STB CICU Collection Guide
This article contains collection information specific to the STB CICU (cardiac sciences) at St Boniface.
Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at StB in the program or unit level articles.
See the following for more general information:
Unit admission log book
The unit admission log book is kept at the main desk in front of where the ward clerk sits along with a binder to keep the completed TISS and green sheets as well.
Ward contacts
If you have questions ask the ward clerk or charge nurse.
Collector "base"
You can sit at the main desk behind the ward clerk to read charts or at the individual patient desks if the nurse is away.
Location of patient chart components
Patient charts and clipboards are in front of the individual cubicles.
Project ABO TEE
In this file I enter blood type and pre-CBP(pre coronary bypass) RV and LV function. You will find the TEE report in the operation section of the chart,usually at the back. If it is not there mark unavailable in the drop down list.
- Question: if there is no TEE done pre-CPB (cardiopulmonary bypass), then can you use a pre-op standard Echo-cardiogram for this?--LKolesar 13:19, 2015 September 16 (CDT)
Special Situations
TEVAR - Thoracic Endovascular aortic repair
I use the appropriate aneurysm repair code and then code peripheral angiogram to indicate this was done in the angio suite percutaneously and not in the OR through a sternotomy. Still code as coming from OR.(Need to change this to actual place coming from see below):
- Do you put the pt as coming from Interventional Radiology or Heart Cath Lab??--LKolesar 14:32, 2017 July 14 (CDT)
TAVI - Transcatheter aortic valve implantation
Minimally invasive, done through large vessel or small incision in chest. I code AVR Repair/Replace then either peripheral angiogram or thoracotomy depending which approach they use. Then code Aortic Stenosis or Aortic Insufficiency.
- Question: What code do you use for a "peripheral angiogram" in TEVAR and TAVI? Is this a coronary angiogram? Also, do you count the angiogram in the lab counts?--LKolesar 13:15, 2015 September 16 (CDT)
- They do not do a coronary angiogram, they approach the valve through a femoral artery cutdown doing a peripheral angiogram to access the artery and aorta. I started coding both AVR and angiogram to indicate the AVR was not done the usual way through a sternotomy. --LBilesky 14:22, 2017 May 25 (CDT)
- There is a whole different discussion going on under Valvuloplasty related to this. Should these be coded as Valvuloplasty or AVR Repair/Replace? The answer eventually might better live in those articles, since they are really more relevant to the dx than to how to code at STB, right? Ttenbergen 17:10, 2017 May 18 (CDT)
Bentall Procedure
This is a combination of aortic valve and or aortic root replacement and ascending aorta replacement. If they replace the root they will reimplant the coronary buttons. I code AVR and TAA for this.
Vasoplegia (vasoplegic syndrome)
This is a combination of low SVR and high CO post surgery requiring cardiac bypass and hypothermia. Some of the cardiac patients develop this post op and require volume and or inotropes usually vasopressin.
ECMO Patient Type
I put the VA ECMO patients down as surgical because they are admitted under a Surgeon in my unit. Lois