carried out less frequently and where dependency is highly dependent on the
environment (e.g. bathing vs showering, shopping depends on distance from
shops, stairs depends on type of living accommodation). This will hopefully
lead to better agreement than leaving it up to the individual rather to decide
what '
everyday activities'means.
5.4 Able to walk without help from other person?
Is the patient able to walk without the aid of another person (Y or N)? They
may use any other aid.
5.4.1 In addition
If this is not in the medical notes, check the physiotherapy and nursing notes.
Often you can find information about mobility, leg weakness, and transfers
with 1/2/hoist.
5.5 Was patient living alone at the time of event?
If the patient is living in a residential or nursing home they should not be
coded as living alone. If they live alone in a warden controlled apartment then
this can be coded as living alone.
5.5.1 In addition
Sometimes it is not clearly stated whether the patient lives alone. Check if
patient has a spouse or other relative with the same phone number as him/her
self
5.6 Current AF confirmed on ECG?
Refers to atrial fibrillation (AF) which is proven on an ECG at the time of
assessment or during any hospital inpatient stay. Please also include AF
proven on ECG at any time between the event for which they are being
assessed and the current assessment. It should not include atrial flutter for
which there is less robust evidence for the effectiveness of anticoagulation in
stroke prevention.
5.6.1 In addition
If it is unclear whether the ECG shows AF or not then somebody needs to
review it. Most ECGs come with a report, which is generally reliable from this
point of view. If AF is not recorded in the notes then it should be entered as
Not Recorded, (*).
5.7 Can the patient talk?
Should the patient be unassessable for any reason code '
NO'(abnormal).
04 February 2004
20
5.7.1 In addition
Check to see if patient said any understandable words. Some patients only
answer Yes/No. Quite often there is "No history from patient" which makes
the answer No.
5.8 On Aspirin at onset?
Had the patient taken aspirin in the 24 hours prior to the onset of stroke
symptoms?
5.9 Are they oriented in time, place and person?
This question is based on the verbal component of the Glasgow Coma Scale,
where:
5 = orientated;
4 = confused;
3 = inappropriate words;
2 = groans;
1 = none.
If 5 record as '
Yes'(orientated), otherwise record as '
No'(including patients
who are unassessable for any reason).
5.10 On Warfarin at onset?
Whether the patient had been prescribed Warfarin prior to and at the time of
first symptoms. This is a question related to patient management, please
ignore complications relating to compliance.
5.11 Swallow screening recorded?
Swallow screening recorded (Y or N)?
A two stage assessment aimed to establish first whether it is safe to proceed
with a formal assessment of swallowing safety and second to determine,
using a simple water swallow test, whether the patient can safely be given
free oral fluids and food. Failure on either part should lead to the patient being
put '
nil by mouth'and given at least hydration and sometimes nutrition via an
alternative route until a formal assessment by a speech and language
therapist.
The fact that a screening test for swallowing problems has been carried out
and its results, should be documented in the medical notes.
5.12 Date swallowing assessed
Date first Swallowing assessment performed.
5.12.1 In addition
Although a Speech and Language Therapist may do a more through
swallowing assessment at a later date, this date should be for the very first
assessment.
04 February 2004
21
6 Inpatient Management
When entering this section you must fill in every field. For each category
where appropriate enter an Y (Yes) or an N (No).
Also you might want to consider keeping a list of types of ACE inhibitors,
Diuretics, Anihypertensives or Statins if you are unfamiliar with these types of
drug names.
The below page collects information on (relevant) Drugs at discharge of an
Inpatient. The data collected is intended to allow audit of the process of care
against SIGN guidelines.
6.1 Was the patient managed in an acute Stroke Unit (SU)?
An acute stroke unit is defined as a specific ward or part of a ward where
patients with acute stroke are admitted either directly from the community,
from the accident & emergency department or after a brief (usually <24 hours)
stay in a medical assessment area.
6.1.1 In addition
Further clarification: An acute stroke unit is a group of beds in one location
which accept specifically stroke patients within the first day of admission from
either A&E, the community or the medical admission unit. It should be looked
after by stroke interested consultants and staff and a weekly MDT meeting
should happen
6.2 Acute Stroke Unit Entry Date?
Date of entry to acute Stroke Unit, from any source - e.g. acute receiving unit
or from another ward or hospital.
6.3 Acute Stroke Unit Exit Date?
Date when patient moves out of acute stroke unit whether it is to home or
another ward or hospital.
