PAAQS Reference Guide

Transcription

1 Q. 1 Patient's Date of Birth (DOB) *Required Enter patient's date of birth PAAQS Reference Guide Q. 2 Starting Anesthesiologist *Required Record the anesthesiologist that started the case Q. 3 Date of Service *Required Record the date of service Q. 4 Reporting Provider Record your name if you did not start the case Q. 5 Adult Smokers Counseled prior to DOS via PAT Report for Adult smoker who was counseled in a PAT clinic prior to DOS - Abstained - Did not abstain * Default answer choice Patient that did not smoke on DOS Patient that smoked on DOS Q. 6 Direct Transfer from OR to any ICU Report for all patients that are a direct transfer from an OR to any ICU unit * Default answer choice Standardized protocol (SBAR) was used Standardized protocol was not used

2 Q. 7 Pediatric PONV Protocol Report for pediatric patient: Aged 3-17 with Inhalation maintenance anesthesia and 2 or more PONV risk factors* *PONV risk factors: Age 3yrs, Surgery>30min, Strabismus, Hx of PONV or PONV in sibling/parent Patient received 2+ anti-emetic agents Patient did not receive at least 2 antiemetic agents for medical reasons - Medical Reason Patient did not receive at least 2 antiemetic agents for unspecified reasons * Default answer choice *Excludes cases where inhalational anesthetic used only for induction Q. 8 Corneal Injury Report for Adult patient with clinical diagnosis of Corneal Abrasion prior to facility discharge DEFAULT Corneal injury occurs corneal injury *Exclusions: Ocular surgery or pre-existing condition Q. 9 Use of Pencil-Point Spinal Needle for OB Anesthesia Report for all OB patients with Spinal Anesthesia where a pencil-point needle is not used to access the intrathecal space DEFAULT Pencil-point needle was not used Pencil-point needle was used Pencil-point needle: Whitacre, Sprotte, Pencan, Gertie Marx

3 Q. 10 Use of Neuraxial Tech and/or PNBs for TKA Report for all TKA patients where neuraxial anesthesia and/or a peripheral nerve block is not performed - Patient Reasons DEFAULT Documentation of patient reason(s) for not using either neuraxial anesthesia or a peripheral nerve block (e.g. patient refusal) Neuraxial anesthesia and/or a peripheral nerve block was not used Neuraxial anesthesia and/or a peripheral nerve block was used Q. 11 Ultrasound Guidance Used for Internal Jugular Central Line Report for all patients with Internal Jugular Central Lines * Default answer choice Ultrasound guidance used during central line placement when internal jugular site used Ultrasound guidance was not used during central line placement when internal jugular site used Q. 12 Patient Survey Report only Adult patients who are unable to respond to our survey Patient reasons DEFAULT - Patient reasons, process reasons, or medical reasons for not receiving survey Survey provided *Excludes ASA PS6 Organ Donors; patient died within 30 days of the procedure

4 Q. 13 Airway Report if patient experiences any of the following airway complications: Aspiration Airway Trauma Difficult Intubation Difficult Mask Ventilation Unplanned Re-intubation Laryngospasm/bronchospasm Esophageal Intubation Unplanned Post op Vent assistance Significant Hypoxemia/hypercapnia Pneumothorax from Anesthesia Failed intubation Entry of material into respiratory tract and accompanied by radiologic findings Injury to structures or tissues of mouth, nasopharynx, oropharynx or larynx resulting from use of any airway device Problematic or challenging insertion of an endotracheal tube into the patient's trachea, requiring at least 3 attempts by one or more skilled individuals The inability of an unassisted trained anesthesia provider to maintain the oxygen saturation as measured by pulse oximetry to > 92% or to prevent or reverse signs of inadequate ventilation during positive-pressure mask ventilation The need to insert an endotracheal tube resulting from inability to sustain adequate spontaneous breathing occurring after the removal of an artificial airway Severe acute upper airway obstruction requiring positive pressure ventilation and/or Succinylcholine administration Unintentionally inserting an endotracheal tube into the esophagus, the anatomic connection between the pharynx and the stomach The need to provide mechanical pulmonary support that was not anticipated or expected at the time that anesthetic care was initiated A persistent abnormal, low partial pressure of oxygen in the arterial blood (less than 60 mmhg measured at standard temperature or an arterial oxygen saturation of less than 90%)/ Abnormally increased arterial carbon dioxide tension greater than 45 mmhg measured in arterial blood at standard temperature The unintended presence of air or gas in the pleural cavity, diagnosed by clinical findings or imaging (xray, CT, or ultrasound) that results from a regional anesthetic such as supraclavicular brachial plexus block, barotrauma, or instrumentation of the airway Inability to insert or pass an endotracheal tube into the trachea

