Biomedical Sciences Institutional Review Board
Transcript of Biomedical Sciences Institutional Review Board
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Baselice, Holly
From: OR IRB Info <[email protected]>Sent: Friday, March 5, 2021 7:54 AMTo: Santry, Heena P.Cc: Baselice, HollySubject: Initial Submission Approved for #2021H0077
Biomedical Sciences Institutional Review Board
300 Research Administration building 1960 Kenny Road
Columbus, OH 43210-1063
orrp.osu.edu
03/05/2021
Study Number: 2021H0077 Study Title: Social Determinants of Acute Abdomen Outcomes
Type of Review: Initial Submission
Review Method: Expedited
Date of IRB Approval: 03/05/2021 Date of IRB Approval Expiration: 03/05/2022
Expedited category: #5
Dear Heena Santry,
The Ohio State Biomedical Sciences IRB APPROVED the above referenced research.
In addition, the following were also approved for this study:
Waiver of Consent Process Full Waiver of HIPAA Research Authorization
Administrative Note:
As the university moves to a staged approach to restarting research activities, refer to Human Subjects Guidance and FAQs. If after reviewing this information and working through your college you have additional questions, please direct emails to [email protected].
As Principal Investigator, you are responsible for ensuring that all individuals assisting in the conduct of the study are informed of their obligations for following the IRB-approved protocol and applicable regulations, laws, and policies, including the obligation to report any problems or potential noncompliance with the requirements or determinations of the IRB. Changes to the research (e.g., recruitment procedures, advertisements, enrollment numbers, etc.) or informed consent process must be approved by the IRB before implemented, except where necessary to eliminate apparent immediate hazards to subjects.
This approval is issued under The Ohio State University's OHRP Federalwide Assurance #00006378 and is valid until the expiration date listed above. Without further review, IRB approval will no longer be in effect on the expiration date. To continue the study, a continuing review application must be approved before the expiration date to avoid a lapse in IRB approval and the need to stop all research activities. A final study report must be provided to the IRB once all research activities involving human subjects have ended.
Records relating to the research (including signed consent forms) must be retained and available for audit for at least 5 years after the study is closed. For more information, see university policies, Institutional Data and Research Data.
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Human research protection program policies, procedures, and guidance can be found on the ORRP website.
Karla Zadnik, OD, PhD, Chair Ohio State Biomedical Sciences IRB
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ConfidentialP1631 - Social Determinants of Acute Abdomen Outcomes
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Institution Information
Database ID__________________________________
Study ID__________________________________(Ex. XX-XXX)
Type of Institution DomesticInternational
Site Ohio State
HOSPITAL LEVELOwnership Non-Governmental
GovernmentalInvestor-owned
ACS Trauma Certified Center YesNo
Medical School Affiliation YesNo
Teaching Status MajorMinorNon-teaching
Location UrbanRural
Bed size < 100100-199200-299300-399400-499> 500
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Basic ID
Database ID__________________________________
Was this patient a re-admission from a prior admit for NoEGS? Yes
DO NOT create a new record for a readmission from a prior admit for EGS; add the readmission using the "90-dayReadmission(s)" page.
Was this patient admitted during the COVID-19 Yespandemic? No
Year of Admission 2017201820192020
DEMOGRAPHICSAge at time of admission:
__________________________________
Gender MaleFemaleOtherUnknown
If 'Other' please explain:__________________________________
Race WhiteBlack/ African AmericanAsianNative American/Alaskan NativeNative Hawaiian/Other Pacific IslanderBi/MultiracialOtherMissing/Unknown
If 'Other' please explain:__________________________________
Hispanic Ethnicity YesNo
Zip__________________________________(5-digit (+4) if available)
County__________________________________
State Abbreviation__________________________________
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Level of Education Less than high school degreeHigh School degree or equivalent (e.g., GED)Some College but no degreeAssociates degreeBachelor degreeGraduate degreeUnknownOther
Does this patient have a primary care provider (PCP)? YesNo
When was the last time this patient had an annual Less than a yearcheck-up with their PCP? 1-2 years
2-3 years3-5 years5-7 years7-10 yearsMore than 10 years
AREA DEPRIVATION INDEX: use the link below, select your state, and enter the patient'saddress in the search box.https://www.neighborhoodatlas.medicine.wisc.edu/mappingADI State Decile (1-10)
__________________________________
ADI National Percentile (1-100)__________________________________
ADMISSION DATAHow Surgery Was Made Aware of Patient Emergency department consult/admission
Direct admit ("transfer") from acute carehospital, rehab, SNF, or LTACDirect admit from homeInpatient consult (overrides ED consult)OtherUnknown
(If patient was admitted to a different servicefrom the ED and surgery was later consulted, thisis considered an inpatient consult and not an EDadmission.)
If 'Other' please explain:__________________________________
Was the patient admitted through the Emergency YesDepartment (to any service)? No
(If patient was admitted to a different servicefrom the ED and surgery was later consulted, theanswer to this should be "yes" (in contrast toprevious question).)
How did the patient come through the ED? HomeTransfer from acute care hospital, rehab, SNF, orLTACOther
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Was the patient admitted as a transfer from another Yesfacility (to any service)? No
Was one of the patient's primary diagnoses sepsis or Noseptic shock? Sepsis
Septic shock
Admission Diagnosis Text__________________________________(DO NOT include sepsis/septic shock)
Admission Diagnosis ICD-10 Code__________________________________(DO NOT include sepsis/septic shock; OMIT PERIODS)
Was the primary diagnosis non-EGS? YesNo
Primary EGS Diagnosis Text__________________________________
Primary EGS Diagnosis ICD-10 Code__________________________________(OMIT PERIODS)
Did the patient have any complications? NoYesUnknown
Which kind? SystemicOperative/Surgical
Were there any unplanned abdominal reoperation(s) Yesduring the index hospitalization? No
CARE TIMELINELength of stay (days)
__________________________________(NOTE: DATE OF ADMISSION IS DAY 0)
Did the patient die while inpatient? YesNo
Was the patient admitted to hospice at time of death? YesNo
Where did patient go upon discharge? HomeHome with ServicesRehabSNFLTACHospiceTransferred to another acute care hospitalOtherUnknown
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If 'Other' please explain:__________________________________
MISC. DATA (NOTES)Mode of Transportation to Hospital Own Transportation
AmbulanceHelicopterLaw EnforcementPrison/Jail EscortOtherUnknown
If 'Other' please explain__________________________________
Did the patient have any pre-existing co-morbidities? NoYesUnknown
INSURANCEType of Primary Insurance No Insurance
MedicareMedicaidPrivateMilitaryOtherUnknown
If 'Other' please explain:__________________________________
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ConfidentialP1631 - Social Determinants of Acute Abdomen Outcomes
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Acute Severity Measures
Database ID__________________________________
ACUTE DISEASES: findings/symptoms/acute co-occurring diagnoses at time of admission orinitial consultation to the surgery service.
These differ from chronic comorbidities in that they may be secondary to theirprimary/underlying diagnosis and show how severe their condition is at time of presentation.Acute Renal Failure Yes
No
Acute Renal Failure - Dialysis requirement DOES NOT require dialysisDOES require dialysis
Acute Renal Failure - Intermittent Dialysis YesNo
Acute Renal Failure - Continuous Hemofiltration YesNo
Only choose one dialysis requirement between none, intermittent, and continuous.
Acute Psychosis YesNo
(Delusions, hallucinations, etc.)
Altered Sensorium (CAM positive) YesNo
(Requires: (acute onset OR fluctuating course) ANDinattention AND (disorganized thinking OR alteredlevel of consciousness))
Cardiac Arrest with ROSC YesNo
(Only applicable if the patient has a documentedcode during their admission but prior to consult.)
Coma YesNo
Dyspnea/shortness of breath YesNo
Ventilated YesNo
(Note that "spontaneous ventilation" does notnecessarily mean a patient is on a ventilator.)
