Accident & Emergency Core Data Standards and... · information, in particular to inform clinical audit and clinical governance requirements. The climate of IM&T development within

For reference only – Do Not Use For more information contact: [email protected]

Accident & Emergency Core Data Standards

30th 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: [email protected]: www.show.scot.nhs.uk/clinicaldatasets/

mailto:[email protected]

http://www.show.scot.nhs.uk/clinicaldatasets/

Contents Overview & Background.......................................................................................... 3 Overview ................................................................................................................................. 3 Background to NCDDP ........................................................................................................... 4 A & E Core Data Standards .................................................................................................... 4 A & E Waiting Times Data Standards ..................................................................................... 5 Approval & Publication............................................................................................................ 5 Clinical Terminology................................................................................................................ 5 Date Recording ....................................................................................................................... 6 Data item template description ............................................................................................... 6

Generic Data Items................................................................................................... 8

A & E Core Data Standards ..................................................................................... 9 1. Arrival Mode {A&E} ............................................................................................................. 9 2. Referral Source {A&E} ........................................................................................................ 9 3. Place of Occurrence of Incident {A&E} ............................................................................. 11 4. Initial Assessment Triage Category {A&E}........................................................................ 14 5. Patient Management Type {A&E} .................................................................................... 15 6. Diagnosis {A&E}................................................................................................................ 15 7. Date and Time of First Full Clinical Assessment {A&E}.................................................... 18 8. Date and Time of Completion of Treatment {A&E} ........................................................... 18 9. Investigation Type {A&E} .................................................................................................. 19 10. Procedure {A&E}............................................................................................................. 20 11. Discharge Type {A&E} .................................................................................................... 22 12. Discharge Destination {A&E} .......................................................................................... 23 13. Referrals {A&E}............................................................................................................... 24

A&E Waiting Times Data Standards ..................................................................... 27 1. Arrival Date & Time {A&E} ................................................................................................ 27 2. Attendance Category {A&E}.............................................................................................. 27 3. Date and Time of Discharge, Admission or Transfer {A&E} ............................................. 28 4. Reason for A&E Wait > 4 hours {A& E} ............................................................................ 29

Appendix 1 - A&E Clinical Working Group .......................................................... 31

Appendix 2 – Measuring A&E Waits Working Group.......................................... 32

Appendix 2A – Medical Assessment Units .......................................................... 33

Appendix 3 - Consultation Distribution List ........................................................ 34

Accident & Emergency Core Data Standards Page 2

Overview & Background

Overview The Scottish Executive Health Department commissioned the development of A&E core data standards for NHS Scotland to ensure common information standards for implementation across all clinical domains in which people attend for emergency care. An A&E Core Data Standards Clinical Working Group was established in January 2005 to progress this work, supported by the National Clinical Dataset Development Programme (NCDDP) support team in ISD (see Appendix 1 for membership list). The NCDDP support team has also assisted the National Waiting Times Unit develop A&E Waiting Times data standards which are included in this consultation (see Appendix 2 for membership list).

The A & E Core Data Standards will:

Define common data items recommended for collection in a wide variety of clinical settings

Support the exchange of patient information between healthcare providers

Support the consistent recording of patient information throughout NHS

Scotland

It is important to understand that these are data standards, not a dataset. This means that the individual data standards 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 as part of a person’s care record, it should be recorded in accordance with the nationally agreed standard. Throughout this document, where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit, regardless of whether or not the attendance results in an admission. In future this may also include Casualty Care Units and Emergency Centres as proposed in ‘Delivering for Health’ (Scottish Executive October 2005). (See Appendix 2A for definition of medical assessment unit).

Comments are now sought from the wider clinical community in order to ensure that these standards are indeed appropriate as national A & E standards. In order to provide comment, please complete the attached Consultation Response Form (Appendix 4) and return to NCDDP Support Team. Some background information on the NCDDP and the A & E Core Data Standards development can be found below. If you have any further queries, please go to our website or contact us.


Background to NCDDP

To date, much of the data collected in NHS Scotland in a nationally consistent way has been through central returns to ISD relating to patient administrative and demographic data and NHS activity data - the content of the SMR Data Manual and the Definitions and Codes Manual reflect this. A limited amount of clinical information is collected at national level, mostly describing diagnoses, operations and procedures and the small number of national audits. Such information is not usually automatically generated as a by-product of operational clinical information, but may require intensive data collection that is quite discrete from any patient care process. There is now a drive from many clinical bodies to collect more meaningful clinical information, in particular to inform clinical audit and clinical governance requirements. The climate of IM&T development within NHS Scotland is an important facilitator and more clinicians are now embracing electronic means of recording clinical information, particularly in primary care. The move towards an integrated care record (ICR) with the availability electronically of appropriate clinical information to health care professionals for direct patient care purposes is one of the key aims of the National e-Health Strategy (April 2004). Electronic integration of clinical information, facilitating appropriate sharing and communication of information is desirable, particularly for the care of patients with chronic disease. Good clinical information systems are required which support direct patient care in this way, whilst also generating secondary information, such as that required for audit, as a by-product where possible. The ability to link patient data across journeys of care requires alignment of clinical data standards across specialties, including their coding schema and clinical definitions. The NCDDP Programme was established in 2003 in response to the health white paper Partnership for Care (February 2003), to provide coordination and support at a national level for the clinically led development of national clinical data standards. The goal is to develop a set of interoperable national datasets initially focussing on the clinical priority areas. More information can be found on our website.

