Demographics IDN: DOB: / / Gender: Male Female. Race: White Black or African American American Indian or Alaska Native

Transcription

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

2 SURGICAL PROFILE Case Form Is the principal operative procedure an initial primary metabolic or bariatric procedure? Yes Does the patient have a history of metabolic or bariatric surgery? Yes Is the principal operative procedure related to a previous metabolic or bariatric surgery? Yes CPT Code: Principal Operative Procedure: Revisions/Other Reasons: Revision/Conversion Yes Initial MBS done at your center Yes Mini-loop gastric bypass Yes Gastric Plication Yes Endoscopic Therapy Yes Intragastric Balloon Yes Vagal Blocking Therapy Yes (VBLOC Therapy) Other Yes CPT Code for Revisions/Other Reasons: principal operative procedure) If Case is an Intragastric Balloon, select balloon brand: Elipse (Allurion Technologies Obalon (Obalon Therapeutics) Orbera (Apollo Endosurgery) ReShape (ReShape Medical) Spatz (Spatz) Other Unknown (Only required when CPT Code or is entered as the If CPT is a Band, select band brand: Realize Band (Ethicon) Lap-Band (Allergan/Inamed) Other Unknown Hospital Admission Date: / / Operation Date: _/ _/ (Required field) Anesthesia Type (Intragastric Balloon Cases Only): General MAC/IV Topical ne Other Unknown Medical Specialist: Metabolic/Bariatric Surgeon Interventional Radiologist General Surgeon Gastroenterologist Other Name of Attending/Surgeon: Surgeon NPI: LCN (optional): Encounter Number (optional): MBSAQIP Case Number: 2

3 Preoperative Risk Assessment Height cm in Unknown Highest Recorded Wt 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 Diabetes Mellitus n-insulin Insulin History of Myocardial Infarction Yes Current Smoker w/in 1 year Yes Previous PCI /PTCA Yes Independent Functional Health Status Partially Dependent Previous Cardiac Surgery Yes Totally Dependent Unknown Pulmonary Hypertension requiring medication Yes COPD (Severe) Yes # of anti-hypertensive meds Oxygen Dependent Yes History of Pulmonary Embolism Obstructive Sleep Apnea requiring CPAP / BiPAP (or similar technology) Gastrointestinal Gastroesophageal Reflux Disease (GERD) requiring medication within 30 days prior to surgery Musculoskeletal Is the patient s ambulation limited most or all of the time? Yes Vascular Yes Yes 3 Hyperlipidemia requiring medication Yes Vein Thrombosis Req. Therapy Yes Venous Stasis Yes IVC Filter Yes IVC Filter Timing Renal Currently requiring or on dialysis Placed in anticipation of Procedure IVC Filter Preexisting Unknown Yes Renal Insufficiency Yes Nutritional / Immune / Oncology / Other Yes Steroid/Immunosuppressant Use for Chronic Condition Yes Therapeutic anticoagulation Yes Previous obesity surgery/foregut surgery Yes Previous Organ Transplant Yes

4 PREOP LABS All Pre-op Labs Unknown Albumin: Date: / / Unknown Hematocrit: Date / / Unknown Serum Creatinine:_ Date: / / Unknown Hemoglobin A1C (HbA1c): Date: / / Unknown OPERATION First Assistant Level of Training: ne PA/NP/RNFA Resident (PGY 1-5+) MIS Fellow Attending Weight Loss Surgeon Attending Other Emergency Case: Yes ASA Class: ne 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 Was the procedure converted to another approach? Yes 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? Yes Notes: Was a drain placed at the time of the initial operation? Yes Was a swallow study performed the day of or the day after the procedure? Yes, routine Yes, selective Was the anastomosis/staple line checked with a provocative test to assess for leak? Yes N/A (only if no anastomosis/staple line) 4

5 Procedure / Surgery Start Time: Date / / Time : Procedure / Surgery Finish Time: Date / / Time : If CPT is a Gastric Sleeve: Bougie (or sizing device) size: French cm t Documented Distance from the pylorus (in cm): t documented Staple line reinforcement: Yes Oversew: Yes OTHER PROCEDURES Other Procedures CPT Concurrent Procedures CPT Is this a Stapling Procedure? (Include Principal Operative Procedure, Other, and Concurrent Procedures) Yes 5

6 GENERAL POSTOPERATIVE OCCURRENCES: Was there a postoperative occurrence? YES NO Wound Occurrences Date Treatments / Outcomes / Comments 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 / / Intraop or Postop 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 Requiring Dialysis YES NO / / Urinary Tract Infection (UTI) YES NO / / UTI PATOS YES NO CNS Occurrences Stroke / CVA YES NO / / Notes: 6