6.4 Acute Stroke Unit Consultant
This should be the consultant under whose care the patient was while in the
acute stroke unit.
6.5 Was the patient managed in a rehab Stroke Unit?
A stroke rehabilitation unit is a ward or part of a ward which is designated
specifically for the rehabilitation of patients with stroke and in which the
majority of patient will have had a stroke. Multidisciplinary team meetings
should take place at least weekly and the staff will have received specific
training in stroke.
6.6 Rehab Stroke Unit Entry Date?
Date of entry to rehab unit, from any source - e.g. stroke unit or from another
ward or hospital.
04 February 2004
22
6.7 Rehab Stroke Unit Exit Date?
Date when patient moves out of stroke rehabilitation unit whether it is to home
or another ward or hospital.
6.8 Rehab Stroke Unit Consultant
This should be the consultant under whose care the patient was while in the
rehab stroke unit.
6.9 Was the patient managed in a Rehab Unit?
A normal rehabilitation unit is a ward or part of a ward which is designated
specifically for the rehabilitation of patients with no particular emphasis on any
disease or condition.
6.10 Rehab Unit Entry Date?
Date of entry to rehab unit, from any source - e.g. stroke unit or from another
ward or hospital.
6.11 Rehab Unit Exit Date?
Date when patient moves out of rehabilitation unit whether it is to home or
another ward or hospital.
6.12 Rehab Unit Consultant
This should be the consultant under whose care the patient was while in the
rehab unit.
6.13 Whether Aspirin given in hospital?
This should be completed by reference to the drug chart.
A patient may have been using aspirin but this is stopped on / immediately
after admission for any reason, e.g. pending results of CT or other tests.
In these circumstances, ignore this use of aspirin when considering how to
answer this question. If aspirin is restarted, answer Yes, and enter the date
restarted as date started. If not restarted, enter No.
If a patient has been using aspirin and this is continued without break, enter
Yes, with the date of admission as the date started.
If a patient is never given aspirin answer No. If newly prescribed aspirin, enter
Yes with the date started.
If the patient is being audited for a stroke that occurred when they were
already in hospital, only that period after their stroke should be considered. In
other words, the time of stroke should be treated as the time of admission to
hospital when considering how to answer this question.
6.14 Date Aspirin started?
Date aspirin first given after hospital admission or after the stroke onset if
stroke occurred in hospital. This should be completed by reference to the drug
chart.
A patient may have been using aspirin but this is stopped on / immediately
after admission for any reason, e.g. pending results of CT or other tests.
04 February 2004
23
In these circumstances, ignore this use of aspirin when considering how to
answer this question. If aspirin is restarted, enter the date restarted as date
started.
If a patient has been using aspirin and this is continued without break, enter
the date of admission (or onset if stroke occurred in hospital) as the date
started.
If newly prescribed aspirin, enter the date started.
6.14.1 In addition
This is the date the patient commenced taking the drug and should be on the
chart.
6.15 Final Discharge from hospital on Aspirin?
Did aspirin appear on the discharge prescription or list of drugs which the
patient should have been taking after discharge.
6.16 Final Discharge from hospital on Clopidogrel (Plavix)?
Did Clopidogrel (Plavix) appear on the discharge prescription or list of drugs
which the patient should have been taking after discharge.
6.17 Final Discharge from hospital on Dipyridamole (Persantin)?
Did Dipyridamole (Persantin/Asasantin) appear on the discharge prescription
or list of drugs which the patient should have been taking after discharge.
6.18 Final Discharge from hospital on Warfarin?
Did Warfarin appear on the discharge prescription or list of drugs which the
patient should have been taking after discharge.
6.19 Final Discharge from hospital on an ACE inhibitor?
Did an ACE Inhibitor appear on the discharge prescription or list of drugs
which the patient should have been taking after discharge.
6.20 Final Discharge from hospital on a Diuretic?
Did a Diuretic appear on the discharge prescription or list of drugs which the
patient should have been taking after discharge. Diuretic is defined as a drug
given with the defined intention of increasing urine flow from the kidneys.
6.21 Final Discharge from hospital on another Antihypertensive?
Did another anti-hypertensive appear on the discharge prescription or list of
drugs which the patient should have been taking after discharge.
6.22 Final Discharge from hospital on a Statin?
Did a Statin appear on the discharge prescription or list of drugs which the
patient should have been taking after discharge.
6.23 Barthel – scores taken at times of your choosing
Total Barthel score out of 20 or 100. You can record multiple Barthel scores in
date order following date of initial assessment.