A & E Core Data Standards Following consultation, the A & E Core Data Standards will be submitted to the NCDDP Programme Board, the eHealth National Clinical Information Steering Group and subsequently the NHS Scotland Information Standards Group, for formal approval as a national standard. The A & E Core Data Standards will then be freely and widely available through publication in the Health and Social Care Data Dictionary. As far as possible they are UK compatible. It is recommended that the these data standards should 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. The A & E Core Data Standards work is not about developing a clinical system, database, querying system or system specification, but rather the step before this, which is developing the rules that system developers can implement. This will ensure that systems are compatible with each other and able to reliably transfer data between each other and to the


regional SCI Store, in support of the strategic direction towards Integrated Care Records. For example, if a system is required to record Nature of the Injury then it should do it in the way specified through the national data standards work (i.e. lifting it 'off-the-shelf' through the Data Dictionary). Non-implementation of national data standards across existing/ new systems will result in non-compatibility of data, thus making the realisation of integrated care records a much more complex, and less reliable task.

Each data item has been measured against the following inclusion criteria: 1. Is it a data item which should be communicated within the A&E team to ensure

appropriate patient care? 2. Is it a data item which A&E staff would expect to receive from or communicate with

health care colleagues in other settings? 3. Is it a data item which would expect to be recorded by most A&E depts/ systems across

Scotland? 4. Is it required to support provision of data on A&E waiting times? 5. Is it needed to support other formal A&E data requirements, e.g. Health & Safety

purposes?

A & E Waiting Times Data Standards These data standards have been developed in conjunction with the Waiting Times Programme, Information Services and National Waiting Times Unit, Scottish Executive in order to comply with the national requirements as stated in 'Fair to All, Personal To Each: The next steps for Scotland' (Scottish Executive December 2004):

We are also introducing a new waiting times target for patients seen in Accident and Emergency Units: from the end of 2007, patients will wait no longer than 4 hours between arriving at a Unit and admission, discharge or transfer, unless there are stated clinical reasons for keeping the patient in the Unit. This maximum wait will also apply to all other emergency care in minor injuries units or areas of assessment units where trolleys are used. http://www.scotland.gov.uk/Publications/2004/12/20400/48699

Approval & Publication Following consultation, the A & E Waiting Times Data Standards will be submitted to the NCDDP Programme Board, the eHealth National Clinical Information Steering Group and subsequently the NHS Scotland Information Standards Group, for formal approval as a national standard. The A & E Waiting Times Data Standards will then be freely and widely available through publication in the Health and Social Care Data Dictionary. As far as possible they are UK compatible. It is recommended that these data standards should 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. Clinical Terminology


http://www.scotland.gov.uk/Publications/2004/12/20400/48699

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. In the meantime, Read code recommendations for the A & E Core and Waiting Times Data Standards will be developed and published in the coming months. Date 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, therefore the A & E Core Data Standards do not deal with this issue. 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. This date 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 A & E Core Data Standards do not include standards for recording dates, though 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.

Data item template description Heading Description Example Formal name This is the full formal name of the

item.

Person Marital Status

Common name

This is any name(s) by which the item is commonly known (if different from formal name), and/or any synonym(s) for the item.

Marital Status

Main source of standard

This indicates the organisation or agency which owns the standard, and/or from which it has been sourced.

Government Data Standards Catalogue (GDSC)

Definition This is the formal semantic description of the item.

An indicator to identify the legal marital status of a person.

Format This indicates the field length and character composition of the codes or values recorded under the item.

1 character

Codes and values

This is the set of recommended codes and the data item categories that they represent (variable data items only).

S = Single M = Married/Civil Partner D = Divorced/Civil Partnership dissolved W = Widowed/Surviving Civil Partner


Explanatory notes relating to values may be represented in tabular form.

P = Separated N = Not disclosed

Attributes Any detail which further qualifies the data item.

Laterality Severity Episodicity

Sub data items

Further data items giving details solely and specifically relating to the parent data item. These have meaning only in relation to the parent data item.

Address type Telephone number type Verification level

Related data items

Other data items which may be linked to this data item as part of a data item group or dataset, but which can exist as discrete data items in their own right.

Further information

Any other explanatory information about the data item.

Reference documents, anticipated developments etc.

Recording guidance

Any information about the use of the data item, including implementation guidance for system developers.


Generic Data Items

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 A & E Core Data Standards working group selected several generic data items for inclusion in their standards. These data items names and definitions 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. Data Item Definition 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.

Health Record Identifier

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.

Structured Name An ordered sequence of person name elements such as title, forename(s) and family name

Address (BS7666) A collection of data describing the addressing of locations Postcode The code allocated by the Post Office to identify a group of postal

delivery points UK Telephone Number

A number, including any exchange or location code, at which a person or organisation can be contacted in the UK by telephonic means

Person Birth Date The date on which a person was born or is officially deemed to have been born, as recorded on the Birth Certificate

Person Current Gender

A statement by the individual about the gender they currently identify themselves to be (i.e. self-assigned)

Ethnic Group A statement made by the service user about their current ethnic group. Registered GP Practice Code

General Medical Practitioners provide general medical services to the population either in partnership with other GMPs or on a single-handed basis. The term GP practice covers both partnerships and single-handed practices. Each GP practice in Scotland is identified by a unique GP practice code. The practice code is a four-digit code plus a check digit with ranges of codes allocated to each Health Board. (SMR)

The A & E Core clinical working group also included the following Generic Standards Phase 3 in their data standards:

Location Specified General Practitioner

Associated Person Associated Professional Allergies, Intolerances and Adverse Reactions

Generic Data Standards (Phase 3) are undergoing development and will be published shortly. If you wish more information on these standards, please contact the [email protected].


http://www.datadictionary.scot.nhs.uk/

http://www.datadictionary.scot.nhs.uk/

mailto:[email protected]

A & E Core Data Standards

1. Arrival Mode {A&E} Common name: Mode of arrival at A&E, Arrival transport mode, Arrived by Definition: The substantive means by which a patient arrived at an A&E department. Format: 2 characters Codes and values: Code Value Explanatory Notes 01 Ambulance (road) Excludes involvement of an A&E retrieval team. 02 Ambulance (air) Travel for all or any part of journey by an aircraft

operating as an ambulance. Includes helicopter. Excludes involvement of an A&E retrieval team.

