AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM - PEDIATRIC Data Collection Worksheet

Transcription

1 AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM - PEDIATRIC Data Collection Worksheet *IDN LMRN Cycle Number Case Number DEMOGRAPHICS PATIENT First Name: MI: Last Name: Street Address: City / Town: State / Province: Zip: Country: *DOB: / / (mm/dd/yyyy) Gestational Age: wks. Gender: Male Female Race: White American Indian/Alaska Native Asian Black/African American Native Hawaiian/Other Pacific Islander Unknown / Not Reported Hispanic Ethnicity: Yes No Preferred Language: English Spanish PARENT/GUARDIAN 1 First Name: MI: Last Name: Relationship: Mother Father Grandmother Grandfather Sister Brother Aunt Uncle Foster Parent Guardian Other Status: Parent/ Legal Guardian Primary Caregiver Current Caregiver 30 day follow-up contact Check box if address is same as the patient s address Street Address: City / Town: State / Province: Zip: Country: Contact Number(s): Home: Work: Cell: Preferred Language: English Spanish PARENT/GUARDIAN 2 First Name: MI: Last Name: Relationship: Mother Father Grandmother Grandfather Sister Brother Aunt Uncle Foster Parent Guardian Other Status: Parent/ Legal Guardian Primary Caregiver Current Caregiver 30 day follow-up contact Check box if address is same as the patient s address Street Address: City / Town: State / Province: Zip: Country: Contact Number(s): Home: Work: Cell: Preferred Language: English Spanish Version date: July 1, ACS NSQIP-P

2 SURGICAL PROFILE Status: Inpatient Outpatient Elective Surgery: Yes No Unknown Hospital Admission Date: / / Transfer / Origin Status: Admitted from home/clinic/dr. s office Transferred from outside hospital (NICU, PICU, Inpatient general, Adult ICU) Chronic Care / Rehab / Intermed Care / Spinal Cord Other Admitted through ER, including outside ER with direct hospital admission Admitting Service on Admission: (select one) 1. Pediatric Cardiac Surgery 8. Plastics 15. General Surgery 2. Pediatric Neurosurgery 9. Neonatal Critical Care Service 16. Gynecology 3. Pediatric Orthopedic Surgery 10. Pediatric Critical Care Service 17. Neurosurgery 4. Pediatric Otolaryngology (ENT) 11. Pediatric Medical Service 18. Orthopedics 5. Pediatric Surgery 12. Adult Critical Care Service 19. Otolaryngology (ENT) 6. Pediatric Urology 13. Adult Medical Service 20. Transplant Surgery 7. Pediatric Plastics 14. Cardiovascular-Thoracic 21. Urology Payor Status: (select all that apply) Commercial Medicare Workman s Comp/Auto Other Blue Cross/Blue Shield Medicaid Self Pay HMO/PPO Champus Unknown *Date of Operation: / / Principal Operative Procedure: CPT Code: Principal Anesthesia Technique: (select one) General Epidural Regional None Unknown Spinal Caudal Local Other *Surgical Specialty (select one) 1. Pediatric Cardiovascular-Thoracic 6. Pediatric Urology 11. Gynecology 2. Pediatric Neurosurgery 7. Pediatric Plastics 12. Neurosurgery 3. Pediatric Orthopedic Surgery 8. Plastics 13. Orthopedics 4. Pediatric Otolaryngology 9. Cardiovascular-Thoracic 14. Otolaryngology (ENT) 5. Pediatric Surgery 10. General Surgery 15. Urology Attending Surgeon s Name: _ LCN: Attending Surgeon s IDN: Encounter Number: _ PREOPERATIVE INFORMATION GENERAL Height CM Inches Unknown Weight KG Pounds Unknown Diabetes Requiring Therapy NO Non-insulin Insulin DNR Status YES NO Premature Birth (# weeks gestation) NO Less than Unknown PULMONARY Ventilator Dependence YES NO Version date: July 1, ACS NSQIP-P

