Operating Theatres Data Standards - Phase 1

For reference only Do Not Use For more information contact: cdsis@nhs.net Operating Theatres Data Standards - Phase 1 November 2006 National Clinical Dataset Development Programme (NCDDP) Support Team Information Services Area 54E Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Tel: 0131 275 7053 Email to: NCDDPsupportteam@isd.csa.scot.nhs.uk Website: www.show.scot.nhs.uk/clinicaldatasets/

Contents CONTENTS OVERVIEW & BACKGROUND... 4 Overview... 4 Operating Theatres Phase 1 Data standards... 5 Background to NCDDP... 5 Clinical Terminology... 6 Date & Time Recording... 6 SECTION 1: GENERIC DATA ITEMS... 8 Generic Data Standards... 8 SECTION 2: PATIENT DETAILS... 9 2.1 ASA status... 9 2.2 NCEPOD category... 10 SECTION 3: OPERATING ENVIRONMENT... 12 3.1 Operating room type... 12 3.2 Operating session type... 13 3.3 Operating list type... 14 3.4 Specialty of session... 15 3.5 Operating hours... 17 3.6 Time of day/night... 18 3.7 Operating List/Session Start Date and Time... 18 3.8 Operating List/Session Finish Date and Time... 20 3.9 Reason for cancellation of list/session... 22 3.10 Reason for late start of list/session... 23 3.11 Reason for late finish of list/session... 23 SECTION 4: THEATRE PROCESSES AND OPERATIVE PROCEDURES... 25 4.1 Specialty of procedure... 25 4.2 Type of theatre case... 27 4.3 Management intent... 28 4.4 Dates and times of theatre processes and operative procedures... 28 4.5 Date and Time of Booking {Operating theatres}... 30 4.5 Operative procedure performed indicator... 31 4.6 Reason operative procedure not performed... 31 SECTION 5: HEALTHCARE PROFESSIONALS... 33 5.1 Associated Professional Role {Operating theatres}... 33 5.2 Associated Professional Grade {Operating theatres}... 35 5.3 Level of surgical/clinical supervision... 36 5.4 Level of anaesthetic supervision... 37 SECTION 6: SOURCE AND DESTINATION OF PATIENT... 38 6.1 Source of admission to operating theatre... 38 6.2 Intended destination from operating theatre/recovery... 39 6.3 Actual destination from operating theatre/recovery... 40 APPENDICES... 41 2

Appendix 1 - Working Group... 41 Appendix 2 - Consultation Distribution List... 42 3

Overview & Background Overview In order to correspond with the Audit Commission s definition of well used operating theatre units in Scotland, the National Theatres Project Steering Group was set up to ensure that relevant data items and their definitions are common throughout NHS Scotland to allow staff to measure and manage their performance against others, both in terms of quality of patient care and efficient utilisation of theatre facilities, and to support the process of service development as described in Building a Health Service Fit for the Future. This group reports to the National Benchmarking Project Board, which in turn is overseen by the Chief Executives. A Glossary of Terms and Definitions for Theatres was created following completion of a process, which combined significant clinical and professional input, liaison with relevant parties, and widespread consultation. The National Theatres Project sought to have this accepted as the national standard across NHS Scotland, and had consequently requested the National Clinical Dataset Development Programme to be involved in the development of data standards for Theatres. An operating theatres phase 1 data standards working group was established in March 2006 consisting of existing members of the National Theatres Project group supported by members of the National Clinical Dataset Development Programme support team. For the purpose of these data standards, the term theatres as used in the title broadly encompasses any operating environment where interventional procedures codeable in Office of Population Censuses & Surveys 4th Revision (OPCS4) take place. The operating theatres phase 1 data standards will: Define common data items recommended for collection in a wide variety of theatre settings Support the consistent recording of information throughout operating theatres within NHS Scotland and other Healthcare providers in Scotland. Allow institutional, clinical groups and individual clinicians accountability for theatre utilisation. Be freely and widely available through publication in the Health & Social Care Data Dictionary It is important to understand that these are data standards, not a dataset. This means that the individual data items included in this document need not all be recorded together in clinical systems but, where it is considered appropriate to record a particular data item 4

as part of a person s care record, it should be recorded in accordance with the nationally agreed standard. We are now asking for feedback from the wider clinical community in order to ensure that these data standards are fit for purpose and ready for inclusion in the national Health and Social Care Data Dictionary. We invite all interested organisations and individuals to take part in this consultation by completing the attached Consultation Response Form and then returning it to NCDDPsupportteam@isd.csa.scot.nhs.uk. Comments on all or any part of the document are welcome. Some background information on the NCDDP and the dataset development can be found below. If you have any further queries, please go to our website or contact NCDDPsupportteam@isd.csa.scot.nhs.uk. Operating Theatres Phase 1 Data standards The membership of the Operating Theatres Data standards Working Group is shown in Appendix 1. This group agreed the inclusion of individual data items using the following criteria: Is the data item required by all those involved in the running of operating theatres? Will it prevent unnecessary duplication of recording? Once consultation is compete the Theatre Data standards will be submitted to the NCDDP Programme Board for formal approval as a national standard, and then passed to the ehealth National Clinical Information Steering Group for endorsement. Once approved the Theatre Data standards will be freely and widely available through publication in the Health and Social Care Data Dictionary. Where possible the data standards are UK compatible. It is expected that the Operating Theatres Data standards will be implemented within existing and emerging national clinical information systems and commercially procured national products, as well as being available to commercial developers to ensure the ability of their systems to support national information requirements. Background to NCDDP The National Clinical Dataset Development Programme (NCDDP) supports clinicians to develop sets of interoperable national data standards to facilitate the implementation of the integrated care records across NHS Scotland. These standards will: Support direct patient care, by reflecting current best practice guidance Facilitate effective communication between health care professionals Improve data quality and support secondary data requirements where possible including data to support clinical governance Be freely and widely available through publication in the web based Health & Social Care Data Dictionary Incorporate agreed national clinical definitions and implement national terminology Be UK compatible where possible 5