Active Pneumonia on Treatment YesNo
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Ascites YesNo
(Found in either CTAB results or laparotomy data)
Open Abdominal Wound YesNo
Stress Dose Steroids YesNo
(Ex. Cortisone, prednisolone, prednisone,methylprednisolone, dexamethasone, etc.; Consultpatient's "scheduled medications" list)
Medication Induced Coagulopathy YesNo
(Ex. Factor X inhibitors (-xabans, Eliquis,Lovenox, others), heparin, tPA, etc.)
Name of medication inducing coagulopathy__________________________________
Physiologic Coagulopathy YesNo
(Ex. DIC)
Sepsis or Septic Shock YesNo
Recent (72 hours) Blood Transfusion YesNo
(Consult "Other Orders" for "TRANSFUSE RED BLOODCELLS" within 72 hours BEFORE consult/admission)
Describe any other acute conditions that the patientpresents with if not listed elsewhere:
__________________________________________
Acute Severity Measure Count (Max: 15)__________________________________
PRESENTING VITALS (Surgical H&P or consult note)Systolic Blood Pressure (mmHg)
__________________________________
Diastolic Blood Pressure (mmHg)__________________________________
Diastolic BP should be less than systolic BP
Temperature (F)__________________________________
Heart Rate (BPM)__________________________________
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Respiratory Rate (breaths/min)__________________________________
Height (inches)__________________________________
Weight (lbs)__________________________________(If not with other vitals, check the top ofanesthesiology report.)
BMI__________________________________
Oxygen Saturation (%)__________________________________
Oxygen Source Room AirNasal CanulaHigh Flow NCMaskNon Re-BreatherNon-Invasive VentilationMechanical VentilationOtherUnknown/Missing
If 'Other' please explain:__________________________________
Amount of Supplemental Oxygen (L/min)__________________________________(Report amount of supplemental oxygen in L/min orFiO2 (below) and enter "999" for value notreported.)
FiO2 (%)__________________________________(Report amount of supplemental oxygen in L/min(above) or FiO2 and enter "999" for value notreported.)
PEEP__________________________________
LAB VALUES AT TIME OF ADMISSION (only use labs from within the 24 hours prior to surgery)
NOTE: If missing then enter 999 as value. If repeated, use the last value reported prior tosurgery.White Blood Cell (WBC) Count
__________________________________
Hemoglobin (Hg)__________________________________
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Hematocrit (HCT)__________________________________
Platelet count__________________________________
% Neutrophils__________________________________(Note that "band neutrophils" are NOT the same.)
% Lymphocytes__________________________________
% Eosinophils__________________________________
% Monocytes__________________________________
Serum Blood Urea Nitrogen (BUN)__________________________________
Serum Sodium (Na)__________________________________
Serum Potassium (K)__________________________________
Serum Chloride (Cl)__________________________________
Serum Creatinine (Cr)__________________________________
Serum Glucose__________________________________
Serum Albumin__________________________________
Serum Pre-Albumin__________________________________
Bilirubin (Direct)__________________________________
Bilirubin (Total)__________________________________
Alkaline phosphatase (Alk Phos)__________________________________
Aminotransferase, alanine (ALT)__________________________________
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Aminotransferase, aspartate (AST)__________________________________
pH__________________________________(From arterial blood gas (ABG) ONLY.)
PaO2__________________________________(From arterial blood gas (ABG) ONLY.)
PaCO2__________________________________(From arterial blood gas (ABG) ONLY.)
Serum Bicarbonate (HCO3)__________________________________
Base Excess__________________________________
Lactate__________________________________
Prothrombin Time (PT)__________________________________
Activated Partial Time (PTT)__________________________________
International Normalized Ratio (INR)__________________________________
Serum Calcium (Ca)__________________________________(Note that "ionized calcium" is NOT the same.)
Serum Magnesium (Mg)__________________________________
Serum Phosphate__________________________________
Serum Ethanol (EtOH)__________________________________
Serum Lipase__________________________________
Serum Amylase__________________________________
HgA1C__________________________________
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Troponin__________________________________
PRESENTING IMAGINGWas a chest x-ray (CXR) done? Yes
No
Was a CXR completed on date of admission? YesNo
If not, what day was it completed on?__________________________________
What time?__________________________________
CXR Results __________________________________________
Was an abdominal x-ray (AXR) done? YesNo
Was an AXR completed on date of admission? YesNo
If not, what day was it completed on?__________________________________
What time?__________________________________
AXR Results __________________________________________
Was an abdominal ultrasound (US) done? YesNo
Was an US completed on date of admission? YesNo
If not, what day was it completed on?__________________________________
What time?__________________________________
US Results __________________________________________
Was an abdominal/pelvis CT (CTAP) done? YesNo
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Was a CTAP completed on date of admission? YesNo
If not, what day was it completed on?__________________________________
What time?__________________________________
CTAP Impression __________________________________________(If ascites noted, make sure to go back to acutediseases and answer "yes" to ascites.)
Was a chest CT done? YesNo
Was a Chest CT completed on the date of admission? YesNo
If not, what day was it completed on?__________________________________
What time?__________________________________
Chest CT Results __________________________________________
Plain Film Site__________________________________
Plain Film Results__________________________________
CODE STATUSCode Status at Admission Full Code
DNRCCADNRCCA/DNIDNRCC (CMO)OtherMissing/Unknown
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ConfidentialP1631 - Social Determinants of Acute Abdomen Outcomes
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Chronic Risk Factors
Database ID__________________________________
Only record conditions that were diagnosed prior to admission.This form will only populate if you indicated that the patient had comorbidities and that the patient is not a 90-dayreadmission.
Co-morbidities: RespiratoryNo Yes
AsthmaCOPDCOPD with oxygen requirement
Co-morbidities: ThromboembolicNo Not currently but has a
history ofCurrent/active thrombosis
Deep vein thrombosis (DVT)Pulmonary embolism (PE)
Co-morbidities: RenalNo Yes
Chronic kidney diseaseChronic kidney disease requiringdialysis (Hemodialysis orperitoneal dialysis)
Co-morbidities: CardiovascularNo Yes
Coronary artery diseaseCoronary artery disease withangina
Previous PTCA/PCI (coronarystents)
ArrhythmiaArrhythmia not requiringimplantable device
Arrhythmia requiring pacemaker(in place)
Arrhythmia requiring AICD (inplace)
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Pulmonary circulation disorderValvular disease (stenosis orregurgitation of any of the heartvalves)
History of myocardial infarction(MI) (confirmed or probable)
Congestive heart failure (CHF)Peripheral vascular disease(PVD)Hypertension (HTN)
Only choose one arrhythmia severity between no device, pacemaker, and AICD.
Co-morbidities: MalignancyNo Yes
Active cancerLocalized solid tumor (nometastatic spread)
Metastatic/stage IV solid tumor(Metastatic disease (lymphnodes, regional or distantmetastasis)
LeukemiaLymphomaHistory of cancerChemotherapy within 30 days ofadmission
Radiotherapy within 30 days ofadmission
Only select one cancer type between localized solid tumor, metastatic solid tumor, leukemia, and lymphoma.
Co-morbidities: NeurologicalNo Yes
History of cerebrovascularaccident (CVA)
History of CVA with deficitHistory of CVA withoutdeficit/transient ischemic attack(TIA)
Cerebrovascular disease
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Neurodegenerative disorder (Ex.Alzheimer's disease, dementia,Huntington's disease, SCA, SMA,etc.)
Alzheimer's diseaseDementiaHemiplegia/hemiparesisParaplegia/paraparesisQuadriplegiaPersistent vegetative state
Only choose one type of paralysis between hemiplegia/hemiparesis, paraplegia/paraparesis, and quadriplegia.