3 Current Pneumonia YES NO History Asthma YES NO History of Cystic Fibrosis YES NO Bronchopulmonary Dysplasia / Chronic Lung Disease YES NO Oxygen Support YES NO Tracheostomy YES NO Structural Pulmonary / Airway Abnormality YES NO GASTROINTESTINAL Biliary / Liver/ Pancreatic Disease YES NO Esophageal / Gastric / Intestinal Disease YES NO CARDIAC Previous Cardiac Surgery / Cardiac Intervention YES NO Cardiac Risk Factors RENAL None Minor Major Severe Acute Renal Failure YES NO Currently Requiring Or On Dialysis YES NO CENTRAL NERVOUS SYSTEM Coma YES NO CVA/Stroke or Traumatic / Acquired Brain Injury w/ Resulting Neurological Deficit YES NO Tumor Involving CNS YES NO Developmental Delay / Impaired Cognitive Status YES NO Seizure Disorder YES NO Cerebral Palsy YES NO Structural CNS Abnormality YES NO Neuromuscular Disorder YES NO Intraventricular Hemorrhage (IVH) Grade No IVH Grade 1 Grade 2 IVH reported but no grade assigned Grade 3 Grade 4 IMMUNOLOGY Immune Diseases / Immunosuppressant Use YES NO Steroid Use (w/in 30 days) YES NO Bone Marrow Transplant YES NO Solid Organ Transplant YES NO NUTRITIONAL / IMMUNE/ ONCOLOGY / OTHER Childhood Malignancy YES NO Open wound with or without infection YES NO Weight loss > 10% / Failure to Thrive YES NO Nutritional Support YES NO Bleeding Disorder YES NO Hematologic Disorder YES NO Chemotherapy for Malignancy (w/in 30 days) YES NO Radiotherapy for Malignancy (w/in 90 days) YES NO SIRS / Sepsis / Septic Shock (w/in 48 hrs) SIRS SEPSIS Septic Shock Version date: July 1, ACS NSQIP-P

4 Inotropic Support (at time of surgery) YES NO Previous CPR w/in 7 days (prior to surgery) YES NO Prior Operation w/in 30 Days YES NO Congenital Malformation(s): I) Neonate < 1500 g at time of surgery YES NO II) Neonate 1500 g or Infants/Children/Teenagers YES NO Blood Transfusions (w/in 48 hrs of surgery) YES NO NEONATAL PATIENT INFORMATION Term Neonate Premature Neonate Gestational Age: weeks Location of Birth: Inborn Outborn Small for Gestational Age: Yes No Mode of Delivery: Vaginal delivery Scheduled C-Section Birth Weight: kg or lbs oz Unknown Unscheduled C-Section Unknown/Not Documented Birth Length: cm or inches Unknown Head circumference at birth: cm or inches Unknown APGAR score 1 minute (0-10): Unknown APGAR score 5 minutes (0-10): Unknown LABORATORY DATA E INFORMATION PREOPERATIVE LAB DATA Value Unknown Date No preoperative labs drawn No labs drawn Serum Sodium (Na) / / Blood Urea Nitrogen (BUN) / / Creatinine (Cr) / / Albumin (ALB) / / Total Bilirubin (TB) / / Serum Glutamic-Oxaloacetic Transaminase (SGOT)/(AST) / / Alkaline Phosphatase (Alk Phos) / / White Blood Count (WBC) / / Hematocrit (Hct) / / Platelets (Plt) / / Prothrombin Time (PT) / / Internat l Normalized Ratio (INR) / / Partial Thromboplastin Time (PTT) / / OPERATIVE INFORMATION Case Status: Elective Urgent Emergent Wound Classification: Clean Clean/ Contaminated Contaminated Dirty/Infected ASA Class (circle one): None Assigned (for local anes. only) Version date: July 1, ACS NSQIP-P

