ACUTE PANCREATITIS STUDY

9 099388 616867

National Confidential Enquiry into Patient Outcome and Death (NCEPOD)

CLINICIAN QUESTIONNAIRE

To identify and explore avoidable and remediablefactors in the process of care for patients withacute pancreatitis.

This form will be electronically scanned. Please usea black or blue pen. Please complete all questionswith either block capitals or a bold cross inside theboxes provided e.g.

Did the patient have any radiological interventionor drainage?

If you make a mistake, please “black-out” theincorrect box and re-enter the correct information,e.g.

NoYes

Grade:

DETAILS OF THE CLINICIAN COMPLETING THIS QUESTIONNAIRE

Specialty:

Information will be collected using two methods; boxcross and free text, where your opinion will berequested.

NoYes

Consultants who complete NCEPODquestionnaires make a valuable contribution to theinvestigation of patient care. It also provides anopportunity for consultants to review their clinicalmanagement and undertake a period of personalreflection. These activities have a continuingmedical and professional development value forindividual consultants. Consequently, NCEPODrecommends that consultants who completeNCEPOD questionnaires keep a record of thisactivity which can be included as evidence ofinternal/self directed Continuous ProfessionalDevelopment in their appraisal portfolio.

If you have any queries about this study or thisquestionnaire, please contact

AP@ncepod.org.uk

Or telephone: 020 7251 9060

Thank you for taking the time to complete thisquestionnaire. The findings of the study will bepublished in summer 2016.

NCEPOD number:

If you (the clinician completing the questionnaire)would like email confirmation of the completion ofthis questionnaire for your records, please clearlysupply your email address below.

Inclusions

Patients aged 16 years or older are included in thestudy if they were admitted to hospital between 1stJanuary 2014 and 30th June 2014 inclusive andwere diagnosed with acute pancreatitis

1) Had an inpatient stay of 3 or more nights

2) Were admitted to critical care during thereinpatient stay

3) Died in hospital

In addition patients must meet one or more of

the following criteria

9 099388 6174062

100 = General Surgery101 = Urology

103 = Breast Surgery

104 = Colorectal Surgery105 = Hepatobiliary &

106 = Upper GastrointestinalPancreatic Surgery

Surgery

107 = Vascular Surgery110 = Trauma & Orthopaedics120 = Ear, Nose & Throat (ENT)

130 = Ophthalmology

140 = Oral Surgery145 = Maxillo-Facial Surgery150 = Neurosurgery

160 = Plastic Surgery

161 = Burns Care170 = Cardiothoracic Surgery172 = Cardiac Surgery173 = Thoracic Surgery180 = Accident & Emergency

190 = Anaesthetics

192 = Critical/Intensive Care

Medicine

300 = General Medicine301 = Gastroenterology302 = Endocrinology

306 = Hepatology307 = Diabetic Medicine314 = Rehabilitation

320 = Cardiology

330 = Dermatology340 = Respiratory Medicine350 = Infectious Diseases352 = Tropical Medicine360 = Genito-Urinary Medicine361 = Nephrology

410 = Rheumatology

303 = Clinical Haematology

315 = Palliative Medicine 370 = Medical Oncology400 = Neurology

430 = Geriatric Medicine500 = Obstetrics & Gynaecology501 = Obstetrics502 = Gynaecology

800 = Clinical Oncology

823 = Haematology

810 = Radiology820 = General Pathology

SURGICAL SPECIALTIES

MEDICAL SPECIALTIES

02 – Staff grade/Associate specialist03 – Trainee with CCT 04 – Senior specialist trainee (ST3+ or equivalent)05 – Junior specialist trainee (ST1&ST2 or CTequivalent)

06 – Basic grade (HO/FY1 or SHO/FY2 orequivalent)

08 - Senior staff nurse,enrolled nurse (EN) etc)

01 – Consultant

07 - Specialist Nurse (Nurse consultant,Nursepractitioner, clinical nurse specialist

Levelsof wardcare

Level 1: Patients at risk of their condition deteriorating, or those recently relocated from higher levelsof care whose needs can be met on an acute ward with additional advice and support from the criticalcare team.Level 2: (e.g. HDU) Patients requiring more detailed observation or intervention including support fora single failing organ system or post operative care, and those stepping down from higher levels ofcare. (NB: When Basic Respiratory and Basic Cardiovascular support are provided at the same timeduring the same critical care spell and no other organ support is required, the care is considered tobe Level 2 care).Level 3: (e.g. ICU) Patients requiring advanced respiratory support alone or basic respiratory supporttogether with support of at least two organs. This level includes all complex patients requiring supportfor multi-organ failure. (NB: Basic Respiratory and Basic Cardiovascular do not count as 2 organs if theyoccur simultaneously (see above under Level 2 care), but will count as Level 3 if another organ issupported at the same time).

