Demographics. MBSAQIP Case Number: *ACS NSQIP Case Number: *LMRN: *DOB: / / *Gender: Male Female

Transcription

1 Demographics MBSAQIP Case Number: *IDN: *ACS NSQIP Case Number: Name: *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: 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 Is the principal operative procedure an initial primary metabolic or bariatric procedure? Does the patient have a history of metabolic or bariatric surgery? Is the principal operative procedure related to a previous metabolic or bariatric surgery (i.e., is the principal operative procedure a revision or reoperation)? *CPT Code: *Principal Operative Procedure: Revisions/Other Reasons: Revision/Conversion Mini-loop gastric bypass Gastric Plication Endoscopic Therapy Other CPT Code for Revisions/Other Reasons: (Only required when CPT Code or is entered as the principal operative procedure) 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 (optional): Encounter Number (optional): MBSAQIP Case Number: *ACS NSQIP Case Number: Preoperative Risk Assessment *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 2

3 Date for Weight Closest to Surgery / / Unknown General Cardiac *Diabetes Mellitus n-insulin Insulin History of Myocardial Infarction *Current Smoker w/in 1 year Previous PCI /PTCA Independent *Functional Health Status Partially Dependent Totally Dependent Previous Cardiac Surgery Unknown Pulmonary *Hypertension requiring medication *COPD (Severe) # of anti-hypertensive meds Oxygen Dependent 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? Vascular Yes Yes Hyperlipidemia requiring medication Yes Vein Thrombosis Req. Therapy Venous Stasis IVC Filter IVC Filter Timing Renal *Currently requiring or on dialysis Placed in anticipation of Procedure IVC Filter Preexisting Unknown Yes Renal Insufficiency Nutritional / Immune / Oncology / Other *Steroid/Immunosuppressant Use for Chronic Condition Therapeutic anticoagulation Previous obesity surgery/foregut surgery PREOP LABS All Pre-op Labs Unknown *Albumin: Date: / / Unknown *Hematocrit: Date: / / Unknown 3

4 OPERATION First Assistant Level of Training: ne PA/NP/RNFA Resident (PGY 1-5+) MIS Fellow Attending Weight Loss Surgeon Attending Other *Emergency Case: *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? 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? Notes: 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 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 / / Time : *Procedure / Surgery Finish Time: Date / / Time : 4

5 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: Oversew: OTHER PROCEDURES *Other Procedures CPT *Concurrent Procedures CPT Is this a Stapling Procedure? 5

6 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 Unplan. Intub. 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 / / 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) 6

7 *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): / / (Optional) ICD Code Occurrence: 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 ICU w/in 30 days / / **Other Metabolic or Bariatric Postop Occurrence (List ICD-9/ ICD-10 code): / / (Optional) ICD Code Occurrence: **Although not required for this program, you may wish to document treatment of the occurrence for internal quality monitoring. 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: 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? Notes: 8

9 13 Internal Hernia MBSAQIP Case Number: *IDN: Name: 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 unplanned at the time of the principal procedure? Did this readmission occur at your hospital? Was this readmission likely related to a metabolic or 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 unplanned at the time of the principal procedure? Did this readmission occur at your hospital? Was this readmission likely related to a metabolic or 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 unplanned at the time of the principal procedure? Did this readmission occur at your hospital? Was this readmission likely related to a metabolic or 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 20 Infection/Fever 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 9

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

11 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 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 20 Infection/Fever 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 INTERVENTIONS Did the Patient have an Intervention within the 30 day Postoperative Period? Intervention #1 Was this intervention unplanned at the time of the principal procedure? Was this intervention likely related to a metabolic or bariatric procedure? Emergency Case Intervention (see table below) Most likely reason for intervention (enter code from table below) Date Performed / / Unknown Information Source Medical Record Patient/Family Report Other Comments: Intervention #2 Was this intervention unplanned at the time of the principal procedure? Yes Was this intervention likely related to a metabolic or bariatric procedure? Yes 11

12 Emergency Case Intervention (see table below) Most likely reason for intervention (enter code from table below) Date Performed / / Unknown Information Source Medical Record Patient/Family Report Other Comments: Intervention #3 Was this intervention unplanned at the time of the principal procedure? Was this intervention likely related to a metabolic or bariatric procedure? Emergency Case Intervention (see table below) Most likely reason for intervention (enter code from table below) Date Performed / / Unknown Information Source Medical Record Patient/Family Report Other Comments: Interventions Diagnostic Endoscopy Therapeutic Endoscopy with Stent Placement/Retrieval 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 Therapeutic Endoscopy with Other Therapeutic Endoscopy Placement of Percutaneous Drain Inferior Vena Cava (IVC) Filter Placement Inferior Vena Cava (IVC) Filter Retrieval Other Intervention Most Likely Reason for 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 Nutritional 20 Infection/Fever 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 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 Was the patient seen by any clinician? 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? 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? Was a letter sent to the patient? Once Twice Never Once Twice Never Was the patient s care transferred to another bariatric specialist? If yes, please list name. Is patient refusing follow-up? 13

14 PATIENT CONTACT MANAGEMENT Contact date: / / Contact Action: Call Letter Document Fax Other Contact Results: 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: 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: answer Left message Letter sent Letter received Talked to patient Talked to family Incorrect number Patient refused Lost to follow-up Contact Notes: 14