04 February 2004
24
6.23.1 In addition
Here is a more detailed look at the Barthel scoring system:
Item
Bowels
Bladder
Grooming
Toilet use
Feeding
Transfer
(e.g. bed to
chair)
Mobility
Dressing
Stairs
Bathing
Total
Score:
/100
0
5
10
0
5
10
0
5
0
5
10
0
5
10
0
5
10
15
0
5
10
15
0
5
10
0
5
10
0
5
100
Score:
/20
0
1
2
0
1
2
0
1
0
1
2
0
1
2
0
1
2
3
0
1
2
3
0
1
2
0
1
2
0
1
20
Categories
Incontinent or needs enemas
Occasional incontinence (< once per week)
Continent
Incontinent/unable to manage catheter
Occasional accident (< once per week)
Continent
Needs help with shaving washing, hair or teeth
Independent
Dependent
Needs some help
Independent on, off, dressing and cleaning
Dependent
Needs some help (e.g. with cutting, spreading)
Independent if food provided within reach
Unable and no sitting balance
Needs major help
Needs minor help
Independent
Unable
Wheelchair independent indoors
Walks with help or supervision
Independent (but may use aid)
Dependent
Needs some help
Independent, including fasteners
Unable
Needs some help or supervision
Independent up and down
Dependent
Independent in bath or shower
6.24 Barthel Dates
Dates of the relevant Barthel scores following initial assessment.
6.25 Barthel Scoring System
Either /20 or /100 - best translate all scores to /100 by multiplying those out of
20 by 5.
This is particularly appropriate because the system can only be set up to
validate against one range. It is impossible to enter values over 20 unless the
system is set up to validate up to 100, so that scale is more appropriate.
Analysis will be much easier if only one scale is used.
6.25.1 In addition
While this field does not appear on the form, it must be entered on the screen
in the Barthel section. There are only two options, /20 and /100. Given the
way the system is set up you should always be selecting the same option.
04 February 2004
25
6.26 FIM – scores taken at times of your choosing
You can record multiple Functional Independence Measure scores in date
order following date of initial assessment.
6.26.1 In addition
This is not collected at all hospitals, some collect Modified Rankin Scores
instead. Here is a further definition of the Functional Independence Measure:
FIM is an 18-item 7 level functional assessment scale that evaluates the
amount of assistance required by a person with a disability to perform basic
life activities safely and effectively. The FIM is scored on a 7-point ordinal
scale.
1
2
3
4
5
6
7
=
=
=
=
=
=
=
Total Assistance
Maximal Assistance
Moderate Assistance
Minimal Contact Assistance
Supervision or Set-up
Modified Independence
Complete Independence
The FIM represents a measure of the amount of assistance and resources a
disabled person will use in their living environment.
6.27 FIM Dates
Dates of the relevant FIM scores following initial assessment.
6.28 Modified Rankin Score
Modified Rankin Score is also known as Oxford Handicap Scale or Score
(OHS).
0 = no symptoms
1 = minor symptoms which do not interfere with lifestyle
2 = some restriction to lifestyle, but look after themselves
3 = significant restriction to lifestyle, preventing total independence
4 = severe handicap preventing independent existence but not requiring
constant attention
5 = severe handicap, totally dependent, requiring attention night and day
6 = dead
You can record multiple scores in date order following date of initial
assessment.
6.28.1 In addition
Generally either FIM is collected or Modified Rankin, but not both.
6.29 Modified Rankin Score Date
Date Modified Rankin Score assessed.
04 February 2004
26
7 Final Classification
When entering this section you must fill in every field. For each category
where appropriate enter an Y (Yes) or an N (No) or if the answer is unknown
a ‘?’.
7.1 CT done?
Computerised tomography of the brain.
7.2 CT date
Date of first CT after stroke onset.
7.3 MRI done?
Magnetic Resonance Imaging scan of the brain.
7.4 MRI date
Date of first MRI after stroke onset.
7.5 Evidence of new haemorrhage on scan?
Based on either review of actual scan or the radiologist’s report. Please
include haemorrhage which is thought to be secondary to cerebral infarction
i.e. haemorrhagic transformation of infarction. If there are only vague signs of
possible petechial haemorrhage into an infarction it would be reasonable to
code haemorrhage as being absent. In this field we are trying to establish
whether there was a definite contra-indication to antithrombotic medication
given and acknowledging the difficulties of distinguishing primary
haemorrhage from that into an area of infarction.