03 Ambulance and A&E retrieval team

Clinical staff go to the patient to provide on site immediate care to stabilise the patient in order to bring them to a healthcare facility. Includes both road and air ambulance modes of transport.

04 Out of Hours transport OOH has arranged transport (includes PTS transport but not emergency ambulance)

05 Private transport Includes car, taxi, motorbike, bicycle, etc 06 Public transport Includes bus, train, etc. 07 Walking On foot. 08 Police/prison transport Patient is brought to A&E in a police or prison vehicle. 98 Other The true value to be recorded is not covered by any of

the specific given categories. For example, a visitor within the hospital brought by trolley. Includes mortuary van.

99 Not known Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. Recording guidance: Only one route should be recorded. For journeys using more than one transport mode, select the main mode used.

2. Referral Source {A&E} Common name: Source of referral to A&E, Referred by, Referral Type Definition: One of a group of organisations, professionals and other individuals who make a referral to an A&E department.


Format: 3 characters Codes and values: Code Value Sub-

code Sub-value Explanatory Notes

A Patient 01 Self referral B Associated

person eg. parent, friend, employer, neighbour.

Excludes where the patient is employed by one of these agencies but the referral relates to an injury occurring in the course of their work, which should be recorded under ’01 – self referral’. A GP Referral from usual GP

practice / practice providing temporary general medical services. Usually referrals within working hours, but may be out-with hours where usual GP practice performs out of hours care.

B Out of hours services

Referral out-with normal working hours from a primary care OOH service.

C 999 emergency services

Includes SAS Paramedic Practitioner

D NHS24 E Minor injuries unit F Same hospital Excludes minor injuries units G Other hospital Excludes minor injuries units

02 Healthcare professional/ service/ organisation

H Other healthcare professional

Another person acting in their healthcare professional capacity but out-with a hospital or minor injuries unit, e.g. dentist, private healthcare professional, pharmacist.

A Education B Social services C Police

03 Local authority

D Other local authority department

04 Private professional /agency /organisation

eg. Nursing home, care agency, etc

05 Other agency Excludes where the patient is employed by another agency but the referral relates to an injury occurring in the course of their work, which should be recorded under ’01 – self referral’.


A Prison/penal establishment B Judicial C Voluntary agency D Armed forces

98 Other The true value to be recorded is not covered by any of the specific given categories.

99 Not known Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. Attendances at GP Out of Hours services are not A&E attendances. Where a GP is employed to attend to patients within an A&E department, the attendance is classified as an A&E attendance. An A&E referral may be a verbal or written referral. Since patients usually present at an A&E department without advance notification, a referral is often received at the same time as a patient presents. However, in certain circumstances, a referral may be received before a patient presents, e.g. advance notification (usually by telephone) of the imminent arrival of a patient.

3. Place of Occurrence of Incident {A&E} Common name: Accident & Emergency incident location type, Place of incident, Place of injury Main source of standard: derived from ICECI (International Classification of External Causes of Injury, WHO) Definition: Where the person was when the incident started. This refers to the high level type of area, building or place where the injury event commenced. Format: up to 3 characters Codes and values:


Code Value Sub-

code Sub-value Explanatory notes

A Home The person’s own home or the home of a third party. Home includes the main dwelling and any associated garden, driveway to home, garage, path (walk) to home, swimming pool in private house or garden, farmhouse, home premises, house, non-institutional place of residence, apartment, boarding house, private caravan park (residential).

01 Place of residence

B Residential institution

An institute with residential accommodation, e.g. home for the elderly, nursing home, prison, children’s home, hospice, military institution, etc

A Public highway, street or road

Publicly owned and maintained highway, street, road, pavements or cycle path.

02 Transport area

B Other transport area

Places where transport out-with a public highway, street or road takes place, e.g. private road, aircraft, ferry terminal, Parking area, Public transport area/facility such as bus terminal, railway station, underground station, airport etc. pedestrian mall, railway line etc.

A Industrial or construction area

A place primarily intended for industrial or construction purposes. Refers to buildings, other structures, excavations and adjacent grounds. Demolition sites, mines quarries, factory/plant, oil and gas extraction facility, power station etc.

03 Business area (excluding recreational & sports areas)

B Farm or other place of primary production

Excludes injuries occurring in the residential area of a farm, where the farm is the injured person’s home.


C Commercial area- non recreational

A commercial area not primarily intended for recreational purposes, e.g. shop, store, commercial garage, office building, café, hotel, restaurant, casino, bar, dance/ night club, swimming pool of hotel, etc.

04 School, educational area

Includes any educational establishment, e.g. nursery, college, university. Includes actual educational building and associated grounds, e.g. school playground. A Sports and athletic

area Any place specifically intended for formal sporting purposes, e.g. leisure centre. Excludes places where informal sporting recreation may take place.

B

Recreational area, cultural area or public building

A place primarily intended for recreational or cultural purposes (whether public or commercially owned) or any other public building. Includes public park/ playground, amusement/ theme park, holiday park, campsite, public religious place.