09 - 1st Level nurse, staff nurse (RGN)

Chronickidneydisease

326 = Acute internal medicine

10 - Non-registered staff (HCA etc.)

Normal kidney function but urine findings and structuralabnormalities or genetic trait point to kidney disease

CKD 1 90+

CKD 2 60-89 Mildly reduced kidney function and other findings (as stage 1)point to kidney disease

Moderately reduced kidney function39-59CKD 3

Severely reduced kidney function15-29CKD 4

CKD 5 <15Very severe endstage kidney failure (sometimes calledestablished renal failure

Estimated GFRStage Urine output criteria

5 099388 6176913

Please use the box below to provide a brief summary of this case, adding any comments orinformation you feel relevant. You may also type on a separate sheet.

2.

NCEPOD attaches great importance to this summary. Please give as much information as

possible about the care of this patient.

Gallstones Alcohol

What was the cause of Acute Pancreatitis?1.

A. CASE SUMMARY

Drugs

Unknown OtherPost ERCP

(please specify drugs)

(please specify)

0 099388 6198124

Age at time of admission3. Gender4. Male Femaleyears

Weight on admission

5a.

kg

OR

st

Not recorded

B. PATIENT DETAILS

BMI on admission

5b.

Height

cm

OR

feet inches

Not recorded

lb

Not recorded

5c.

Smoking history6.

8. Family History: Hereditary Pancreatitis

Cystic Fibrosis

Non smoker Ex-smoker Current smoker

Yes No

packs/week years smoking

Current drinker7a.

Had the patient had a previous admission for Acute Pancreatitis?9a. YesNo (please go toquestion 10

If Yes, when was their most recent admission (prior tothis admission) for Acute Pancreatitis?

9b.

d d m m y y

Unknown

Gallstones Alcohol

What was the cause of the above episode of Acute Pancreatitis?9c.

Drugs

Post ERCP

If the patient had gallstone pancreatitis how was this treated (please mark all that apply)?9d.

Cholecystectomy ERCP No treatment

Other (please specify)

If the patient had alcohol induced pancreatitis werethey referred to an alcohol cessation service?

9f. Yes No

N/A

N/A

Yes No If Yes units/week

When was definitive treatment for gallstonepancreatitis (this might be a subsequentadmission)?

9e.

d d m m y y

N/A

Unknown

No definitive treatment

7b.Unknown

Unknown

Unknown Other

(please specify drugs)

(please specify)

Unknown

Unknown

Unknown

Yes No Unknown

6 099388 6522405

Did the patient have any co-morbid conditions?10a.

COPD/Asthma

Current cancer treatment

Angina/previous myocardialinfarction

Gallstones Stroke/TIA/carotid surgery

Haemodialysis/peritoneal dialysis

Please list othermajor comorbidities

Date of admission:

d d m m y y h h m m

11.

What was the mode of admission?12b.

Via the Emergency department (ED)

Direct from a GP

Following outpatients/telephone consultation

Hospital transfer

Other

Yes No

If Yes, please mark all that apply.10b.

Cirrhosis

C. ADMISSION/RECOGNITION AND DIAGNOSIS OF ACUTE PANCREATITIS

TraumaChronic kidney disease(*grade 3-5)

Time of admission:

(please specify)

Was this admission?12a. Non-elective Elective

* see definitions on pg 2

Following ERCP

13a.

13f.

How long from arrival in ED did patient wait to havebaseline observations done?

h h m m

In your opinion was this appropriate?13b.

13c. Was an EWS completed in the ED? Yes No

If Yes, which scoring system?13d.

Did the score trigger a response? Yes No

13j. How long from arrival in ED did the patient wait to be seen by a doctor?

h h m m13k. How long was the patient in the ED before being moved to a ward?

h h m m

In your opinion was the management of the patient in ED satisfactory?13l. Yes No

13m. If No, why was this?

Yes No

NEWS MEWS Other

What was the score?13e.

