Daniel Weegmann   (EPR Health Issues & Terminology Specialist Nurse, Salford Royal NHS Foundation Trust)

Professor Jaideep Pandit  (Council Member, Royal College of Anaesthetists

Dr Kathleen Ferguson  (President, Association of Anaesthetists of Great Britain and Ireland)

Lucie Mussett ( NHS Improvement DPSIMs  (Development of the Patient Safety Incident Management System) Project)

Venue: Westminster Room, Waldorf Hilton, Aldwych London WC2B 4DD

Morning Conference Call Details

Meeting time is 2019-04-10 09:00 UK to 12:30; 04:00 US ET (0800 UTC)

Meeting ID: 524-400-204

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Afternoon Conference Call Details

Meeting time is 2019-04-10 13:30 UK to 16:30; 08:30 US ET (1230 UTC)

Meeting ID: 933-287-627

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Discussion items

10900Introductions and apologies

Introductions were made. Apologies for were received from Patrick McCormick Andrew Marchant user-d48df

The group noted with some concern that Andrew Marchant had been denied leave to attend the meeting and that the process of obtaining time to contribute to professional activity such as this was generally becoming more difficult. Additionally the group has noted difficulty in recruiting newer younger members and hoped that more engagement with governing professional bodies as evidence by the agenda of this meeting might help overcome this issue. Jane Millar and Charles Gutteridge are taking up issues of engagement with professional bodies

Minutes of previous meetingMinutes from 2019-03-26 Anesthesia CRG Meeting were agreed to be a true record of the meeting
Matters arising from the minutes

The group discussed the matter raised by Zac Whitewood-Moores regarding the anesthesia for xxxx codes. It was noted that they would create "noise" in an attempt to generate an anesthesia subset. To the group's knowledge it is the CPT codes themselves rather than the SNOMED equivalents that are used for billing and reimbursement in the USA. They would not conform to current SNOMED editorial guidelines. Agreed they should be retired from International release, possibly retained in US extension.

Outstanding SNOMED CT terminology requests

Include recent correspondence on CRS request 740106 Mechanical Insufflation - Exsufflation

Item not reached


Electronic Anaesthesia Record Development, Salford

Health issues coding in SNOMED CT

James Palmer

Daniel Weegmann

Discussion started with consideration of para of ACSA (Anaesthesia Clinical Standards Accreditation run by the Royal College of Anaesthetists). As currently drafted, these advocate the use of an electronic anaesthesia record in a fairly open way. Additional wording was suggested to mandate the use of record standards and controlled terminology which would be specified (HL7, open EHR, SNOMED CT) in the guidance notes. James Palmer will take these suggested revisions to ACSA for discussion and approval.

Daniel Weegmann gave a presentation on development work within the EPR at Salford Royal Hospitals Trust. This presentation focused on the move from free text entry to structured records based on health issues. Health issues have been gradually structured into Clinical terms (diagnoses, problems), Procedures and Risk factors. Entries since October 2018 are SNOMED encoded. Various methods of searching EPR records were demonstrated on a test data base.

A list of 18 significant anaesthesia issues (significant assessments or events that would have significant bearing on future procedures had been identified and implemented.

The group agreed that this work represented real progress in EPR functionality and utility. It was agreed that the team from Salford would be invited to present their anaesthesia records at the April 2020 meeting.

James Palmer raised some terminology issues:

1) At risk of difficult airway - existing number of finding terms. An at risk term would be included in terminology requests

2) Calder score (airway assessment - jaw protrusion) . Andrew Norton commented that for assessment scales to be included in SNOMED there needed to be a reasonable evidence base and a clear defintion - from internet search did not appear that these criteria were met but it would be further researched.

Post meeting note: There are SNOMED CT terms for reducued mandibular protrusion findings., original reference for Calder scale Anaesthesia 1992 47 582-9.

Definitions for coma and unconsciousnessPaul Amos

See prior discussion on Confluence:

"There are a number classification concepts currently within the terminology which are of the form: 

450569000 |Traumatic brain injury with loss of consciousness one hour or more (disorder)| 

in addition there seems to be an overlap between the use of the terminology to describe coma v loss of consciousness.  ..."

Some discussion took place in the morning with the Salford representatives present. James Palmer suggested that a definition of coma would be a GCS of 7 or below(suggesting need for airway support) + an AVPU (as part of NEWS scoring) of U. Discussion noted that the preferred way of doing this kind of assessment is Glasgow Coma Scoring and that GCS thresholds in definitions of coma and unconsciousness vary .

It was agreed that further input would be sought from Ed Cheetham (has already contributed in the discussion pages) and from the Academy of Medical Royal Colleges (via RCoA). Andrew Marchant is trying to get a contribution to the discussion from neurosurgeons in Edinburgh.

