NCDR® PVI Registry™(Peripheral Vascular Intervention Registry) v 2 Carotid Artery Stenting, Carotid Endarterectomy and Carotid PTA Module- DRAFT A. DEMOGRAPHICS
First Name2010:
Last Name2000: SSN2030:
-
Birth Date2050:
Race:
(check all that apply)
□ SSN N/A2031
-
Middle Name 2020:
Patient ID2040:
Other ID2045:
(auto)
□
Patient Zip Code3005:
Sex2060: O Male O Female
mm / dd / yyyy
Zip Code N/A3006
□ White2070 □ Black/African American2071 □ American Indian/Alaskan Native2073 □ Asian2072 If Yes, □ Asian - Indian2080 □ Chinese2081 □ Filipino2082 □ Japanese2083 □ Korean2084 □ Vietnamese2085 □ Other2086 □ Native Hawaiian/Pacific Islander2074 If Yes, □ Native Hawaiian2090 □ Guamanian or Chamorro2091 □ Samoan2092 □ Other Island2093
Hispanic or Latino Ethnicity2076 : O No
If Yes, Ethnicity Type: (Select all that apply)
O Yes
□ Mexican, Mexican-American, Chicano
2100
□ Puerto Rican2101
□ Cuban2102
□ Other Hispanic, Latino or Spanish Origin2103
B. EPISODE OF CARE
Arrival Date/Time3000/3001:
mm / dd / yyyy HH:MM
Admitting Provider Name, NPI 3050,3051,3052,3053: Attending Provider Name, NPI
3055,3056,3057,3058
:
_______,__,___________________,______________ _______,__,___________________,______________
O No O Yes Health Insurance3005: N674 If Yes, Payment Source : (Select all that apply)
□ Private Health Insurance □ State-Specific Plan (non-Medicaid)
□ Medicare □ Medicaid □ Military Health Care □ Indian Health Service □ Non-US Insurance
HIC # 3030: Research Study3035:
O No
□ Patient RestrictionN683
O Yes
If Yes, Study Name3036, Patient ID3037:
_______________, _________
C. HISTORY (LEADING TO EPISODE OF CARE)
Hypertension4000: Dyslipidemia
O No
4005
:
Coronary Artery Disease4025: 4065
Prior Myocardial Infarction
:
If Yes, Within 30 Days4070: PCI 4090: CABG 4095: Heart Failure4080:
O Yes
O No
O Yes
O No
O Yes
O No
O Yes
O No
O Yes
O No O No
O Yes O Yes
O No
O Yes
5210
If Yes, NYHA Class w/in 2 weeks O Class III O Class I O Class II
O Yes
LV Systolic Dysfunction108:
O No
O Yes
O No _______%
O Yes
O No
O Yes
O No
O Yes
O No
O Yes
Chronic Kidney Disease : If Yes,Currently On Dialysis 4020:
O No
O Yes
O No
O Yes
Chronic Lung Disease4060:
O No
O Yes
4100
Prior Valve Surgery/Procedure
Prior History of Arrhythmia
:
109
Positive Cardiac Stress Test C112
:
C114
:
cm
Weight4120:
_______
4010
O No
Diabetes Mellitus : If Yes, Diabetes Therapy C120: □ None □ Diet □ Oral Anginal Classification w/in 2 Weeks
Cerebrovascular Disease
O No
If Yes, Pre-Procedure LVEF 5700:
_______
5205
:
Hemorrhagic Stroke
O Yes
O No symptoms O CCSI O CCSII O CCSIII O CCSIV
4040
Stroke4041: Nxxx
kg
□ Insulin □ Other
Peripheral Artery Disease History 4050:
: O Class IV
Cardiomyopathy107:
Pre-Procedure LVEF Assessed 5701:
Height 4115:
:
O No
O Yes
O No
O Yes
O No
O Yes
O No
O Yes
Tobacco Use 4105: O Current - Some Days O Never O Current, Frequency Unknown O Former O Current, Every Day If any Current, Tobacco Type4626 (select all that apply) □ Cigarettes □ Cigars □ Pipe □ Smokeless If Current - Every Day and Cigarettes, Amount O Light tobacco use (< 10/day) O Heavy tobacco use (>= 10/day)
4627
Page 1 of 11
NCDR® PVI Registry™(Peripheral Vascular Intervention Registry) v 2 Carotid Artery Stenting, Carotid Endarterectomy and Carotid PTA Module - DRAFT C. HISTORY (LEADING TO EPISODE OF CARE, CONTINUED)
Neck Radiation4125:
O No 4130
Neck Surgery (other than CEA)