05 Sports & Recreational area

C Countryside / open nature area

Refers to open nature area not classified elsewhere eg. beach, cave, forest. Includes injuries occurring in water or the sea, where not part of a formal transport area e.g. marsh/ swamp, river, loch.

06 Medical service area/Health care area

Any formal healthcare establishment, including hospital, heath centre, screening mobile van, etc.

98 Other specified 99 Not known Includes unspecified place of occurrence Related data items: Activity when injured Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. “In general, places include attached grounds, outbuildings, etc. For example, home includes the dwelling and any associated garden, garage, shed, etc. Likewise, Factory/plant includes buildings and premises like roadways, parking areas, and industrial yards. Any exceptions to this rule are specified by inclusions and exclusions for given code.” (ICECI v1.2) To code Place of Occurrence, select the place where things started to go wrong not where the injury event ended. Choose a category referring to the whole entity (i.e., a structure or space owned or operated as a whole) within which an injury occurred, rather than a category


referring to only a part of such an entity. For example, if an injury occurs while in a swimming pool which is part of a holiday park, code Place of Occurrence as the holiday park, rather than the swimming pool; likewise if in a school gymnasium, record the school. ‘Place of Occurrence’ data help group injuries by areas of responsibility and may help injury prevention practitioners better target interventions and use resources more effectively. This information can also provide insight into injury aetiology. To most accurately identify the sector of responsibility for injury prevention, combine ‘Place of Occurrence’ data with ‘Activity when injured’ data. Refer to ICECI classification for further guidance on coding place of occurrence of incident http://www.iceci.org/csi/iceci.nsf/!OpenDocument Recording guidance: Record only one place of occurrence. If more than one injury is involved, select the place associated with the most severe injury. 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).

4. Initial Assessment Triage Category {A&E} Common name: Manchester Triage Category, Triage Category Main source of standard: derived from Manchester Triage Scale Definition: The category assigned to a patient as a result of an initial assessment by medical or nursing staff in an A&E department. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 Not triaged 01 Immediate resuscitation Patients in need of immediate treatment for

preservation of life 02 Very urgent Seriously ill or injured patients whose lives are

not in immediate danger 03 Urgent Patients with serious problems, but apparently

stable condition 04 Standard Standard A&E cases without immediate danger

or distress 05 Non-urgent Patients whose conditions are not true accidents

or emergencies Further Information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit.


Manchester Triage Scale: Number Colour Category 1 Red Immediate 2 Orange Very urgent 3 Yellow Urgent 4 Green Standard 5 Blue Non-urgent

Reference: Triage and case-mix accident and emergency medicine. Marrow, J. European Journal of Emergency Medicine 1998; 5: 53-58.

5. Patient Management Type {A&E} Common name: Patient Type, Presentation Type Definition: A retrospective classification of the patient according to the clinical management received during their A&E attendance. Format: 2 characters Codes and values: Code Value Explanatory Notes 01 Resuscitation Patients underwent resuscitation, regardless of

outcome. 02 Major Patients required a longer period of assessment

and observation in addition to diagnostics and treatment.

03 Minor Patients treated and discharged relatively quickly and who may have had straightforward diagnostic assessment eg. Single plain X-ray.

99 Not known Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. Reference: Reforming Emergency Care First Steps to a New Approach (2001) http://www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/EmergencyCare/KeyEmergencyCareDocuments/fs/en

6. Diagnosis {A&E}


Source of standard: derived from ICD10 Definition: The working diagnosis(es) on discharge from A&E, or where no working diagnosis is made, the main symptom, abnormal finding, or problem. Format: 2 characters + ICD10 code (2 + 4 characters) or 2 characters + free text (total 98 characters) Codes and values: Code Value ICD10

Code Working diagnosis derived from local diagnostic lists

Explanatory Notes

00 Nothing abnormal detected 01 Trauma/ injury/ poisoning Refer to Injury

Surveillance Dataset 02 Alcohol &/or substance use

problems

03 Cardiovascular 04 Dental Does not include dental

injury - refer to Injury Surveillance Dataset

05 Dermatology Does not include skin injury - refer to Injury Surveillance Dataset

06 Endocrine/metabolic 07 ENT

Does not include foreign bodies - refer to Injury Surveillance Dataset

08 Gastrointestinal

09 Gynaecological

10 Haematology 11 Infection It may be necessary to

notify communicable diseases. Excludes infections specific to particular anatomical site or physiological system, e.g. skin, respiratory system.

12 Musculoskeletal 13 Neurology 14 Obstetrics

15 Ophthalmology

Does not include foreign bodies or eye injury - refer to Injury Surveillance Dataset

16 Psychiatry

17 Respiratory


18 Genito-urinary

19 Social circumstances

99 Diagnosis not known Attributes: Priority of diagnoses Code Value Explanatory Notes 01 Main diagnosis The main medical (or social) condition diagnosed at the end

of the episode of health care, primarily responsible for the patient’s need for treatment or investigation. If no working diagnosis was made, the main symptom, abnormal finding, or problem should be selected as the main condition.

02 Other diagnosis (co-morbidity)

Other conditions are defined as those conditions that co-exist or develop during the episode of healthcare and affect the management of the patient.