If Yes, what?

In your opinion was this appropriate?13h. Yes No

If No, why not?

If the patient was admitted via the emergency department please complete Q13

13g.

13i.

Were comorbidities controlled on admission?10c. Yes No

Was a referral made for specialist input withregard to the patients comorbidities?

10d. Yes No

N/A

Unknown

N/A

(please specify)

0 099388 6546396

15b.

What was the grade and specialty of the Doctor thatfirst assessed the patient (this includes anyassessment in the ED)?

please enter grade codefrom pg 2

Unknown

Unknown15a.

please enter specialty codefrom pg 2

To what location was the patient first admitted?

General Medical Ward

Medical Assessment/Admissions Unit

General Surgical Ward

Surgical Assessment/Admissions Unit

Hepatology Ward

High Dependency Unit (level 2 care)

Intensive Care Unit (level 3 care)

Gastroenterology Ward

Other

(please specify)

Gastrointestinal Surgery Ward

HPB Surgery Ward

Were any problems/delays encountered with the transfer?14c. Yes No

If Yes, please provide details.14d.

If Yes, what was the main reason for the inter-hospital transfer (please mark all that apply)?14b.

Surgical Intervention Interventional Radiology

Endoscopic intervention

Other

Specialist critical care

Was the hospital transfer primarily for management of the patient'sAcute Pancreatitis?

14a. Yes No

Specialist AP service

Critical care bed

(please specify)

What was the time since onset of AP symptoms?

(time since patient first noticed symptoms at home relative to presentation at hospital)

< 3 hours >12 - 24 hours >24 - 48 hours

Unknown

>3 - 6 hours >6 - 12 hours

How did the patient present with their AP (please mark all that apply)?16a.

Abdominal pain Raised lipase

Vomiting

Back pain

Other

Raised amylase

(please specify)

Shock

>2 - 5 days >5 - 7days > 7 days

16b.

If the patient was a hospital transfer please complete Q14

see definitions on pg 2

Unknown

4 099388 6546117

On recognition of AP what was the patient's first pulse, systolic blood pressure and O saturation?17a.

bpmPulse mm HgSystolic BP %O sat2

What was the date of the first registrar (ST3 orabove) review post admission?

d d m m y y

Unknown18a.

What was the time of this review?18b. Unknown

No Registrar review

What was the date of the first consultant reviewpost admission?

d d m m y y

Unknown

What was the time of this review?

h h m m

Unknown18e.

18d.

What was the specialty of the consultant? please enter specialty codefrom the list on pg 2

What was the specialty of the registrar?18c. please enter specialty codefrom the list on pg 2

18f.

17e.

17b. Was an EWS performed following admission? Yes No

If Yes, which scoring system?17c.

Did the score trigger a response? Yes No

NEWS MEWS Other

What was the score?17d.

If Yes, what?

In your opinion was this appropriate?

17f.

Yes No

If No why not?

17g.

17h.

Which of the following medication was the patient on prior to their admission for AP?19a.

5-aminosalicylic acid

Other drugs relevant to thepatient's AP

Azathioprine

DiureticsSteroids

(please specify) (please specify) (please specify)

(please specify)

Statins

(please specify)

2

h h m m

0 099388 7110288

Which of the following medications were stopped?19b.

Which of the following investigations were undertaken at the time AP was suspected? (pleasemark all that apply)

20a.

Clotting screen

Full blood count Liver function tests

Urea and electrolytes Group and save

Cross-match

INR/PT APTR/PTT Fibrinogen

Amylase Lipase CRP

Troponin ECG ABGs

In your opinion were all appropriate investigations done?20b. Yes No

If No, what was omitted? (please mark all that apply)20c.

LDH Glucose Serum calcium

Triglycerides Lipid profile

In your opinion was this appropriate?19c. Yes No Unknown

If No, please expand on this19d.

5-aminosalicylic acid

Other drugs relevant to thepatient's AP

Azathioprine

DiureticsSteroids

(please specify) (please specify) (please specify)

(please specify)

Statins

(please specify)

CXR

Clotting screen

Full blood count Liver function tests

Urea and electrolytes Group and save

Cross-match

INR/PT APTR/PTT Fibrinogen

Amylase Lipase CRP

Troponin ECG ABGs

LDH Glucose Serum calcium

Triglycerides Lipid profile CXR

Other

(please specify)

Other

(please specify)

1 099388 7110109

Please complete the table below for the time frames indicated. If the patients CRP level or a risk assessment score altered the management planfor the patient (e.g CT performed, admitted to critical care, transferred for specialist care) please provide details of this the in box provided

21a.