: 4145:
Previous Carotid Revascularization
O No
O Yes
O No
O Yes
If Yes, Type/Side:
Tracheostomy Present4135:
O Yes
Laryngeal Nerve Palsy
4140
:
Right
Carotid Artery Stent4150,4170:
O No
O Yes
O No
O Yes - Right O Yes - Left O Yes - Bilateral
Left
4155 O No O Yes If Yes, Date : mm / dd / yyyy O No O Yes
If Yes, Date 4175: mm / dd / yyyy
Carotid Endarterectomy4160,4180: O No O Yes If Yes, Date4165: mm / dd / yyyy O No O Yes
If Yes, Date 4185: mm / dd / yyyy
Carotid PTA 113, 115:
O No O Yes If Yes, Date
114
:
mm / dd / yyyy
O No O Yes
If Yes, Date
116
: mm / dd / yyyy
CVD Presentation5200: O Asymptomatic O Acute evolving stroke
O TIA O Ischemic Stroke
O IC Hemorrhage or Hemorrhagic Stroke 5200
, TimeframeN684:
If yes to any CVD
O ≤ 60 days O ≥ 60 days to 180 days O ≥ 180 days D. PRESENTATION AND EVALUATION (COMPLETE FOR EACH PROCEDURE. LEADING TO THE PROCEDURE)
Ambulation Status
158
:
O No functional limitations O Ambulates with assistive devices
Pre-Admission Living 159: O Home Independent O Home with Caregiver CSHA Clinical Frailty Score
1 160
:
O Wheelchair/stretcher bound
O Skilled Nursing Facility
O 1 = Very Fit O 2 = Well O 3 = Well, with treated comorbid disease O 4 = Apparently Vulnerable O 5 = Mildly Frail
O Homeless
O Other
O 6 = Moderately Frail O 7 = Severely Frail O 8 = Very Severely Frail O 9 = Terminally Ill
PRE-PROCEDURE ASSESSMENT (COMPLETE FOR EACH PROCEDURE TYPE, ONLY FOR SIDE(S) AFFECTED)
RIGHT Duplex Ultrasound Performed 5360,5560:
O No
O Yes
O No O Yes _________cm/sec
5365,5565
:
_________cm/sec
5370,5570
:
_________cm/sec
_________cm/sec
_________
_________
If Yes, Peak Systolic Velocity
If Yes, End Diastolic Velocity If Yes, ICA/CCA Ratio
LEFT
5375,5575
:
O No O Yes _________ %
O No O Yes _________ %
:
_________ %
_________ %
5430,5630
O No O Yes _________ %
O No O Yes _________ %
If Yes, ICA Max % Stenosis 5435,5635:
_________ %
_________ %
CT Angiography Performed
5395,5595
:
If Yes, CCA Max % Stenosis If Yes, ICA Max % Stenosis
5400,5600
:
5405,5605
MR Angiography Performed 5425,5625: If Yes, CCA Max % Stenosis
:
NIH Stroke Scale Total Score 5710: _______
Modified Rankin Score5705: O 0: No symptoms at all O 3: Moderate disability O 1: No sig disability despite symptoms O 4: Mod severe disability O 2: Slight disability O 5: Severe disability
Date Administered5706: mm / dd / yyyy
□ Not Administered5707
Date Administered5711:
mm / dd / yyyy
□ Not Administered 5712
Examiner Name 5715,5720,5725: Certified 5730:
O No
O Yes
1
Canadian Study of Health and Aging Clinical Frailty Scale is Used with Permission For The American College of Cardiology Foundation By Dr. Kenneth Rockwood (© Kenneth Rockwood, MD)
Page 2 of 11
NCDR® PVI Registry™(Peripheral Vascular Intervention Registry) v 2 Carotid Artery Stenting, Carotid Endarterectomy and Carotid PTA Module- DRAFT I. PRE-PROCEDURE MEDICATIONS (ADMINISTERED WITHIN 24 HOURS PRIOR TO THE PROCEDURE, COMPLETE FOR EACH PROCEDURE TYPE) 7800
MEDICATION
ADMINISTERED
DOSAGE961
7805
Direct Thrombin Inhibitors P2Y12 Antagonists
Thrombolytics
Thrombin Receptor Antagonist
Antiplatelets
VitK Ant
Direct Factor Xa Inhibitors
Anticoagulants
Heparin and Derivatives
Low
ACE-I
Other
PCSK9 Inhibitor PDE Inhibitor
High
Fondaparinux
O No
O Yes
Low Molecular Wt Heparin
O No
O Yes
Unfractionated Heparin
O No
O Yes
Heparin / Derivative (Other)
O No
O Yes