Related data items: Nature of Injury

Bodily Location of Injury Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. The working diagnosis at the time of discharge from A&E will not necessarily be the same as a definitive diagnosis reached once any further assessment and investigation has been undertaken. If no working diagnosis is made, the main symptom, abnormal finding, or problem should be recorded. It is recommended that the high level 2 character values, which are based upon the International Classification of Diseases (ICD10) chapter headings, should be used as the minimum. Many local departments have their own diagnostic lists of the conditions commonly presenting to their department. They should map these against the 2 character codes and values in the table above to create local sub-codes/ sub-values. Ideally the appropriate ICD10 codes should be identified for each diagnosis in these lists such that they may be recorded by the clinical information system as the 2 character high level code plus the 4 character ICD10 code. It is recommended that assistance from local coding departments is sought to ensure accurate use of ICD10. Use of ICD10 will facilitate electronic communications of diagnostic information and will also support departments’ ability to carry out their own audits and to undertake comparisons at regional and national level. Where the appropriate diagnosis is not included in a department’s diagnostic list, it is not sufficient to record ‘other diagnosis’, nor to shoehorn into the ‘nearest fit’, rather this should be recorded as the 2 character code/ value followed by a free text description. The codes and values table above should be adapted to include local diagnostic lists e.g. Chest pain would be recorded as Cardiovascular and the local coding department would advise that the ICD10 code is R07.4. This would then be implemented in the local A&E system. In addition to the main condition, other conditions or problems dealt with during the episode of health care should also be recorded. This may include where a patient is under the influence of alcohol or drugs.


Recording guidance: Where an injury, poisoning or foreign body is recorded, it is recommended that the IT system should automatically direct users to the injury surveillance dataset area of the system. IT systems should allow for the recording of multiple diagnoses and allow for the recording of free text if necessary. In the future all diagnoses, health problems and issues should be recorded using SNOMED Clinical Terms and codes. In due course, it is recommended that IT systems incorporate a clinical terminology browser to facilitate recording of appropriate diagnoses.

7. Date and Time of First Full Clinical Assessment {A&E} Definition: The date and time when a clinical assessment that results in positive progress of the patient through the A&E department is made by either a doctor or emergency nurse practitioner. This may be when the decision to treat is made. Format: 25 characters (CCYY-MM-DDThh:mm:ssTZD) Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. At this stage, active, positive intervention may occur (e.g. issuing pain relief) to advance the progress of the patient through the A&E department. This does not include initial triage assessment. 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. Government Data Standards Catalogue

8. Date and Time of Completion of Treatment {A&E} Common name: Attendance Conclusion Time {A&E}, Departure Ready Time {A&E} Main source of standard: derived from NHS Connecting for Health (England) Definition: The date and time, recorded using a 24 hour clock, that a patient's treatment in A&E is completed and they are ready for discharge, admission or transfer. Format: 25 characters (CCYY-MM-DDThh:mm:ssTZD)


Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. This date and time is not necessarily the same as date & time of discharge, admission or transfer. For those patients admitted into hospital, or transferred from A&E, the date and time of completion of treatment is recorded as the time when the decision to admit or transfer was made. For those patients who died or had an incomplete discharge, the date and time of completion of treatment (attendance concludes) is recorded as the time when the patient was declared dead by a clinician or when the incomplete discharge was recorded. 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. Government Data Standards Catalogue

9. Investigation Type {A&E} Main source of standard: derived from NHS Connecting for Health (England) Definition: A broad coding of types of investigation which may be requested to assist with diagnosis during attendance at an A&E department. Format: up to 3 characters Codes and values: Code Value Subcode Subvalue 00 None

A X-ray B Computerised tomography

(CT) C Ultrasound D Magnetic Resonance Imaging

(MRI)

01 Radiology

Z Other radiology A ECG B Echocardiogram

02 Cardiac investigations

Z Other cardiac investigation A Full blood count B Clotting studies C ESR

03 Haematology

Z Other haematology 04 Cross match 05 Biochemistry A Blood alcohol


B Blood gases C Blood glucose D Pregnancy test / HCG E Toxicology / drug levels Z Other biochemistry A Bacteriology B Virology

06 Microbiology

Z Other microbiology 07 Histology

A Urinalysis B Peak flow C Slit lamp examination

08 Near patient testing

Z Other near patient test 98 Other investigation 99 Not known Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. Appropriate sub-codes and sub-values can be further developed if required locally provided they map to the codes and values in the table above. Recording guidance: IT systems should allow for the recording of multiple investigations types. Where ‘98 – Other investigation’ is recorded, systems may be configured to include a text box to allow specification of the investigation. 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). In the future all investigations should be recorded using SNOMED Clinical Terms and codes.

10. Procedure {A&E} Common names: A&E Procedure Definition: A broad coding of types of procedure which may be performed upon a patient during attendance at an A&E department. Format: up to 3 characters Codes and values: Code Value (level 1) Sub-

codeSub-value (level 2)

00 No procedure 01 Wound care A Toilet only


B Debridement C Removal of foreign material D Dressing E Wound closure Z Other wound care A Toilet only B Debridement C Removal of slough D Dressing

02 Burn care

Z Other burn care A Plaster immobilisation B Splint immobilisation

03 Limb immobilisation

Z Other limb immobilisation A Reduction of dislocation B Manipulation of fracture C Joint aspiration / injection

04 Procedure on bones & joints

Z Other procedure on bones & joints A Nasopharyngeal airway B Laryngeal mask C Intubation D Surgical airway

05 Airway management

Z Other airway management A Manual 06 Ventilation B Mechanical A External cardiac massage B Cardio-version including defibrillation C Temporary pacing D Fluid resuscitation E Blood transfusion

07 Circulatory support

Z Other circulatory support A Central venous access (including

femoral) B Arterial line C Intra-osseous access

08 Vascular access

Z Other vascular access A Aspiration B Insertion of chest drain

09 Pleural cavity procedures

Z Other pleural cavity procedures 10 Decontamination

A Removal of foreign body from orifice B Gastric lavage C Urinary catheterisation

11 Other specific procedures

D Incision & drainage 98 Other 99 Not known

Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit.


