Welcome, and thank you for joining this learning activity titled CVASC Registry Education to Sequence Numbers. This is a learning activity with focused education on the sequence numbers in the permanent pacemaker portion of the CVASC registry. After participation in this learning activity, the learner should be able to identify, discuss, and explore the sequence number elements in the permanent pacemaker portion of the registry. This presentation includes many elements at once and is provided as baseline education. In addition to this education, the user can search individual portions of this presentation by accessing individual videos using the search functionality provided. We thank you for choosing the American College of Cardiology's CVASC registry, and we'd like to welcome you to the team. If you have any questions after watching these educational resources, please let us know via the contact us feature on your registry homepage. Now buckle in for some educational time as we navigate the sequences in the registry. Cardiac arrest is defined as an acute cardiac event documented by one of the following ventricular fibrillation or rapid ventricular tachycardia or bradycardia with hemodynamic compromise causing loss of consciousness or PEA or asystole. Once an acute cardiac event defined as above is met, then it needs to require cardiopulmonary resuscitation of two or more chest compressions or open chest massage, emergent temporary pacing, pericardiocentesis, institution of ECMO or defibrillation. As without these measures, death would have almost certainly resulted. Also note, if an event occurs that meets the above definition of cardiac arrest, you're going to code yes regardless of a resuscitation status such as DNR, hospice, or comfort care. Cardiac tamponade is captured when a patient experiences fluid in the pericardial space compromising cardiac filling and requiring intervention. This information must be documented by either one echocardiogram showing pericardial fluid and signs of tamponade such as right heart compromise or two systemic hypotension due to pericardial fluid compromising cardiac function. A pocket hematoma is captured when the patient experiences one because of the EPDI procedure, whether it's a permanent pacemaker or ICD, requiring a re-operation, evacuation, or a transfusion. Myocardial infarction is captured when the patient experiences a new occurrence of biomarker positive myocardial infarction. At least one determination of biomarkers obtained no sooner than six hours after the procedure and preferably within the interval of six to 24 hours post-procedure should be used. The notes further clarify for sites to code yes when there's new QAs diagnosed by advanced practice professionals are present with absent, incomplete, or inconclusive biomarkers. Additionally, when biomarkers are not obtained in the setting of post-PCI acute MI, yes will be coded. Stroke is captured when the patient experiences an ischemic or hemorrhagic stroke. Ischemic stroke is defined as an acute episode of focal or global neurological dysfunction caused by brain, spinal cord, or retinal vascular injury because of infarction of the central nervous system tissue. A hemorrhagic stroke is defined as an acute episode of focal or global cerebral or spinal dysfunction caused by intraperenchymal, intraventricular, or subarachnoid hemorrhage. If a patient experiences a subdural hematoma, these are considered intracranial hemorrhagic events, but they're not strokes in and of themselves. You may notice some events do not have a data definition attached. This was intentional as these will require a physician diagnosis. However, we will expand on what these events are for your own knowledge. Cardiac perforation may or may not be symptomatic and may or may not be self-sealing. It can be documented by migration of pacing or defibrillator leads to the epicardial surface, resulting in pain or hypotension, pericardial effusion, cardiac tamponade, failure to capture, of the diaphragm, phrenic nerve or intercostal muscles, or sufficient magnitude to require repositioning. Coronary venous dissection is caused by manipulation of the pacing or defibrillating leads in the coronary sinus, which can result in a tear of the coronary sinus endothelium with dissection into the coronary sinus wall, sometimes at times referred to as staining, following contrast injection. This can also result in perforation of the coronary sinus. Hemothorax is an accumulation of blood in the thorax. Pneumothorax is an accumulation of air in the thorax, and lastly, TIA is a transient episode of focal neurological dysfunction caused by brain spinal cord or retinal ischemia without acute infarction. Since 9002, intra-post-procedure events occurred is indicating if the specified event did or did not occur between the start of the procedure and until next procedure or discharge. The term procedure in the target value is in reference to the CAP-PCI or EPDI procedure, and while this data element is shared with our hospital registries, where multiple procedures may occur during one episode of care, the ASC registry was initially built to handle one pathway per episode of care. Thus, the target value for an ASC is better understood if written any occurrence between start of procedure and discharge. Sequence 9255, set screw problem, is indicating if the patient had a pacing or sensing problem associated with high impotence due to a poor connection between a lead and device caused by a loose set screw between completion of the EPDI procedure as coded in sequence 7005, procedure ending time, and until next procedure or discharge. And while this data element is shared with our hospital registries, where multiple procedures may occur during one episode of care, the ASC registry was initially built to handle one pathway per episode of care. Thus, the target value for an ASC is better understood if written any occurrence between completion of the procedure or discharge. Sequence 9260, lead dislodgement, is indicating if the patient experienced a lead dislodgement as documented by movement of a lead that requires repositioning and re-operation between completion of the EPDI procedure as coded in sequence 7005, procedure ending time, and until next procedure or discharge. The repositioning and re-operation can occur at any time. And while this data element is shared with our hospital registries, where multiple procedures may occur during one episode of care, the ASC registry was initially