The programme was established by the Chief Medical Officer in 2003 to support clinicians developing national clinical data standards, initially to support the national priority areas. These standards are an essential element of the Electronic Health Record, a central aim of the National e-health Strategy. More information can be found on our website. Clinical Terminology The strategic standard for clinical terminology in NHS Scotland is SNOMED-Clinical Terms. This means that clinical information systems will record clinical data using this international standard. It is intended that the NCDDP Support Team will develop recommended SNOMED CT specifications as part of the data standards and datasets it supports. This work will be commenced once SNOMED CT tools become available. Date & Time Recording It is good record-keeping practice always to identify the date of recording of any clinical information. It is expected that all clinical information systems should include date stamping as standard functionality. In many clinical situations, the date of an event, investigation, etc. is required for clinical purposes and should be visible to the health care professional (it will be seen that dates and times appear quite prominently in the Operating Theatres Data Standards). It is important to note that the date of an event may not be the same as the date on which the data are entered onto the system. In these instances the system must allow the health care professional to enter whichever date is appropriate. These issues must be addressed during system specification and development. The date format for storage and management within a system should conform to the Government Data Standards Catalogue format: CCYY-MM-DD. However, this does not preclude entry or display of data on the user interface using the traditional DD-MM-CCYY format. An example of a date & time in correct format is: 1997-07-16T19:20:30+01:00 (CCYY- MM-DDThh:mm:ssTZD). It is recommended that a time should always be recorded with the appropriate date and not on its own; however, it may not be necessary to display the date along with the time. This is of particular importance where any calculations or analyses are likely to be performed. Automated times recorded by IT systems should include all elements of the time, i.e. hours, minutes and seconds, and are expected to be actual. Where times are entered manually, it is likely that only the hours and minutes will be required, although in some circumstances only hours may be required. Time, or any element of the time (hours, minutes or seconds) may be actual or estimated. In some circumstances only an actual time may be acceptable, whilst in others an estimated time may be allowed. In the latter situation, it may be necessary to identify whether the time recorded is actual or estimated. Times identified as actual may be used in calculations and analyses. Times marked as estimated should be treated with caution and the implications of undertaking any calculations or analyses should be 6

considered in the particular context within which the time is recorded or to be made subsequent use of. Where an estimated time is allowed, the appropriate degree of verification detail required should be decided, again dependent on the context in which it is recorded and how the time is to be used. Government Data Standards Catalogue 1. All times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00. 2. Values of any element less than 10 should be entered with a zero in the first position. 3. All times for UK transactions/events will be assumed to be GMT. 4. Systems should record whether the time is Coordinated Universal Time or British Summer Time in the Time zone designator. This will allow time elapsed to be calculated correctly, for example for A&E waiting times. 7

Section 1: Generic Data Items Generic Data Standards Data standards, which are relevant to all patients and are used across specialties, disciplines and settings have already been developed by wider Generic Data Standards clinical working groups and approved as national data standards for NHS Scotland. The Operating Theatres Data Standards working group selected five generic data items for inclusion in their standards. The names and definitions of these items are listed in this document for information. The detail of these existing standards are available on the web based Health and Social Care Data Dictionary or by contacting barbara.iwinska@isd.csa.scot.nhs.uk. Data Item Definition 1.1 CHI Number The Community Health Index (CHI) is a population register, which is used in Scotland for health care purposes. The CHI number uniquely identifies a person on the index. 1.2 Person Birth The date on which a person was born or is officially deemed to have Date been born, as recorded on the Birth Certificate 1.3 Associated Associated Professionals are those individuals who are involved with Professionals the client/ patient in a professional capacity e.g. consultant, social 1.4 Associated Professional Group 1.5 Health Record Identifier worker, occupational therapist, etc. The recognised professional group to which the care professional belongs and in which they are employed. A Patient Health Record Identifier is a code (set of characters) used to uniquely identify a patient within a health register or a health records system e.g. PAS. 8

Section 2: Patient Details 2.1 ASA status Common name: Patient status Main source of standard: American Society of Anaesthesiologists. Definition: The ASA PS classification globally assesses the degree of "sickness" or "physical state" prior to selecting the anaesthetic or prior to performing surgery. Format: characters Field length: 2 Code P1 P2 P3 P4 P5 P6 Description A normal healthy patient. A patient with mild systemic disease. A patient with severe systemic disease A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive without the operation. A declared brain-dead patient whose organs are being removed for donor purposes. Further information: The American Society of Anaesthesiologists (ASA) physical status classification serves as a guide to better communication among anaesthesiologists about clinical conditions of patients. The ASA classification system by itself does not predict risk. However, one can estimate higher or lower medical risk when factoring anaesthetic technique and the extent of surgical trauma. 9

