19 Date clinically ready for DD/MM/YYYY Record date patient was clinically ready for discharge after delay 2

Transcription

1 Australian Rehabilitation Outcomes Centre (AROC) Amputation Impairment specific adjunct module to the AROC dataset Please use this excel workbook to record additional data on your amputatee patients. Collection of these additional data items was identified as clinically relevant through a benchmarking workshop. They have been identified by clinicians for the providers of am This excel workbook (file) has two worksheets. The first is an information sheet instructing data managers and clinicians how to complete the data collection sheet. The second is the data collection sheet/proforma itself. The adjunct module has been designed to recordamputee episodes (AROC impairmentcodes ) It comprises 16 additional data items. All code sets for the adjunct data items are available from a dropdown list. Some fields require free text. It is necessary to enter some data for each episode that has already been entered into your inpatient data in order to link the records. The adjunct data set should be saved to your hard-drive/server with the following name: AROC_Amputee_adjunct_FacilityName.xls where Facility name is your facility name When submitting a copy of your facility s adjunct data set it should be saved to have the following name: AROC_Amputee_adjunct_FacilityName_yyyymmdd.xls - where Facility name is your facility name and yyyymmdd is the date this file was sent to AROC After submitting the dataset, please keep working in the same spreadsheet and adding new data; please do not create a new spreadsheet. The adjunct data set should be submitted to AROC quarterly via to aroc@uow.edu.au (same timing as the inpatient and ambulatory data sets, however your inpatient and ambulatory data will still need to be submitted via AROC Online Services), AROC Adjunct Data Item Item Format Item Code set Comments Item Number 1* Establishment identifier Alphanumeric Facility Code 2* Person Identifier Alphanumeric Medical Record Number (MRN) 3* Episode begin date DD/MM/YYYY Date admitted to rehabilitation ward or started rehabilitation program 4* AROC Impairment code Numeric 5.x See Appendix A 5 Date of surgery DD/MM/YYYY Date of amputation surgery 6 Date ready for casting DD/MM/YYYY Date wound has healed and stump is ready for casting 7 Phase of amputee care Numeric 1 = Pre-operative 2 = Delayed wound 3 = Pre Prosthetic 4 = Prosthetic 5 = Follow-up 8 Prosthetic Numeric 1=Yes A patient is prosthetic if they already or will in the future have a prosthetic device fitted. A patient is not prosthetic if there is no potential to ambulate. 0=No 9 Frailty (pre-morbid) Numeric 1=Very Fit Rockwood Frailty Score see Appendix C for definitions 2=Well 3=Well, with treated comorbid disease 4=Apparently vulnerable 5=Mildly frail 6=Moderately frail 7=Severely frail 8=Terminally ill 9=Unknown or N/A 10 Date first prosthetic fitting DD/MM/YYYY Date of first fitting of interim prosthesis 11 Reason 1 for delay in first Alphanumeric Record reason for delay in first interim prosthetic fitting prosthetic fitting 12 Discharge Timed up and go Numeric XX.X test 13 Discharge 6 minute walk test Numeric XXX.X 14 Discharge 10 metre walk +/- Numeric XX.X aid test 15 Date clinically ready for DD/MM/YYYY Record date patient was clinically ready for. A patient is clinically ready for when the treating multidisciplinary team determine that there are no further rehabilitation goals that require ongoing inpatient rehabilitation and their ongoing needs can be adequately met by services available outside the in-patient setting. 16 Reason 1 for delayed Alphanumeric Record reason for delayed if date clinically ready for is not the same as episode end date 17 Date clinically ready for DD/MM/YYYY Record date patient was clinically ready for after delay 1 after delay 1 18 Reason 2 for delayed Alphanumeric Record reason for delayed if date clinically ready for after delay 1 is not the same as episode end date 19 Date clinically ready for DD/MM/YYYY Record date patient was clinically ready for after delay 2 after delay 2 20 Reason 3 for delayed Alphanumeric Record reason for delayed if date clinically ready for after delay 2 is not the same as episode end date 21* Episode end date DD/MM/YYYY Date d from rehabilitation ward or ended rehabilitation program * Core AROC data collection items Record phase of care patient is in at admission. Use comment field to indicate if patient passes through multiple phases during the rehabilitation episode e.g. multiple phases 2,3,4 See Appendix B for definitions of phases of care Record time (minutes and seconds) taken to complete assessment at, to one decimal place. If test is not applicable or not appropriate for episode of care, code 999 Record distance (metres) completed during assessment at, to one decimal place. If test is not applicable or not appropriate for episode of care, code 999 Record time (minutes and seconds) taken to complete assessment at, to one decimal place. If test is not applicable or not appropriate for episode of care, code 999