Afternoon session

Paul Amos noted the problems and overlap in defintions for coma and unconsciousness and there are a number of poor compound terms for brain injury many of which are ambiguous or imprecise. The QA initiative is hoping to remove ambiguous terms. There will be some additions to SNOMED for representation of Glasgow Coma Scoring

NICE (UK National Institute for Clinical Excellence) guidance on brain injury supports the use of Glasgow Coma Scoring with frequent remeasurement as indicated clinically.

The ICD 11 definition of coma was reviewed but it was felt that this added confusion and was factually incorrect in some respects " Acute state lasting more than one hour and usually less than a month. The comatosed patient is unresponsive, lying with his/her eyes closed and cannot be aroused even by vigorous and noxious stimuli. Motor responses to noxious stimulation are limited to reflexive behavior. "

It was agreed that it would be helpful to produce a short briefing paper including as much as possible a consensus definition of coma, recognise the imprecision of definition of unconsciousness and concussion (the latter by definition has to have traumatic aetilogy) and support the clean up of SNOMED CT eliminating ambiguous dual concepts.

SNOMED updatesMonica Harry

Monica Harry mentioned her new role as content manager and noted the quality assurance process taking place with regard to existing SNOMED CT content


SNOMED CT content for anaesthesia records

HL7 International Anesthesia Work Group; HL7 Domain Analysis Model for intraoperative anesthesia records

Presentations to and discussion with invited leaders of Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland

Discussion paper "RCOA Council briefing paper on anaesthesia relevant coding" JJ Pandit, J Palmer & I Moppett - copy in meeting files

Andrew Norton gave a short presentation on the history, development and current content of SNOMED CT to support anaesthesia information management systems(AIMS) and the potential uses of SNOMED CT encoding that could be made for both clinical noting and a wide range of local and national reporting purposes. It was noted that historically the RCoA and AAGBI had published standards for and recommended content of paper anaesthesia records and it was proposed that this would also be useful to support electronic anaesthesia records.

It was suggested that at some stage there will be much wider implementation of AIMS in the UK and therefore wise to plan now in terms of professional recommendations for their implementation. To that end a discussion (item 5 above) was held to suggest some revisions and additions to the ACSA standards as regards electronic anaesthesia records.

Ian Green outlined SNOMED International structures, the international release, National Release Centres and the potential role and benefit of subsets.

Jaideep Pandit noted that the Royal College of Anaesthetists now has a coding panel (remit outlined in Coding Briefing paper outline Vers1.docx

The group also discussed the PRSB (Professional Records Standards Body) Standards for the Structure and Content of Health Care Records, noting that as currently published these relate to more general documents such as discharge summaries with no published example of a specialised record such as anaesthesia or invasive cardiology procedures. The rigorous standards for endorsement and wide engagement were noted. This will be discussed further with the RCoA representatives to the PRSB (Professor Ian Moppett and James Palmer

Kathleen Ferguson and Jaideep Pandit outlined a number of considerations in a move towards AIMS systems including:

  • Ability to support time dependency and costing aspects dependent on patient complexity and comorbidity
  • Information governance and security issues, especially with information transfer for secondary purposes
  • Interoperability and integration between AIMS and wider hospital and primary care systems
  • Performance gain vs workload aspects of AIMS

It was requested that the RCoA and AAGBI give consideration to developing some fairly high level recommendations for the implementation of electronic anaesthesia records that would include informatics standards to be used, record content and potential secondary use purposes of such records.

HL7 Anesthesia DAM discussion

Martin Hurrell gave a presentation describing the role of HL7 as a standards body, an outline of the purpose of a Domain Analysis Model. He then went on to demonstrate UML class diagrams to represent particular areas of activity and how these are used to generate a document from the DAM model. The DAM is of potential use to a developer as a road map in terms of a conceptual framework that could proceed to the production of an implementation guide as a detailed resource from which to build systems.

Summary points for plenary closing sessionAndrew NortonSummary points were noted including the presentations from Salford, discussion with leaders of the profession, clinical engagement and the discussions on coma, unconsciousness and associated terms.
Any other business
Next meeting

Tuesday, May 28, 2019

Meeting Files

Coding Briefing paper outline Vers1.docx

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  1. Hi Andrew,

    I have multiple clashes at the April Business meetings this year.

    Would it be possible to schedule the session on Coma v Loss of Consciousness as the first item on Wednesday afternoon at 13.30, I will then have to leave to join another group.

    Apologies for the late notice.

    Regards, Paul

  2. Paul,

    Sure we can manage something - James Palmer is only able to attend in the morning and we have some invited guests from the Royal College and Association of Anaesthetists coming around 2pm, so we might have some discussion in the morning and then we can pick things up with you when you are able to join.

    Best wishes


  3. Hello, as intimated at the last conference call, I haven't been able to be reased from clinical duties to attend this meeting. I may join for short periods via ZOOM if my clinic allows.

    Apologies, Andrew Marchant.