2.2 NCEPOD category Common name: NCEPOD urgency categories Main source of standard: National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Classification of Interventions, December 2004 Definition: NCEPOD classification categorizes the urgency of the patient s intervention. Format: characters Field length: 3 (NCEPOD Classification of Interventions, December 2004) Code Value Sub code Sub value 01 Immediate Definition: Life, limb or organ saving intervention Explanatory notes Resuscitation simultaneous with surgical treatment. The target time to theatre is within minutes of decision taken to operate. e.g. Ruptured aortic aneurysm, major trauma to abdomen or thorax, fracture with major neurovascular deficit etc. 02 Urgent Definition: Acute onset or deterioration of conditions that threaten life, limb or organ survival. A Intervention within 6 hours The target time to theatre is within 6 hours of decision to operate and normally once B Intervention within 24 hours 03 Expedited Definition: Stable patient requiring early intervention for a condition that is not an immediate threat to life, limb or organ survival. resuscitation is complete. The target time to theatre is within 24 hours of decision to operate and normally once resuscitation is complete. The target time to theatre is within days of decision to operate. 10

04 Elective Definition: Surgical procedure planned or booked in advance of routine admission to hospital Target time to theatre is planned. Encompasses all conditions not classified as immediate, urgent or expedited. Further information: Apart from defining the urgency of the patient s intervention, the classification also informs clinicians and managers responsible for preparing procedure lists and allocating theatres on the day (day to day communications) checks that patients are operated on within the time frame appropriate for their condition (patient experience and clinical governance) checks that medical staff are operating out-of-hours only when it is appropriate (clinical governance) and reviews the allocation of types of patient to types of theatre session in order to take appropriate corrective action within the current organization of surgical, radiological and cardiological services and to aid further development of these services (organization and planning). NCEPOD recommends that the consultant who will perform the intervention should assign the category. This should be done at the time of the decision to operate and when the theatre is booked.. 11

Section 3: Operating environment 3.1 Operating room type Main source of standard: Adapted from National Theatres Project Definition: The type and setting of the room in a hospital where an interventional procedure codeable in OPCS4 takes place. Format: Numeric Field length: 3 Code Value Sub code Sub value 01 Category 1 Main theatre suite A B C D Operating theatre Anaesthetic room Recovery room Procedure room 02 Category 2 A Satellite or isolated theatre B Day theatres 03 Category 3 A Endoscopy Suite B Radiology C Cardiac Catheterisation Lab D Procedure room E Pain clinic 04 Category 4 A ICU B A & E C Wards 98 Other Any other location not included in the above Further information: An operating room accommodates patients at a time during and only during the period in which, under the direct supervision of a practitioner, the patient can undergo operative treatment for the prevention, cure, relief or diagnosis of disease. Healthcare providers, at a local level, may have unique identifiers for each operating room by allocating local codes, numbers, letters or names. Satellite theatres are operating theatres situated out with the main operating theatre suite. 12

3.2 Operating session type Main source of standard: National Data Dictionary, Connecting for Health, England Definition: The type of period of operating time allocated to a consultant. Format: Characters Field length: 3 Codes Value Sub Sub value Explanation code 01 Scheduled A Planned Periods of theatre time allocated to a consultant, usually on a regular basis, in which the Consultant or a member of the firm can perform operations, the majority of which have been arranged beforehand. The maximum duration of a scheduled session is a notional half-day B Emergency Periods of time allocated to a Consultant on a regular basis for patient whose visit to the operating theatre was not foreseen but takes place as a result of illness or a complication requiring an urgent operation. The maximum duration of a scheduled session is a notional halfday e.g. trauma sessions / sessions sometimes locally known as CEPOD sessions. 02 Unscheduled Periods of time allocated to one or more consultants outside scheduled sessions allocated to a consultant and used by that consultant or one of the same main specialty, for specific Theatre Case, usually at short notice 13

3.3 Operating list type Main source of standard: Adapted from National Theatres Project Definition: The type of published list, which consists of a set of patients who are to be operated on in a session. The list documents the patients and the details of their impending operation. Format: Characters Field length: 2 Code Value Explanation 01 Elective An operating list that comprises of solely elective cases. 02 Emergency An operating list that comprises of solely emergency cases. Further information: An elective list consists of patient details, proposed operation and laterality. An emergency list consists of the time of booking and clinical priority (see NCEPOD classification), in addition to the contents of the elective list. NCEPOD classifications 1 & 2 usually refer to emergencies, whilst NCEPOD classifications 3 & 4 normally refer to electives. 14