5 Q. 14 CNS/Eye Report if patient experiences any of the following CNS/Eye complications: PONV Flumazenil/Naloxone Stroke Awareness under General Anesthesia Perioperative Visual Loss Seizure Nausea or vomiting that occurs between conclusion of procedure for which anesthesia care was provided and the DISCHARGE FROM PACU/ICU time and requiring a rescue antiemetic medication for treatment Use while patient is in peri-operative areas or with neuraxial opioids The sudden death of neurons in a localized area of brain due to inadequate blood flow that produces motor, sensory, or cognitive dysfunction that persists > 24 hrs Patient becomes conscious or has recall of events Total or partial loss of sight in one or both eyes after non-ocular surgery not caused by direct trauma or injury to the eye or the CNS Abnormal electric activity of the neurons in the brain that may have several clinical manifestations such as a sudden, violent involuntary series of contractions of a group of muscles (grand mal seizure); this outcome does not apply to seizures that are medically induced as part of a therapy such as electroconvulsive therapy (ECT) Q. 15 Cardiopulmonary Report if patient experiences blockage of blood flow in a coronary artery causing damage or death of a portion of the heart muscle* Myocardial Infarction Pulmonary Edema Sig. Dysrythmia,tachy/bradycardia Hypotension, decreased perfusion Occurs within 48 hours Accumulation of extravascular fluid in lung tissues and alveoli diagnosed by chest x-ray, ultrasound, clinical examination, or blood gas analysis Significant slowness of the heart rate that poses a threat to the patient and requires treatment An unintentional low systemic arterial blood pressure at a level that may result in inadequate perfusion of critical organs

6 Suspected Myocardial Ischemia Significant Hypertension Immediate Peri. Cardiac Arrest Immediate Peri. Mortality such as the brain, kidney, or heart (arbitrarily defined in adults as a systolic blood pressure less than 20% below the patient's baseline or a systolic blood pressure less than 80 mmhg or a diastolic blood pressure less than 50 mmhg lasting for more than 10 minutes) A temporary condition in which there is inadequate circulation of blood and transport of oxygen and glucose via the coronary arteries to the heart muscle but does not result in death of myocardium. It may be diagnosed by clinical symptoms of angina, ECG (ST segment or T wave) changes, new myocardial wall motion abnormality, or small increases in troponin An unplanned elevation of the systemic arterial blood pressure to a level likely to induce adverse consequences (arbitrarily defined in adults as a systolic or diastolic blood pressure more than 20% above baseline or a systolic pressure greater than 190 mmhg or diastolic pressure greater than 110 mmhg and lasting for more than 10 minutes) Unplanned cardiac arrest prior to Anesthesia End Time Death that occurs prior to Anesthesia End Time *Diagnosis Criteria (ONE from below): 1. Documented ECG changes indicative of acute MI with 1 or more of the following a. ST elevation > 1 mm in 2 or more contiguous leads not resolved within 20 mins b. New left bundle branch block c. New q-wave in two or more contiguous leads 2. New elevation in troponin > than 3x the upper level of the reference range in the setting of suspected MI 3. Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality

7 Q. 16 Regional Anesthesia Report if patient experiences any of the following regional anesthesia complications: Incomplete Labor Epidural Analgesia Incomplete Regional Anesthesia for C-section Infection after Epidural or Spinal Anes. High Spinal or Epidural PDPH LAST Peripheral Neurological Deficit >3 attempt at block/epidural placement >30 min to start of emergency CS Failed Regional Block Unplanned Dural Puncture/ Wet Tap Labor Epidural needs to be replaced to control painful labor (a second catheter placed, include caths inadvertently pulled out) Epidural or spinal anesthesia is not sufficient for surgery and requires a repeat regional anesthetic or conversion to general anesthesia Infectious complications associated with neuraxial anesthesia and analgesia Neuraxial anesthesia in which the level of sensory denervation extends at least to the second thoracic dermatome and that produces hypotension, bradycardia, and/or respiratory insufficiency that requires intubation or ventilatory assistance New onset postural HA within 72 hours of intended or unintended dural puncture Major adverse effects observed following injection of a local anesthetic resulting in elevated plasma drug concentration that produces seizures, somnolence, loss of consciousness, respiratory depression/apnea, bradycardia/asystole, or ventricular tachycardia/fibrillation In patient that received regional anesthesia or analgesia, residual sensory and/or motor and/or autonomic block 72 hours after the last LA injection If occurred If occurred If occurred Unintentionally piercing or perforating the dura mater (the tough, fibrous membrane forming the outer covering of the central nervous system).