Argatroban
O No
O Yes
Bivalirudin
O No
O Yes
Dabigatran
O No
O Yes
Apixaban
O No
O Yes
Edoxoban
O No
O Yes
Rivaroxaban
O No
O Yes
Direct Factor Xa Inhibitors (Other)
O No
O Yes
Warfarin
O No
O Yes
Aspirin
O No
O Yes
Dipyridamole
O No
O Yes
Glycoprotein IIb/IIIa Inhibitor (Any)
O No
O Yes
Clopidogrel
O No
O Yes
O No
O YesN717
Prasugrel
O No
O Yes
O No
O YesN718
Ticagrelor
O No
O Yes
O No
O YesN719
Vorapaxar
O No
O Yes
Alteplase
O No
O Yes
Reteplase
O No
O Yes
Streptokinase
O No
O Yes
Tenecteplase
O No
O Yes
Thrombolytic (Other)
O No
O Yes
ACE-Inhibitor (Any)
O No
O Yes
ARB (Any)
O No
O Yes
Valsartan/Sacubitril
O No
O Yes
Beta Blockers (Any)
O No
O Yes
Calcium Channel Blockers (Any)
O No
O Yes
Diuretics (Any)
O No
O Yes
Vasodilators (Any)
O No
O Yes
Statin (Any)
O No
O Yes
O No
O YesN698
Alirocumab
O No
O Yes
Evolocumab
O No
O Yes
PCSK9 Inhibitors (any)
O No
O Yes
Phosphodiesterase Inhibitor (Any)
O No
O Yes
ARB
Sta tin
Moderate
Loading Dose Administered Pre-Procedure
O
O
O
Page 3 of 11
NCDR® PVI Registry™(Peripheral Vascular Intervention Registry) v 2 Carotid Artery Stenting, Carotid Endarterectomy and Carotid PTA Module- DRAFT E. PROCEDURE (COMPLETE FOR EACH PROCEDURE TYPE)
Procedure Start Date/Time6000/6001:
Procedure End Date/Time6005/6006:
mm / dd / yyyy / hh:mm
Operator Name6015, 6020, 6025: Operator Assistant Name
Procedure Type6010:
Operator NPI
N685, N686, N687
O Carotid Artery Stent : O Elective
:
Operator Assistant NPIN688:
:
6035
Procedure Status
mm / dd / yyyy / hh:mm
(break scrub at end of case) 6030
O Carotid Endarterectomy
O Urgent
O Carotid Percutaneous Transluminal Angioplasty
O Emergency
O Cath Lab O IR O OR O Hybrid O Free-standing clinic Location of Procedure 6038 : 6041 O Urgent Cardiac Surgery w/in 30 days Procedure Indication : O Asymptomatic O Restenosis in Target Vessel, prior CEA O Spontaneous Carotid Artery Dissection O Restenosis in Target Vessel, prior CAS O Symptomatic Lesion w/in 6 months Sedation 6050:
O No Sedation O Minimal Sedation/Anxiolysis O Moderate Sedation/Analgesia (Conscious Sedation)
O Deep Sedation/Analgesia O General Anesthesia
Blood Pressure303, 304: (lowest during procedure) _______ / _______ mmHg Blood Pressure
Heart Rate 307: (lowest during procedure) _______ bpm
305, 306
□ Alcohol □ Iodine □ Chlorhexidine
Skin Prep309: (select all that apply) Target Vessel6045:
Heart Rate 308: (highest during procedure) _______ bpm
: (highest during procedure) _______ / _______ mmHg
O Right Carotid O Left Carotid
Contralateral Carotid Artery Occlusion 6070:
Fibromuscular Dysplasia of Carotid Artery Peri-Operative Antibiotic Indicated
O No
O Yes
: O No
O Yes
6075
N450
:
O No
If Yes, Administered within 1 hour of incision st
If Yes, Antibiotic 1 or 2
nd
312
: 314
Generation Cephalosporin
:
If Yes, Antibiotic discontinued within 24 hours of procedure Intra-Procedure Vasopressor AgentsN689: Intra-Procedure Atropine
O No
N690
:
O No
N691
Intra-Procedure NTG
:
O No
313
:
O Yes
O Yes
O No – No Reason
O No – Medical Reason
O Yes
O No – No Reason
O No – Medical Reason
O Yes
O No – No Reason
O No – Medical Reason
O Yes
Intra-Procedure Thrombolytics N451:
O No
O Yes
O Yes
Intra-Procedure AnticoagulantsN180 :
O No
O Yes
O No
O Yes
O No
O Yes
If Yes, Heparin
O Yes
N181
:
If Yes,Direct Thrombin Inhibitor
E107
:
ARTERIAL ACCESS (COMPLETE FOR EACH CAS. CODE IN THE ORDER ATTEMPTED.)