3.4 Specialty of session Main source of standard: National Data Dictionary, SMR Definition: The specialty of the consultant to whom the operating session has been allocated. A specialty is defined as a division of medicine or dentistry covering a specific area of clinical activity and identified within one of the Royal Colleges or Faculties. Format: Characters Field length: 3 Code Value A1 General Medicine A2 Cardiology A7 Dermatology A9 Gastroenterology AA Genitourinary medicine AM Palliative Medicine AQ Respiratory Medicine C1 General Surgery C12 Vascular Surgery C3 Anaesthetics C4 Cardiothoracic Surgery C41 Cardiac surgery C42 Thoracic surgery C5 Ear, Nose & Throat C6 Neurosurgery C7 Ophthalmology C8 Trauma and orthopaedics C9 Plastic surgery CA Paediatric Surgery CB Urology D3 Oral Surgery F2 Gynaecology F3 Obstetrics G1 General psychiatry H1 Clinical Radiology R11 Surgical podiatry TBD Dental surgery TBD Maxillofacial TBD Interventional radiology 98 Other (specify) 15

Further information: Specialties denoted by TBD (To Be Determined) do not have existing codes at present. Once codes are allocated, they will be notified appropriately. Although not available on SMR they are available in SNOMED. Where 98 - Other, specify is recorded, systems should provide an associated text box to accommodate a description of the specific value. Specialty of session is not necessarily the same as Specialty of procedure. 16

3.5 Operating hours Common name(s): Operating hours Main source of standard: National Theatres Project Definition: The hours during which the procedure was performed. Format: Characters Field length: 2 Code Value Explanation 01 Office hours 08:00 hrs to 17:59 hrs Monday to Friday 02 Out of hours 18:00 hrs to 07:59 hrs Monday to Friday and all day Saturday and Sunday Further Information: Formal sessions may exist out of hours but may be determined locally. 17

3.6 Time of day/night Main source of standard: National Theatres Project Definition: The period during which the procedure was carried out. Format: Characters Field length: 2 Code Value Explanation 01 Daytime 08:00 17:59 hours 02 Evening 18:00 23:59 hours 03 Night 00:00 07:59 hours Further Information: Formal sessions may exist out of hours but may be determined locally. 3.7 Operating List/Session Start Date and Time Main source of standard: Government Data Standards Catalogue Definition: The combined date and time of when the anaesthetist takes charge of the (first) patient in preparation for anaesthesia. The actual time and allocated time of handover can be recorded to identify variation from the scheduled operating list/session. Format: Characters (CCYY-MM-DDThh:mm:ssTZD) Field length: 25 N/A Sub Data Item: Status Code Value Explanatory notes 01 Allocated start time of Time when the anaesthetist is scheduled to take charge of the list/session (first) patient in preparation for anaesthesia 02 Actual start time of Time when the anaesthetist actually takes charge of the (first) list/session patient in preparation for anaesthesia. Related data items: Reason for late start of list/session Further information: For Audit purposes the following information can be derived: Planned hours of The difference between the Allocated start time of list/session and 18

list/session: List run time List under run List over run Allocated finish time of list/session. The time difference between the actual list/session start time and the actual list/session finish time. When the List run time is less than the Planned hours of list/session. The term, as used in the Acute Hospital Portfolio, does not necessarily mean the list finished early, as it might have started late. When the List run time exceeds the Planned hours of list/session. The term, as used in the Acute Hospital Portfolio, does not necessarily mean the list finished late, as it might have started early The Acute Hospital Portfolio is a collection of acute care topics for measuring NHS trusts performance. It includes indicators of quality of care, efficiency and effectiveness. An example of a date & time in correct format is: 1997-07-16T19:20:30+01:00 (CCYY-MM- DDThh:mm:ssTZD). It is recommended that a time should always be recorded with the appropriate date and not on its own. However, it may not be necessary to display the date along with the time. This is of particular importance where any calculations or analyses are likely to be performed. Times automatically recorded by IT systems should include all elements of the time, ie. hours, minutes and seconds, and are expected to be actual. Where times are entered manually, it is likely that only the hours and minutes will be required, although in some circumstances only hours may be required. Time, or any element of the time (hours, minutes or seconds) may be actual or estimated. In some circumstances only an actual time may be acceptable, whilst in others an estimated time may be allowed. In the latter situation, it may be necessary to identify whether the time recorded is actual or estimated. Times identified as actual may be used in calculations and analyses. Times marked as estimated should be treated with caution and the implications of undertaking any calculations or analyses should be considered in the particular context within which the time is recorded or to be made subsequent use of. Where an estimated time is allowed, the appropriate degree of verification detail required should be decided, again dependent on the context in which it is recorded and how the time is to be used. Recording guidance: Government Data Standards Catalogue All times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00. Values of any element less than 10 should be entered with a zero in the first position. All times for UK transactions/events will be assumed to be GMT. Systems should record whether the time is Coordinated Universal Time or British Summer Time in the Time zone designator. This will allow time elapsed to be calculated correctly. 19