Co-morbidities: EndocrineNo Yes
Type 1 diabetes mellitusType 2 diabetes mellitusType 2 diabetes mellitus, dietcontrolled
Type 2 diabetes mellitus, oralmedication controlled
Type 2 diabetes mellitus, insulincontrolled
Diabetes with end organdamage (Ex. retinopathy,neuropathy, nephropathy)
Hypothryoid disease (includingHashimoto's thyroiditis)
Hyperthyroid disease (includingGraves disease)
Only choose one form of diabetes mellitus between type 1 and type 2.
Only choose one degree of T2DM severity between diet-controlled, oral medication-controlled, and insulin-controlled.
Co-morbidities: HepaticNo Yes
CirrhosisLiver diseaseMild liver disease (chronichepatitis or cirrhosis withoutportal hypertension)
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Moderate liver disease (cirrhosisand portal hypertension withoutvariceal bleeding)
Severe liver disease (cirrhosisand portal hypertension withvariceal bleeding)
Esophageal varices
Only choose one degree of severity between mild, moderate, and severe liver disease.
Co-morbidities: HematologicNo Yes
Clotting disorder(hypercoagulable states such asfactor V Leiden, protein S or Cdeficiencies, etc.)
Bleeding disorder(coagulopathies such ashemophilia, von Willdebrand,etc.)AnemiaChronic blood loss anemiaDeficiency anemia
Co-morbidities: GastrointestinalNo Yes
Gastroesophageal reflux disease(GERD)
Peptic ulcer disease (PUD)(history of or current)
Inflammatory bowel disease (IBD= UC, Crohn's)
Ulcerative colitisCrohn's diseaseHistory of GI/abdominal surgery(NOT WITHIN 90 DAYS)
What was this previous abdominal surgery?__________________________________
What year?__________________________________
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Co-morbidities: PsychiatricNo Yes
Major depressive disorder(requiring pharmacotherapy tocontrol)
Major anxiety disorder (requiringpharmacotherapy to control)
SchizophreniaObsessive compulsive disorder(OCD)
Co-morbidities: MiscellaneousNo Yes
Chronic steroid use (onprednisone or equivalent; have ahigh index of suspicion if +connective tissue/autoimmunedisease or adrenal insufficiency)
Raynaud's syndromeConnective tissue disease (ex.rheumatoid arthritis, lupus,scleroderma, etc.)
Rheumatoid arthritis/rheumaticdisease
Other autoimmune disorder (notspecified elsewhere)
Chronic pain syndromeFluid/electrolyte disorder (ex.diabetes insipidus)
HIV/AIDSCongenital abnormalities (ex.spina bifida, cerebral palsy, cleftlip/palate, congenital heartdefects)
>10% body weight loss over last6 months
MalnutritionObesity (BMI >/= 30.0)
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Surgical historyNo Yes
Previous cardiac surgeryHistory of organ transplant
Social historyNever History of Active
Tobacco abuseOpiate abuseExcessive alcohol use (> 7/weekwomen, > 14/week men)
CALCULATIONSCharlson Comorbidity Index: Age Points ([age])
__________________________________
cci_ckd__________________________________
cci_liverdisease__________________________________
cci_hemiplegia__________________________________
cci_cancercll__________________________________
cci_cancerdis__________________________________
cci_hivaids__________________________________
Deyo-Charlson Comorbidity Score__________________________________
eci_chf__________________________________
eci_rhythm__________________________________
eci_valvular__________________________________
eci_pulmcircdo__________________________________
eci_pvd__________________________________
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eci_paralysis__________________________________
eci_neurodegen__________________________________
chronicresp__________________________________
eci_respiratory__________________________________
eci_ckd__________________________________
eci_liverdisease__________________________________
eci_lymph__________________________________
eci_dissem__________________________________
eci_ctrl__________________________________
eci_bleedingdo__________________________________
eci_obesity__________________________________
eci_weightloss__________________________________
eci_lytedo__________________________________
eci_anemia__________________________________
etohabuse__________________________________
drugabuse__________________________________
eci_opiates__________________________________
eci_depression__________________________________
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Elixhauser-van Walraven Comorbidity Score__________________________________(Rough estimate as actual value is based on ICDcodes.)
ahrq_chf__________________________________
ahrq_pulmcircdo__________________________________
ahrq_pvd__________________________________
ahrq_htn__________________________________
ahrq_paralysis__________________________________
ahrq_neurodegen__________________________________
ahrq_respiratory__________________________________
ahrq_diabetes__________________________________
ahrq_ckd__________________________________
ahrq_liverdisease__________________________________
ahrq_lymph__________________________________
ahrq_dissem__________________________________
ahrq_ctrl__________________________________
ahrq_bleedingdo__________________________________
ahrq_obesity__________________________________
ahrq_weightloss__________________________________
ahrq_lytedo__________________________________
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ahrq_anemiacbl__________________________________
ahrq_anemiadef__________________________________
ahrq_etoh__________________________________
ahrq_opiates__________________________________
ahrq_psychosis__________________________________
ahrq_depression__________________________________
AHRQ Elixhauser Comorbidity Scale__________________________________
Other chronic conditions if not listed elsewhere: __________________________________________
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ConfidentialP1631 - Social Determinants of Acute Abdomen Outcomes
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Social Variables
Database ID__________________________________
CASE MANAGEMENT NOTESource of information Patient
FamilyFriendElectronic medical record
Who does the patient live with? AlonePartner/adultChildrenParentsExtended familyFacilityGrandchild(ren)OtherMissing/Unknown
If 'Other' please explain:__________________________________
Living Arrangement Extended Care FacilityApartmentHouseHomelessMobile HomeOtherMissing/Unknown
If 'Other' please explain:__________________________________
Primary Care is Provided by: SelfAgencyPartnerChild(ren)Sibling(s)Parent(s)Extended FamilyFriend(s)OtherMissing/Unknown
If 'Other' please explain:__________________________________
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Primary Care is Provided for: NonePartnerSibling(s)Child(ren)Parent(s)Friend(s)Pet(s)Grandchild(ren)OtherUnknown/Missing
If 'Other' please explain:__________________________________
Quality of Relationships UnsupportiveSupportiveVery SupportiveUnknown/Missing
(Take this verbatim from the case managementnotes.)
Types of Support Systems: Immediate FamilyExtended FamilyFriendsReligious OrganizationCommunityOtherMissing/Unknown
Describe 'Religious Organization':__________________________________
Describe 'Community':__________________________________
If 'Other' please explain:__________________________________
Employment Status: Not EmployedEmployedRetiredDisabledMissing/Unknown
Employment Concern: YesNoMissing/Unknown
Source of Income: NoneDisabilitySalary/WagesRetirement/PensionSocial SecurityOtherMissing/Unknown
If 'Other' please explain:__________________________________
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Financial Concern: YesNoMissing/Unknown
Transportation at Time of Discharge Family will provideFriend will provideFriend or family (not specified) will provideOtherMissing/Unknown
If 'Other' please explain:__________________________________
Subjective Quality of Social Support UnsupportiveSupportiveVery supportiveUnknown
(Make a subjective judgment based on informationincluded in case management notes.)
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Emergency Department Data
Database ID__________________________________
This form will only populate if you indicated that the patient was admitted to an abdominal surgical service from theED on the Basic ID page.
ED Encounter Note > Care TimelineED Arrival Time
__________________________________
ED Departure Time__________________________________(May or may not be the same as the time ofadmission (depending on if beds were available))
ED Disposition Operating RoomFloorStep downICUOtherUnknown/Missing
If 'Other' please explain:__________________________________
ED NotesPre-hospital Location Home
Acute Care Hospital EDRehabSkilled Nursing FacilityLong Term Acute Care FacilityOtherUnknown/Missing
(Most likely the same as address/residence typeunless otherwise stated in ED notes.)
If 'Other' please explain:__________________________________
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Referring Facility Data
Database ID__________________________________
This form will only populate if you indicated that the patient was a transfer on the Basic ID page.