Site(s)6200 1
2
Side6205
Vessel6211
O Right O Left
O Femoral O Radial O Brachial/Axillary
O Carotid O Other
O Right O Left
O Femoral O Radial O Brachial/Axillary
O Carotid O Other
Closure Method(s)6220,25,30
□ Not Documented
□ Not Documented
UDI6235-6245
1
(future)
2
(future)
1
(future)
2
(future)
BEST (VISUAL) ESTIMATE OF VASCULAR ANATOMY (COMPLETE FOR EACH CAS. CODE MOST SEVERE LESION IN EACH VESSEL.) Aortic Arch Type6250: O Type I Bovine Arch N692:
O No
O Type II
O Type III
O Not Documented
O Yes Right – Max Stenosis
Native Vessel
_________%
□ CTO
Internal Carotid:
_________%6335
□ CTO6336 □ Not Available6337
_________%6435
□ CTO6436 □ Not Available6437
Vertebral:
_________%6340
□ CTO6341 □ Not Available6342
_________%6440
□ CTO6441 □ Not Available6442
6331
□ Not Available
Left – Max Stenosis
Common Carotid:
6330
6332
6430
_________%
□ CTO6431 □ Not Available6432
Page 4 of 11
NCDR® PVI Registry™(Peripheral Vascular Intervention Registry) v 2 Carotid Artery Stenting, Carotid Endarterectomy and Carotid PTA Module- DRAFT G. CAROTID STENT AND PTA PROCEDURE (COMPLETE FOR EACH CAROTID PROCEDURE ATTEMPTED OR PERFORMED)
Lesion Counter 7300:
1
Lesion Location7305:
O Isolated CCA O Isolated ICA
Lesion Difficult to Access Surgically7310: 7315
If Yes, Lesion Location
:
Thrombus Present7320:
Ulceration
7325
:
O No
2
O Bifurcation
O Isolated CCA O Isolated ICA
O Yes
O No
O Yes
O High Cervical (C2 or higher) O Low Intrathoracic (below clavicle)
O High Cervical (C2 or higher) O Low Intrathoracic (below clavicle)
O No
O Yes
O No
O Yes
O No
O Yes
O No
O Yes
Calcification7330:
O None O Dense
Lesion Length7335:
_______mm
Stenosis Immediately Prior to Rx7350:
_______%
Embolic Protection Attempted7355:
O No
O Yes
O No
O Yes
If Yes, Pre-dilation Prior to EPD Deployment7360:
O No
O Yes
O No
O Yes
If Yes, Pre-dilation Prior to Attempted Stent Implant7365 (after Embolic Protection Device):
O No
O Yes
O No
O Yes
If Yes, Total Filter/Total Reversal TimeN693:
O Bifurcation
O Mild to Moderate O Concentric
O None O Dense
O Mild to Moderate O Concentric
_______mm
(use NASCET technique unless CCA)
_______minutes
_______%
_______minutes
Post-dilation Performed7370: Procedure Treatment Incomplete or Aborted7375: If Yes, Reason(s) Procedure Treatment AbortedN694: (Select all that apply) □ Failure to gain vascular access □ Hypotension □ Hypertension □ Arrhythmia □ Cardiac ischemia □ Other
O No
O Yes
O No
O Yes
O No
O Yes
O No
O Yes
Lesion Treatment Incomplete or Aborted N695: If Yes, Reason(s) Lesion Treatment AbortedN696: (Select all that apply)
O No
O Yes
O No
O Yes
Post-Procedure Final Stenosis 7400:
________%
□ □ □ □ □ □ □ □ □
(use NASCET technique unless CCA)
Failure to confirm significant stenosis Unable to deploy EPD Unable to place guide catheter / sheath Unable to deliver stent Unable to deploy stent Difficult to access due to tortuosity Unable to cross guidewire Unable to cross balloon Other
□ □ □ □ □ □ □ □ □
Failure to confirm significant stenosis Unable to deploy EPD Unable to place guide catheter / sheath Unable to deliver stent Unable to deploy stent Difficult to access due to tortuosity Unable to cross guidewire Unable to cross balloon Other
O Not documentedN697 ________%
(use NASCET technique unless CCA)
O Not documented
(use NASCET technique unless CCA)
LIST ALL DEVICES IN CHRONOLOGICAL ORDER: Device(s) Used7410,7415 1 2 3
Associated Lesion(s)7420 (Specify Lesion Counter, Seq. 7300)
Device Activated7425
UDI7430-7440
______ , ______, ______
O No
O Yes
(future)
______ , ______, ______
O No
O Yes
(future)
