Anesthesia Technique: Neuraxial

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Description

This phenotype is used to determine whether or not a case included neuraxial anesthesia and if that neuraxial anesthesia was spinal, epidural, caudal, multiple types, combined spinal-epidural, or unknown. This phenotype is applicable to all cases. This phenotype is used in exclusion/inclusion criteria for measures.

Limitation

Variance in electronic health record documentation or incorrect variable mapping may cause an incorrect result for a case. This phenotype is limited to documentation within notes that are associated with neuraxial anesthesia.

Data quality is limited to individual site documentation accuracy, completeness, and variable mapping, which is performed by each site, independently. MPOG, as the coordinating center, reviews data quality at each data upload and monthly via Data Diagnostics and Case Validation tools. This review, while thorough, may not contain all data elements relevant to this phenotype and thus should be carefully reviewed by the user.

Value Type

Categorical

Enumeration

Value	Value Code	Definition

Return Columns

Column Name	Data Type

Granularity

Logic

Start with all cases.

First, compile a list of all neuraxial types that a case may qualify for using steps 1-6.

Step 1: Determine if case has 'Epidural' flags

1. Evaluate if case has any epidural note concepts:

50154 Epidural anesthesia catheter placement note
50159 Epidural needle length (cm)
50162 Epidural loss of resistance depth (cm)
50163 Epidural catheter type or brand
50164 Epidural catheter withdrawn to depth (cm)
50164 Epidural catheter withdrawn to depth (cm)
50166 Epidural paresthesias during placement
50339 Epidural catheter withdrawn to depth (cm) - detail
50344 Epidural catheter secured
50347 Epidural meniscus fall assessment - note
50348 Epidural meniscus fall yes / no - detail
50349 Epidural test dose administered - note
50350 Epidural test dose administered - number of ML detail

2. If any of the above notes present, add ‘Epidural’ to the list of neuraxial types that the case qualifies for and move to step 2.

3. If none of these notes present, move to step 2.

Step 2: Determine if case has other neuraxial documentation with values suggesting epidural placement:

Evaluate if case has any of these note concepts:

50050 Obstetrics- labor epidural start
50051 Obstetrics- Labor epidural end
50614 Neuraxial technique- combined spinal/epidural technique note
50643 Neuraxial - Epidural placed for postoperative pain control
50254 Categorized note: Regional or neuraxial note

If any of these notes present, evaluate if that note has text 'Epidural' AND that note does NOT have text 'Combined Spinal' or ‘Spinal’ (via AIMS value text)

If yes, add 'Epidural' to the list of neuraxial types that case qualifies for and move to step 3.
If no flags present, move to step 3

Step 3: Determine if case has epidural route concept:

Evaluate if the epidural route concept 2005 is present.

If yes, add ‘Epidural’ to the list of neuraxial types that case qualifies for and move to step 4.
If no, move to step 4.

Step 4. Determine if case has 'Spinal' flags

Evaluate if case has any of the following concepts:

90320- High Spinal (Outcome)
100313- Spinal (Access type)
50147 Neuraxial- Spinal vertebral interspace final
50148 Neuraxial- Spinal needle approach
50149 Neuraxial - Spinal needle type
50150 Neuraxial- Spinal needle diameter (gauge)
50151 Neuraxial- Spinal needle length (cm)
50153 Neuraxial- Spinal dermatomal level achieved
50351 Neuraxial - Spinal placement CSF observed note
50352 Neuraxial - Spinal placement CSF observed yes / no detail
50353 Neuraxial - Spinal placement Blood observed in spinal needle note
50354 Neuraxial - Spinal placement Blood observed yes / no detail
50614 Neuraxial technique - Combined Spinal / Epidural technique note
50680 - Neuraxial- Spinal or Epidural performed and value text does not contain 'Combined Spinal'

2. If any of the above concepts present, add ‘Spinal’ to the list of neuraxial types that the case qualifies for and move to step 5.

3. If no flags are present, move to step 5.

Step 5. Determine if case has 'Combined Spinal Epidural (CSE)' flags

Evaluate if case has one of the note concepts

50614 Neuraxial technique - Combined Spinal / Epidural technique note
50154 Epidural anesthesia catheter placement note

If any of the above notes present, evaluate if the note has text 'CSE' or 'Combined Spinal'

If yes, add 'Combined Spinal Epidural (CSE)' to list of neuraxial types that case qualifies for and move to Step 6
If no flags present, move to Step 6

Step 6. Determine if case has 'Caudal' flags

Evaluate if case has note 50635 (Regional - Caudal block performed)

If yes, add 'Caudal' to the list of neuraxial types that case qualifies for and move to final check.
If no, move to Step 7