Name of Transferring Facility__________________________________
Address__________________________________
City__________________________________
State Abbreviation__________________________________
Zip Code__________________________________
Transferring Facility Type Acute Care HospitalRehabSkilled Nursing FacilityLong Term Acute Care FacilityOtherUnknown/Missing
If 'Other' please explain:__________________________________
Transferring Service SurgeryGeneral MedicineEmergency MedicineOtherUnknown/Missing
If 'Other' please explain:__________________________________
Location prior to Transfer ORFloorStepdownICUEDOtherUnknown/Missing
If 'Other' please explain:__________________________________
Was the date of admission to referring facility the Yessame calendar day as the admission to the new Nohealthcare facility?
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If not, how many days did the patient spend at thereferring facility? __________________________________
Urgency of Original Admission Elective/PlannedUrgent/Emergent/Unplanned
Primary Diagnosis__________________________________
Primary Diagnosis ICD-10 Code__________________________________(OMIT PERIODS)
Reason for Transfer__________________________________(E.g. Anesthesia needs, critical care needs,complications, etc.)
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Consult Data
Database ID__________________________________
This form will only populate if you indicated that the patient was an inpatient consult to an abdominal surgicalservice on the Basic ID page.
Service of physician who consulted surgical service Hospital MedicineMICUOther ICUVascular SurgeryCardiac SurgeryOrthopedic SurgeryPlastic SurgeryOB/GYNOtherUnknown/Missing
If 'Other' please explain:__________________________________
Primary Service at Time of Consult Hospital MedicineMICUOther ICUVascular SurgeryCardiac SurgeryOrthopedic SurgeryPlastic SurgeryOB/GYNOtherUnknown/Missing
If 'Other' please explain:__________________________________
Patient Location at Time of Consult Operating RoomFloorStepdownICUOtherUnknown/Missing
If 'Other' please explain:__________________________________
What day of this admission was a consult requested?__________________________________
Consult Request Time__________________________________
What day of this admission was the consult completed?__________________________________
Consult Seen Time__________________________________
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Consult Disposition Patient to ORFollowed patient as consultTransferred patient to ACS servicePatient stayed in OR with consulting surgeonOtherUnknown/Missing
If 'Other' please explain:__________________________________
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Laparotomy Data
Database ID__________________________________
Did the patient have an operation? YesNo
Brief Op Note & Operative ReportWas the operation completed within one calendar day? Yes
No
Day of surgery during admission__________________________________
Attending Surgeon__________________________________(Only include the first and last name of thesurgeon.)
Pre-procedure diagnosis text__________________________________
Pre-procedure ICD-10 diagnosis code__________________________________(OMIT PERIODS)
Post-procedure diagnosis text__________________________________
Post-procedure ICD-10 diagnosis code__________________________________(OMIT PERIODS)
How many procedures were performed?__________________________________
Primary surgical ICD-10 procedure code__________________________________(OMIT PERIODS)
Primary surgical CPT code__________________________________(Refer to "Procedures" > "Case Request - Surgery"for this)
Primary surgical procedure text__________________________________
Secondary surgical ICD-10 procedure code__________________________________(OMIT PERIODS)
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Secondary surgical CPT code__________________________________(Refer to "Procedures" > "Case Request - Surgery"for this)
Secondary surgical procedure text__________________________________
Tertiary surgical ICD-10 procedure code__________________________________(OMIT PERIODS)
Tertiary surgical CPT code__________________________________(Refer to "Procedures" > "Case Request - Surgery"for this)
Tertiary surgical procedure text__________________________________
Quaternary surgical ICD-10 procedure code__________________________________(OMIT PERIODS)
Quaternary surgical CPT code__________________________________(Refer to "Procedures" > "Case Request - Surgery"for this)
Quaternary surgical procedure text__________________________________
Quintary surgical ICD-10 procedure code__________________________________(OMIT PERIODS)
Quintary surgical CPT code__________________________________(Refer to "Procedures" > "Case Request - Surgery"for this)
Quintary surgical procedure text__________________________________
Intraoperative findings __________________________________________
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First Assistant Attending AlonePGY-1PGY-2PGY-3PGY-4PGY-5PGY-6Other AttendingOtherMedical Student(s)Unknown/Missing
If 'Other' please explain:__________________________________
Degree of contamination NonePhlegmonFree airPurulent contaminationFeculent contaminationGangrenous visceraOther
If 'Other' please explain:__________________________________
Were there any intraoperative complications? YesNo
Complication text__________________________________
Was the fascia closed? YesNo
How? Running SutureInterrupted SutureUnknown/Missing
Retention sutures used: Running SutureInterrupted SutureUnknown/Missing
If fascia left open, what was the temporary closure Abtheratype? Bogota Bag
Whitmann PatchVicyrl MeshGortex MeshOtherUnknown/Missing
If 'Other' please explain:__________________________________
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How was the skin closed? Closed with staplesClosed with subcuticular stitchClosed with wicksClosed with Provena/Topical NPWTOpen with wet to dryOpen with antibiotic soaked gauzeOpen with NPWTOtherUnknown/Missing
If 'Other' please explain:__________________________________
Were any packs/laps left in abdomen during temporary Yesclosure? No
How many?__________________________________
Were any drains placed in the abdomen? YesNo
How many?__________________________________
Were there any drains placed in the sub-q? YesNo
How many?__________________________________
If ascites was a finding that was noted within the operative report, make sure to go back to acute severity measuresto answer "yes" to ascites.
Anesthesia RecordAnesthesia Type General
EpiduralGeneral + EpiduralLocalMACSpinalRegionalOtherUnknown/Missing
If 'Other' please explain:__________________________________
ASA Classification Normal (I)Mild Systemic Disease (II)Severe Systemic Disease (III)Severe Systemic Disease w/ Constant Threat to Life(IV)Moribund, Not Expected to Survive (V)Unknown/Missing
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Did the patient receive a perioperative antibiotic? NoAmpicillin-sulbactam (Unasyn)CefazolinCefotetanCefoxitinErtapenem (Invanz)Fluoroquinolone (any drug ending in "-floxacin")Fluoroquinolone-metronidazole (ex. Cipro-Flagyl)GentamicinMetronidazolePiperacillin-tazobactam (Zosyn)VancomycinOther
(Medications)
If "Other", please describe__________________________________
Drug Given Time__________________________________
Was the first antibiotic given within 1 hour of Yesincision? No
(Will need to determine incision time (nextsection) first)
Did the patient receive another perioperative Noantibiotic? Ampicillin-sulbactam (Unasyn)
CefazolinCefotetanCefoxitinErtapenem (Invanz)Fluoroquinolone (any drug ending in "-floxacin")Fluoroquinolone-metronidazole (ex. Cipro-Flagyl)GentamicinMetronidazolePiperacillin-tazobactam (Zosyn)VancomycinOther
If "Other", please describe__________________________________
Drug Given Time__________________________________
Was the second antibiotic given within 1 hour of Yesincision? No
(Will need to determine incision time (nextsection) first)
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Was a beta blocker administered? NoAtenololBisoprololEsmololLabetalolLandiololMetoprololNadololOxprenololPindololPropranololSotalolOther
(Medications)
If "Other", please describe__________________________________
IV fluids given (crystalloid) (mL)__________________________________(Medications)
Colloid given (mL)__________________________________(Medications)
Starting Temperature (F)__________________________________(Intraprocedure grid)
Ending Temperature (F)__________________________________(Intraprocedure grid)
Lowest Temperature (F)__________________________________(Intraprocedure grid)
Lowest Mean Arterial Pressure < 40 mmHg40-54 mmHg55-69 mmHg>= 70 mmHg
(Intraprocedure graph)
Lowest Heart Rate >85 bpm76-85 bpm
"Pathologic bradycardia" includes sinus arrest, AV 66-75 bpmblock or dissociation, junctional or ventricular 56-65 bpmescape rhythm < = 55 bpm
Pathologic bradycardia or asystole(Intraprocedure graph)
Estimated Blood Loss > 1000 mL601-1000 mL101-600 mL< = 100 mL
(Intraprocedure grid)
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Urine Output (mL)__________________________________(Intraprocedure grid)
Was a urinary catheter placed? YesNo
(Lines, drains, and airways)
Was a central venous line (CVL, may only be listed as Yes"Central Line") placed? No
(Lines, drains, and airways)
Was an arterial line placed? YesNo
(Lines, drains, and airways)
Note that 1 unit is ~300 mL.Packed Red Blood Cells (# of units transfused)
__________________________________(Blood products; if not listed, assume 0)
Fresh Frozen Plasma (# of units transfused)__________________________________(Blood products; if not listed, assume 0)
Whole Blood (# of units transfused)__________________________________(Blood products; if not listed, assume 0)
Cryoprecipitate (# of units transfused)__________________________________(Blood products; if not listed, assume 0)
