New Jersey Department of Health

OPEN HEART SURGERY RISK STRATIFICATION PROJECT

DATA COLLECTION FORM, VERSION 4.3

A.	DEMOGRAPHICS
Patient: Last Name (1):
First Name (2):
MI(3):
Date of Birth (mm/dd/yyyy)(4):	/ /	Gender (5): Male = 0 Female = 1
SS# (6): __ __ __ - __ __ - __ __ __ __	Medical Record # (7):
Patient Zip Code (8): __ __ __ __ __
Race (9): White=1 Black=2 Asian=3 Native American/Alaska Native=4 Hawaiian/Other Pacific Islander=5 Other=6 Multiracial=7
Hispanic or Latino (10): No=0 Yes=1
Referring Cardiologist: Last Name (11):
First Name (12):
MI(13):
Referring Physician: Last Name (15):
First Name (16):
MI(17):

B.	HOSPITALIZATION
Hospital Code (18): __ __ __ __	Medical Facility Transferred From Code (19): __ __ __ __
Payor (20): Blue Cross/Blue Shield=1 Commercial=2 HMO=3 Medicaid=4 Medicare=5 Self-Pay=6 Tricare (CHAMPUS)=7
Uninsured/Indigent=8 Other=9
Date of Admission (mm/dd/yyyy)(21):	/ /	Date of Surgery (mm/dd/yyyy)(22):	/ /
Date of Discharge (mm/dd/yyyy)(23):	/ /
Discharged Where (24): Not Discharged=0 Home=1 Other Acute Care Hosp=2 Rehab/Sub-Acute/LTAC=3 Nursing Home=4
Other=5 Deceased=6 Left AMA=7 Hospice=8 Unknown=9

C.	PREOPERATIVE RISK FACTORS
Weight (25):
(kg) Height (26):
(cm)
Ever Smoker (27):	No=0 Yes=1
If Yes, Current Smoker (28):	No=0 Yes=1
Diabetes (29):	No=0 Yes=1
If Yes, Control Type (30): None=0 Diet=1 Oral=2 Insulin=3 Other/Other Subq=4
Dyslipidemia (31):	No=0 Yes=1
If Yes, Control Type (32): None=0 Statin=1 Non-Statin=2 Both=3
Last Creatinine Level Preop (33):
Renal Failure (34):	No=0 Yes=1
If Yes, Dialysis (35):	No=0 Yes=1
Hypertension (36):	No=0 Yes=1
Cerebrovascular Accident (37):	No=0 Yes=1
If Yes, When (38):	Recent <30 Days=1 Remote >30 Days=2
Cerebrovascular Disease (CVD) (39):	No=0 Yes=1
If Yes, Type of CVD (40):	Coma=1 CVA=2 RIND=3 TIA=4 Non-Invasive >79%=5 Prior Carotid Surgery=6
Moderate Disease 50-79%=7
Infectious Endocarditis (41):	No=0 Yes=1
If Yes, Type (42): Treated=1 Active=2
Chronic Lung Disease (43):	No=0 Mild=1 Moderate=2 Severe=3 Lung Disease Documented, Severity Unknown=4
Immunosuppressive Therapy (44):	No=0 Yes=1
Peripheral Vascular Disease (45):	No=0 Yes=1

D.	PREVIOUS CV INTERVENTIONS
Incidence (46):	First CV Surgery=1 First reop=2 Second reop=3 Third reop=4 Four or more reops=5
Prior PCI (47):	No=0 Yes=1
If Yes, Prior PCI-Interval (48): <6 Hours=1 >6 Hours=2