7.6 Post-mortem performed
No definition is given in the Help text. However, the answer should be NO
unless the patient died.
7.7 Evidence of new haemorrhage on PM?
No help text given.
7.8 Final Syndrome Classification
This refers to the clinical syndrome at the time of maximal deficit (see table).
Coding should take account of the results of imaging where available.
7.9 ICD 10 Final Diagnosis
Pick the most appropriate and specific ICD 10 code from the list provided,
based on the diagnosis given in the Discharge Letter.
7.9.1 In addition
ICD10 is generally not properly designed for stroke. As long the codes you
select differentiate between ischaemic, haemorrhagic and TIA that is all one
would expect of it.
04 February 2004
27
8 Additional Commonly used fields
These are fields that have been added to the minimum dataset by several
participating hospitals.
8.1 Family history of premature vascular disease?
Is there a family history of premature vascular disease?
Please consider:
• Family - first degree relatives only;
• Premature - aged <65; and
• Vascular disease - include cardiovascular, cerebrovascular and arterial
disease but excluding venous disorders.
8.2 Previous Stroke
Any stroke which occurred prior to the event which has lead to this referral.
8.3 Previous TIA
Any Transient Ischaemic Attack (TIA) including Transient Monocular
Blindness (TMB or Amaurosis Fugax, AFx) which occurred prior to the event
which has lead to this referral (and was not coded under "final diagnosis").
A TIA is '
a clinical syndrome characterized by an acute loss of focal cerebral
or monocular function with symptoms lasting less than 24 hours and which is
thought to be due to inadequate cerebral or ocular blood supply as a result of
low blood flow, arterial thrombosis or embolism associated with disease of the
arteries, heart or blood'
.
8.4 Diabetes
Details of any Diabetes recorded.
Where Diabetes is diagnosed for Fasting Glucose > 7 mmol/l on 2 or more
occasions.
8.5 Weekly Alcohol intake
Approximate number of units of alcohol consumed per week.
I unit = half pint of beer or one glass of wine or one measure of spirit.
8.6 Diastolic Blood Pressure at admission/discharge
Measured with the patient sitting or lying. If there is a difference in diastolic
blood pressure between the left and right arm, the reading from the arm with
the higher reading should be recorded. The disappearance of the sound
should be taken as the diastolic pressure rather than the pressure at which it
becomes muffled. The latter should only be used when the sound is still
audible with the cuff fully deflated.
8.7 Systolic Blood Pressure at admission/discharge
Measured with the patient sitting or lying. If there is a difference in systolic
blood pressure between the left and right arm, the reading from the arm with
the higher reading should be recorded. The disappearance of the sound
should be taken as the systolic pressure rather than the pressure at which it
04 February 2004
28
becomes muffled. The latter should only be used when the sound is still
audible with the cuff fully deflated.
8.8 Was the patient managed in an Integrated Stroke Unit?
An Integrated Stroke Unit is defined as a specific ward or part of a ward where
patients with acute stroke are admitted either directly from the community,
from the accident & emergency department or after a brief (usually <24 hours)
stay in a medical assessment area. That same unit will provide specifically for
the rehabilitation of patients with stroke. Multidisciplinary team meetings
should take place at least weekly and the staff will have received specific
training in stroke care.
Standard Outpatient Form
Although not everyone will be using this version of the form, a discussion of
each of the sections should help you collect the basic patient dataset. Each
field has the help text given and additional information below.
One confusing thing about the data entry screens for the Outpatient form is
that the Registration data you must enter is identical to the data on the
Inpatient form. It skips over the Referral information collected at the top of the
form because this is not core data. The Referral information is collected after
all of the Registration data has been entered in a Referral section.
1 Personal
See the Inpatient Form’s Personal section for the definitions as they are
identical.
2 Next of Kin/ GP
See the Inpatient Form’s Next of Kin/GP section for the definitions as they are
identical.
3 Care
Once you have entered the information in the Personal section the other
sections then become available. In order to enter information into the Care
section for the first time you must click on the ‘New Event’ button to enable
you to enter information in the provided fields. See the Inpatient Form’s Care
section for the definitions as they are identical.
4 Final Diagnosis and Status
When entering this section you must fill in every field. For each category
enter an Y (Yes) or an N (No). You should find the final diagnosis in the
Discharge Letter. See the Inpatient Form’s Final Diagnosis and Status section
for these definitions as they are identical.
5 Outpatient service data
This is where you record the referral data from the top of the form.