5 OPERATIVE TIMES: Patient in Room: : Procedure / Surgery Start: : Patient Out Of Room: : Anesthesia Start: : Procedure/Surgery Finish: : Anesthesia Finish: : ADDITIONAL OPERATIVE PROCEDURES 1. Other Procedure CPT 1. Concurrent Procedure CPT OCCURRENCES INTRAOPERATIVE OCCURRENCES: YES NO Cardiac Arrest requiring CPR (If yes, select from the following) Death During Operation Unplanned Extubation Other ICD-9 Code: _ POSTOPERATIVE OCCURRENCES: 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 Comments Wound Occurrences Superficial Incisional SSI / / Incisional SSI / / Organ/Space SSI / / Wound Disruption / / Respiratory Occurrences Pneumonia / / Unplanned Intubation / / Pulmonary Embolism / / Urinary Tract Occurrences Progressive Renal Insufficiency / / Acute Renal Failure / / Urinary Tract Infection (UTI) / / CNS Occurrences Coma > 24 hours / / CVA/Stroke or Intracranial Hemorrhage / / Seizure / / Nerve Injury / / IVH Grade / / Grade 1 Grade 2 Grade 3 Grade 4 Unknown /Specific grade not documented Cardiac Occurrences Cardiac Arrest Req. CPR / / Other Postoperative Occurrences Bleeding Requiring Transfusion (72 hr. surgery start time) / / # of mls / units transfused: Graft/Prosthesis/Flap Failure / / Venous Thrombosis requiring Therapy / / Sepsis / Septic Shock / / Central Line-Assoc. Bloodstream Infect. / / Other: ICD-9 Code: / / HOSPITAL DISCHARGE INFORMATION Oxygen at Discharge (or at 30 days if still in hospital): YES NO Nutritional Requirement at Discharge (or at 30 days if still in-hospital): YES NO Version date: July 1, ACS NSQIP-P

6 Total number of days of mechanical ventilation: If > than 30 days, check box Discharge Destination: Skilled Care Facility, not Home Unskilled Facility, not Home Facility which was not Home Rehab Home Separate Acute care (transferred to another acute care facility) Expired Unknown Post-op ICD.9 Code Diagnosis: Still in hospital >30 days: YES NO (NOTE: If this box is checked, completion of hospital discharge date is optional) Hospital Discharge Date: / / (mm/dd/yyyy) Postoperative Death: Postop Death w/in 30 days: YES NO Postop Death > 30 days: (if remained in acute care) YES NO Date of death: / / Unknown Date of death: / / Unknown Readmission Readmission for any reason within 30 days of the principal procedure? YES NO If YES, date: / / Information Source (select one) Medical Record Patient / Family Report Other If yes, enter the primary ICD-9 code associated with the readmission: ICD-9 code Unplanned Reoperation Did the patient have an unplanned return to the operating room for a surgical procedure w/in the 30-day postoperative period? If yes, surgery date: / / CPT code: ICD-9 Code: Source (select one) Medical Record Patient/Family Report Other Note: If CPT code is not documented, describe the surgery in the procedure description box. Was the return to the OR for a post operative occurrence that was likely related to the principal procedure or to any additional surgery ("other" or "concurrent" procedures) performed under the same anesthetic as the principal procedure? YES NO Unknown Did the patient have a SECOND unplanned return to the operating room for a surgical procedure, within the 30-day postoperative period? YES NO If yes, surgery date: / / CPT code: ICD-9 Code: Source (select one) Medical Record Patient/Family Report Other Note: If CPT code is not documented, describe the surgery in the procedure description box. Was the SECOND return to the OR for a post operative occurrence that was likely related to the principal procedure or to any additional surgery ("other" or "concurrent" procedures) performed under the same anesthetic as the principal procedure?? YES NO Unknown Were there more than two unplanned reoperations for a postoperative occurrence likely related to the principal surgery within 30 days? YES NO If yes, enter information in comments box. Version date: July 1, ACS NSQIP-P

7 FOLLOW-UP Follow Up Within 30 Days Were you able to follow the case for the full 30 days? YES NO Note: Answer yes for death within 30 days of surgical procedure) If you were unable to obtain the 30-day follow up information: A) How many days (0-29) were you able to follow this case? B) Which methods were used to obtain the 30-day follow-up information? Select all that apply. Note: A minimum of three attempts should be made to contact the patient Method # of attempts Method # of attempts Phone Documentation Letter Other Patient Contact Management Contact date: / / Contact Action: Phone Letter Document Fax Other Contact Results: No Answer Letter Received Incorrect Number Message Left Talked to Patient Patient Refused Letter Sent Talked to Family Contact Notes: Contact date: / / Contact Action: Phone Letter Document Fax Other Contact Results: No Answer Letter Received Incorrect Number Message Left Talked to Patient Patient Refused Letter Sent Talked to Family Contact Notes: Contact date: / / Contact Action: Phone Letter Document Fax Other Contact Results: No Answer Letter Received Incorrect Number Message Left Talked to Patient Patient Refused Letter Sent Talked to Family Contact Notes: Version date: July 1, ACS NSQIP-P