E.	PREOPERATIVE CARDIAC STATUS
Myocardial Infarction (49):	No=0 Yes=1
If Yes, When (50):	<6 Hours=1 >6 Hours but <24 Hours=2 1-7 Days=3 8-21 Days=4 >21 Days=5
Congestive Heart Failure (51):	No=0 Yes=1
Angina (52):	No=0 Yes=1
If Yes, Angina Type (53):	Stable=1 Unstable=2
Cardiogenic Shock (54):	No=0 Yes at the time of the proc=1 Yes not at proc but <24 hours=2
If Yes, Cardiogenic Shock Type (55):	Refractory Shock=1 Hemodynamic Instability=2
Resuscitation (56):	No=0 <1 Hour=1 >1 Hour but within 24 Hours=2
Arrhythmia (57):	No=0 Recent (<30 Days)=1 Remote (>30 Days)=2
If Yes, Arrhythmia Type (58):	None=0 Sust VT/VF=1 Heart Block=2 AFib/Flutter=3 Sick Sinus Syndrome=4
NYHA Classification (59):	I = 1 II = 2 III = 3 IV = 4

New Jersey Department of Health

OPEN HEART SURGERY RISK STRATIFICATION PROJECT

DATA COLLECTION FORM, VERSION 4.3 (Continued)

F.	PREOPERATIVE MEDICATIONS
Beta Blockers (60):	No=0 Yes=1
ACE Inhibitors/ARBs (61):	No=0 Yes=1
Contraindicated=2
Nitrates-IV (62):	No=0 Yes=1
Anticoagulants (63):	No=0 Yes=1
If Yes, Anticoagulant Medication Name (64): Heparin (Unfractionated)=1 Heparin (Low molecular)=2 Thrombin Inhibitors=3 Other=9
Coumadin (65):	No=0 Yes=1
Inotropes (66):	No=0 Yes=1
Steroids (67):	No=0 Yes=1
Aspirin (68):	No=0 Yes=1
ADP Inhibitor (69):	No=0 Yes=1
Glyco IIB IIIA (70):	No=0 Yes=1
Other (71):	No=0 Yes=1

G.	PREOPERATIVE HEMODYNAMICS AND CATH
Number of Diseased Coronary Vessels (Left Main Counts as Two) (72): None=0 One=1 Two=2 Three=3 Not Documented/Unknown=9
Left Main Disease (>50% Occlusion) (73):	No=0 Yes=1 Not Documented/Unknown=9
Ejection Fraction Done (74):	No=0 Yes=1
If Yes, Ejection Fraction % (75):
Ejection Fraction Method (76): LVgram=1 Radionuclide=2 Estimate=3 Echo=4 MRI=5 Other=6

H.	OPERATIVE PROCEDURE
Surgery: Last Name (77):
First Name (78):
MI(79):
License #(80):
Status of Procedure (81):	Elective=1 Urgent=2 Emergent=3 Emergent Salvage=4
If Urgent, Reason (82):	AMI=1 IABP=2 Worsening CP=3 CHF=4 Anatomy=5 USA=6 Rest Angina=7
Valve Dysfunction=8 Aortic Dissection=9 Angiographic Accident=10 Cardiac Trauma=11
Infected Device=12 Syncope=13 PCI/CABG Hybrid=14 PCI Failure w/o Clinical Deterioration=15
Aortic Aneurysm=16 Device Failure=17 Diagnostic/Interventional Procedure Complication=18
Endocarditis=19 Failed Transcatheter Valve Therapy=20 Intracardiac Mass or Thrombus=21
Ongoing Ischemia=22 PCI w/Clinical Deterioration=23 Pulmonary Edema=24
Shock Circ. Support=26 Shock No Circ. Support=27 Transplant=28 Other=29
If Emergent, Reason (83):	Shock Circ Supp=1 Shock No Circ Supp=2 Pulmonary Edema=3 AEMI=4 Ongoing Ischemia=5
Valve Dysfunction=6 Aortic Dissection=7 Angiographic Accident=8 Cardiac Trauma=9
Infected Device=10 Syncope=11 PCI/CABG Hybrid=12 Anatomy=13 Aortic Aneurysm=14
Congestive Heart Failure=15 Device Failure=16 Diag/Intervention Proc Complication=17
Endocarditis=18 Failed Transcatheter Valve Therapy=19 IABP=20
Intracardiac Mass or Thrombus=21 PCI Incomplete w/o Clinical Deterioration=22
PCI or attempted PCI w/Clinical Deterioration=23 Pulmonary Embolism=24 Rest Angina=25
Transplant=26 Unstable Angina=27 Worsening Chest Pain=28 Other=29
Operative Category (84): CAB=1 CAB+Valve=2 CAB+Other=3 CAB+Valve+Other=4 Valve=5 Valve+Other=6 Other=7
Robotic Technology used (85):	No=0 Yes=1
Minimally Invasive Incision Attempted (86):	No=0 Yes=1
If Yes, Conversion to Standard Incision (87):	No=0 Yes=1
CPB Utilization (88):	None=0 Combination=1 Full=2
If Combination or Full, Perfusion Time (min) (89):
Aortic Occlusion (90):	None=0 Aortic Crossclamp=1 Balloon Occlusion=2 Partial Crossclamp=3
If Aortic Crossclamp or Balloon Occlusion, Cross Clamp Time (min) (91):
Cardioplegia (92):	No=0 Yes=1
IABP (93):	No=0 Yes=1
If Yes, When Inserted (94):	Preoperatively=1 Intraoperatively=2 Postoperatively=3
Indication (95): Hemodynamic Instability=1 Procedural Support=2 Unstable Angina=3 CPB Wean=4 Prophylactic=5 Other=6
Blood Products Used During Surgery (96):	No=0 Yes=1