04 February 2004
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5.1 Date of referral
Date on which any referral letter or fax was dictated (or typed if date of
dictation not stipulated) or date of any telephone or email referral made,
whichever was the earliest.
5.2 From GP?
Whether referral was from patient'
s General Practitioner.
5.3 Date referral received
Date on which the referral was received by those responsible for making
appointments. Often incoming letters are stamped with the date of receipt. If
the referral was by FAX, email or phone call the date should be the same as
the date the referral was sent.
5.4 Date of first appointment offered
This is the date of the first appointment which was offered to the patient. This
should be the earliest date you offer, regardless of whether the patient
accepts, declines, cancels or does not attend that appointment.
Sometimes the patient does not attend and therefore the date of first
appointment may not be the same as the date of first assessment. However
the date of first appointment is important for us in auditing our processes.
6 Outpatient Clinical Assessment
6.1 Date of most recent TIA/Stroke (or best estimate)
This is the date (or best estimate of the date) on which the patient had their
last TIA, stroke or eye attack prior to their initial assessment.
6.2 Side of brain/eye lesion
The presumed side of any brain lesion or episode of Afx or RAO should be
coded. If the patient’s symptoms are not lateralising (e.g. truncal ataxia,
confusion then these should be coded as midline. Isolated dysphasia will
normally be attributable to a left sided lesion whilst isolated visuospatial
problems should normally be attributed to a right sided lesion. Where there is
clear evidence of bilateral lesions these should be coded as bilateral.
Uncertain should only be used if specifically chosen by the clinician. This
applies where it has been considered and it is genuinely not possible to locate
the side of the lesion from the information available. This is not quite the
same thing as unassessable which applies more when the patient is
unconscious or somehow unable to provide the information. If it'
s not
completed at all, then code is not recorded.
6.3 Blood pressure
6.3.1 Systolic Blood Pressure
Measured with the patient sitting or lying. If there is a difference in systolic
blood pressure between the left and right arm, the higher reading should be
recorded.
04 February 2004
30
6.3.2 Diastolic Blood Pressure
Measured with the patient sitting or lying. If there is a difference in systolic
blood pressure between the left and right arm, the higher reading should be
recorded. The disappearance of the sound should be taken as the diastolic
pressure rather than the pressure at which it becomes muffled. The latter
should only be used when the sound is still audible with the cuff fully deflated.
6.4 Known history of atrial fibrillation?
If patient has had Atrial Fibrillation (AF) confirmed on ECG at any time prior to
the event currently being assessed, code Yes. Those with proven paroxysmal
AF should also be included.
7 Data to audit use of Secondary preventive drugs
7.1 At time of event
7.1.1 Aspirin
Had the patient taken aspirin in the 24 hours prior to the onset of stroke
symptoms?
7.1.2 Dipyridamole (Perstatin/Asasantin)
Had the patient taken dipyridamole (Persantin or Asasantin) in the 24 hours
prior to the onset of stroke symptoms?
7.1.3 Clopidogrel
Had the patient taken clopidogrel (Plavix) in the 24 hours prior to the onset of
stroke symptoms?
7.1.4 Warfarin
Had the patient taken warfarin in the 24 hours prior to the onset of stroke
symptoms?
7.1.5 ACE Inhibitor
Had the patient taken an ACE inhibitor in the 24 hours prior to the onset of
stroke symptoms?
7.1.6 Diuretic
Had the patient taken any Diuretic drug in the 24 hours prior to the onset of
stroke symptoms.
7.1.7 Other antihypertensive
Had the patient taken any blood pressure lowering drug in the 24 hours prior
to the onset of stroke symptoms with the purpose of lowering BP.
7.1.8 Statin / lipid lowering agent
Had the patient taken a lipid lowering drug (e.g. statin, fibrate, cholestyramine,
nicotinic acid) in the 24 hours prior to the onset of stroke symptoms?
04 February 2004
31
7.1.9 None
The patient had taken none of these drugs in the 24 hours prior to the onset of
stroke symptoms.
7.2 At time of first assessment
7.2.1 Aspirin
Had the patient taken aspirin in the 24 hours prior to the 1st assessment?
7.2.2 Dipyridamole (Perstatin/Asasantin)
Had the patient taken dipyridamole (Persantin or Asasantin) in the 24 hours
prior to the 1st assessment?
7.2.3 Clopidogrel
Had the patient taken clopidogrel (Plavix) in the 24 hours prior to the 1st
assessment?