7 Cardiac Occurrences Intraop or Postop Cardiac Arrest Requiring CPR YES NO / / Intraop or Postop Myocardial Infarction YES NO / / Other Occurrences Transfusion Intraop/Postop (72h of surgery start time) YES NO / / # of units transfused (transfusion of units) Vein Thrombosis req. Therapy YES NO / / C. Diff YES NO / / If Yes, Type of test: Toxin DNA Other (C. Diff) Other (non-c. Diff) Unknown None Result of C. diff test: Positive Negative Treatment for C. diff: YES NO Loose stools/diarrhea 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 OPTIONAL: Other Postoperative Occurrence (List ICD-9/ ICD-10 code): METABOLIC/BARIATRIC POSTOPERATIVE OCCURRENCES Was there a metabolic/bariatric postoperative occurrence? YES NO Coma > 24 hours YES NO / / Peripheral Nerve Injury YES NO / / Unplanned Admission to ICU within 30 days YES NO / / OPTIONAL: Other Postoperative Occurrence (List ICD-9/ ICD-10 code): Notes: 7

8 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 Death During Operation (Intraoperative Death) or Postoperative Death w/in 30 Days of Procedure: Yes Date of Death: / _/ Unknown Was the Death Likely Related to the Operation: Yes Most Likely Cause of Death: (select code number from list below) Most Likely Cause Anastomotic/Staple Line Leak GI Perforation Other Abdominal Sepsis Strictures/Stomal Obstruction Intestinal Obstruction Gastric Distention Fluid, electrolyte, or nutritional depletion Anastomotic Ulcer Gastro-Gastric Fistula Gallstone Disease Wound Infection/Evisceration Internal Hernia Most Likely Cause Incisional Hernia Bleeding Vein Thrombosis Requiring Therapy Pulmonary Embolism Pneumonia Other Respiratory Failure Infection/Fever Band Slippage/Prolapse Band Erosion LAGB Port, Tubing or Band problem Bile Reflux Gastritis Other Was the Death Reviewed by the Bariatric Committee within 60 Days of Death? Yes Notes: Did the Patient Receive Treatment for Dehydration (Nausea and Vomiting, Fluid, Electrolyte, or Nutritional Depletion) as an Outpatient? Yes If yes; # of treatments Was the Patient Seen in any Emergency Department (ED) which did not result in an Inpatient Admission? Yes If yes; # of visits 8

9 HOSPITAL READMISSIONS Did the patient have a hospital readmission within 30 days of the principal procedure? Yes Readmission #1 Readmission Date: _/ / Unknown Discharge Date: _/ / Unknown N/A Information Source Medical Record Patient/Family Report Other Was this readmission unplanned at the time of the principal procedure? Yes Did this readmission occur at your hospital? Yes Was this readmission likely related to a metabolic or bariatric procedure? Yes Most likely reason for admission Readmission #2 Readmission Date: / / Unknown Discharge Date: _/ / Unknown N/A Information Source Medical Record Patient/Family Report Other Was this readmission unplanned at the time of the principal procedure? Yes Did this readmission occur at your hospital? Yes Was this readmission likely related to a metabolic or bariatric procedure? Yes Most likely reason for admission Readmission #3 Readmission Date: / / Unknown Discharge Date: _/ / Unknown N/A Information Source Medical Record Patient/Family Report Other Was this readmission unplanned at the time of the principal procedure? Yes Did this readmission occur at your hospital? Yes Was this readmission likely related to a metabolic or bariatric procedure? Yes Most likely reason for admission 9

10 Most likely reason for readmission: Most Likely Reason Nausea, Vomiting, Fluid, Electrolyte or Nutritional Depletion Anastomotic/Staple Line Leak Anastomotic Ulcer Band Slippage/Prolapse Band Erosion Bleeding Gastric Distention Gastro-Gastric Fistula GI Perforation Internal Hernia LABG Port, Tubing, or Band Problem Stricture/Stomal Obstruction Incisional Hernia Wound Infection/Evisceration Other Respiratory Failure (including pleural effusions) Pneumonia Pulmonary Embolism Shortness of Breath (without diagnosis of PE) Cardiac, Not Otherwise Specified (arrhythmia, CHF) Most Likely Reason Chest Pain (cardiac enzymes not required to be positive) Myocardial Infarction Abdominal Pain, Not Otherwise Specified Intestinal Obstruction Other Abdominal Sepsis (diverticulitis, pancreatitis, intra-abdominal abscess) CVA Psychiatric-Related Nephrolithiasis Renal Insufficiency Bile Reflux Gastritis Gallstone Disease Infection/Fever Medication-Related Musculoskeletal Pain Other Planned Surgery Vein Thrombosis Requiring Therapy 10