Step 7. Determine if the case has broad neuraxial notes

Evaluate if case has the following note concepts present in parent or child note

50156 Epidural needle approach
50165 Epidural dermatomal level achieved
50229 Induction procedure
50254 Categorized note: Regional or neuraxial note
50507 Procedures - Epidural Blood Patch
50665 Procedures - Other unlisted procedure
50677 Regional - Block location
50690 Categorized Note - Regional Anesthesia
50691 Categorized note - Neuraxial anesthesia
50764 Misc - Primary Anesthesia Technique Used
If any of the above notes have text 'CSE' or 'Combined Spinal' OR has text 'Epidural' AND 'Spinal' in same note, then add 'Combined Spinal Epidural (CSE)' to list of neuraxial types that case qualifies for and move to Step 8.
If any of the above notes have text 'Epidural' but does not have text 'Spinal', 'Combined Spinal', or 'CSE', then add 'Epidural' to the list of neuraxial types that case qualifies for and move to to Step 8.
If any of the above notes have text 'Spinal' but do not contain 'Epidural' or 'Combined Spinal' or 'CSE', then add 'Spinal' to the list of neuraxial types that case qualifies for and move to Step 8.
If any of the above notes have text 'Caudal' but do not have text 'Combined Spinal' or 'CSE', then add 'Caudal' to the list of neuraxial types that case qualifies for and move to Step 8.
If none of the above, move to Step 8

Step 8. Then, check for additional neuraxial note concepts:

Evaluate if case has any of the following note concepts

50034 Neuraxial – Vertebral interspace final (unspecified)
50146 Neuraxial technique patient position
50154 Epidural anesthesia catheter placement note
50165 Epidural dermatomal level achieved
50329 Neuraxial technique sterile prep and drape note
50330 Neuraxial technique sterile prep type detail
50333 Neuraxial technique subcutaneous skin infiltrated with local anesthetic
50335 Neuraxial insertion paresthesia assessment- note
50336 Neuraxial insertion paresthesia yes / no detail
50338 Neuraxial insertion aspiration of blood or CSF- detail
50363 Neuraxial technique - Sensory Level Tested Left Note
50364 Neuraxial technique - Sensory Level Left Detail
50365 Neuraxial technique - Sensory Level Left Testing Device Detail
50366 Neuraxial technique - Sensory Level Tested Right Note
50367 Neuraxial technique - Sensory Level Right Level Detail
50368 Neuraxial technique - Sensory Level Right Testing Device Detail
50370 Neuraxial technique - Bilateral Sensory Level Tested Note
50371 Neuraxial technique - Bilateral Sensory Level Detail
50372 Neuraxial technique - Bilateral Sensory Level Testing Device Detail
50691 Categorized note - Neuraxial anesthesia
If case has any of the above note concepts, add 'Neuraxial - Unknown Type' to the list of neuraxial types that case qualifies for. Do not consider any terms in note text. Proceed to Final Check.

Final Check: Compile complete list of Neuraxial Types that a case qualifies for based on above logic. One case can have zero assignments or many assignments. Consider complete list of Neuraxial Types assigned in the steps above:

If list has 'Combined Spinal Epidural (CSE)', then assign final result 'Combined Spinal Epidural (CSE)'
If case does not have 'Combined Spinal Epidural (CSE)' assignment, then check for 'Caudal', 'Epidural' and 'Spinal' independently:

If case has 'Caudal' and no other neuraxial types on list OR has 'Caudal' and 'Epidural', then assign final result 'Caudal'
If case has 'Epidural' and no other neuraxial types on list, then assign final result 'Epidural'
If case has 'Spinal' and no other neuraxial types in list, then assign final result 'Spinal'
If case has 'Caudal' and 'Spinal', then assign final result 'Neuraxial- Multiple Types Listed'
If case has 'Epidural' and 'Spinal'
- Evaluate if the ‘epidural’ assignment is based on step 3 alone (no epidural notes found in step 1 or 2; epidural route only 2005).
If yes, evaluate if the ‘spinal’ assignment is based on concept 50680 alone (Step 4, Part 3):
- If yes, then assign final result: ‘Neuraxial - Unknown Type’
- If no, then assign ‘spinal’
If no, evaluate if the ‘spinal’ assignment is based on concept 50680 alone (Step 4, Part 3):
- If yes, then assign final result: ‘Epidural’
- If no, then assign final result: ‘Neuraxial - Multiple Types Listed’
If case does not have 'Epidural', 'Spinal', 'Caudal' or 'Combined Spinal Epidural (CSE)' and has 'Neuraxial- Unknown Type Assignment', then assign final result 'Neuraxial- Unknown Type'

3. If case has no neuraxial types assigned to it, then assign final result 'None'