7.2.4 Warfarin
Had the patient taken warfarin in the 48 hours prior to the 1st assessment?
7.2.5 ACE Inhibitor
Had the patient taken an ACE inhibitor in the 24 hours prior to the 1st
assessment?
7.2.6 Diuretic
Had the patient taken any Diuretic drug in the 24 hours prior to the 1st
assessment.
7.2.7 Other antihypertensive
Had the patient taken any blood pressure lowering drug in the 24 hours prior
to the 1st assessment with the purpose of lowering BP.
7.2.8 Statin / lipid lowering agent
Had the patient taken a lipid lowering drug (e.g. statin, fibrate, holestyramine,
nicotinic acid) in the 24 hours prior to the 1st assessment.
7.2.9 None
The patient had taken none of these drugs in the 24 hours prior to the 1st
assessment.
7.3 Recommended following NV assessment
7.3.1 Aspirin
Did the doctor in the neurovascular clinic either prescribe or recommend the
patient continue or start aspirin (either on the day of the clinic or having
reviewed the results of investigations).
04 February 2004
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7.3.2 Dipyridamole (Perstatin/Asasantin)
Did the doctor in the neurovascular clinic either prescribe or recommend the
patient continue or start dipyridamole (either on the day of the clinic or having
reviewed the results of investigations).
7.3.3 Clopidogrel
Did the doctor in the neurovascular clinic either prescribe or recommend the
patient continue or start clopidogrel (either on the day of the clinic or having
reviewed the results of investigations).
7.3.4 Warfarin
Did the doctor in the neurovascular clinic either prescribe or recommend the
patient continue or start warfarin (either on the day of the clinic or having
reviewed the results of investigations)
7.3.5 ACE Inhibitor
Did the doctor in the neurovascular clinic either prescribe or recommend the
patient continue or start an ACE inhibitor (either on the day of the clinic or
having reviewed the results of investigations)
7.3.6 Diuretic
Did the doctor in the neurovascular clinic either prescribe or recommend the
patient continue or start an extra diuretic drug (either on the day of the clinic
or having reviewed the results of investigations) with the purpose of lowering
BP. Thus if he/she simply recommends increasing the diuretic treatment this
should be ticked.
7.3.7 Other antihypertensive
Did the doctor in the neurovascular clinic either prescribe or recommend the
patient continue or start an extra antihypertensive drug (either on the day of
the clinic or having reviewed the results of investigations) with the purpose of
lowering BP. Thus if he/she simply recommends increasing the
antihypertensive treatment this should be ticked.
7.3.8 Statin / lipid lowering agent
Did the doctor in the neurovascular clinic either prescribe or recommend the
patient continue or start a lipid lowering drug (either on the day of the clinic or
having reviewed the results of investigations)?
7.3.9 None
The doctor in the neurovascular clinic neither prescribed or recommended any
change with respect to these drug treatments.
7.4 Patient known not to tolerate
7.4.1 Aspirin
Patient is known to be intolerant of aspirin. For example they may have
reported a rash, another allergic reaction or dyspeptic symptoms which would
preclude future use.
04 February 2004
33
7.4.2 Dipyridamole (Perstatin/Asasantin)
Patient is known to be intolerant of dipyridamole. For example they may have
reported an allergic reaction, headache or diarrhoea which would preclude
future use.
7.4.3 Clopidogrel
Patient is known to be intolerant of clopidogrel.
7.4.4 Warfarin
Patient is known to have contraindications to warfarin therapy e.g. prior bleed
on warfarin, confusion and living alone, frequent falls or injury, recent blood
loss, unexplained anaemia, binge drinking.
7.4.5 ACE Inhibitor
Patient is known to be intolerant of ACE inhibitors.
You may record that a patient is intolerant of an ACE inhibitor even when they
are being (or have been) treated satisfactorily with another.
7.4.6 Diuretic
Patient is known to be intolerant of Diuretics.
7.4.7 Other antihypertensive
Patient is known to be intolerant of Other antihypertensives.
You may record that a patient is intolerant of Other antihypertensives inhibitor
even when they are being (or have been) treated satisfactorily with one.
7.4.8 Statin / lipid lowering agent
Patient is known to be intolerant of Statin / lipid lowering agents.
You may record that a patient is intolerant of one or more drugs in this class
even when they are being (or have been) treated satisfactorily with another.
8 Brain Imaging and Final Classification
8.1 CT date
Date of first CT after stroke onset.