I.	CORONARY BYPASS
Number of Distal Anastomoses With Arterial Conduits (97):
Number of Distal Anastomoses With Venous Conduits (98):
Number of IMA Distal Anastomoses (99):
Number of Radial Artery Distal Anastomoses (100):
Number of Gastro-Epiploic Artery (GEPA) Distal Anastomoses (101):
Other Arterial Anastomoses (102):

New Jersey Department of Health

OPEN HEART SURGERY RISK STRATIFICATION PROJECT

DATA COLLECTION FORM, VERSION 4.3 (Continued)

J.	VALVE SURGERY
Aortic (103):	No=0	Replacement (excluding TAVR)=1 Repair/Reconstruct=2 Root Reconstruction with Valve Conduit=3

Replacement + Aortic Graft Conduit (not a valve conduit)=4 Root Reconstruction with Valve Sparing=5

Resuspension Aortic Valve with Replacement of Ascending Aorta=6

Resuspension Aortic Valve w/o Replacement of Ascending Aorta=7 Resection Sub-Aortic Stenosis=8

Apico-Aortic Conduit=9 Autograft with Pulmonary Valve-Ross Procedure=10 Homograft=11

Transcatheter AV Replacement=12
Mitral (104):	No=0	Annuloplasty Only=1 Replacement (excluding Transcatheter)=2 Reconstruction with Annuloplasty=3

Reconstruction without Annuloplasty=4 Transcatheter Replacement=5
Tricuspid (105):	No=0	Annuloplasty Only=1 Replacement (excluding Transcatheter)=2 Reconstruction with Annuloplasty=3

Reconstruction without Annuloplasty=4 Valvectomy=5 Transcatheter Replacement=6
Pulmonic (106):	No=0 Replacement (excluding Transcatheter)=1 Repair/Reconstruction=2 Valvectomy=3

Transcatheter Replacement=4

K.	OTHER PROCEDURES
Left Vent Aneurysm Repair (107):	No=0 Yes=1
Vent. Septal Defect Repair (108):	No=0 Yes=1
Atrial Septal Defect Repair (109):	No=0 Yes=1
Surgical Ventricular Restoration (110):	No=0 Yes=1
Congenital Defect Repair (111):	No=0 Yes=1
TMR (112):	No=0 Yes=1
Cardiac Trauma Repair (113):	No=0 Yes=1
Cardiac Transplant (114):	No=0 Yes=1
Pacemaker (115):	No=0 Yes=1
AICD (116):	No=0 Yes=1
Atrial Fib Correction (117):	None=0 MAZE=1 Other=2 Combination=3 Left Atrial Appendage Ligation/Removal=4
Aortic Aneurysm Repair (118):	No=0 Yes=1
Other Cardiac (119):	No=0 Yes=1
Carotid Endarterectomy (120):	No=0 Yes=1
Other Vascular (121):	No=0 Yes=1
Other Thoracic (122):	No=0 Yes=1
VAD (123): None=0 LVAD=1 RVAD=2 BiVAD=3
Other non-Cardiac (124)	No=0 Yes=1