______ , ______, ______
O No
O Yes
(future) Page 5 of 11
NCDR® PVI Registry™(Peripheral Vascular Intervention Registry) v 2 Carotid Artery Stenting, Carotid Endarterectomy and Carotid PTA Module- DRAFT H. CAROTID ENDARTERECTOMY PROCEDURE (COMPLETE FOR EACH CAROTID ENDARTERECTOMY ATTEMPTED OR PERFORMED)
Arteriotomy Patch Used7600: 7605
Thrombus Present
O No
(on direct visual inspection):
Shunt Used7610:
O No 7615
Surgical Procedure Terminated
O No
O No
O Yes
O Yes
O Yes
If Yes, Reason(s) for Termination of Surgery:N714 (Select all that apply) □ Hypotension □ Cardiac instability □ Difficulty with anesthesia □ Inability to implement shunting □ Difficult dissection □ Excessive bleeding □ ICA string sign / atresia □ Inability to access lesion due to anatomy □ Other
: O No
□ Hypertension □ Nerve compromise □ Excessive scar tissue □ Carotid artery thrombosis
Concomitant CABGN713:
O Yes
O Yes
J. PROCEDURE TOTALS (COMPLETE FOR EACH CAS) Contrast Volume8000: Cumulative Air Kerma
Dose Area Product
Fluoro Time8005:
_______ mL 900
:
901
:
_______ minutes
N456
________ O mGy
O Gy
CO2 Used
________ O Gy-cm2
O dGy-cm2
O cGy-cm2
:
O No
O Yes
O mGy-cm2
O µGy-M2
K. LABS (COMPLETE FOR EACH PROCEDURE TYPE) Pre-Procedure / Baseline Creatinine8100:
Post-Procedure (post-procedure only)
□ Not Drawn8105
________mg/dL
Creatinine8130:
________mg/dL
8101/8102
mm/dd/yyyy / hh:mm 8110
Hemoglobin
:
□ Not Drawn
________g/dL
8115
Hemoglobin
8111/8112
mm/dd/yyyy / hh:mm HbA1c 902:
8140
:
(lowest value w/in 72 hrs)
□ Not Drawn8135
mm/dd/yyyy / hh:mm8131/8132 ________g/dL □ Not Drawn8145 mm/dd/yyyy / hh:mm8141/8142
□ Not Drawn 905
________%
903, 904
mm/dd/yyyy / hh:mm
□ Not Drawn8125 ________mg/dL 413 8121/8122 mm/dd/yyyy / hh:mm
LDL:
L. POST-PROCEDURE ASSESSMENT (COMPLETE FOR EACH PROCEDURE, ONLY FOR THE TARGET VESSEL SIDE(S) AFFECTED) Modified Rankin Score8260:
NIH Stroke Scale Total Score8265: _______
O 0: No symptoms at all O 3: Moderate disability O 1: No sig disability despite symptoms O 4: Mod severe disability O 2: Slight disability O 5: Severe disability O 6: Death
Date Administered8261: mm / dd / yyyy
Date Administered8266:
□ Not Administered 8262
mm / dd / yyyy
Examiner Name8270,8275,8280: O No Certified8285:
□ Not Administered 8267
O Yes
M. INTRA OR POST-PROCEDURE EVENTS (COMPLETE FOR EACH PROCEDURE TYPE)
Event
Event Occurred
Event Date(s)
CARDIOVASCULAR Myocardial Infarction8400:
O No
O Yes
mm/dd/yyyy / hh:mm704
Cardiac Arrest705:
O No
O Yes
mm/dd/yyyy / hh:mm706
Heart Failure 8410:
O No
O Yes
mm/dd/yyyy / hh:mm710
New Arrhythmia Requiring Treatment8420:
O No
O Yes
mm/dd/yyyy / hh:mm708
O No
O Yes
Unexpected Intubation 721:
O No
O Yes
mm/dd/yyyy / hh:mm722
Pneumonia723:
O No
O Yes
mm/dd/yyyy / hh:mm724
PULMONARY
mm / dd / yyyy
Page 6 of 11
NCDR® PVI Registry™(Peripheral Vascular Intervention Registry) v 2 Carotid Artery Stenting, Carotid Endarterectomy and Carotid PTA Module- DRAFT M. INTRA OR POST-PROCEDURE EVENTS (COMPLETE FOR EACH PROCEDURE TYPE) ( CONTINUED)
Event
Event Occurred
Event Date(s)
NEUROLOGIC Cranial Nerve InjuryN699:
O No
O Yes
mm/dd/yyyy / hh:mmN700
TIA8425:
O No
O Yes
mm/dd/yyyy / hh:mm713
Ischemic Stroke8430:
O No
O Yes
mm/dd/yyyy / hh:mm714
Hemorrhagic Stroke8435
O No
O Yes
mm/dd/yyyy / hh:mm715
Undetermined Stroke8440:
O No
O Yes
mm/dd/yyyy / hh:mm716
If TIA8425 or any Stroke Type8430/35/40 = Yes, (Select all that apply) CNS Event Territory N701:
□ Right Hemisphere or Retinal □ Left Hemisphere or Retinal □ Vertebrobasilar □ Unknown New Seizure8450:
O No
O Yes
mm/dd/yyyy / hh:mmN702
Intracranial Hemorrhage8455:
O No
O Yes
mm/dd/yyyy / hh:mmN703
O No
O Yes
mm/dd/yyyy / hh:mmN704
Thrombosis8475:(CAS Only)
O No
O Yes
mm/dd/yyyy / hh:mmN342
Embolism8480:
O No
O Yes
mm/dd/yyyy / hh:mmN343
Persistent Hypotension >24h Requiring Rx8415:
O No
O Yes
mm/dd/yyyy / hh:mm709
Anaphylactoid Contrast Reaction8525: (CAS Only)
O No
O Yes
mm/dd/yyyy / hh:mm739
Emergency CNS Rescue8460:
(CAS Only)
SYSTEMIC
(CAS Only)
VASCULAR Significant Dissection8485:
(CAS Only)
O No
O Yes
mm/dd/yyyy / hh:mm725
Perforation8490:
(CAS Only)
O No
O Yes
mm/dd/yyyy / hh:mm726
O No
O Yes
mm/dd/yyyy / hh:mm728
O No
O Yes
mm/dd/yyyy / hh:mm720
Procedure-Related Infection Req Antibiotics 8530:
O No
O Yes
mm/dd/yyyy / hh:mm745
Surgical Site Infection742
O No
O Yes
mm/dd/yyyy / hh:mm743
Other Vascular Complication Req Treatment8500: GENITOURINARY AND GASTROINTESTINAL
New Requirement for Dialysis8465: INFECTION
If Yes, Surgical Site Infection Type
744
:
O Superficial O Deep O Organ Space
Page 7 of 11
NCDR® PVI Registry™(Peripheral Vascular Intervention Registry) v 2 Carotid Artery Stenting, Carotid Endarterectomy and Carotid PTA Module- DRAFT M. INTRA OR POST-PROCEDURE EVENTS (CONTINUED)
Event
Event Occurred
Event Date(s)
BLEEDING Bleeding Event w/in 72 Hours8535:
O No
O Yes
mm/dd/yyyy / hh:mmN344
O No
O Yes
mm/dd/yyyy / hh:mmN345
O No
O Yes
mm/dd/yyyy / hh:mmN346
If Yes, Retroperitoneal Bleeding 8560:
O No
O Yes
mm/dd/yyyy / hh:mmN347
If Yes, GI Bleed 8565:
O No
O Yes
mm/dd/yyyy / hh:mmN348
If Yes, GU Bleed8570:
O No
O Yes
mm/dd/yyyy / hh:mmN349
If Yes, Other Bleed8575:
O No
O Yes
mm/dd/yyyy / hh:mmN350
O No
O Yes
mm/dd/yyyy / hh:mm746
If Yes, Bleeding at Access Site8540: (CAS Only) If Yes, Access Bleed Location8545: Use Access Site ID / Seq. Num 6200:
______ , ______ , ______ If Yes, Hematoma at Access Site 8550: (CAS Only) If Yes, Access Hematoma Location8555:
(CAS Only)
Use Access Site ID / Seq. Num 6200:
______ , ______ , ______
RBC/Whole Blood Transfusion8580:
If Yes, Hgb Prior to 1st Transfusion 8585: ________ mg/dL If Yes, Number of units Transfused 747: ________ units
N. DISCHARGE (COMPLETE FOR EACH EPISODE OF CARE) Discharge Date9000:
mm / dd / yyyy HH:MM
Discharging Provider Name, NPI 10070,10071,10072,10073: Discharge Status 9005: O Alive
________,__,__________________,______________
O Deceased
If Alive, Discharge Location9010:
O Home O Extended Care/TCU/rehab
If Alive, Hospice Care 9015:
O No
If Deceased, Death during Procedure9025: O No
O O O O O O O
O No
O Yes
O Yes
9030
:
Acute myocardial infarction Sudden cardiac death Heart failure Stroke Cardiovascular procedure Cardiovascular hemorrhage Other cardiovascular reason
Discharge Ambulation Status907:
O Other O Left AMA
O Yes
If Alive and Current Tobacco User, Cessation Counseling9020:
If Deceased, Cause of Death
O Transfer to other acute care hospital O Skilled Nursing Facility
O O O O O O O
Pulmonary Renal Gastrointestinal Hepatobiliary Pancreatic Infection Inflammatory/Immunologic
O O O O O O O
Hemorrhage Non-cardiovascular procedure or surgery Trauma Suicide Neurological Malignancy Other non-cardiovascular reason
O No functional limitations O Ambulates with assistive devices
O Wheelchair/stretcher bound
Page 8 of 11
NCDR® PVI Registry™(Peripheral Vascular Intervention Registry) v 2 Carotid Artery Stenting, Carotid Endarterectomy and Carotid PTA Module- DRAFT N. DISCHARGE (COMPLETE FOR EACH EPISODE OF CARE)
DISCHARGE MEDICATIONS Discharge medications are not required for patients who expired, discharged to “Other acute care Hospital,” “AMA”, or are receiving Hospice Care.