Cell-Saver (mL)__________________________________(Blood products; if not listed, assume 0)
Did the patient leave the OR intubated? YesNo
(Handoff report or operative notes/report)
Did the patient go to the PACU? YesNo
(Handoff report)
PACU Arrival Time__________________________________(Handoff report)
PACU Discharge Time__________________________________(Events)
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Linked SurgeryCase Booking Status (Case Classification) Status A - Emergent (60 min)
Status B - Urgent ( < 6 hours)Status C - Regular CaseMissing
(Log report)
NSQIP Wound Classification CleanClean/contaiminatedContaminatedDirty infectionUnknown/Missing
(Procedure(s))
OR Start Time (Patient In-Room)__________________________________(Case tracking events)
Incision Time (Incision/Procedure Start)__________________________________(Case tracking events)
End of Operation Time (Incision Close/Procedure End)__________________________________(Case tracking events)
OR End Time (Patient Out-Room)__________________________________(Case tracking events)
Type of prep used: Chlorhexidine (ChloraPrep)BetadineOtherUnknown/Missing
(Patient preparation)
If 'Other' please explain:__________________________________
How was hair removed? Not removedClippedShavedNot applicableOtherUnknown/Missing
(Patient preparation)
If 'Other' please explain:__________________________________
What kind of DVT prophylaxis was used? NoneSCDsHSQLovenoxOtherUnknown/Missing
(Sequential compression devices (Or Anesthesia >Medications if heparin or Lovenox))
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If 'Other' please explain:__________________________________
Encounter > Additional Orders and Documentation > Detailed Report > ADT EventsWhere did the patient go after index operation, not Floorincluding PACU? Stepdown
ICUOtherUnknown/Missing
If 'Other' please describe:__________________________________
Procedures: CASE REQUEST - SURGERYWas the case request submitted on the same calendar Yesday as the operation? No
If not, what day of admission was the case requestedcompleted? __________________________________
OR Case Request Submitted Time__________________________________
CALCULATED VALUESCalculated incision-to-antibiotic time is > 60 minutes and you answered 'yes' to 'Was the first/second antibiotic givenwithin 1 hour of incision?'.
Surgical Apgar Score__________________________________
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ConfidentialP1631 - Social Determinants of Acute Abdomen Outcomes
Page 1
Index Hospital Complications
Database ID__________________________________
UNPLANNED REOPERATION(S)# of Unplanned Reoperations During IndexHospitalization __________________________________
This complications fields will only populate if you indicated that the patient had systemic or surgical complications onthe Basic ID page.
SYSTEMIC COMPLICATIONS: only include those not present on admission# of Systemic Complications
__________________________________
Day of systemic complication #1__________________________________
Category of Systemic Complication #1 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #1__________________________________
ICD-10 code for complication #1__________________________________(OMIT PERIODS)
Day of systemic complication #2__________________________________
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Category of Systemic Complication #2 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #2__________________________________
ICD-10 code for complication #2__________________________________(OMIT PERIODS)
Day of systemic complication #3__________________________________
Category of Systemic Complication #3 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
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Text of Systemic Complication #3__________________________________
ICD-10 code for complication #3__________________________________(OMIT PERIODS)
Day of systemic complication #4__________________________________
Category of Systemic Complication #4 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #4__________________________________
ICD-10 code for complication #4__________________________________(OMIT PERIODS)
Day of systemic complication #5__________________________________
Category of Systemic Complication #5 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
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Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #5__________________________________
ICD-10 code for complication #5__________________________________(OMIT PERIODS)
Day of systemic complication #6__________________________________
Category of Systemic Complication #6 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #6__________________________________
ICD-10 code for complication #6__________________________________(OMIT PERIODS)
Day of systemic complication #7__________________________________
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Category of Systemic Complication #7 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #7__________________________________
ICD-10 code for complication #7__________________________________(OMIT PERIODS)
Day of systemic complication #8__________________________________
Category of Systemic Complication #8 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
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Text of Systemic Complication #8__________________________________
ICD-10 code for complication #8__________________________________(OMIT PERIODS)
Day of systemic complication #9__________________________________
Category of Systemic Complication #9 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicHealthcare Acquired Infection (HAI)Other
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #9__________________________________
ICD-10 code for complication #9__________________________________(OMIT PERIODS)
Day of systemic complication #10__________________________________
Category of Systemic Complication #10 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
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Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
ICD-10 code for complication #10__________________________________(OMIT PERIODS)
Text of Systemic Complication #10__________________________________
SURGICAL COMPLICATIONS# of Surgical Complications
__________________________________
Day of surgical complication #1__________________________________
Category of Surgical Complication #1 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #1__________________________________
ICD-10 code for complication #1__________________________________(OMIT PERIODS)
Day of surgical complication #2__________________________________
Category of Surgical Complication #2 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #2__________________________________
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ICD-10 code for complication #2__________________________________(OMIT PERIODS)
Day of surgical complication #3__________________________________
Category of Surgical Complication #3 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #3__________________________________
ICD-10 code for complication #3__________________________________(OMIT PERIODS)
Day of surgical complication #4__________________________________
Category of Surgical Complication #4 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #4__________________________________
ICD-10 code for complication #4__________________________________(OMIT PERIODS)
Day of surgical complication #5__________________________________
Category of Surgical Complication #5 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #5__________________________________
ICD-10 code for complication #5__________________________________(OMIT PERIODS)
Day of surgical complication #6__________________________________
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Category of Surgical Complication #6 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #6__________________________________
ICD-10 code for complication #6__________________________________(OMIT PERIODS)
Day of surgical complication #7__________________________________
Category of Surgical Complication #7 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #7__________________________________
ICD-10 code for complication #7__________________________________(OMIT PERIODS)
Day of surgical complication #8__________________________________
Category of Surgical Complication #8 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #8__________________________________
ICD-10 code for complication #8__________________________________(OMIT PERIODS)
Day of surgical complication #9__________________________________
Category of Surgical Complication #9 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
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Text of Surgical Complication #9__________________________________
ICD-10 code for complication #9__________________________________(OMIT PERIODS)
Day of surgical complication #10__________________________________
Category of Surgical Complication #10 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #10__________________________________
ICD-10 code for complication #10__________________________________(OMIT PERIODS)
CODE STATUSYou stated that the patient's code status at time of Yesadmission was [code_status] (Basic ID). No
Did the patient have a change in code status?
Day changed:__________________________________
What did it change to? Full codeDNRCCADNRCCA/DNIDNRCC (CMO)
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ConfidentialP1631 - Social Determinants of Acute Abdomen Outcomes
Page 1
Index Unplanned Reoperations
Database ID__________________________________
This form will only populate if you indicated that the patient had at least 1 unplanned reoperation in the IndexHospital Complications and Events page.