Time from APdiagnosis

CRP mg/L(highest level)

0 hours

ModifiedGlasgow score

Managementimpacted

Details

Yes No

Yes No>0 - 24 hours

Yes No>24 - 48 hours

Yes No>48 - 72 hours

Yes No>3 - 5 days

Yes No>5 - 7 days

Yes No> 7 days

EWS

In your opinion was risk assessment appropriate?21b. Unknown

If No, what was omitted?21c.

(please specify score and local threshold used)

Yes No

4 099388 71097310

How was the AP diagnosed? (please mark all that apply)22.

Pain Raised enzymes Imaging Other

Did the patient receive IV fluids? UnknownYes No25a.

25d. Please indicate the resuscitation fluids (ml) the patient received during the different time framesbelow (if none please put a 0)

Time from APdiagnosis

Hartmann's

0-3 hours

>12 - 24 hours

>24 - 48 hours

>48 - 72 hours

> 72 hours

5% Dextrose DextroseSaline

Other Other

> 3 - 6 hours

> 6 - 12 hours

(please specify) (please specify)

NormalSaline

If No, in your opinion should they have? UnknownYes No25b.

If Yes to 25b, why was this required?25c.

In your opinion was VTE prophylaxis adequate? Unknown23b.

Was the patient prescribed regular prophylactic Low MolecularWeight Heparin?

23a.

Yes No

UnknownYes No

Yes NoIn your opinion, was the above fluid management appropriatefor the the patient's condition?

25e. Unknown

If No, please expand on your answer.25f.

What was the lowest oxygen saturation prior to resuscitation?24a.

Did the patient have supplemental oxygen prescribed?24b.

Did the patient have supplemental oxygen administered?24c.

If Yes to 24c, did it improve oxygen saturation?

%O sat2

UnknownYes No

UnknownYes No

24d. UnknownYes No

Was management of the patient's oxygenation appropriate?24e. UnknownYes No

(please specify)

D. INITIAL MANAGEMENT

8 099388 71081811

What was their haemoglobin level at the beginning of resuscitation?30a. g/L

Were vasoactive drugs commenced during the initial resuscitation?29a.

h h m m 24 hr clock d d m m y y y y

Time unknown Date unknown

If Yes to 29a, please state the time and date:29d.

BP improved

29e. If Yes to Q29a, did the patient respond to vasoactive drugs?

BP target reached

If Yes, which vasoactive drug?29b.

What was the maximum dose in the first hour?

Did the patient require organ support? Yes No Unknown

If Yes was this Cardiovascular Respiratory Renal

HaemofiltrationVentilation CPAP

lactate improved lactate normalised

Yes No Unknown

If Yes to Q29e how did they respond? Please mark all that apply

Other

Did the patient have a central line inserted? Yes No

If Yes was one port reserved for TPN?

Yes NoDid they receive a blood transfusion?30b. Unknown

Level 1 Level 2What was the patient's level of careduring initial resuscitation?

31a. Level 3

What was their frequency of monitoring at this time?31b.

In your opinion was transfusion appropriate? Yes No Unknown30d.

>1-2 hourlyHourly (or more frequent) >2-4 hourly >4-6 hourly

>6-12 hourly >12 hourly

What was the pre-transfusion haemoglobin level?30c. g/L

Other

Yes No

Did the patient have hourly urinary output monitoring ?

26a. Unknown

Yes No

Did the patient have a urinary catheter?

26b. Unknown

Yes NoIf Yes to 26c, in your opinion could AKI have been prevented?26d. Unknown

IV fluids OxygenIf Yes to 26d, how could AKIhave been prevented?

26e.

Other

Stopping nephrotoxic drugs

Did the patient develop Acute Kidney Injury (AKI)?26c. Yes No Unknown

27a.

27b.

28a.

28b.

N/A

Haemodialysis

Adrenaline Noradrenaline Dobutamine Dopamine

29c.

(please specify)

Unknown

Yes No Unknown

Yes No Unknown

Other(please specify)

(please specify)

29f.

see definitions on pg 2

Continuous

Unknown

(please specify)

9 099388 71075612

Please complete the table below for each antimicrobial the patient was given during this admission32a.

