Demographics. MBSAQIP Case Number: IDN: ACS NSQIP Case Number:

Transcription

1 Demographics *LMRN: *DOB: / / *Gender: Male Female *Race: White Native Hawaiian/Other Pacific Islander Black or African American Asian American Indian or Alaska Native Unknown *Hispanic Ethnicity: Unknown First Name: MI: Last Name: Address: City: State: Zip Code: Country (if not US): Home #: ( ) - Work #: ( ) - Cell #: ( ) - Preferred Language: English Spanish 1

2 Case Form - Surgical Profile SURGICAL PROFILE Is the Patient Currently Undergoing a Metabolic or Bariatric Procedure, or is the Current Procedure Related to a Previous Metabolic or Bariatric Procedure? *CPT Code: *Principal Operative Procedure: Revisions/Other Reasons: Revision/Conversion Mini-loop gastric bypass Endoscopic Therapy Other CPT Code for Revisions/Other Reasons: If CPT is a Band, select band brand: RealizeTM Band (Ethicon) Lap-BandTM (Allergan/Inamed) Other Unknown *Hospital Admission Date: / / *Operation Date: / / (Required field) Name of Attending/Surgeon: Surgeon NPI: LCN (not required): Encounter Number (not required): * 2

3 Case Form Preoperative Risk Assessment PREOP *Height cm in Unknown Highest Recorded Weight within 1 year kg lbs Unknown Date for Highest Recorded Weight / / Unknown *Weight Closest to Surgery kg lbs Unknown Date for Weight Closest to Surgery / / Unknown General Cardiac Non-insulin History of Myocardial *Diabetes Mellitus No Insulin Infarction *Current Smoker w/in 1 year *Functional Health Status Previous PCI /PTCA Independent Partially Dependent Totally Dependent Unknown Previous Cardiac Surgery *Hypertension requiring Pulmonary medication *COPD (Severe) # of anti-hypertensive meds Hyperlipidemia requiring Oxygen Dependent medication History of Pulmonary Embolism Obstructive Sleep Apnea requiring CPAP / BiPAP (or similar technology) Gastrointestinal GERD requiring medications (within 30 days prior to surgery) Musculoskeletal Is the patient s ambulation limited most or all of the time? Vascular Vein Thrombosis Req. Therapy Venous Stasis IVC Filter Placed in anticipation of IVC Filter Timing Procedure IVC Filter Preexisting Unknown Renal *Currently requiring or on dialysis Renal Insufficiency Nutritional / Immune / Oncology / Other *Steroid/Immunosuppressant Use for Chronic Condition Therapeutic anticoagulation Previous obesity surgery/foregut surgery 3

4 Case Form Preop Labs/Operation PREOP LABS All Pre-op Labs Unknown *Preop Albumin: Date: / / Unknown *Preop Hematocrit: Date: / / Unknown NOTES: (If desired, e.g., list antihypertensive meds for future reference): OPERATION First Assistant level of training: None PA/NP/RNFA Resident (PGY 1-5+) MIS Fellow Attending Weight Loss Surgeon Attending Other *Emergency Case? *ASA Class: None Assigned Surgical Approach: N.O.T.E.S. (Natural Orifice Transluminal Endoscopic Surgery) Single Incision Robotic-assisted Conventional laparoscopic (thoracoscopic) Laparoscopic assisted (thoracoscopic assisted) Hand-assisted Open Notes: 4

5 Case Form Operation (cont.) OPERATION (cont.) Was the procedure converted to another approach: If yes, then what was the final operative approach: Single Incision Robotic-assisted Conventional laparoscopic (thoracoscopic) Laparoscopic assisted (thoracoscopic assisted) Hand-assisted Open Notes: Was the case aborted? If yes, please explain: Was a drain placed at the time of the initial operation? Was a swallow study performed the day of or the day after the procedure? Yes, routine Yes, selective No Was the anastomosis/staple line checked with a provocative test to assess for leak? N/A (only if no anastomosis/staple line) *Procedure / Surgery Start Time: Date / / *Procedure / Surgery Finish Time: Date / / Time : Time : If CPT is a Gastric Sleeve: Bougie (or sizing device) size French cm Not Documented Distance from the pylorus # (in cm) Not documented Staple line reinforcement: Oversew: 5