Index unplanned reoperation # (out of[unplanned_reop_num]) __________________________________
Brief Op Note & Operative ReportWas the operation completed within one calendar day? Yes
No
Day of Unplanned Reoperation during admission:__________________________________
Attending Surgeon__________________________________(Only include the first and last name of thesurgeon.)
Post-procedure diagnosis text__________________________________
Post-procedure ICD-10 diagnosis code__________________________________(OMIT PERIODS)
How many procedures were performed?__________________________________
Primary surgical ICD-10 procedure code__________________________________(OMIT PERIODS)
Primary surgical CPT code__________________________________(Refer to "Procedures" > "Case Request - Surgery"for this)
Primary surgical procedure text__________________________________
Secondary surgical ICD-10 procedure code__________________________________(OMIT PERIODS)
Secondary surgical CPT code__________________________________(Refer to "Procedures" > "Case Request - Surgery"for this)
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Secondary surgical procedure text__________________________________
Tertiary surgical ICD-10 procedure code__________________________________(OMIT PERIODS)
Tertiary surgical CPT code__________________________________(Refer to "Procedures" > "Case Request - Surgery"for this)
Tertiary surgical procedure text__________________________________
Quaternary surgical ICD-10 procedure code__________________________________(OMIT PERIODS)
Quaternary surgical CPT code__________________________________(Refer to "Procedures" > "Case Request - Surgery"for this)
Quaternary surgical procedure text__________________________________
Quintary surgical ICD-10 procedure code__________________________________(OMIT PERIODS)
Quintary surgical CPT code__________________________________(Refer to "Procedures" > "Case Request - Surgery"for this)
Quintary surgical procedure text__________________________________
First Assistant Attending AlonePGY-1PGY-2PGY-3PGY-4PGY-5PGY-6Other AttendingOtherUnknown/Missing
If 'Other' please explain:__________________________________
Were there any intraoperative complications? YesNo
Complications text__________________________________
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Was the fascia closed? YesNo
How? Running SutureInterrupted Suture
Retention sutures used: Running SutureInterrupted Suture
If fascia left open, what was the temporary closure Abtheratype? Bogota Bag
Whitmann PatchVicyrl MeshGortex MeshOtherUnknown/Missing
If 'Other' please explain:__________________________________
How was the skin closed? Closed with staplesClosed with subcuticular stitchClosed with wicksClosed with Provena/Topical NPWTOpen with wet to dryOpen with antibiotic soaked gauzeOpen with NPWTOtherUnknown/Missing
If 'Other' please explain:__________________________________
Were any packs/laps left in abdomen during temporary Yesclosure? No
How many?__________________________________
Were any drains placed in the abdomen? YesNo
How many?__________________________________
Were there any drains placed in the sub-q? YesNo
How many?__________________________________
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Anesthesia RecordAnesthesia Type General
EpiduralGeneral + EpiduralLocalMACSpinalRegionalOtherUnknown/Missing
If 'Other' please explain:__________________________________
ASA Classification Normal (I)Mild Systemic Disease (II)Severe Systemic Disease (III)Severe Systemic Disease w/ Constant Threat to Life(IV)Moribund, Not Expected to Survive (V)Unknown/Missing
Did the patient receive a perioperative antibiotic? NoAmpicillin-sulbactam (Unasyn)CefazolinCefotetanCefoxitinErtapenem (Invanz)Fluoroquinolone (any drug ending in "-floxacin")Fluoroquinolone-metronidazole (ex. Cipro-Flagyl)GentamicinMetronidazolePiperacillin-tazobactam (Zosyn)VancomycinOther
(Medications)
If "Other", please describe__________________________________
Drug Given Time__________________________________
Was the first antibiotic given within 1 hour of Yesincision? No
(Will need to determine incision time (nextsection) first)
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Did the patient receive another perioperative Noantibiotic? Ampicillin-sulbactam (Unasyn)
CefazolinCefotetanCefoxitinErtapenem (Invanz)Fluoroquinolone (any drug ending in "-floxacin")Fluoroquinolone-metronidazole (ex. Cipro-Flagyl)GentamicinMetronidazolePiperacillin-tazobactam (Zosyn)VancomycinOther
If "Other", please describe__________________________________
Drug Given Time__________________________________
Was the second antibiotic given within 1 hour of Yesincision? No
(Will need to determine incision time (nextsection) first)
Was a beta blocker administered? NoAtenololBisoprololEsmololLabetalolLandiololMetoprololNadololOxprenololPindololPropranololSotalolOther
(Medications)
If "Other", please describe__________________________________
IV fluids given (crystalloid) (mL)__________________________________(Medications)
Colloid given (mL)__________________________________(Medications)
Starting Temperature (F)__________________________________(Intraprocedure grid)
Ending Temperature (F)__________________________________(Intraprocedure grid)
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Lowest Temperature (F)__________________________________(Intraprocedure grid)
Lowest Mean Arterial Pressure < 40 mmHg40-54 mmHg55-69 mmHg>= 70 mmHg
(Intraprocedure graph)
Lowest Heart Rate >85 bpm76-85 bpm
"Pathologic bradycardia" includes sinus arrest, AV 66-75 bpmblock or dissociation, junctional or ventricular 56-65 bpmescape rhythm < = 55 bpm
Pathologic bradycardia or asystole(Intraprocedure graph)
Estimated Blood Loss > 1000 mL601-1000 mL101-600 mL< = 100 mL
(Intraprocedure grid)
Urine Output (mL)__________________________________(Intraprocedure grid)
Was a urinary catheter placed? YesNo
(Lines, drains, and airways)
Was a central venous line (CVL) placed? YesNo
(Lines, drains, and airways)
Was an arterial line placed? YesNo
(Lines, drains, and airways)
Note that 1 unit is ~300 mL.Packed Red Blood Cells (# of units transfused)
__________________________________(Blood products)
Fresh Frozen Plasma (# of units transfused)__________________________________(Blood products)
Whole Blood (# of units transfused)__________________________________(Blood products)
Cryoprecipitate (# of units transfused)__________________________________(Blood products)
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Cell-Saver (mL)__________________________________
Did the patient leave the OR intubated? YesNo
(Handoff report or operative notes/report)
Did the patient go to the PACU? YesNo
(Handoff report)
PACU Arrival Time__________________________________(Handoff report)
PACU Discharge Date & Time__________________________________(Events)
Where did the patient go after index operation, not Floorincluding PACU? Stepdown
ICUOtherUnknown/Missing
If 'Other' please describe:__________________________________
Linked SurgeryCase Booking Status (Case Classification) Status A - Emergent (60 min)
Status B - Urgent ( < 6 hours)Status C - Regular CaseMissing/unknown
(Log report)
NSQIP Wound Classification CleanClean/contaiminatedContaminatedDirty infectionUnknown/Missing
(Procedure(s))
OR Start Time (Patient In-Room)__________________________________(Case tracking events)
Incision Time (Incision/Procedure Start)__________________________________(Case tracking events)
End of Operation Time (Incision Close/Procedure End)__________________________________(Case tracking events)
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OR End Time (Patient Out-Room)__________________________________(Case tracking events)
Type of prep used: Chlorhexidine (ChloraPrep)BetadineOtherUnknown/Missing
(Patient preparation)
If 'Other' please explain:__________________________________
How was hair removed? Not removedClippedShavedNot applicableOtherUnknown/Missing
(Patient preparation)
If 'Other' please explain:__________________________________
What kind of DVT prophylaxis was used? NoneSCDsHSQLovenoxOtherUnknown/Missing
(Sequential compression devices (Or Anesthesia >Medications if heparin or Lovenox))
If 'Other' please explain:__________________________________
Procedures: CASE REQUEST - SURGERYWas the case request submitted on the same calendar Yesday as the operation? No
If not, what day of admission was the case requestedcompleted? __________________________________
OR Case Request Submitted Time__________________________________
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CALCULATED VALUESCalculated incision-to-antibiotic time is > 60 minutes and you answered 'yes' to 'Was the first/second antibiotic givenwithin 1 hour of incision?'.