8.2 MRI done?
Magnetic Resonance Imaging scan of the brain.
8.3 MRI date
Date of first MRI after stroke onset.
8.4 Evidence of new haemorrhage on scan?
Based on either review of actual scan or the radiologists report. Please
include haemorrhage which is thought to be secondary to cerebral infarction
i.e. haemorrhagic transformation of infarction. If there are only vague signs of
possible petechial haemorrhage into an infarction it would be reasonable to
04 February 2004
34
code haemorrhage as being absent. In this field we are trying to establish
whether there was a definite contra-indication to antithrombotic medication
given and acknowledging the difficulties of distinguishing primary
haemorrhage from that into an area of infarction.
8.5 ICD 10 Final Diagnosis
Pick the most appropriate and specific ICD 10 code from the list provided.
9 Cardiac investigations
This section collects information on processes concerned with selecting
secondary prevention for an Outpatient with proven carotid vessel
abnormalities. The data collected is intended to allow audit of the process of
care against SIGN guidelines.
9.1 ECG since event available?
An ECG has been performed between the date of symptom onset and the
completion of investigations.
9.2 AF on ECG?
Refers to atrial fibrillation (AF) which is proven on an ECG at the time of
assessment or during any hospital inpatient stay. Please also include AF
proven on ECG at any time between the event for which they are being
assessed and the current assessment. It should not include atrial flutter for
which there is less robust evidence for the effectiveness of anticoagulation in
stroke prevention.
9.3 LVH on ECG?
Evidence of left ventricular hypertrophy on either the ECG (deep S in V1 & tall
R in V5 with sum of these measuring greater than 35mm (7 large squares)
with or without changes in lateral ST and T waves) or on a good quality
echocardiogram.
9.4 Echocardiogram performed?
An echocardiogram has been performed between the date of symptom onset
and the completion of investigations.
9.5 Date of first echocardiogram
Date on which the first echocardiogram has been performed after the date of
symptom onset.
9.6 LVH on echo?
Evidence of left ventricular hypertrophy on either the ECG (deep S in V1 & tall
R in V5 with sum of these measuring greater than 35mm (7 large squares)
with or without changes in lateral ST and T waves) or on a good quality
echocardiogram.
04 February 2004
35
10 Data to audit carotid intervention service
10.1 Carotid Duplex examination performed?
First carotid doppler performed after date of referral to hospital for
assessment.
10.2 Date of first Duplex?
Date of first carotid doppler performed after date of referral to hospital for
assessment.
10.3 Second Carotid Duplex performed?
Whether a second carotid doppler was performed to check the results of the
first.
10.4 Date of second Duplex?
Date of any second carotid doppler performed to check the results of the first.
10.5 MR Angiography performed?
Magnetic Resonance Angiography of the carotid vessels.
10.6 Date of MR Angiography?
Date of first Magnetic Resonance Angiography of the carotid vessels after
date of referral to hospital for assessment.
10.7 CT Angiography performed?
CT angiography (following contrast injection) of carotid vessels.
10.8 Date of CT Angiography?
Date of first CT angiography (following contrast injection) of carotid vessels
after date of referral to hospital for assessment.
10.9 Conventional Angiography performed?
Angiogram involving intra-arterial injection of contrast to visualise the carotid
arteries.
10.10 Date of Angiography?
Date of first Angiogram involving intra-arterial injection of contrast to visualise
the carotid arteries.
10.11 Referred to vascular surgeons/interventional radiologist?
Any form of communication which request the opinion of a vascular surgeon
regarding carotid endarterectomy or a radiologist regarding angioplasty (with
or without stent).
Carotid endarterectomy is an operation involving opening of the carotid artery
and removal of atheromatous plaque.
04 February 2004
36
10.12 Date referred?
Date that any referral letter or fax was dictated (or typed if date of dictation not
stipulated) or that telephone or email referral was made, whichever was the
earliest.
10.13 If not referred, why?
Possible reasons are: Intervention is not clinically appropriate – risks clearly
outweigh benefits e.g. there is no evidence of severe stenosis; clinically not
worthwhile - in the opinion of clinicians involved, risks outweigh benefits;
mutual agreement - clinicians involved and patient have discussed potential
risks and benefits and reached agreement that intervention should not be
pursued; patient choice - the patient chooses not to have intervention
(regardless of clinical indications).
10.14 If referred – intervention considered?
Whether considered for Carotid Endarterectomy (CEA) or Angioplasty (with or
without stent). CEA is an operation involving opening of the carotid artery and
removal of atheromatous plaque.