3.8 Operating List/Session Finish Date and Time Main source of standard: Government Data Standards Catalogue Definition: The combined date and time when the anaesthetist hands over the care of the last patient to recovery staff. The actual time and allocated time of handover can be recorded to identify variation from the scheduled operating list/session. Format: Characters (CCYY-MM-DDThh:mm:ssTZD) Field length: 25 N/A Sub Data Item: Status Code Value Explanatory notes 01 Allocated finish time of list/session The time when the anaesthetist is scheduled to hand over the care of the last patient to recovery staff. 02 Actual finish time of list/session The time when the anaesthetist actually hands over the care of the last patient to recovery staff Related data items: Reason for late finish of list/session Further information: For Audit purposes the following information can be derived: Planned hours of list/session: List run time List under run List over run The difference between the Allocated start time of list/session and Allocated finish time of list/session. The time difference between the actual list/session start time and the actual list/session finish time. When the List run time is less than the Planned hours of list/session. The term, as used in the Acute Hospital Portfolio, does not necessarily mean the list finished early, as it might have started late. When the List run time exceeds the Planned hours of list/session. The term, as used in the Acute Hospital Portfolio, does not necessarily mean the list finished late, as it might have started early The Acute Hospital Portfolio is a collection of acute care topics for measuring NHS trusts performance. It includes indicators of quality of care, efficiency and effectiveness. An example of a date & time in correct format is: 1997-07-16T19:20:30+01:00 (CCYY-MM- DDThh:mm:ssTZD). It is recommended that a time should always be recorded with the appropriate date and not on its own. However, it may not be necessary to display the date along with the time. This is of particular importance where any calculations or analyses are likely to be performed. Times automatically recorded by IT systems should include all elements of the time, ie. hours, minutes and seconds, and are expected to be actual. Where times are entered 20

manually, it is likely that only the hours and minutes will be required, although in some circumstances only hours may be required. Time, or any element of the time (hours, minutes or seconds) may be actual or estimated. In some circumstances only an actual time may be acceptable, whilst in others an estimated time may be allowed. In the latter situation, it may be necessary to identify whether the time recorded is actual or estimated. Times identified as actual may be used in calculations and analyses. Times marked as estimated should be treated with caution and the implications of undertaking any calculations or analyses should be considered in the particular context within which the time is recorded or to be made subsequent use of. Where an estimated time is allowed, the appropriate degree of verification detail required should be decided, again dependent on the context in which it is recorded and how the time is to be used. Recording guidance: Government Data Standards Catalogue All times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00. Values of any element less than 10 should be entered with a zero in the first position. All times for UK transactions/events will be assumed to be GMT. Systems should record whether the time is Coordinated Universal Time or British Summer Time in the Time zone designator. This will allow time elapsed to be calculated correctly. 21

3.9 Reason for cancellation of list/session Common name(s): Theatre session cancellation reason Main source of standard: Raising the Standard, Royal College of Anaesthetists 2000 Definition: An explanation of why an operating list or session did not take place as planned. Format: Characters Field length: 3 Code Value Sub code Sub value 01 Public holiday 02 Cancelled by surgeon/main A Planned leave operator B Sick leave C On Call Z Other reason 03 Cancelled by anaesthetic A Planned leave department B Sick leave C Skill mix Z Other reason 04 Theatre Staff A Sick leave B Skill mix Z Other 05 Training/Continuing Professional Development 06 Maintenance 07 Equipment failure/unavailable 08 Administrative error 09 No ward beds 10 No High Dependency Unit beds available 11 No Intensive Care Unit beds available 98 Other reason for cancellation 99 Not known Further information: An Operating Theatre Session should be considered cancelled if the time slot allocation is not used to perform at least one operation. Recording guidance: Only one item to be recorded. More than one may be recorded for local purposes. 22

3.10 Reason for late start of list/session Common name(s): Reason for delayed start of list/session Main source of standard: Raising the Standard, Royal College of Anaesthetists 2000 Definition: An explanation for the theatre list/session starting later than its allocated start time. Format: Characters Field length: 2 Code Value 01 Porter not available 02 Patient arrived late to hospital 03 Patient not fasted 04 Patient not ready in ward 05 Patient not consented 06 Staff not available to accompany the patient 07 Investigations or x-rays missing 08 Blood not available 09 Intrusion of other specialty or emergency 10 Anaesthetist delayed 11 Surgeon/main operator delayed 12 Theatre staff delayed 13 Anaesthetic assistant delayed 14 Theatre not adequately staffed 15 Theatre not ready 16 Equipment failure/unavailable 98 Other 99 Not known Related data items: Allocated start time of list/session, Actual start time of list/session. Further information: Late starts to theatre sessions build in delays to lists and result in inefficient use of an expensive resource. By starting a list late, the possibility of overrunning and impinging on other sessions, or of cancellation of patients, is increased. Late start: When the Actual start time of list/session is later than the Allocated start time of list/session. Recording guidance: Only one item to be recorded. More than one may be recorded for local purposes. 3.11 Reason for late finish of list/session 23

Common name(s): Reason for overrun of list, Reason for theatre overrun. Main source of standard: Raising the Standard, Royal College of Anaesthetists 2000 Definition: An explanation for the list finishing later than its allocated finish time. Format: Characters Field length: 2 Code Value 01 Late start of list/session 02 Unexpectedly difficult procedure 03 Difficult or unexpected anaesthetic problem 04 Intrusion of other speciality 05 Intrusion of other emergency 06 Delayed availability of recovery facilities 07 Delayed availability of High Dependency Unit facilities 08 Delayed availability of Intensive care Unit facilities 09 List overbooked 10 Equipment failure/unavailable 98 Other 99 Not known Related data items: Allocated finish time of list/session, Actual finish time of list/session. Further information: Theatre time is an expensive resource and late finishes are disruptive to patients and staff. As well as increased costs, overruns also have implications on emergency theatre planning with evening emergency operating sessions being delayed whilst theatres finish their daytime workload. Late finish: When the Actual finish time of list/session is later than the Allocated finish time of list/session. 24