Datecommenced

Timecommenced

Antibiotic / antifungal Duration (days)Indication

d d m m h h m m

Route

IV Oral

Pro-calcitoninmeasured atoutset

Yes No

d d m m h h m m

IV Oral Yes No

d d m m h h m m

IV Oral Yes No

d d m m h h m m

IV Oral Yes No

d d m m h h m m

IV Oral Yes No

d d m m h h m m

IV Oral Yes No

d d m m h h m m

IV Oral Yes No

d d m m

IV Oral Yes No

In your opinion was the above (antimicrobial management) appropriate for the patient?32b. Yes No

If No, why not?32c.

h h m m

6 099388 71072813

h h m m 24 hr clock d d m m y y y y

Time unknown Date unknown

Following diagnosis with AP, what was the time/date the patient was first reviewed by a medicaldoctor on the ward?

35a.

What was the grade and specialty of the clinician?35b. (see p.2 for list of grades and

specialties)

h h m m 24 hr clock d d m m y y y y

36a.

Time unknown Date unknown

Following diagnosis with AP, (if different from above) what was the first time the patient was reviewedby a consultant?

Following diagnosis with AP, how often was the patient monitored for standard observations?39a.

Following diagnosis with AP, what was the first time the patient was reviewed by a consultantintensivist?

37a.

h h m m 24 hr clock d d m m y y y y

Time unknown N/A - Not reviewed

Date unknown

Is there evidence of a consistent structuredhandover from the day team and out-of-hoursteam treating this patient? N/A- care was not handed over

Yes No33.

In your opinion was this appropriate? NoYes39b.

h h m m 24 hr clock d d m m y y y y

Time unknown

N/A not reviewed byspecialist nurse

Following diagnosis with AP, what was the time/date the patient was first reviewed by a specialist nurse(eg. an HPB nurse specialist or equivalent) on the ward?

34a.

What was the specialty of the nurse?34b.

Date unknown

Following diagnosis with AP, what was the first time the patient wasreviewed by a trainee intensivist?

38a.

h h m m 24 hr clock d d m m y y y y

Time unknownN/A - Not reviewed

Date unknown

What was the grade of the trainee?38b. (see p.2 for list of grades)

>1-2 hourlyHourly (or more frequent) >2-4 hourly >4-6 hourly

>6-12 hourly >12 hourly Other

Continuous

Unknown

36b. What was the specialty of the consultant? (see p.2 for list specialties)

grade

specialty

0 099388 665017

What response was triggered? Review by critical care outreach team (CCOT)

Review by other emergency team eg:Medical Emergency Team (MET), RapidResponse Team (RRT)

Review by critical care clinician

Other(pleasestate):

If Yes, please state the time/date the patient was first seen:41b.

h h m m 24 hr clock d d m m y y y y

Time unknown Date unknown

At any time, following diagnosis with AP, was this patientseen by the CCOT or other emergency team (MET, RRTetc.)?

41a. Yes No

If No to 41a, was this because:41c.

No CCOT (or equivalent)at this hospital

CCOT (or equivalent) notavailable out of hours

CCOT (or equivalent) did not see patient for other reason - please state:

40h.

Review by other clinician

Not requiredPatient admitted directly tocritical care

14

Did patient observations include monitoring with an Early Warning Score?40a. Yes No

If Yes, please specify which one:40b.

If Yes, is an escalation response required when thescore triggers?

40c. Yes No

40e.

What Early Warning Score triggers a response in this hospital/ward : Unknown

If Yes to 40a, was escalation triggered for this patient?

40d.

Yes No

If Yes to question 40e, what date/time did the patient first trigger EWS?

h h m m 24 hr clock d d m m y y y y

Time unknown Date unknown

40f.

If Yes to question 40e, what was the date/time of the first documented response?

h h m m 24 hr clock d d m m y y y y

Time unknown Date unknown

40g.

40i. In your opinion was this response appropriate? Yes No

40j. In your opinion was this response timely for the patient'scondition?

Yes No

NEWS MEWS Other

Was the patient admitted to critical care (HDU or ICU) during this admission?42a. Yes No

If No, in your opinion should they have been?42b. Yes No

9 099388 74209215

In your opinion was analgesia given in a timelymanner?

UnknownYes No

Was the patient's pain score measured onadmission?

44a. UnknownYes No

If Yes what pain score was used?44b.