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3 AROC Impairment Establishment identifier Person identifier Episode begin date Code Date of Surgery Date ready for casting

4 Admission phase of amputee care Prosthetic Frailty (premorbid) Date first prosthetic fitting Reason 1 for delay in first prosthetic fitting Discharge Timed up and go test Discharge 6 minute walk test

5 Discharge 10 metre walk +/- aid Date clinically ready for Reason 1 for delayed Date clinically ready for after delay 1 Reason 2 for delayed Date clinically ready for after delay 2 Reason 3 for delayed

6 Episode end date Comment

7 APPENDIX A: AROC IMPAIRMENT CODES GUIDELINES FOR AMPUTATION OF LIM The aim of these guidelines is to assist in correctly classifying a rehabilitation episode according to impairment groups. There are 2 over-riding rules that need to be considere when using these guidelines: 1. The episode should be classified according to the primary reason for the curren episode of rehabilitation care 2. Rehabilitation program names related to funding are not necessarily the same as impairment group names (eg. a patient in a debility/reconditioning funding program may be having rehabilitation due to deconditioning related to a cardiac disorder this episode should be classified to 9.2 Chronic cardiac insufficiency not to 16 Reconditioning/restorative Please note that the examples of aetiologic diagnoses are not exhaustive. Include cases in which the major deficit is partial or complete absence of a limb. AROC Impairment Group AMPUTATION OF LIMB AROC Impairment Group Code 5.1 Single Upper Amputation Above the Elbow 5.2 Single Upper Amputation Below the Elbow 5.3 Single Lower Amputation Above the Knee (includes through the knee) 5.4 Single Lower Amputation Below the Knee 5.5 Double Lower Amputation Above the Knee (includes through the knee) 5.6 Double Lower Amputation Above/Below the Knee 5.7 Double Lower Amputation Below the Knee 5.8 Partial Foot Amputation (includes single/double) 5.9 Other Amputation Aetiologic Diagnosis Neoplasm of bones or cartilage and other soft tissue of limb Secondary neoplasm of bone Diabetes with neurologic manifestations or diabetes with peripheral circulatory disorders Hereditary and idiopathic peripheral neuropathy Inflammatory and toxic neuropathy Atherosclerosis of the extremities Peripheral vascular disease, unspecified Arterial embolism and thrombosis, extremities Buerger s disease Acquired deformity or injury affecting limbs Aneurysm of extremities Traumatic amputation (complete) (partial) Amputation stump complication/ revision Haemangioma Vasculitis (eg scleroderma, SLE) Connective tissue disorders Gangrene Infective processes (eg osteomyelitis/ cellulitis) Congential limb loss (when prosthesis required)

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9 APPENDIX B: AMPUTEE PHASES OF CARE DEFINITION SUMMARIES 1 = Pre-operative Clinical decision to perform amputation including assessment of urgency (following trauma or infection). Comprehensive interdisciplinary baseline assessment o patient s status including medical assessment, functiona status including function of contralateral limb, pain contr and psychological and cognitive assessment, patient s goals, social environment and support systems Post-operative care plan should be determined by surgeon rehabilitation team to address medical, wound or surgical a rehabilitation requirements 2 = Delayed wound Where problems occur with wound healing, consider additional interventions as needed including revision surgery, vascular and infection evaluation, aggressive lo wound care and hyperbaric oxygen 3 = Pre Prosthetic Patient is d from acute care and enters inpatie rehabilitation program or is treated in ambulatory setting Postoperative assessment to review patient s status including physical and functional assessment; completio FIM baseline and other relevant assessments Determine rehabilitation goals, establish or update rehabilitation treatment plan and provide patient educati Provide physical and functional interventions based on current and potential function Determine whether a prosthesis is appropriate to improv functional status and meet realistic patient goals 4 = Prosthetic Determine functional goals of prosthetic fitting Prescribe prosthesis based on current or potential level ambulation Interim or permanent prosthetic fitting and training, and early rehabilitation management Provision of prosthetic gait training and patient education functional use of prosthesis for transfers, balance and safety 5 = Follow-up Scheduled follow-up appointment after from rehabilitation Assessment of patient s goals, functional assessment, secondary complications, prosthetic assessment (repair replacement, mechanical adjustment and new technolog and vocational and recreational needs Provide secondary amputation prevention (where releva

10 of al rol and and ocal ent g on of ion ve of n on r, gy) ant)

11 APPENDIX C: ROCKWOOD CLINICAL FRAILTY SCALE

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