Section 4: Theatre processes and operative procedures 4.1 Specialty of procedure Common name(s): Specialty Main source of standard: National data dictionary, SMR Definition: The specialty of the consultant who is responsible for the patient s care. A specialty is defined as a division of medicine or dentistry covering a specific area of clinical activity and identified within one of the Royal Colleges or Faculties. Format: Characters Field length: 3 Code Value A1 General Medicine A2 Cardiology A7 Dermatology A9 Gastroenterology AA Genitourinary medicine AM Palliative Medicine AQ Respiratory Medicine C1 General Surgery C12 Vascular Surgery C3 Anaesthetics C4 Cardiothoracic Surgery C41 Cardiac surgery C42 Thoracic surgery C5 Ear, Nose & Throat C6 Neurosurgery C7 Ophthalmology C8 Trauma and orthopaedics C9 Plastic surgery CA Paediatric Surgery CB Urology D3 Oral Surgery F2 Gynaecology F3 Obstetrics G1 General psychiatry H1 Clinical Radiology R11 Surgical podiatry TBD Dental surgery TBD Maxillofacial TBD Interventional radiology 25

98 Other, specify Further information: Specialties denoted by TBD (To Be Determined) do not have existing codes at present. Once codes are allocated, they will be notified appropriately.. Although not available on SMR they are available in SNOMED. Where 98 - Other, specify is recorded, systems may be configured to include a text box to allow a description of the specific specialty. The procedure performed may not always correspond to the specialty of the allocated session e.g. when an orthopaedic theatre has to be interrupted to allow a leaking aortic aneurysm or other NCEPOD category 1 vascular case to be done due to the unavailability of a vascular surgery theatre. 26

4.2 Type of theatre case Main source of reference: National Theatres Project Definition: An indication of the type of patient visit to the operating theatre to undergo one or more operative procedures. Format: Characters Field length: 3 Code Value Sub code Sub value Explanation 01 02 Scheduled Unscheduled Includes scheduled or elective cases where the operation was planned in advance. Where the operation was unexpected or could not be planned in advance. A Emergency B Revisit to theatre When it was necessary for the patient to be referred to theatre for a further operation/procedure as a result of complication(s) related to a previous operation/procedure undertaken during the same episode of care. Related data items: NCEPOD category Further information: Scheduled or elective case means the operation was planned in advance. Recording guidance: It is recommended that the 2 character codes and values should be used as the minimum, but ideally the relevant sub-values should also be implemented (full 3 character codes). 27

4.3 Management intent Common name(s): Intended length of stay Main source of standard: UK Healthcare Commission (http://www.healthcarecommission.org.uk/assetroot/04/00/25/36/04002536.pdf) Definition: Whether or not the patient's attending clinician expects, at the time of booking, that the patient will be admitted and discharged on the same calendar day, or discharged on a subsequent date. Format: Characters Field length: 2 Code Value Explanation 00 None Where no decision has been taken 01 Inpatient Where the patient is expected to be discharged on a subsequent date following the procedure. 02 Day case Where the patient is expected to be discharged on the same calendar day after the procedure 03 Extended recovery unit Where patients are admitted, operated on and stay for one night post-operatively in a hospital facility (overall stay up to 23 hours). (International association for Ambulatory Surgery) 99 Not known 4.4 Dates and times of theatre processes and operative procedures Main source of standard: Government Data Standards Catalogue Definition: The combined date and time at which a specified component of theatre processes and operative procedures occurs. Format: Characters (CCYY-MM-DDThh:mm:ssTZD) Field length: 25 N/A Further Information: The National Theatres Project has identified the following times, during theatre processes and operative procedures, as being appropriate to be recorded. Time patient sent for The time that the theatre team sent the request for the patient to be 28

Time patient arrived in theatre premises Time into anaesthetic room Start time of anaesthesia Time into theatre Start time of procedure Finish time of procedure Time Patient entered recovery Time patient ready to leave recovery Time patient actually left recovery brought to the operating theatre department The time that the patient actually arrived in the operating theatre premises The time at which the patient was brought into the anaesthetic room The time of start of the anaesthetic procedure where this takes place either in the operating theatre or in the anaesthetic room The time at which the patient is transferred from the anaesthetic room into theatre The time of commencement of the procedure regardless of whether an anaesthetic is given or not. This should be knife to skin or equivalent. The time at which the procedure was finished and any dressings applied. The time at which the patient was transferred into the recovery area. The time at which the patient was assessed as meeting the discharge criteria of the recovery room The time at which the patient actually left the recovery room An example of a date & time in correct format is: 1997-07-16T19:20:30+01:00 (CCYY-MM- DDThh:mm:ssTZD) It is recommended that a time should always be recorded with the appropriate date and not on its own, however it may not be necessary to display the date along with the time. This is of particular importance where any calculations or analyses are likely to be performed. Automated times recorded by IT systems should include all elements of the time, i.e. hours, minutes and seconds, and are expected to be actual. Where times are entered manually, it is likely that only the hours and minutes will be required. Times identified as actual may be used in calculations and analyses. Start time of procedure does not include positioning, with the exception of manipulation of fractures. Recording guidance: 1. All times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00. 2. Values of any element less than 10 should be entered with a zero in the first position. 3. All times for UK transactions/events will be assumed to be GMT. 4. Systems should record whether the time is Coordinated Universal Time or British Summer Time in the "Time zone designator". This will allow time elapsed to be calculated. 29