11 REOPERATIONS Did the Patient have a Reoperation within the 30 day Postoperative Period? Yes Reoperation #1 Was this reoperation unplanned at the time of the principal procedure? Yes Was this reoperation performed at your hospital? Yes Was this reoperation likely related to a metabolic or bariatric procedure? Yes Emergency Case Yes Was this a stapling procedure? Yes Was this procedure a Revision/Conversion? Yes Was this procedure a Mini-Loop Gastric Bypass? Yes Was this procedure a Gastric Plication? Yes Was this procedure an Endoscopic Therapy? Yes Reoperation (see table below) CPT Code for Reoperations: Most likely reason for reoperation Date Performed _/ / Unknown Information Source Medical Record Patient/Family Report Other Reoperation #2 Was this reoperation unplanned at the time of the principal procedure? Yes Was this reoperation performed at your hospital? Yes Was this reoperation likely related to a metabolic or bariatric procedure? Yes Emergency Case Yes Was this a stapling procedure? Yes Was this procedure a Revision/Conversion? Yes Was this procedure a Mini-Loop Gastric Bypass? Yes Was this procedure a Gastric Plication? Yes Was this procedure an Endoscopic Therapy? Yes Reoperation (see table below) CPT Code for Reoperations: Most likely reason for reoperation Date Performed _/ / Unknown Information Source Medical Record Patient/Family Report Other Reoperation #3 Was this reoperation unplanned at the time of the principal procedure? Yes Was this reoperation performed at your hospital? Yes Was this reoperation likely related to a metabolic or bariatric procedure? Yes Emergency Case Yes Was this a stapling procedure? Yes Was this procedure a Revision/Conversion? Yes Was this procedure a Mini-Loop Gastric Bypass? Yes Was this procedure a Gastric Plication? Yes Was this procedure an Endoscopic Therapy? Yes Reoperation (see table below) CPT Code for Reoperations: Most likely reason for reoperation Date Performed _/ / Unknown Information Source Medical Record Patient/Family Report Other 10

12 Reoperations: Operative Drain Placement Gastrostomy Tube (G-tube) Placement Jejunostomy Tube (J-tube) Placement Anastomotic Revision Band Removal Band Tubing or Port Revision Band Placement Internal Hernia Repair Incisional Hernia Repair Cholecystectomy Bowel Resection Re-exploration Tracheostomy (Open or Percutaneous) Other-Abdominal Other Reoperation Most Likely Reason for Reoperation: Most Likely Reason Nausea, Vomiting, Fluid, Electrolyte or Nutritional Depletion Anastomotic/Staple Line Leak Anastomotic Ulcer Band Slippage/Prolapse Band Erosion Bleeding Gastric Distention Gastro-Gastric Fistula GI Perforation Internal Hernia LABG Port, Tubing, or Band Problem Stricture/Stomal Obstruction Incisional Hernia Wound Infection/Evisceration Other Respiratory Failure (including pleural effusions) Pneumonia Pulmonary Embolism Shortness of Breath (without diagnosis of PE) Cardiac, Not Otherwise Specified (arrhythmia, CHF) Most Likely Reason Chest Pain (cardiac enzymes not required to be positive) Myocardial Infarction Abdominal Pain, Not Otherwise Specified Intestinal Obstruction Other Abdominal Sepsis (diverticulitis, pancreatitis, intra-abdominal abscess) CVA Psychiatric-Related Nephrolithiasis Renal Insufficiency Bile Reflux Gastritis Gallstone Disease Infection/Fever Medication-Related Musculoskeletal Pain Other Planned Surgery Vein Thrombosis Requiring Therapy 12

