Surgery

	Reporting Data Item	Business Justification	Definition Note: Where ‘NHS Wales Data Dictionary’ the definition is as per the Data Dictionary.	Permissible Values
6. SURGERY
6.0 ENCDv4.5b (7.4)	Surgical intent	To enable analysis by surgical intent.	The purpose of the surgical procedure(s) being carried out.	Permissible values are agreed by the clinical steering groups and conform to the requirements of the reporting output specifications. Currently there is no explicit requirement to map to terminologies or classifications. This will be kept under review. • Diagnostic • Staging • Curative • Palliative
6.1 ENCDv4.5b (7.9) GCI	Date on which surgical procedure(s) started	Diagnostic and staging procedures To estimate the level of accuracy of the diagnosis and staging when accounting for casemix and outcome analysis. Curative and palliative procedures To identify the date diagnostic and staging procedures were performed. To determine the time interval between referral and diagnosis by the specialist team and the start of treatment. Required to be able to measure survival time from the start of treatment. To enable the date of first definitive treatment to be recorded.	The date on which the surgical procedure was performed.
6.2 ENCDv4.5b (7.10 & 7.11) GCI	Surgical procedure(s) carried out	To determine type of surgery performed to enable analysis of surgically related data. To measure the effectiveness of surgical procedures performed and to be used as a measure for survival.	The type of procedure performed.	See the current version of the Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures (OPCS) of interventions and procedures. *Permissible grouped values and labels will be dependent upon the output specifications.
6.3 GCI	Site code (of surgery)	To enable surgical analysis by organisation / surgical centre. Required for submission to the national clinical cancer audits.	The organisation code for the site where the patient is treated.	NHS Wales Data Dictionary
6.4 GCI	Early onset (≤30 days post surgery) complication(s)	To determine patterns of adverse events associated with a treatment. Required for the reporting of the gynaecological clinical indicators.	The complication(s) which arise less than or equal to 30 days post surgery.	Permissible values are agreed by the clinical steering groups and conform to the requirements of the reporting output specifications. Currently there is no explicit requirement to map to terminologies or classifications. This will be kept under review. • Blood loss => 1000ml • Wound infection • Superficial wound breakdown • Wound dehiscence (full thickness) • Anastomotic leak • Paralytic ileus • Vault Haematoma • Pelvic abscess • Bladder injury • Ureteric injury • Bowel injury • Deep vein thrombosis / pulmonary embolism • Myocardial infarct • Other: infection requiring treatment • Other: resulting in return to theatre • Other: resulting in an unscheduled stay on intensive care unit / high dependency unit • Other: specify [multiple responses possible]
6.5 GCI	Grade of early onset (≤30 days post surgery) complication(s)	To determine patterns of adverse events associated with a treatment. Required for the reporting of the gynaecological clinical indicators.	The worse case grade of each complication which arises less than or equal to 30 days post surgery. Definitions of the permissible values are as values: • Grade I Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic and radiological interventions. Allowed therapeutic regimens are: drugs as antiemetics, antipyretics, analgetics, diuretics, electrolytes and physiotherapy. This grade also includes wound infections opened at the bedside. • Grade II Complication requiring pharmacological treatment with drugs other than such allowed for grade I complications. Blood transfusions and total parenteral nutrition are also included. • Grade III Complication requiring surgical, endoscopic or radiological intervention under or not under general anaesthesia. • Grade IV Life threatening complication including; central nervous system complications (brain haemorrhage, ischemic stroke, subarrachnoid bleeding), Signal (including dialysis) and multiple organ dysfunction which require intermediate care or intensive care unit management. • Grade V Complication resulting in the death of a patient.	Refer to the Dindo, Demartines and Clavien, Classification of Surgical Complications • Grade I • Grade II • Grade III • Grade IV • Grade V