If Yes, Dose908 Low Moderate High
IF NO - PT. REASON, PATIENT RATIONALE14206
O
Direct Thrombin Inhibitor (Other)
O
O
O
O
Apixaban
O
O
O
O
Rivaroxaban
O
O
O
O
Direct Factor Xa Inhibitor (Other)
O
O
O
O
□ Alternative Therapy Preferred □ Cost □ Negative Side Effect
Warfarin
O
O
O
O
□ Alternative Therapy Preferred □ Cost □ Negative Side Effect
Aspirin
O
O
O
O
□ Alternative Therapy Preferred □ Cost □ Negative Side Effect
Dipyridamole
O
O
O
O
□ Alternative Therapy Preferred □ Cost □ Negative Side Effect
Clopidogrel
O
O
O
O
□ Alternative Therapy Preferred □ Cost □ Negative Side Effect
Prasugrel
O
O
O
O
Ticagrelor
O
O
O
O
□ Alternative Therapy Preferred □ Cost □ Negative Side Effect
P2Y12 Antagonist (Other)
O
O
O
O
□ Alternative Therapy Preferred □ Cost □ Negative Side Effect
ACE-I
ACE-I (Any)
O
O
O
O
□ Alternative Therapy Preferred □ Cost □ Negative Side Effect
ARB
ARB (Any)
O
O
O
O
Beta Blocke r
Beta Blocker (Any)
O
O
O
O
Sta tin
Statin (Any)
O
O
O
O
PDE Inhibitor
PDE Inhibitor (Any)
O
O
O
O
Alirocumab
O
O
O
O
Evolocumab
O
O
O
O
PCSK9 Inhibitors (Any)
O
O
O
O
P2Y12 Antagonists
Antiplatelets
Anticoagulants
Thrombin Inhibitors
□ Cost □ Negative Side Effect
Dabigatran
Direct Factor Xa Inhibitors
Yes
Prescribed at Discharge9505 No – No No – Medical No-Patient Reason Reason Reason O O O
VitK Ant
Medication9500
PCSK9 Inhibitor
□ Alternative Therapy Preferred □ Cost □ Negative Side Effect
□ Alternative Therapy Preferred □ Cost □ Negative Side Effect □ Alternative Therapy Preferred □ Cost □ Negative Side Effect □ Alternative Therapy Preferred □ Cost □ Negative Side Effect
□ Alternative Therapy Preferred □ Cost □ Negative Side Effect
□ Alternative Therapy Preferred □ Cost □ Negative Side Effect □ Alternative Therapy Preferred □ Cost □ Negative Side Effect
O
O
O
□ Alternative Therapy Preferred □ Cost □ Negative Side Effect □ Alternative Therapy Preferred □ Cost □ Negative Side Effect □ Alternative Therapy Preferred □ Cost □ Negative Side Effect □ Alternative Therapy Preferred □ Cost □ Negative Side Effect □ Alternative Therapy Preferred
Discharge Medication Reconciliation Completed 14020: If Yes, Medications Reconciled Include:
□
Non Prescription (OTC) Medications
14025
O No
(Select all that apply)
□
O Yes
□
Vitamins / Minerals
Prescriptions: Cardiac
□
□ Prescription: Non Cardiac
Herbal Supplements
Page 9 of 11
NCDR® PVI Registry™(Peripheral Vascular Intervention Registry) v 2 Carotid Artery Stenting, Carotid Endarterectomy and Carotid PTA Module- DRAFT O. FOLLOW-UP (30 DAYS POST INDEX PROCEDURE: +/- 7 DAYS AND 1 YEAR POST INDEX PROCEDURE: +/- 60 DAYS)
Assessment Date10000:
Reference Episode Arrival Date/Time xxxx:
mm / dd / yyyy
mm/dd/yyyy / hh:mm
Reference Procedure Start Date/Time10001/10002: mm/dd/yyyy / hh:mm Reference Episode Discharge Date/Time xxxx: mm/dd/yyyy / hh:mm Method(s) to Determine Status10005-11: (Select all that apply)
Follow-up Status10015: O Alive
□ Office Visit □ Medical Records □ Letter from Medical Provider □ Phone Call □ Social Security Death Master File □ Hospitalized □Other
O Deceased
O Lost to Follow-up
If Deceased, Date of Death10020: mm / dd / yyyy If Deceased, Cause of Death10025: O O O O O O O