6 Case Form Other Procedures OTHER PROCEDURES *Other Procedures CPT *Concurrent Procedures CPT

7 Case Form Occurrences GENERAL POSTOPERATIVE OCCURRENCES: Was there a postoperative occurrence? YES NO (Although not required for this program, you may wish to document treatment and outcome to date of the occurrence for internal quality monitoring) Date Treatments / Outcomes / Comments Wound Occurrences Superficial Incisional SSI YES NO / / Superficial Incisional SSI PATOS YES NO Deep Incisional SSI YES NO / / Deep Incisional SSI PATOS YES NO Organ/Space SSI YES NO / / Organ/Space SSI PATOS YES NO Wound Disruption YES NO / / Respiratory Occurrences Pneumonia (PNA) YES NO / / Pneumonia PATOS YES NO Intraop or Postop Unplanned Intubation YES NO / / Pulmonary Embolism YES NO / / On ventilator > 48 hours YES NO / / On ventilator > 48 hours PATOS YES NO Urinary Tract Occurrences Report the most significant level (Progressive Renal Insufficiency or Acute Renal Failure) Progressive Renal Insufficiency YES NO / / Acute Renal Failure YES NO / / Urinary Tract Infection (UTI) YES NO / / UTI PATOS YES NO CNS Occurrences Stroke / CVA YES NO / / Cardiac Occurrences Intraop or Postop Cardiac Arrest req. CPR YES NO / / Intraop or Postop Myocardial Infarction YES NO / / 7

8 Case Form Occurrences (cont.) Other Occurrences Transfusion Intraop/Postop (72h of surgery start time) YES NO / / # of units transfused (transfusion of units) Vein Thrombosis req. Therapy YES NO / / Report the most significant level (Sepsis or Septic Shock) Sepsis YES NO / / Sepsis PATOS YES NO Septic Shock YES NO / / Septic Shock PATOS YES NO **Other Postoperative Occurrence (List ICD-9/ ICD-10 code): / / METABOLIC/BARIATRIC POSTOPERATIVE OCCURRENCES Was there a metabolic/bariatric postoperative occurrence? YES NO Date Treatments / Outcomes / Comments Coma > 24 hours / / Peripheral Nerve Injury / / Unplanned Admission to the ICU within 30 days / / **Other Metabolic or Bariatric Postoperative Occurrence (List ICD-9/ ICD-10 code) / / **Although not required for this program, you may wish to document treatment of the occurrence for internal quality monitoring. 8

9 Case Form Discharge DISCHARGE *Acute Hospital Discharge Date / / *Hospital Discharge Destination Skilled care not home Separate Acute Care Unskilled facility not home Rehab Facility which was home Expired Home Unknown *Still in Hospital > 30 days Yes No Death During Operation (Intraoperative Death) or Postoperative Death w/in 30 Days of Procedure Yes No Date of Death / / Unknown Was the Death Likely Related to the Operation Most Likely Cause of Death: (select code number from list below) Code Most Likely Reason Code Most Likely Reason 1 Anastomotic/Staple Line Leak 13 Incisional Hernia 2 GI Perforation 14 Bleeding 3 Other Abdominal Sepsis 15 Vein Thrombosis Requiring Therapy 4 Strictures/Stomal Obstruction 16 Pulmonary Embolism 5 Intestinal Obstruction 17 Pneumonia 6 Gastric Distention 18 Other Respiratory Failure 7 Fluid, electrolyte, or nutritional depletion 19 Infection/Fever 8 Anastomotic Ulcer 20 Band Slippage/Prolapse 9 Gastro-Gastric Fistula 21 Band Erosion 10 Gallstone Disease 22 LAGB Port, Tubing or Band problem 11 Wound Infection/Evisceration 23 Bile Reflux Gastritis 12 Internal Hernia 24 Other Was the Death Reviewed by the Bariatric Committee within 60 Days of Death? Comments 9

10 Case Form- Readmissions HOSPITAL READMISSIONS Did the patient have a hospital readmission within 30 days of the principal procedure? Readmission #1 Readmission Date: / / Unknown Discharge Date: / / Unknown N/A Information Source Medical Record Patient/Family Report Other Was this readmission likely related to a bariatric procedure? Most likely reason for admission (enter code from table below) Comments: Readmission #2 Readmission Date: / / Unknown Discharge Date: / / Unknown N/A Information Source Medical Record Patient/Family Report Other Was this readmission likely related to a bariatric procedure? Most likely reason for admission (enter code from table below) Comments: Readmission #3 Readmission Date: / / Unknown Discharge Date: / / Unknown N/A Information Source Medical Record Patient/Family Report Other Was this readmission likely related to a bariatric procedure? Most likely reason for admission (enter code from table below) Comments: Most Likely Reason for Readmission Code Most Likely Reason Code Most Likely Reason 1 Anastomotic/Staple Line Leak 14 Incisional Hernia 2 GI Perforation 15 Bleeding 3 Other Abdominal Sepsis 16 Vein Thrombosis Requiring Therapy 4 Strictures/Stomal Obstruction 17 Pulmonary Embolism 5 Intestinal Obstruction 18 Pneumonia 6 Gastric Distention 19 Other Respiratory Failure 7 Nausea, Vomiting, Fluid, electrolyte or nutritional depletion 20 Infection/Fever 8 Abdominal Pain, Not Otherwise Specified 21 Band Slippage/Prolapse 9 Anastomotic Ulcer 22 Band Erosion 10 Gastro-Gastric Fistula 23 LAGB Port, Tubing or Band problem 11 Gallstone Disease 24 Bile Reflux Gastritis 12 Wound Infection/Evisceration 25 Other 13 Internal Hernia 10