built to handle one pathway per episode of care. Thus, the target value for an ASC is better understood if written any occurrence between completion of the procedure and discharge. When a lead becomes dislodged prior to discharge, sequence 9265, lead location dislodgement, is capturing the location of the dislodged lead. These are the selections for lead location. Each definition is available in the data dictionary, and we encourage you to read through them and become familiar with the terminology. Please take a few moments, if needed, to read through this slide. Sequence 10101, discharge date and time, is indicating the date and time the patient was discharged from your facility, as identified in the medical record. Sequence 10105, discharge status, is indicating whether the patient was alive or deceased at discharge. Sequence 10110, discharge location, is indicating the location to which the patient was discharged. Home would be selected any time a patient returns to their place of residence. This includes assisted living facilities. Skilled nursing facility would be selected when the patient returns to a facility for a longer anticipated length of stay. An extended care or transitional care or rehab unit typically provides a high level of intensive therapy as well as specialized nursing and physician care. This discharge setting may also be called subacute care or long-term acute care. And when a patient is discharged to one of these types of facilities, this selection would be selected. Other would be selected when the patient discharges anywhere other than the options provided. This would include facilities such as a jail. If the patient is discharged or transferred to another hospital that provides acute care services, then acute care hospital would be selected. If the patient was discharged or eloped against medical advice, then left against medical advice would be selected. Since 15608 emergent transfer to acute care hospital is indicating if the transfer to the acute care hospital was done emergently, the term emergent is defined as a situation where the absence of immediate higher level of medical attention could result in a severe life-threatening or possibly disabling condition. If the patient was discharged to an acute care hospital, the suspected condition or conditions prompting the transfer are captured in sequence 15702 suspected conditions. The options include concerns for a gastrointestinal bleed, a retroperitoneal bleed, or another bleed that is neither gastrointestinal or retroperitoneal, NSTEMI, other vascular complications, stroke or a TIA. If the suspected condition prompting the transfer is not available for selection, then other would be coded. In clinical scenarios where there is no suspected condition documented prompting the transfer, none documented would be coded. Each CV ASC procedure pathway is assigned unique and specific discharge medications. The entire team, including ambulatory, surgery center, and office-based lab stakeholders thoughtfully and concisely appointed these medications to their respective pathway based on reporting needs and keeping in mind the need for a lean data set. So while the data dictionary lists every possible discharge medication that could be used within the entire registry, constraints are applied in the back end to allow certain medications to appear once a specific pathway is selected in the data collection tool. Thus, the easiest means to know which medications are captured for a single procedure is the data collection form. Additionally, discharge medications will only be made available for capture if the patient is alive at discharge or rather and they discharge anywhere other than another acute care hospital or leaving against medical advice. Discharge medications are controlled by the medication master file, which is managed by the NCDR. If additional medications need added for capture, the NCDR will update the master file. For ACC data collection tool users, these updates occur automatically. For third-party vendor tool users, the list is made available for downloading and uploading into the application from the ASC registry website under resources with the label technology downloads. Use 10205, discharge medications prescribed, is capturing if a certain medication was prescribed, not prescribed, or was not prescribed for either a medical or patient reason on discharge. Yes, would be selected if a certain medication was prescribed on discharge. No, no reason would be selected if a certain medication was not prescribed post-procedure or for discharge and there was no mention of a reason why it was not ordered within the medical documentation. No medical reason would be selected if a certain medication was not prescribed post-procedure or for discharge and there was a reason documented related to a medical issue or concern for not prescribing that medication. A medication that is acceptable to code no medical reason must include a specific reason the medication was not prescribed. Examples of acceptable documentation include physician documentation that the medication was not prescribed due to an existing medical condition, an intolerance or allergy to a medication, active bleeding, oral anticoagulation therapy as pre-arrival medication, as a medical exception to prescribing aspirin. Examples of acceptable documentation continued include specific reasons for not prescribing one medication would apply to the entire class. This gives the physician credit for addressing and assumes reasons provided applies to the entire class. As an example, documentation of no plavix due to bleeding risk supports coding no medical reason for all P2Y12 inhibitors. Another example of acceptable documentation continued includes general clinician documentation, patient contraindication without specifying the exact contraindication. As an example, documentation of patient has contraindication to aspirin supports coding no medical reason for aspirin. Documentation that is either absent or too generic or general is not acceptable to support coding. The physician's documentation may indicate a decision was made not to prescribe a specific medication, however, the reason or contraindication is not implicitly provided. No patient reason would be selected if a certain medication was not prescribed post-procedure or for discharge and there was a reason documented related to the patient's preference.

sequence numbers

CVASC registry

permanent pacemakers

cardiac events

discharge documentation