How long after admission did the patient first receive analgesia?45a.

45e.

E. PAIN MANAGEMENT

In your opinion was the patient given adequateanalgesia?

UnknownYes No45c.

What type of analgesia was the patient given?45b.

oral opiateoral paracetamol oral NSAID IM morphine

IM NSAID IV paracetamol IV NSAID IV opiate (not PCA)

PCA epidural analgesia Other

In No, please expand on your answer45d.

Was the patient seen by the acute pain team? UnknownYes No46.

In your opinion was the patient's pain adequatelycontrolled during their admission?

UnknownYes No47a.

What was the score?

fentanyl

morphine

other

If Yes to 42b, why?42c.

If the patient was admitted to critical care (HDU or ICU) during this admission when was this?43a.

h h m m 24 hr clock d d m m y y y y

Time unknown Date unknown

How many days in total did the patient spend on critical care (HDU/ICU)?43c.

Was the patient readmitted to critical care at any point after discharge?43b. Yes No

days hours

47b. If No, please expand on this?

(please specify)

(please specify)

6 099388 71490016

Did the patient have a CT to diagnose AP?50a. Yes No Unknown

F. RADIOLOGY

If Yes what did this show?50b.

Did this include?50c.

In your opinion was this appropriate?50d. Yes No Unknown

How many CT scans did the patient undergo during this admission?51a.

d d m m h h m m

Date and time of scan Reason for scan Protocol used

Please complete a row of the table below for each CT or MRI scan undertaken ?51c.

Acute pancreatitis

Pancreatic abcess

Gallstones

Obstructing gall stones Pancreatic necrosis

Pseudoaneurysm

Portal vein thrombosis Acute fluid collection Peri-pancreatic collection

Non contrast Arterial phase Portal venous phase

%

Other

Did the scan resultchange patientsmanagement

Yes No

If this scan changed the patients manangement, how?

d d m m h h m m

Yes No

If this scan changed the patients manangement, how?

d d m m h h m m

Yes No

If this scan changed the patients manangement, how?

Did the patient have an ultrasound scan?48a. Yes No Unknown

If Yes what did it show (please mark all that apply)?48b.

Gallstones CBD stones Dilated CBD

Pancreatic collection

Did the patient have an MRCP?49a. Yes No

If Yes to 49a what did it show (please mark all that apply)?49c.

Gallstones CBD stones Dilated CBD

Other

How many MRI scans did the patient undergo during this admission?51b.

CT

MRI

CT

MRI

CT

MRI

Scan type

Unknown

Normal Pancreatitis

Other

Pancreatic calcification

If Yes, was secretin used?49b. Yes No Unknown

Infected necrosis

(please specify)

(please specify)

(please specify)

0 099388 71063217

d d m m h h m m

Date and time of scan Reason for scan Protocol used

Did the scan resultchange patientsmanagement

Yes No

If this scan changed the patients manangement, how?

d d m m h h m m

Yes No

If this scan changed the patients manangement, how?

d d m m h h m m

Yes No

If this scan changed the patients manangement, how?

CT

MRI

CT

MRI

CT

MRI

Scan type

d d m m h h m m

Yes No

If this scan changed the patients manangement, how?

d d m m h h m m

Yes No

If this scan changed the patients manangement, how?

d d m m h h m m

Yes No

If this scan changed the patients manangement, how?

CT

MRI

CT

MRI

CT

MRI

d d m m h h m m

Yes No

If this scan changed the patients manangement, how?

CT

MRI

In your opinion was the number and timing of scans appropriate for the patient? Yes No

If No, please expand on your answer

51d.

51e.

5 099388 715076

G. ERCP

Did the patient undergo ERCP during this admission?52a. Yes (please goto Q53)

No Unknown

What was the reason for ERCP (please mark all that apply)?53a.

Prevention of gallstonepancreatitis not suitable forlaparoscopic cholecystectomy

Other

Cholangitis CBD stones Stricture

What was the date/time of the first ERCP during this admission?

h h m m 24 hr clockd d m m y y y y

Time unknownDate unknown

54a.

In your opinion was this an appropriate time frame?54b. Yes No Unknown

If No what was the reason for the delay?54c.

Where was the ERCP undertaken?55c.

Endoscopy unitICU (level 3) HDU (level 2) Theatre

Was the ERCP carriedout under:

55d.Generalanaesthesia

Conscioussedation

Was the patient intubated?55e. Yes No

What was the grade of the endoscopist?55a.