Where greater detail of the specific procedure performed is required, this should be recorded using the OPCS4 classification. In order to classify procedures using OPCS4, the type of procedure plus the bodily part treated plus the nature of injury may all be required. Excludes treatments which are not procedures, for example, thrombolysis should be recorded under the medications section of a system. Recording guidance: IT systems should allow for the recording of multiple procedures. 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). Where ‘98 - Other’ is recorded, local systems may be configured to include a text box to allow specification of the procedure. In the future all procedures should be recorded using SNOMED Clinical Terms and codes.

11. Discharge Type {A&E} Common name: Disposal, Discharge status, Departure status Definition: The outcome of an attendance or series of attendances at an A&E department in connection with a specific complaint. Format: 3 characters Codes and values: Code Value Sub-


A With no follow up

Did not require any follow up treatment (other than GP letter). Includes patients treated and discharged by nurse.

B With follow up by Primary Care team

Follow up treatment to be provided by patient’s own GP/other member of the Primary Care Team. Includes specialist GPs/nurses, own dentist, etc

01 Discharged

C With referral Referral made to another professional, service or organisation. Includes referral to an out-patient clinic.

02 Admitted To same health care provider/hospital 03 Transferred To other health care provider/hospital

A Patient left before assessment completed 04 Incomplete B Patient left before being treated


C Patient refused treatment D Patient left after treatment started E Patient

removed by police

e.g. into police custody

A Died in department B Dead on arrival

05 Died

C Died at scene

Only applies where A&E retrieval team has gone to provide care to patient at scene.

98 Other 99 Not known

Related Data Items: Discharge Destination {A&E} Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. Recording guidance: It is recommended that the 2 character codes and values should be used as the minimum. For those departments wishing to record Discharge Type in greater detail, then the relevant sub-values can also be implemented (full 3 character codes). Local sub-values for ’02 - Admitted’, ‘03 - Transferred’ and ‘98 - Other’ can be developed as appropriate.

12. Discharge Destination {A&E} Common name: A&E Discharge Destination, Departure Destination Definition: The immediate destination of the patient on discharge from the A&E department. Format: 3 characters Codes and values: Code Value

Sub-code

Sub-value

Explanatory Notes

00 Death

A Usual place of residence

01 Private residence

B Not usual place of residence

e.g. staying with relatives or friends

A Usual place of residence

02 Residential institution

B Not usual place of residence


A Holiday accommodation

B Student accommodation C Legal establishment /prison D No fixed abode

03 Temporary residence

Z Other temporary residence A A&E ward Includes A&E observation ward, A&E

short stay ward, etc B Assessment

unit

C Medical ward Includes medical admissions unit, coronary care unit

D Surgical ward Includes surgical admissions unit, orthopaedic ward

04 Admission to same NHS healthcare provider / hospital

Z Other ward

A Psychiatric hospital B Other

specialist centre

e.g. eye hospital, paediatric hospital

C Community hospital

05 Transfer to other NHS healthcare provider / hospital

Z Other NHS hospital

06 Private healthcare provider 98 Other 99 Not known

Related data items: Discharge Type {A&E}

Date and Time of Discharge, Admission or Transfer {A&E} Referrals {A&E} Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. Recording guidance: It is recommended that the 2 character codes and values should be used as the minimum as required for SMR, but ideally the relevant sub-values should also be implemented (full 3 character codes).

13. Referrals {A&E} Common name: Referred to (A&E), A&E Referrals Definition: The professionals, services or organisations a patient may be referred on to for the purpose of further investigation and/or ongoing care following an attendance at an A&E department.


Format: up to 3 characters Code and values: Code Value Sub-


A A&E clinic B Fracture clinic

01 Clinic

Z Other clinic A GP B Practice nurse C Community nurse Excludes Community Psychiatric

Nurse D Specialist nurse E Physiotherapist F Other AHP G Dentist H Mental health service Includes Community Psychiatric

Nurse J Community pharmacy

02

Healthcare professional / service or organisation

Z Other A Education B Social work

03 Local authority

Z Other Includes Police 04 Private agency

/ organisation

05 Other agency Includes voluntary agency 06 Drug/alcohol

service May be provided by health

service, local authority, private or voluntary agency

98 Other 99 Not known

Related data items: Discharge Type {A&E}

Date and Time of Discharge, Admission or Transfer {A&E} Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. Patients may be referred on to more than one professional, service or organisation, so more than one may be recorded. If they are discharged it does not mean that their health problem /issue no longer exists but it is being dealt with by another professional. Appropriate sub-codes and sub-values can be further developed if required locally e.g. Rapid access chest pain clinic, provided they map to the codes and values in the table above. Recording guidance:


IT systems should allow for the recording of multiple referrals. 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).