Surgical Apgar Score__________________________________
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30-Day Complications
Database ID__________________________________
Was there an unplanned readmission within 30 days of Yesindex surgery? No
How many of these unplanned readmissions were there intotal? __________________________________
Was there an unplanned reoperation within 30 days of Yesindex surgery? No
How many of these unplanned reoperations were there intotal? __________________________________
Did the patient have any 30-day complications? YesNo
Which kind? SystemicOperative/Surgical
Has the patient died within 30 days of index surgery? YesNo
(Regardless of whether the patient wasreadmitted/inpatient at the time of death.)
If so, how many days since their discharge from thehospital? __________________________________
SYSTEMIC COMPLICATIONS# of Systemic Complications
__________________________________
How many days post hospital discharge did systemiccomplication #1 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #1 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
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Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #1__________________________________
ICD-10 code for complication #1__________________________________(OMIT PERIODS)
How many days post hospital discharge did systemiccomplication #2 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #2 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Text of Systemic Complication #2__________________________________
ICD-10 code for complication #2__________________________________(OMIT PERIODS)
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
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How many days post hospital discharge did systemiccomplication #3 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #3 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #3__________________________________
ICD-10 code for complication #3__________________________________(OMIT PERIODS)
How many days post hospital discharge did systemiccomplication #4 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #4 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
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Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #4__________________________________
ICD-10 code for complication #4__________________________________(OMIT PERIODS)
How many days post hospital discharge did systemiccomplication #5 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #5 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #5__________________________________
ICD-10 code for complication #5__________________________________(OMIT PERIODS)
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How many days post hospital discharge did systemiccomplication #6 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #6 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #6__________________________________
ICD-10 code for complication #6__________________________________(OMIT PERIODS)
How many days post hospital discharge did systemiccomplication #7 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #7 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
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Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #7__________________________________
ICD-10 code for complication #7__________________________________(OMIT PERIODS)
How many days post hospital discharge did systemiccomplication #8 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #8 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #8__________________________________
ICD-10 code for complication #8__________________________________(OMIT PERIODS)
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How many days post hospital discharge did systemiccomplication #9 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #9 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Text of Systemic Complication #9__________________________________
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
ICD-10 code for complication #9__________________________________(OMIT PERIODS)
How many days post hospital discharge did systemiccomplication #10 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #10 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicHealthcare Acquired Infection (HAI)Other
Was this complication a healthcare-acquired infection? YesNo
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Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
ICD-10 code for complication #10__________________________________(OMIT PERIODS)
Text of Systemic Complication #10__________________________________
SURGICAL COMPLICATIONS# of Surgical Complications
__________________________________
How many days post hospital discharge did surgicalcomplication #1 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #1 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #1__________________________________
ICD-10 code for complication #1__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #2 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #2 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #2__________________________________
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ICD-10 code for complication #2__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #3 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #3 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #3__________________________________
ICD-10 code for complication #3__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #4 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #4 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #4__________________________________
ICD-10 code for complication #4__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #5 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #5 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #5__________________________________
ICD-10 code for complication #5__________________________________(OMIT PERIODS)
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How many days post hospital discharge did surgicalcomplication #6 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #6 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #6__________________________________
ICD-10 code for complication #6__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #7 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #7 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #7__________________________________
ICD-10 code for complication #7__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #8 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #8 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #8__________________________________
ICD-10 code for complication #8__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #9 happen? __________________________________
(Day of discharge is Day 0)
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Category of Surgical Complication #9 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #9__________________________________
ICD-10 code for complication #9__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #10 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #10 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #10__________________________________
ICD-10 code for complication #10__________________________________(OMIT PERIODS)
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ConfidentialP1631 - Social Determinants of Acute Abdomen Outcomes
Page 1
30-Day Readmissions
Database ID__________________________________
This form will only populate if you indicated that the patient had at least 1 unplanned readmission in the 30-daycomplications page.
Unplanned 30-day readmission # (out of[read_30day_num]) __________________________________
Was the patient readmitted to an outside hospital Yes(records cannot be viewed in EMR)? No
Fill out the data below with as much information as is available.
30-DAY READMISSION DATAHow many days from index hospital discharge was thepatient readmitted? __________________________________
(Day of discharge is Day 0)
Readmission Time__________________________________
Readmission Source Emergency DepartmentDirect admit ("transfer") from acute carehospital, rehab, SNF, or LTACDirect admit from homeInpatient consult (overrides ED)OtherUnknown
(If patient was admitted to a different servicefrom the ED and surgery was later consulted, thisis considered an inpatient consult and not an EDadmission.)
If 'Other' please explain:__________________________________
Was the patient admitted through the Emergency YesDepartment? No
(If patient was admitted to a different servicefrom the ED and surgery was later consulted, theanswer to this should be "yes" (in contrast toprevious question).)
Admission Diagnosis Text__________________________________
Admission Diagnosis ICD-10 Code__________________________________
Did the patient die while inpatient? YesNo
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How many days post index hospital discharge did thepatient die? __________________________________
(Day of discharge is Day 0)
Was the patient admitted to hospice at time of death? YesNo
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ConfidentialP1631 - Social Determinants of Acute Abdomen Outcomes
Page 1
90-Day Complications
Database ID__________________________________
Was there an unplanned readmission within 90 days of Yesindex surgery? No
How many of these unplanned readmissions were there intotal? __________________________________
Was there an unplanned reoperation within 90 days of Yesindex surgery? No
How many of these unplanned reoperations were there intotal? __________________________________
Did the patient have any 90-day complications? YesNo
Which kind? SystemicOperative/Surgical
Has the patient died within 90 days of index surgery? YesNo
(Regardless of whether the patient wasreadmitted/inpatient at the time of death.)