8 Q. 17 Reactions to Medications/Blood Report if patient experiences any of the following reactions to medications/blood: Anaphylaxis Malignant Hyperthermia Transfusion Reaction Prolonged Neuromuscular Blockade Adverse Drug Reaction A severe, life-threatening allergic response, which is rapid in onset and characterized by a sudden drop in blood pressure and/or respiratory insufficiency A potentially fatal, inherited disorder usually associated with the administration of volatile anesthetics and/or succinylcholine Hemolytic reaction from major blood group incompatibilities An unanticipated increased duration of patient weakness after administration of a neuromuscular blocking agent Any unexpected, unintended, undesired, or excessive response to a drug that requires discontinuing the drug (therapeutic or diagnostic), changing the drug therapy, or modifying the dose (except for minor dosage adjustments). The adverse reaction must be severe enough that it requires prolonged observation or stay in a health care facility, necessitates supportive treatment, negatively affects prognosis, or results in temporary or permanent harm, disability, or death

9 Q. 18 latrogenic Report if patient experiences any of the following iatrogenic complications: Medication error Wrong patient Wrong surgery site Unplanned hospital admission Unplanned ICU admission Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer Administering anesthesia to or performing a procedure on a patient for whom it was not intended An operation on the incorrect or unintended anatomic part, organ, body side, or location or surgery performed on a body part not consistent with the documented informed consent for that patient Transfer of a patient, scheduled for an outpatient procedure, to an in-patient status from an anesthetizing site, PACU, or other clinical location that was not anticipated or arranged at the time that anesthetic care was initiated; within 48 hours of induction Transfer of a patient to an ICU from an anesthetizing site, PACU, or other clinical location that was not anticipated or arranged at the time that anesthetic care was initiated; within 48 hours of induction Q. 19 Death Report if patient death occurs Death The irreversible cessation of all vital functions as indicated by permanent stoppage of the heart, respiration, and brain activity; the end of life; within 48 hours of induction *Provide additional details from the case in a free response format Q. 20 Labor Analgesia Death Report if Plan initiated <30 min If occurred >30 min If occurred

10 Q21-31: For Williamsburg only Q. 21 STOP IN performed Report one of the following: Q. 22 Main OR/GOC delay Report one of the following: Surgeon late for 1 st case/ missing between cases Anesthesia Delay IV/line problem Incomplete history or consent Delay waiting for room/instruments Delay for labs/x-ray Delay for medical reasons or clearance Other delay Patient arrived late Q. 23 Endoscopy delay Report one of the following: Anesthesia late Endoscopist late Other delay* *Please explain Q. 24 Case Cancellation Report one of the following: By surgeon By 2 anesthesiologists Patient no show Q. 25 Anesthesia Ready Time Report anesthesia ready time Time hh:mm AM/PM format

11 Q. 26 In OR/endo Time Report in OR/endo time Time hh:mm AM/PM format Q. 27 Endoscopy anesthesia start on time, 1 st case of the day Report one of the following: Q. 28 Post-Op Hypothermia Report one of the following Temp <96.8 Temp >=96.8 Active warming used (Bair Blanket) Based on patient temperature Based on patient temperature Based on patient temperature Q. 29 Airway assessment and sleep apnea screening Report one of the following Excluded Completed all Deferred Q. 30 Anesthesia and surgical consent present Report one of the following * t needed, labor epidural *Please explain Q. 31 Miscellaneous Report if Equipment Failure The medical device did not provide the expected service or was not functioning as per its specifications

12 Q. 32 Other Report the following: Reason for Case Cancellation Patient complaints Unexpected outcomes Any important contextual information Enter DONE to complete your PAAQS report.