13 INTERVENTIONS Did the Patient have an Intervention within the 30 day Postoperative Period? Yes Intervention #1 Was this intervention unplanned at the time of the principal procedure? Yes Was the intervention at your site? Yes Was this intervention likely related to a metabolic or bariatric procedure? Yes Emergency Case Yes Intervention (see table below) Most likely reason for intervention Date Performed _/ / Unknown Information Source Medical Record Patient/Family Report Other If Balloon Case: Anesthesia Type: General MAC/IV Topical ne Other Unknown Balloon Brand: Elipse (Allurion Technologies) Obalon (Obalon Therapeutics) Orbera (Apollo Endosurgery) ReShape (ReShape Medical) Spatz (Spatz) Other Unknown Intervention #2 Was this intervention unplanned at the time of the principal procedure? Yes Was the intervention at your site? Yes Was this intervention likely related to a metabolic or bariatric procedure? Yes Emergency Case Yes Intervention (see table below) Most likely reason for intervention Date Performed _/ / Unknown Information Source Medical Record Patient/Family Report Other If Balloon Case: Anesthesia Type: General MAC/IV Topical ne Other Unknown Balloon Brand: Elipse (Allurion Technologies) Obalon (Obalon Therapeutics) Orbera (Apollo Endosurgery) ReShape (ReShape Medical) Spatz (Spatz) Other Unknown Intervention #3 Was this intervention unplanned at the time of the principal procedure? Yes Was the intervention at your site? Yes Was this intervention likely related to a metabolic or bariatric procedure? Yes Emergency Case Yes Intervention (see table below) Most likely reason for intervention Date Performed _/ / Unknown Information Source Medical Record Patient/Family Report Other If Balloon Case: Anesthesia Type: General MAC/IV Topical ne Other Unknown Balloon Brand: Elipse (Allurion Technologies) Obalon (Obalon Therapeutics) Orbera (Apollo Endosurgery) ReShape (ReShape Medical) Spatz (Spatz) Other Unknown 13

14 Interventions: Diagnostic Endoscopy Therapeutic Endoscopy : Therapeutic Endoscopy with Dilation (no Stent) Therapeutic Endoscopy to Control Bleeding Therapeutic Endoscopy with Stoma Resizing Therapeutic Endoscopy with Gastro-Gastric Fistula Closure Therapeutic Endoscopy with Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement Therapeutic Endoscopy with Band Removal Therapeutic Endoscopy with ERCP Placement of Percutaneous Drain Other Intervention Planned/Scheduled Intragastric Balloon Removal per Protocol Intragastric Balloon Intolerance Intragastric Balloon Rupture Obstruction Aspiration Perforation Bleeding Gastric Ulcer Inferior Vena Cava (IVC) Filter Placement Inferior Vena Cava (IVC) Filter Retrieval Most Likely Reason for Intervention: Most Likely Reason Nausea, Vomiting, Fluid, Electrolyte or Nutritional Depletion Anastomotic/Staple Line Leak Anastomotic Ulcer Band Slippage/Prolapse Band Erosion Bleeding Gastric Distention Gastro-Gastric Fistula GI Perforation Internal Hernia LABG Port, Tubing, or Band Problem Stricture/Stomal Obstruction Incisional Hernia Wound Infection/Evisceration Other Respiratory Failure (including pleural effusions) Pneumonia Pulmonary Embolism Shortness of Breath (without diagnosis of PE) Cardiac, Not Otherwise Specified (arrhythmia, CHF) Most Likely Reason Chest Pain (cardiac enzymes not required to be positive) Myocardial Infarction Abdominal Pain, Not Otherwise Specified Intestinal Obstruction Other Abdominal Sepsis (diverticulitis, pancreatitis, intraabdominal abscess) CVA Psychiatric-Related Nephrolithiasis Renal Insufficiency Bile Reflux Gastritis Gallstone Disease Infection/Fever Medication-Related Musculoskeletal Pain Other Planned Surgery Vein Thrombosis Requiring Therapy 14

15 FOLLOW-UP Visit Period Were you able to follow the patient for the full 30 days? Yes What is the assessment date? _/ _/ Unknown Was an exam performed by a bariatric physician or PA/NP? Yes Was the patient seen by any clinician? Yes General Weight: kg lbs. Unknown Date weight taken: _/ / Unknown Weight: kg lbs. Unknown Date weight taken: _/ / Unknown Weight: kg lbs. Unknown Date weight taken: _/ / Unknown 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? Yes Yes Yes ATTEMPTS BY THE BARIATRIC CENTER TO CONTACT PATIENT Was a follow-up appointment made but patient did not show for appointment? Yes Was a phone call placed to the patient? Was a letter sent to the patient? Once Twice Never Once Twice Never Was the patient s care transferred to another bariatric specialist? Yes If yes, please list name. Is patient refusing follow-up? Yes 15

16 PATIENT CONTACT MANAGEMENT Contact date: _/ / Contact Action: Call Letter Document Fax Other Contact Results: answer Left message Letter sent Letter received Talked to patient Contact Notes: Talked to family Incorrect number Patient refused Lost to followup Contact date: _/ / Contact Action: Call Letter Document Fax Other Contact Results: answer Left message Letter sent Letter received Talked to patient Contact Notes: Talked to family Incorrect number Patient refused Lost to followup Contact date: _/ / Contact Action: Call Letter Document Fax Other Contact Results: answer Left message Letter sent Letter received Talked to patient Contact Notes: Talked to family Incorrect number Patient refused Lost to followup 16