L.	IN HOSPITAL COMPLICATIONS
OPERATIVE:	INFECTION:
Reop-Bleeding/Tamponade (125):	No=0 Yes=1
Sternal-Deep (131):	No=0 Yes=1
Reop-Valvular Dysfunction (126):	No=0 Yes=1
Thoracotomy (132):	No=0 Yes=1
Reop-Graft Occlusion(127):	No=0 Yes=1
Leg (133):	No=0 Yes=1
Reop-Other Cardiac Problem (128):	No=0 Yes=1
Septicemia (134):	No=0 Yes=1
Reop-Other Non-Cardiac Problem (129):	No=0 Yes=1
UTI (135):	No=0 Yes=1
Perioperative MI (130):	No=0 Yes=1
NEUROLOGIC:	PULMONARY:
Postoperative Stroke For >24 Hrs (136):	No=0 Yes=1
Prolonged Ventilation (139):	No=0 Yes=1
Transient Neurologic Deficit (137):	No=0 Yes=1
Pulmonary Embolism (140):	No=0 Yes=1
Coma/Encephalopathy (138):	No=0 Yes=1
Pneumonia (141):	No=0 Yes=1
RENAL:
Renal Failure (142):	No=0 Yes=1
If Yes, Dialysis (143):	No=0 Yes=1
VASCULAR:
Iliac/Femoral Dissection (144):	No=0 Yes=1
Acute Limb Ischemia (145):	No=0 Yes=1
OTHER:
Heart Block (146):	No=0 Pacemaker=1 ICD=2
Pacemaker/ICD=3 Other=4
Cardiac Arrest (147):	No=0 Yes=1
Anticoagulant (148):	No=0 Yes=1
Tamponade (149):	No=0 Yes=1
GI Complication (150):	No=0 Yes=1
Multi System Failure (151):	No=0 Yes=1
A-Fib/Flutter (152):	No=0 Yes=1
Aortic Dissection (153):	No=0 Yes=1
Other (154):	No=0 Yes=1
If Yes, Specify (155):

New Jersey Department of Health

OPEN HEART SURGERY RISK STRATIFICATION PROJECT

DATA COLLECTION FORM, VERSION 4.3 (Continued)

M.	MORTALITY
Discharge Status (156): Alive=1 Dead=2
Status at 30 Days after Surgery (160): Alive=1 Dead=2 Unknown=3
If Dead, Date of Death (mm/dd/yyyy) (157):	/ /
Location of Death (158):	OR During Initial Surgery=1 Hospital=2 Home=3 Other Care Facility=4

OR During Reoperation=5 Unknown=6 Extended Care Facility=7 Hospice=8

Acute Rehab=9 Other=10
Primary Cause of Death (Select Only One) (159):

Cardiac=1 Neurologic=2 Renal=3 Vascular=4

Infection=5 Pulmonary=6 Valvular=7 Other=8 Unknown=9

HCQ-9

DEC 16	Page 2 of 4 Pages

DEC 16	Page 1 of 4 Pages

HCQ-9, formerly HCQO-22, Open Heart Surgery Risk Stratification Project, Data Collection Form

HCQ-9, (formerly HCQO-22), Health Care Quality Assessment, Open Heart Surgery Risk Stratification Project, Data Collection Tool, Open Heart Surgery, Version 4.1

EWhite

2016-11-29

NJDHSS