A&E Waiting Times Data Standards

1. Arrival Date & Time {A&E} Common name: Date & Time of Arrival at A&E, Date & Time of A&E attendance Definition: The date & time of arrival of a patient at an A&E department. If the patient arrives by ambulance this will be taken from the ambulance data, otherwise this is when the patient arrives at A&E reception. Format: 25 characters (CCYY-MM-DDThh:mm:ssTZD) Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. This is the start date and time which will be used in measuring the waiting time between arriving at a unit and subsequent admission, discharge or transfer as required for the Scottish Executive national waiting times target (Reference: 'Fair to All, Personal To Each: The next steps for Scotland' (Scottish Executive Edinburgh December 2004) http://www.scotland.gov.uk/Publications/2004/12/20400/48699) For patients arriving by ambulance, the date and time at which the ambulance arrives at the A&E facility is used and not the (later) time when the patient is then brought in to the reception. 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. Government Data Standards Catalogue

2. Attendance Category {A&E} Common name: A&E Attendance type, Type of A&E Visit, Type of A&E Attendance Main source of standard: Derived from NHS Connecting for Health (England) Definition: A record of whether a patient is making a first or follow-up attendance at a particular A&E department. Format: 2 characters Codes and values: Code Value Explanatory Notes 01 New The first in a series, or the only attendance, in a particular


A&E episode 02 Return – planned A subsequent planned attendance at the same

department, and for the same incident as the first attendance

03 Return – unplanned A subsequent unplanned attendance at the same department, and for the same incident as the first attendance

Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. A new attendance is the first or only attendance for the same incident, which may be an injury or occurrence of a condition; a return attendance is a visit to the same department for the same incident as the first visit within the episode. If a patient has a recurring condition, such as epilepsy, or a tendency for joints to dislocate, there would be a new first attendance each time that the patient presents with the condition. A subsequent attendance may not always be a return attendance. It could qualify as an attendance at a consultant outpatient clinic and if so, it needs to be recorded appropriately. Reference:http://www.nhsia.nhs.uk/datastandards/pages/dd/data_dictionary/attributes/a/a_and_e_attendance_category_de.asp?shownav=1 Codes and values ‘01 New’ and ‘03 Return – unplanned’ are included in the Scottish Executive Waiting Times target, whilst ‘02 Return – planned’ is not. Reference: 'Fair to All, Personal To Each: The next steps for Scotland' (Scottish Executive Edinburgh December 2004) http://www.scotland.gov.uk/Publications/2004/12/20400/48699)

3. Date and Time of Discharge, Admission or Transfer {A&E} Common name: A&E departure date & time Main source of standard: derived from NHS Connecting for Health (England) & National Waiting Times Survey (SMR30C) Definition: This is the date and time that a patient leaves the A&E department after an A&E attendance has concluded and/or the department is no longer responsible for the care of the patient. Format: 25 characters (CCYY-MM-DDThh:mm:ssTZD) Related data items: Discharge Type {A&E}

Discharge Destination {A&E} Further information:


Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. Discharge is when the patient leaves the A&E department or when they are officially informed they may leave, whichever is the sooner. Admission is when the patient leaves the A&E department to go directly to an inpatient ward. Where assessment areas contain allocated beds and have the normal facilities of a ward (washing and toileting facilities etc) they should be regarded as admission to a ward. Transfer is when the patient leaves the A&E department to be taken, usually by ambulance, to another hospital. For those patients who died or had an incomplete discharge, date and time of discharge is recorded as the time when the patient was declared dead by a clinician or when the incomplete discharge was recorded. This data item is required for the Scottish Executive National Waiting Times target. Reference: 'Fair to All, Personal To Each: The next steps for Scotland' (Scottish Executive Edinburgh December 2004) http://www.scotland.gov.uk/Publications/2004/12/20400/48699 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. Government Data Standards Catalogue

4. Reason for A&E Wait > 4 hours {A& E} Main source of standard: derived from National A&E Waiting Times Survey (SMR30C) Definition: The reason(s) for keeping the patient in the A&E department if the patient spends longer than 4 hours between arriving at the A&E department and admission, discharge or transfer. Format: 3 characters Codes and values: Code Value Sub-

codeSub-value Explanatory Notes

00 No delay Patients whose stay in A&E is less than or equal to 4 hours

01 Wait for a bed 02 Wait for transport Commissioned by A&E 03 Wait for a specialist

Refers to the initial A&E treatment. A To commence

04 Wait for treatment

B To be completed 05 Wait for diagnostic A To be performed


test(s) B Awaiting results

Refers to results which will determine the next step in the patient journey

06 Wait for first assessment 07 Clinical reason

(specify) In the judgement of the senior emergency department doctor and/ or nurse involved, the patient’s condition mandates a stay in the emergency department of greater than four hours, i.e. where the patient is too ill to be moved.

08 Major Incident The A&E department has had a formal role as part of a major incident.

98 Other reason (specify) Further information: Where reference is made to A&E, this includes all patients who attend for emergency care in an A&E department, minor injuries unit or medical assessment unit. If the delay in patients leaving the department is due to resource constraints then it cannot be considered a clinical reason. Lack of an appropriate bed for a patient is not a clinical reason. For example if a patient needs a critical care bed and resuscitation is complete but no bed is available and they remain in the department for over four hours, this should not be counted as a clinical reason. This data item is required for the Scottish Executive National Waiting Times target. Reference: 'Fair to All, Personal To Each: The next steps for Scotland' (Scottish Executive Edinburgh December 2004) http://www.scotland.gov.uk/Publications/2004/12/20400/48699 Recording guidance: Codes and values ‘07 – Clinical reason’ or ‘98 – Other reason’ should only be recorded if values 01 – 06 are not appropriate. Where ‘07 – Clinical reason’ or ‘98 – Other reason’ is recorded, local systems should be configured to include a text box to allow specification of the reason.