10.15 Seen by surgeon / radiologist?
Has the patient been seen by a surgeon or radiologist?
10.16 Date Seen
The first date actually seen by a vascular surgeon or radiologist after referral
for consideration for secondary preventative treatment.
10.17 Intervention performed?
Was an intervention performed?
10.18 Date of procedure
Date of first procedure after referral to interventionist (i.e. surgeon or
radiologist
10.19 If yes, Side
The following options are available:
L
Left
R
Right
B
Both / Bilateral
M
Midline
C
Cerebellar / Brainstem
U
Uncertain
?
Not known
=
Unassessable
*
Not recorded
#
Notes ambiguous or illegible
These options will all be available wherever you need to enter side to conform
with other requirements for Side data. In some circumstances, some of the
options are not appropriate (e.g. C is not an appropriate code for "Left or Right
04 February 2004
37
handed ?") but will not be blocked. Please be careful to punch only codes that
are appropriate.
Uncertain should only be used if specifically chosen by the clinician. This
applies where it has been considered and it is genuinely not possible to
determine the side from the information available. This is not quite the same
thing as unassessable which applies more when the patient is unconscious or
somehow unable to provide the information. If it'
s not completed at all, then
code is not recorded.
10.20 Stroke within 30 days of intervention?
Any focal cerebral symptoms lasting longer than 24 hours whose onset
occurred from the start of the carotid endarterectomy through to day 30 where
the day of surgery was Day 0.
10.21 Other complication(s) of intervention?
This would include complications of the anaesthetic, death within 30 days,
pulmonary embolism, deep venous thrombosis, wound haematoma or
infection, vocal cord paralysis, facial pain and sensory symptoms over neck.
10.22 Other complication(s) of intervention, please specify?
These could include complications of the anaesthetic, death within 30 days,
focal cerebral symptoms lasting less than 24 hours, pulmonary embolism,
deep venous thrombosis, wound haematoma or infection, vocal cord
paralysis, facial pain and sensory symptoms over neck.
10.23 Reviewed in NV clinic?
Seen in the neurovascular clinic after any carotid procedure.
10.24 Date reviewed
Date seen in the neurovascular clinic after any carotid procedure.
11 Carotid Imaging results
11.1 ICA % stenosis on first Duplex Left?
On Doppler: where the flow distal to the stenosis is thought to be minimal, or
damped or where the ICA appears very narrow though not due to atheroma
i.e. the walls have collapsed inwards) so that the ratio of the ICA diameter
where the ICA walls are parallel above the stenosis to the CCA diameter is
less than 0.42; on MRA: where the residual diameter of the ICA is reduced
distal to the stenosis so that the ratio of the ICA diameter where the ICA walls
are parallel above the stenosis to the CCA diameter is less than 0.42; or
angiography: where the residual diameter of the ICA is reduced distal to the
stenosis so that the ratio of the ICA diameter where the ICA walls are parallel
above the stenosis to the CCA diameter is less than 0.42.
NOTE - this ratio was calculated from angiograms and has not been validated
in MRA or Doppler but is the best information we have to go on.
(Thanks to Joanna Wardlaw for the definition).
If Left ICA stenosis is recorded as 0% code No (normal).
04 February 2004
38
If no information from Doppler, MRA or angiography, including that none of
these was performed, code ? (not known).
11.2 ICA % stenosis on first Duplex Right?
On Doppler: where the flow distal to the stenosis is thought to be minimal, or
damped or where the ICA appears very narrow though not due to atheroma
i.e. the walls have collapsed inwards) so that the ratio of the ICA diameter
where the ICA walls are parallel above the stenosis to the CCA diameter is
less than 0.42; on MRA: where the residual diameter of the ICA is reduced
distal to the stenosis so that the ratio of the ICA diameter where the ICA walls
are parallel above the stenosis to the CCA diameter is less than 0.42; or
angiography: where the residual diameter of the ICA is reduced distal to the
stenosis so that the ratio of the ICA diameter where the ICA walls are parallel
above the stenosis to the CCA diameter is less than 0.42.
NOTE - this ratio was calculated from angiograms and has not been validated
in MRA or Doppler but is the best information we have to go on.
(Thanks to Joanna Wardlaw for the definition)
If Right ICA stenosis is recorded as 0% code No (normal).
If no information from Doppler, MRA or angiography, including that none of
these was performed, code ? (not known).
04 February 2004
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