4.5 Date and Time of Booking {Operating theatres} Main source of standard: Government Data Standards Catalogue Definition: The combined date and time at which the theatre team were notified that the patient required a procedure in theatre. Format: Characters (CCYY-MM-DDThh:mm:ssTZD) Field length: 25 N/A Further Information: An example of a date & time in correct format is: 1997-07-16T19:20:30+01:00 (CCYY-MM- DDThh:mm:ssTZD) It is recommended that a time should always be recorded with the appropriate date and not on its own, however it may not be necessary to display the date along with the time. This is of particular importance where any calculations or analyses are likely to be performed. Automated times recorded by IT systems should include all elements of the time, i.e. hours, minutes and seconds, and are expected to be actual. Where times are entered manually, it is likely that only the hours and minutes will be required. Times identified as actual may be used in calculations and analyses. Start time of procedure does not include positioning, with the exception of manipulation of fractures. System developers should adhere to the specific dates and times identified by the National Theatres Project. Recording guidance: 5. All times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00. 6. Values of any element less than 10 should be entered with a zero in the first position. 7. All times for UK transactions/events will be assumed to be GMT. Systems should record whether the time is Coordinated Universal Time or British Summer Time in the "Time zone designator". This will allow time elapsed to be calculated. 30

4.5 Operative procedure performed indicator Main source of standard: Audit Commission Report Definition: An indication of whether or not an operative procedure was performed. Format: Characters Field length: 2 Code Value 01 Procedure performed 02 Patient anaesthetised but procedure not performed 03 Procedure cancelled 99 Not known 4.6 Reason operative procedure not performed Common name: Reason procedure cancelled Main source of standard: AAGBI, National Theatres Project Definition: An explanation for an operative procedure not having taken place as planned. Format: Characters Field length: 3 Code Value Subcode Subvalue 01 Secretarial error 02 Cancelled by A Unable to attend patient B No longer wishes procedure C Did not attend reason not known Z Other 03 Cancelled by A Procedure not required Surgeon/main B Patient not prepared operator C Surgeon/main operator not available Z Other 04 Cancelled by A Patient not fit anaesthetist B Patient not prepared C Anaesthetist not available (Sickness) 31

05 Cancelled by theatre management 06 Cancelled by hospital 07 Preoperative guidance not followed 98 Other reason for cancellation 99 Not known D Z A B C D E F Z A B C D Z Anaesthetist not available (Skill mix) Other Staff not available (Sickness) Staff not available (Skill mix) Equipment not available Intervention by emergency case Intervention by priority case Lack of theatre time Other No ward bed No High Dependency Unit bed available No Intensive Care Unit bed available Administrative error Other 32

Section 5: Healthcare professionals 5.1 Associated Professional Role {Operating theatres} Definition: An indication of the role carried out by each professional. Professionals are those individuals who are involved with the client/patient in a professional capacity. Format: characters Field length: 3 Code Value 01 Consultant responsible for care 02 Operating surgeon/main operator (Main operating clinician) 03 Surgical first assistant (First operating assistant) 04 Assistant surgeon (Additional operating assistant) Sub code Sub value Explanation/definition Consultant who carries clinical responsibility for a patient s healthcare during an episode Clinician performing the procedure An individual who assists the operating surgeon in performing the procedure Any other individual (in addition to the first assistant) who assist the operating surgeon/clinician in performing the procedure 05 Supervising surgeon/clinician Surgeon/clinician supervising the procedure 06 Main anaesthetist Medical practitioner responsible for the administration of anaesthesia / sedation 07 Assistant anaesthetist Practitioner assisting the main anaesthetist in the administration of anaesthesia / sedation 08 Supervising anaesthetist A B Medical practitioner Non medical practitioner Anaesthetist supervising the anaesthetic procedure 33

09 Anaesthetic assistant Non-medical person assisting the anaesthetist/s in the administration of anaesthesia / sedation 10 Scrub practitioner Registered practitioner responsible for the preparation and handling of instrumentation, swabs, needles etc during a surgical procedure 11 Circulating Practitioner assisting the scrub practitioner 12 Recovery room practitioner practitioner Registered practitioner responsible for care of patient during recovery from procedure 13 Radiographer 98 Other Includes medical and nursing students, medical trainees, medical representatives, AHP trainees or any other observers 34

5.2 Associated Professional Grade {Operating theatres} Definition: The grade of the associated professional in the operating theatre. Format: Characters Field length: 2 Code Value 01 Consultant 02 Associate Specialist 03 Staff Grade 04 Specialist Run Through Training Number of years variable (ST1, ST2, ST3 etc.) 05 Fixed Term Specialist Training 1 FTST1 06 Fixed Term Specialist Training 2 FTST2 07 Specialist Registrar year 1-4 08 Senior House Officer 09 Foundation Year 2 (Senior House Officer 1) 10 Foundation Year 1 (Pre-Registration House Officer) 11 Nurse: Bands 2-8 12 Operating Department Practitioner 13 Operating Department Assistant 14 Physicians assistant - anaesthesia 15 Surgical practitioner 98 Other Attributes: Associated Professional status: Permanent Locum Temporary Agency Bank Further information: Specialist Programme also known as Specialist Run Through Training, will replace Specialist Registrar year 1 4and Senior House Officer from August 2007. Fixed Term Specialist Training 1 and Fixed Term Specialist Training 2 will be grades in parallel to run through training from August 2007. 35

