Objectives

• To review the Anesthesia Quality Institute / National Anesthesia Clinical Outcomes Registry Data elements for outcomes with regard to SNOMED CT content, definitions and identify work to be undertaken to ensure comprehensive SNOMED CT content in this area 

Purpose

The purpose of this meeting was to review the outcome terms section (pages 28-65) of the Anesthesia Quality Institute (AQI) / National Clinical Anesthesia Outcomes Registry (NACOR) with regard to:

• Draft SNOMED coding of the elements
• Identify erroneous SNOMED CT codes
• Identify concepts for which SNOMED CT code available
• Make recommendations and request submissions to SNOMED International for additional terms
• Review definitions of the outcome data elements with a view to potential suitability for recommendation to SNOMED International to include in SNOMED RF2 release files

General observations

Some general observations with regard to the outcome data elements include:

• Some concepts are outcomes, some are physiological states
• It is useful to check definitions against other authoritative sources
• Definitions would normally need to be acceptable across more than one national domain for potential inclusion in SNOMED CT
• Sources of definitions should be referenced
• Severity coding / recording of reported outcomes is highly desirable
• Outcome data elements and definitions will be clarified and refined over time
• Who, what, where, when, why as components for reporting

Detailed discussion of data elements

The meeting reviewed a large number of the outcomes concepts, including

• There are some changes needed to preferred terms used for clarity of meaning
• Further work is required on the case cancelled terms (before anaesthesia start time, before induction time, after induction time. There are currently no SNOMED CT concepts to enable this degree of detail.
• Changes in SNOMED CT to difficult and failed intubation were noted as were the implications and need for a specific term for difficult mask ventilation
• Need to model concepts for ICU delirium and emergence delirium
• Not currently totally clear way of expressing high spinal and /or high epidural. Most suitable is Excessive cephalad spread of local anesthetic following regional anesthesia. May need new concepts or additional synonyms
• There is difficulty in currently coding the infection related to neuraxial and peripheral block terms. New concepts required and for further discussion at follow up meeting on 18/01/2017
• Terminology related to temporary and transient changes in blood pressure - most current SNOMED CT terminology is disorder rather than transient situation oriented. No suitable concept to record transient hypotension, especially in the anesthesia setting

Additional meeting 2pm CST 18/01/2017

Present

• user-d48df
• Heather Sherman
• Patrick McCormick
• Andrew Norton
• Terri Monk
• John Walsh

Background and AQI/NACOR conceptual data elements

An additional call was made to review progress made at the time noted above.

Arnold Berry gave an outline of the evolution of NACOR under the Anesthesia Quality Institute. It was noted that there was currently no underlying data dictionary with clear reference to submitters as to the meaning and constraints on concepts to be reported. Many providers of submissions to AQI are only able to provide billing data with little or no outcomes information

AB noted the need to enhance and develop the quality improvement activity in the NACOR database because of the financial incentives and penalties from CMS Medicare in relation to quality improvement activity and data submission

AB had led a working group to put together a data dictionary of conceptual elements for NACOR.  This had subsequently been published for field testing and comment from anesthesiologists. The results had informed the AQI/NACOR conceptual data elements  v2.0 published October 2016.  The IHTSDO Anesthesia SIG is now engaged to review the terminology and definitions of the data elements with a view to alignment with SNOMED CT and objectives outlined.

A further version of the data elements would be published in due course, hopefully with the addition of some co-morbidity information.

Terminology discussions arising from terminology review on 17/01/2017

• AN gave an outline of the terminology review of the data elements illustrating a number of the findings and suggestions from the Anesthesia SIG
• It was agreed that terminology to represent transient states of blood pressure change are needed in SNOMED CT, but members felt that the current definitions represent  degrees of change that would frequently be seen in anesthesia without necessarily representing a reportable adverse outcome.  AQI definitions would not be suitable for SNOMED CT
• Infection after neuraxial blocks and peripheral nerve blocks. AB explained how these were closely modelled from NSQIP and CDC reportable events for sepsis. Current SNOMED CT terminology only enables coding of a few of the elements defined here. Noted that concepts relating to infection after epidural anesthesia would have a wider context than surgical anesthesia - they could potentially occur after procedures in pain management and epidural analgesia for labour
• Case cancellation terms are significant in quality metrics for anesthesia. More specific terms as defined in the AQI/NACOR data elements are desirable for inclusion in SNOMED CT.

Actions agreed 

• IHTSDO Anesthesia SIG will complete the review of the outcomes section of the data elements. The edited outcomes document is available by request from Andrew Norton.
• The completed mapping of SNOMED CT to the outcome data elements will be returned to AQI including:
  • Suggested changes and corrections in SNOMED CT maps
  • Comments made during the mapping process
  • Planned submissions via the SNOMED Request Service for new terms
  • Definitions that are proposed for inclusion in SNOMED RF2 release files
  • Other concept definitions identified from authoritative sources during this review.

Meeting Files