Acute myocardial infarction Sudden cardiac death Heart failure Stroke Cardiovascular procedure Cardiovascular hemorrhage Other cardiovascular reason
O O O O O O O
Pulmonary Renal Gastrointestinal Hepatobiliary Pancreatic Infection Inflammatory/Immunologic
O O O O O O O
Hemorrhage Non-cardiovascular procedure or surgery Trauma Suicide Neurological Malignancy Other non-cardiovascular reason
CLINICAL ASSESSMENT AT FOLLOW-UP (30 DAYS POST INDEX PROCEDURE: +/- 7 DAYS AND 1 YEAR POST INDEX PROCEDURE: +/- 60 DAYS) Follow-Up Ambulation Status913:
O No functional limitations O Ambulates with assistive devices
Follow-Up Living Status914:
O Home Independent O Home with Caregiver O Skilled Nursing Facility O Homeless O Other
Follow-Up CSHA Clinical Frailty Score 1 915:
O 1 = Very Fit O 2 = Well O 3 = Managing Well O 4 = Vulnerable O 5 = Mildly Frail
Modified Rankin Score10030:
Date Administered10031:
O 6 = Moderately Frail O 7 = Severely Frail O 8 = Very Severely Frail O 9 = Terminally Ill
O 0: No symptoms at all O 4: Mod severe disability O 1: No sig disability despite symptoms O 5: Severe disability O 2: Slight disability O 6: Death O 3: Moderate disability □ Not Administered 10032 mm / dd / yyyy
NIH Stroke Scale Total Score 10035: _______ Date Administered10036:
O Wheelchair/stretcher bound
mm / dd / yyyy
Examiner Name 10040, 10045, 10050:
□ Not Administered 10037
Certified Examiner 10055:
O No
Right O No
Follow-Up Carotid Duplex Ultrasound Performed N705, N709: If Yes, Peak Systolic VelocityN706, N710: N707, N711
If Yes, End Diastolic Velocity
If Yes, ICA/CCA Ration N708, N712:
:
O Yes
O Yes
Left O No
O Yes
_________cm/sec
_________cm/sec
_________cm/sec
_________cm/sec
_________
_________
1
Canadian Study of Health and Aging Clinical Frailty Scale is Used with Permission For The American College of Cardiology Foundation By Dr. Kenneth Rockwood (© Kenneth Rockwood, MD)
Page 10 of 11
NCDR® PVI Registry™(Peripheral Vascular Intervention Registry) v 2 Carotid Artery Stenting, Carotid Endarterectomy and Carotid PTA Module- DRAFT O. FOLLOW-UP (CONTINUED)
EVENTS SINCE DISCHARGE Readmitted10400:
If Yes, Readmission Related to procedure N367 : If Yes, Readmission Length of Stay : _____ days O No
O Yes
O No
O Yes
O Indeterminate
10405
If Yes, Readmission Date 10410:
mm / dd / yyyy
If Yes, Hospitalized at time of Follow-up10415:
Event
O No
O Yes
Event Occurred
Event Date(s)
CARDIOVASCULAR Myocardial Infarction 10420:
O No
O Yes
mm / dd / yyyy933
Ischemic Stroke 10425:
O No
O Yes
mm / dd / yyyy934
Hemorrhagic Stroke10430:
O No
O Yes
mm / dd / yyyy935
Undetermined Stroke10435:
O No
O Yes
mm / dd / yyyy936
Carotid Endarterectomy10470: (CEA only)
O No
O Yes
mm / dd / yyyyN715
O No
O Yes
mm / dd / yyyyN716
O No
O Yes
mm / dd / yyyyN720
O No
O Yes
mm / dd / yyyyN721
O No
O Yes
mm / dd / yyyyN723
O No
O Yes
mm / dd / yyyyN725
O No
O Yes
mm / dd / yyyy937
O No
O Yes
mm / dd / yyyy944
O No
O Yes
mm / dd / yyyy938
NEUROLOGIC
If Yes, Target Vessel Revascularization 10475 Carotid Artery Stent10480: (CAS only) If Yes, Target Vessel Revascularization10485 Carotid PTA N722: If Yes, Target Vessel RevascularizationN724 VASCULAR Major Vascular Complication 10440: GENITOURINARY AND GASTROINTESTINAL
New Requirement for Dialysis10450: BLEEDING Life Threatening Bleeding10445:
Page 11 of 11