SYSTEMIC COMPLICATIONS# of Systemic Complications
__________________________________
How many days post hospital discharge did systemiccomplication #1 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #1 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
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Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #1__________________________________
ICD-10 code for complication #1__________________________________(OMIT PERIODS)
How many days post hospital discharge did systemiccomplication #2 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #2 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Text of Systemic Complication #2__________________________________
ICD-10 code for complication #2__________________________________(OMIT PERIODS)
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
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How many days post hospital discharge did systemiccomplication #3 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #3 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #3__________________________________
ICD-10 code for complication #3__________________________________(OMIT PERIODS)
How many days post hospital discharge did systemiccomplication #4 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #4 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
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Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #4__________________________________
ICD-10 code for complication #4__________________________________(OMIT PERIODS)
How many days post hospital discharge did systemiccomplication #5 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #5 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #5__________________________________
ICD-10 code for complication #5__________________________________(OMIT PERIODS)
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How many days post hospital discharge did systemiccomplication #6 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #6 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #6__________________________________
ICD-10 code for complication #6__________________________________(OMIT PERIODS)
How many days post hospital discharge did systemiccomplication #7 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #7 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
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Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #7__________________________________
ICD-10 code for complication #7__________________________________(OMIT PERIODS)
How many days post hospital discharge did systemiccomplication #8 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #8 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
Text of Systemic Complication #8__________________________________
ICD-10 code for complication #8__________________________________(OMIT PERIODS)
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How many days post hospital discharge did systemiccomplication #9 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #9 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicOther
Was this complication a healthcare-acquired infection? YesNo
Text of Systemic Complication #9__________________________________
Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
ICD-10 code for complication #9__________________________________(OMIT PERIODS)
How many days post hospital discharge did systemiccomplication #10 happen? __________________________________
(Day of discharge is Day 0)
Category of Systemic Complication #10 ShockCardiacPulmonaryNeurologicalGenitourinaryThromboembolicHealthcare Acquired Infection (HAI)Other
Was this complication a healthcare-acquired infection? YesNo
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Microbe name AcinetobacterBurkholderia cepaciaClostridioides difficile (C diff)Enterobacteriaceae with carbapenem resistanceKlebsiellaMethicillin-resistant staphylococcus aureus (MRSA)NorovirusPseudomonas aeruginosaStaphylococcus aureusTuberculosis (TB)Vancomycin-resistant Staphylococcus aureus orenterococciVancomycin-intermediate Staphylococcus aureus
ICD-10 code for complication #10__________________________________(OMIT PERIODS)
Text of Systemic Complication #10__________________________________
SURGICAL COMPLICATIONS# of Surgical Complications
__________________________________
How many days post hospital discharge did surgicalcomplication #1 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #1 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #1__________________________________
ICD-10 code for complication #1__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #2 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #2 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #2__________________________________
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ICD-10 code for complication #2__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #3 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #3 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #3__________________________________
ICD-10 code for complication #3__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #4 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #4 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #4__________________________________
ICD-10 code for complication #4__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #5 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #5 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #5__________________________________
ICD-10 code for complication #5__________________________________(OMIT PERIODS)
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How many days post hospital discharge did surgicalcomplication #6 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #6 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #6__________________________________
ICD-10 code for complication #6__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #7 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #7 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #7__________________________________
ICD-10 code for complication #7__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #8 happen? __________________________________
(Day of discharge is Day 0)
Category of Surgical Complication #8 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #8__________________________________
ICD-10 code for complication #8__________________________________(OMIT PERIODS)
How many days post hospital discharge did surgicalcomplication #9 happen? __________________________________
(Day of discharge is Day 0)
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Category of Surgical Complication #9 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #9__________________________________
ICD-10 code for complication #9__________________________________(OMIT PERIODS)
Date of surgical complication #10__________________________________(Day of discharge is Day 0)
Category of Surgical Complication #10 WoundHemorrhageDeep SpaceAnastomotic LeakIntestinalOther
Text of Surgical Complication #10__________________________________
ICD-10 code for complication #10__________________________________(OMIT PERIODS)
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ConfidentialP1631 - Social Determinants of Acute Abdomen Outcomes
Page 1
90-Day Readmissions
Database ID__________________________________
This form will only populate if you indicated that the patient had at least 1 unplanned readmission in the 90-daycomplications page.
Unplanned 90-day readmission # (out of[read_90day_num]) __________________________________
Was the patient readmitted to an outside hospital Yes(records cannot be viewed in EMR)? No
Fill out the data below with as much information as is available.
90-DAY READMISSION DATAHow many days from index hospital discharge was thepatient readmitted? __________________________________
(Day of discharge is Day 0)
Readmission Time__________________________________
Readmission Source Emergency DepartmentDirect admit ("transfer") from acute carehospital, rehab, SNF, or LTACDirect admit from homeInpatient consult (overrides ED)OtherUnknown
(If patient was admitted to a different servicefrom the ED and surgery was later consulted, thisis considered an inpatient consult and not an EDadmission.)
If 'Other' please explain:__________________________________
Was the patient admitted through the Emergency YesDepartment? No
(If patient was admitted to a different servicefrom the ED and surgery was later consulted, theanswer to this should be "yes" (in contrast toprevious question).)
Admission Diagnosis Text__________________________________
Admission Diagnosis ICD-10 Code__________________________________
Did the patient die while inpatient? YesNo
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How many days post index hospital discharge did thepatient die? __________________________________
(Day of discharge is Day 0)
Was the patient admitted to hospice at time of death? YesNo
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ConfidentialP1631 - Social Determinants of Acute Abdomen Outcomes
Page 1
Followup
Database ID__________________________________
This form will not populate if you indicated that the patient died during their index admission (Basic ID).
How many follow-up appointments did the patient have?__________________________________(Max is 12)
How many days post index hospital discharge did thepatient have follow-up appointment #1? __________________________________
(Day of discharge is Day 0)
Did the patient show up for their appointment? YesNo
What was the primary purpose of this follow-up visit? Routine Follow-upConcern for wound infectionOngoing wound careOngoing painGI symptomsOtherUnknown
If 'Other' please explain:__________________________________
How many days post index hospital discharge did thepatient have follow-up appointment #2? __________________________________
(Day of discharge is Day 0)
Did the patient show up for their appointment? YesNo
What was the primary purpose of this follow-up visit? Routine Follow-upConcern for wound infectionOngoing wound careOngoing painGI symptomsOtherUnknown
If 'Other' please explain:__________________________________
How many days post index hospital discharge did thepatient have follow-up appointment #3? __________________________________
(Day of discharge is Day 0)
Did the patient show up for their appointment? YesNo
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What was the primary purpose of this follow-up visit? Routine Follow-upConcern for wound infectionOngoing wound careOngoing painGI symptomsOtherUnknown
If 'Other' please explain:__________________________________
How many days post index hospital discharge did thepatient have follow-up appointment #4? __________________________________
(Day of discharge is Day 0)
Did the patient show up for their appointment? YesNo
What was the primary purpose of this follow-up visit? Routine Follow-upConcern for wound infectionOngoing wound careOngoing painGI symptomsOtherUnknown
If 'Other' please explain:__________________________________
How many days post index hospital discharge did thepatient have follow-up appointment #5? __________________________________
(Day of discharge is Day 0)
Did the patient show up for their appointment? YesNo
What was the primary purpose of this follow-up visit? Routine Follow-upConcern for wound infectionOngoing wound careOngoing painGI symptomsOtherUnknown
If 'Other' please explain:__________________________________
How many days post index hospital discharge did thepatient have follow-up appointment #6? __________________________________
(Day of discharge is Day 0)
Did the patient show up for their appointment? YesNo
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What was the primary purpose of this follow-up visit? Routine Follow-upConcern for wound infectionOngoing wound careOngoing painGI symptomsOtherUnknown
If 'Other' please explain:__________________________________
How many days post index hospital discharge did thepatient have follow-up appointment #7? __________________________________
(Day of discharge is Day 0)
Did the patient show up for their appointment? YesNo
What was the primary purpose of this follow-up visit? Routine Follow-upConcern for wound infectionOngoing wound careOngoing painGI symptomsOtherUnknown
If 'Other' please explain:__________________________________
How many days post index hospital discharge did thepatient have follow-up appointment #8? __________________________________
(Day of discharge is Day 0)
Did the patient show up for their appointment? YesNo
What was the primary purpose of this follow-up visit? Routine Follow-upConcern for wound infectionOngoing wound careOngoing painGI symptomsOtherUnknown
If 'Other' please explain:__________________________________
How many days post index hospital discharge did thepatient have follow-up appointment #9? __________________________________
(Day of discharge is Day 0)
Did the patient show up for their appointment? YesNo
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What was the primary purpose of this follow-up visit? Routine Follow-upConcern for wound infectionOngoing wound careOngoing painGI symptomsOtherUnknown
If 'Other' please explain:__________________________________
How many days post index hospital discharge did thepatient have follow-up appointment #10? __________________________________
(Day of discharge is Day 0)
Did the patient show up for their appointment? YesNo
What was the primary purpose of this follow-up visit? Routine Follow-upConcern for wound infectionOngoing wound careOngoing painGI symptomsOtherUnknown
If 'Other' please explain:__________________________________
How many days post index hospital discharge did thepatient have follow-up appointment #11? __________________________________
(Day of discharge is Day 0)
Did the patient show up for their appointment? YesNo
What was the primary purpose of this follow-up visit? Routine Follow-upConcern for wound infectionOngoing wound careOngoing painGI symptomsOtherUnknown
If 'Other' please explain:__________________________________
How many days post index hospital discharge did thepatient have follow-up appointment #12? __________________________________
Did the patient show up for their appointment? YesNo
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What was the primary purpose of this follow-up visit? Routine Follow-upConcern for wound infectionOngoing wound careOngoing painGI symptomsOtherUnknown
If 'Other' please explain:__________________________________