CODE 1   Yes

Code 1 is used where the patient had one or more unplanned returns to the operating theatre during an episode of admitted patient care.

CODE 2   No

Code 2 is used where the patient did not have one or more unplanned returns to the operating theatre during an episode of admitted patient care.

CODE 9   Not stated/inadequately described

Code 9 is used where it is uncertain or inadequately documented in the primary data collection to know whether the patient did or did not have one or more unplanned returns to the operating theatre during an episode of admitted patient care.

The return to the operating theatre should be for a surgical procedure related to the initial procedure, but may be performed by the same surgeon or a different surgeon. There is no defined postoperative period within which the return needs to occur but it needs to occur within the same episode of care.

Returns to the operating theatre are not included where the subsequent procedure was planned and documented prospectively at the time of the original procedure (for example, staged procedures).

Where a patient has one or more unplanned returns to the operating theatre during an episode of admitted patient care, this item is coded as ‘yes’.

Unplanned returns to the operating theatre are frequently due to complications, for example to treat bleeding. Some complications following complex surgery are to be expected due to patients’ pre-existing diseases or conditions and the nature of the disease or condition being treated. The rate of unplanned returns should be interpreted in the context of other patient health-care safety and quality information.

The Australian Council of Healthcare Standards (2013) defines a similar data element, 'Unplanned return to operating room'. This data element only covers patients who are admitted to day procedure facilities for an operation or procedure. Within this data element, the operating room is defined to include not just rooms equipped for surgery but also rooms equipped for other therapeutic, diagnostic or endoscopic procedures.

The Australian Council of Healthcare Standards (ACHS) 2013. Clinical indicator program information 2013. Sydney: ACHS. http://www.achs.org.au/media/58466/
achsclinicalindicatorprograminformation2013.pdf