11 Case Form- Reoperations/Interventions REOPERATION/INTERVENTION Did the Patient have a Reoperation/Intervention within the 30 day Postoperative Period? Reoperation #1 Was this reoperation/intervention likely related to a bariatric procedure? Reoperation/Intervention (see table below) Most likely reason for reoperation/intervention (enter code from table below) Date Performed / / Unknown Information Source Medical Record Patient/Family Report Other Comments: Reoperation #2 Was this reoperation/intervention likely related to a bariatric procedure? Reoperation/Intervention (see table below) Most likely reason for reoperation/intervention (enter code from table below) Date Performed / / Unknown Information Source Medical Record Patient/Family Report Other Comments: Reoperation #1 Was this reoperation/intervention likely related to a bariatric procedure? Reoperation/Intervention (see table below) Most likely reason for reoperation/intervention (enter code from table below) Date Performed / / Unknown Information Source Medical Record Patient/Family Report Other Comments: Reoperations/Interventions Abdominal Reoperation Operative Drain Placement Gastrostomy Anastomotic Revision Band Removal Band, Tubing or Port Revision Band Placement Internal Hernia Repair Incisional Hernia Repair Cholecystectomy Bowel Resection Re-exploration Other Abdominal Operation Other Reoperations/Interventions Tracheostomy Endoscopy Gastro-gastric fistula closure ERCP Placement of Percutaneous Drain IVC Filter Placement IVC Filter Retrieval Other (please specify) 11

12 Case Form- Reoperations/Interventions (cont.) Most Likely Reason for Reoperation/Intervention Code Most Likely Reason Code Most Likely Reason 1 Anastomotic/Staple Line Leak 14 Incisional Hernia 2 GI Perforation 15 Bleeding 3 Other Abdominal Sepsis 16 Vein Thrombosis Requiring Therapy 4 Strictures/Stomal Obstruction 17 Pulmonary Embolism 5 Intestinal Obstruction 18 Pneumonia 6 Gastric Distention 19 Other Respiratory Failure 7 Nausea, Vomiting, Fluid, electrolyte or 20 Infection/Fever nutritional depletion 8 Abdominal Pain, Not Otherwise Specified 21 Band Slippage/Prolapse 9 Anastomotic Ulcer 22 Band Erosion 10 Gastro-Gastric Fistula 23 LAGB Port, Tubing or Band problem 11 Gallstone Disease 24 Bile Reflux Gastritis 12 Wound Infection/Evisceration 25 Other 13 Internal Hernia 12

13 Case Form- Follow-up VISIT PERIOD Were you able to follow the patient for the full 30 days? What is the assessment date? / / Unknown Was an exam performed by a bariatric physician or PA/NP? Yes No Was the patient seen by any clinician? GENERAL Height: cm in Weight: kg lbs Unknown Date weight taken: / / Unknown Was anticoagulation initiated for presumed/confirmed vein thrombosis/pe? Was an incisional hernia noted on exam? Was an operative drain still present at 30 days? 13

14 Case Form Attempts to Contact Patient ATTEMPTS BY THE BARIATRIC CENTER TO CONTACT PATIENT Was a follow-up appointment made but patient did not show for appointment? Was a phone call placed to the patient? Once Twice Never Was a letter sent to the patient? Once Twice Never Was the patient s care transferred to another bariatric specialist? If yes, please list name. Name: Is patient refusing long-term follow-up? Is the patient lost to follow-up? PATIENT CONTACT MANAGEMENT Contact date: / / Contact Action: Call Letter Document Fax Other Contact Results: No answer Left message Letter sent Letter received Talked to patient Talked to family Incorrect number Patient refused Lost to follow-up Contact Notes: Contact date: / / Contact Action: Call Letter Document Fax Other Contact Results: No answer Left message Letter sent Letter received Talked to patient Talked to family Incorrect number Patient refused Lost to follow-up Contact Notes: Contact date: / / Contact Action: Call Letter Document Fax Other Contact Results: No answer Left message Letter sent Letter received Talked to patient Talked to family Incorrect number Patient refused Lost to follow-up Contact Notes: 14