Appendix 1 - A&E Clinical Working Group Membership of the A & E Core Data Standards Clinical Working Group Member Organisation Position Brodie Paterson (Chairman)

Ninewells Hospital, NHS Tayside Consultant in Emergency Medicine

Alan Lannigan Crosshouse Hospital, NHS Ayrshire and Arran

Consultant in Emergency Medicine

Ann Ward Information Services (ISD) NCDDP Support Team Manager

Chantal Spence Information Services (ISD) Data Quality Adviser Dave Murphy Information Services (ISD) Data Analyst David Ritchie Victoria Infirmary, NHS Glasgow Consultant in

Emergency Medicine Derek Bell Royal Infirmary of Edinburgh, NHS

Lothian Consultant in Acute Medicine

Diana Beard Scottish Trauma Audit Group Ernest Beattie Information Services (ISD) A&E System National

Project Manager Gordon McNaughton Royal Alexandra Hospital, NHS

Argyll & Clyde A&E Consultant

Ian Kerr NHS Lothian GP (SCIMP) John Alexander Scottish Ambulance Service Medical Adviser John Keaney Hairmyres Hospital, NHS

Lanarkshire Consultant in Emergency Medicine

Kathryn Darling Unscheduled Care Collaborative Information Manager Lesley Graham Substance Misuse Programme, ISD Programme Principal Linda Imrie Ninewells Hospital, NHS Tayside IT Support Manager Lorna Ramsay Information Services (ISD) NCDDP Clinical Lead Mike Jones King's Cross Hospital, NHS Tayside Mike Tooke Royal Alexandra, NHS Argyll &

Clyde A & E Nurse

Paul Leonard Royal Infirmary of Edinburgh, NHS Lothian

Acting Consultant in Emergency Medicine

Robin Lawrenson

Scottish Ambulance Service National Clinical Audit Manager

Susan Fraser Aberdeen Royal Infirmary, NHS Grampian

EDIS Project Manager

Tom Brown Gartnavel Royal Infirmary, NHS Glasgow

Consultant Psychiatrist


Appendix 2 – Measuring A&E Waits Working Group Membership of the Measuring A&E Waits Working Group

Member Organisation Position Alex Bowerman National Waiting Times Unit Andy Carver Information Services Division (ISD) Programme Principal,

Waiting Times Programme

Ann Ward Information Services Division (ISD) NCDDP Support Team Manager

David Murphy Information Services Division (ISD) Ernest Beattie Information Services Division (ISD) A&E System National

Project Manager Helen Brown Information Services Division (ISD) John Robertson Performance Management Division Kate Harley Information Services Division (ISD) Head of Programme Kathryn Darling Unscheduled Care Collaborative Information Manager Lesley Brannan National Waiting Times Unit Nicki McNaney Centre for Change and Innovation Programme Manager

Unscheduled Care Collaborative

Rosemary Jamieson Analytical Services Division (ASD)


Appendix 2A – Medical Assessment Units An Acute Assessment Unit is : • A safe clinically appropriate environment for patients, relatives and staff. Where

emergency patients are assessed, with a clear operational policy for referral, admission, discharge, lengths of stay and clinical support.

• Where patients undergo prompt competent clinical assessment and any necessary tests rapidly; the initial management process should be completed within four hours

• Where total lengths of stay including observation and initiation of treatment should be limited to the period of intensive investigation and treatment or observation, in accordance with the operational policy, maximum 72 hours (with rare exceptions e.g. a dying patient or imminent discharge) • For "sifting and sorting" patients in order to fast-track those who require admission,

to the right specialty ward for their needs and those for potential discharge to a rapid investigation and assessment process.

An Acute Assessment Unit is not: • A holding bay where the clock is stopped to prevent breaches against the 4- hour emergency access target. The target will be monitored against a continuous

patient journey. For those patient requiring a longer period of assessment this must be managed in a properly resourced and safe clinical environment.

• A dumping ground • Another bit of A&E, HDU etc. • A panacea or substitute for a properly designed whole-system emergency care package Adapted from DH Emergency Units – a checklist (version 1 July 2003)


Appendix 3 - Consultation Distribution List Chief Executives Medical Directors A & E Consultants Other Key A & E Stakeholders • Analytical Services Division, SEHD • Association of Scottish Pharmacists • British Association of Emergency Medicine • British Paramedic Association • Centre for Change and Innovation (CCI) Primary Care Collaborative • Child Accident Prevention Trust (CAPT) • Coastguard Service • Department of Public Health & Policy, NHS Lothian • Department of Transport • Drug and Alcohol Action Teams Associations • Fire Department • Health and Safety executive • Health Promotion • Health Promotion Managers Group • Health Protection Scotland • Healthy Environment for Scotland • Local Authorities • Medical Records • National A&E Implementation Steering Group • National Emergency Access Delivery Team • National Waiting Times Unit, SEHD • PEACH Unit, Yorkhill • Police • Royal National Lifeboat Institute • Royal Society for Prevention of Accidents (RoSPA) • Scottish Ambulance Service (SAS) • Scottish Association of Community Hospitals (SACH) • Scottish Intercollegiate Group on Alcohol • Scottish Trauma Audit Group (STAG) • Substance Misuse Programme, ISD • Waiting Times Programme, ISD NCDDP Stakeholders • Clinical eHealth Leads • Community Nursing Network (CNN) • Electronic Community Health Information Project (eCHIP) • Health & Social Care Information Centre, Datasets Development Programme (England) • Improving Mental Health Information Programme • Information Services Division, NSS


• Information Standards Group • NHS Board Directors of Public Health • NHS Health Scotland • NHS Quality Improvement Scotland • NHS24 • Open Scotland Information Age Framework (OSIAF) • 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 • UK Data Standards Forum • Voluntary Health Scotland NCDDP Reference & Working Groups • NCDDP Board • NCDDP Support Team • A & E Core Data Standards Clinical Working Group • A & E Clinical Reference Group • Injury Dataset Clinical Working Group