5.3 Level of surgical/clinical supervision Definition: Where a non consultant is involved this indicates the level of supervision in place and the location or whereabouts of the supervising consultant/clinician. Format: Characters Field length: 3 Code Value 00 No supervision 01 Operating room Sub code Sub value A Present in operating room Scrubbed B Present in operating room Not scrubbed environment C In operating department but not in operating room 02 Office 03 Home 98 Other 36

5.4 Level of anaesthetic supervision Definition: Where a non consultant is involved this indicates the level of supervision in place and the location or whereabouts of the supervising consultant anaesthetist. Format: characters Field length: 3 Code Value Sub Sub value code 00 No supervision 01 Operating room A Present In operating room environment B In operating department but not in operating room 02 Office 03 Home 98 Other Further information: Code 01A is equivalent to the Royal College of Anaesthetists (RCA) Level 1. Code 01B is equivalent to RCA Level 2. Code 02 is equivalent to RCA Level 3 and Code 03 is equivalent to RCA Level 4. 37

Section 6: Source and destination of patient 6.1 Source of admission to operating theatre Definition: The originating location within the hospital from where the patient was brought to theatre. Format: Characters Field length: 2 Code Value Explanatory notes 01 Inpatient ward Local identifiers may include ward numbers, names etc. 02 Day bed unit 03 Emergency care unit 04 A&E 05 High Dependency Unit 06 Intensive Care Unit Synonyms include Critical Care Unit (Adult/Paediatric), Intensive Therapy Unit etc. 07 Admissions unit 98 Other source 38

6.2 Intended destination from operating theatre/recovery Definition: The planned or intended location to which the patient is to be sent from the operating theatre/recovery area. Format: Characters Field length: 2 Code Value Explanatory notes 01 Inpatient ward Local identifiers may include ward numbers, names etc. 02 Day bed unit 03 Emergency care unit 04 Extended recovery unit Where patients are admitted, operated on and stay for one night post-operatively in a hospital facility (overall stay up to 23 hours). (International association for Ambulatory Surgery) 05 High Dependency Unit 06 Intensive Care Unit Synonyms include Critical Care Unit (Adult/Paediatric), Intensive Therapy Unit etc. 07 Transfer to other hospital 08 Home 98 Other destination 39

6.3 Actual destination from operating theatre/recovery Definition: The actual location to which the patient was sent from the operating theatre/recovery. Format: Characters Field length: 2 Code Value Explanatory notes 01 Inpatient ward Local identifiers may include ward numbers, names etc 02 Day bed unit 03 Emergency care unit 04 Extended recovery unit Where patients are admitted, operated on and stay for one night post-operatively in a hospital facility (overall stay up to 23 hours). (International association for Ambulatory Surgery) 05 High Dependency Unit 06 Intensive Care Unit Synonyms include Critical Care Unit (Adult/Paediatric), Intensive Therapy Unit etc. 07 Transfer to other hospital 08 Home 09 Mortuary 98 Other destination 40

Appendices Appendix 1 - Working Group Membership of Theatres Data Standards Working Group Name Position Organisation Dr Jane Burns (Chair) Consultant Anaesthetist NHS Lanarkshire Anne Couser Senior Theatre Manager NHS Tayside Sandra Storrie Dataset development officer ISD Kirsty Anderson Dataset development officer ISD Dr Jagannathan Clinical Advisor NCDDP, ISD Sundaresan Dr Lorna Ramsay Clinical Lead NCDDP, ISD Leigh Brown Information Manager NCDDP, ISD 41

Appendix 2 - Consultation Distribution List Chief Executives Medical Directors Theatre managers NCDDP Stakeholders Association for perioperative practice (AfPP) Association of Operating Department and Practitioners (AODP) Clinical ehealth Leads Community Nursing Network (CNN) Electronic Community Health Information Project (echip) Health & Social Care Information Centre, Datasets Development Programme (England) Information Services Division, NSS Information Standards Group National Benchmarking Project Board NHS Board Directors of Public Health NHS Health Scotland NHS Quality Improvement Scotland Royal College of Paediatrics and Child Health Royal College of General Practitioners (Scotland) Royal College of Nursing (Scotland) Royal College of Physicians Royal College of Physicians and Surgeons Glasgow Royal College of Physicians, London Royal College of Surgeons Scottish Clinical Information Management Practice (SCIMP) Scottish ehealth Nursing Forum Scottish Executive Centre for Change and Innovation Scottish Executive Data Standards Branch Scottish Intercollegiate Guidelines Network Scottish Executive Health Department Society for Computing and Technology in Anaesthesia (SCATA) UK Data Standards Forum NCDDP Reference & Working Groups NCDDP Board NCDDP Support Team Clinical Information Standards Working Group (CISG) 42