Consultant

Senior trainee (SpR or fellow)directly supervised by consultant

Senior trainee indirectlysupervised by consultant

Senior trainee performed alone

Was a trainee assisting?55b. UnknownYes No

Unconscioussedation

Nosedation

18

Radiology department

If No, in your opinion should they have?52b. Yes No Unknown

If Yes to 52b, why?52c.

In your opinion was this appropriate?53b. Yes No Unknown

If No, please expand on this53c.

Suspected ampullary lesion/ pancreatic mass

(please specify)

5 099388 710422

Was there an endoscopy nurse present?57. Yes No Unknown

58.

bpmhighest

pulsemm Hgsystolic BP %O2

What was the highest pulse, lowest systolic BP and lowest oxygen saturation during ERCP (pleaseinclude the other 2 observations recorded at the time of each measurement)?

What were the findings of the ERCP?59a.

What treatment was undertaken?59b.

Total number of ERCPs duringthis admission?

60.

Were there any complications of ERCP?61a. Yes No

If Yes, what?61b.

CBD stones Stricture Ampullary lesion Pancreas divisum

Normal

Biliary sphincterotomy

Sphincteroplasty

Balloon trawl Plastic stent

Pre-cut sphincterotomy Other

19

Exacerbation of Acute Pancreatitis

Cholangitis

Significant bleeding Death

Other

None

Was the ERCP technically successful?59c. Yes No

What monitoring was used? (Please mark all that apply)56d.

PulsePulse oximetry Blood pressure ECG

Other

In your opinion was documentation ofmonitoring adequate?

56e. Yes No

(please specify)

If No, was sedation undertaken by the endoscopist?56b. Yes No

If Yes to 56b, who undertook themonitoring?

56c. Unknown

Was sedation undertaken by an anaesthetist?56a. Yes No

(please specify)

lowest

systolic BPbpmpulse %O2

%lowest O2bpmpulse mm Hgsystolic BP

mm Hg

Septic shock

(please specify)

Visceral perforation

(please specify)

4 099388 71567120

If the patient had gallstone pancreatitis did they havedefinitive management of their gallstones during thisadmission?

62a.Yes No

H. DEFINITIVE GALLSTONE TREATMEMT

N/A - patient did not havegallstone pancreatitis

What definitive management did thepatient have?

64a. ERCP and sphincterotomy Cholecystectomy

Other

(please specify)

In your opinion was this appropriate?64b. Yes No

If No to 62a, what was the reason for deferral?62b.

Severe pancreatitis withongoing complications

Lack of access to ERCPLack of access toemergency theatres

Other

What was the date/time of the first definitive treatment of gallstones?

h h m m 24 hr clockd d m m y y y y

Time unknownDate unknown

63a.

In your opinion was this acceptable?63b. Yes No

What was the grade of the primary surgeon?65a.

Consultant

Senior trainee (SpR or fellow)supervised by consultant (scrubbed)

Senior trainee supervised byconsultant (unscrubbed)

Senior trainee performed alone

Unknown

Was a trainee assisting?65b. UnknownYes No

What was the grade of the anaesthetist anaesthetising the patient?66.

What was the specialty of the primary surgeon?65c. Please enter the specialty codefrom the list on pg 2 Unknown

What was the sub-specialty interest of the primarysurgeon?

65d. Please enter the specialty codefrom the list on pg 2 Unknown

If the primary surgeon was not a consultant, whatwas the sub-specialty interest of the supervisingconsultant?

65e. Please enter the specialty codefrom the list on pg 2 Unknown

Consultant

Senior trainee (SpR or fellow)supervised by consultant

Senior trainee performed alone

Unknown

Please complete this section if the patient underwent laparoscopic cholecystectomy for management

of their gallstones (during this admission or subsequently)

If No to 62a, in your opinion was this appropriate?62c. Yes No

If No, did waiting list pressures contribute to this?63c. Yes No

(please specify)

5 099388 74978121

To what location did the patient go immediately post recovery?68a.

Upper GI surgery ward

General surgical ward

HPB surgery ward

High dependency unit (level 2 care)

Intensive care unit (level 3 care) Other (please specify)

In your opinion was this location appropriate?68b. Yes No

If No, pleaseexplain why not?

68c.

Did the patient suffer any post-operativecomplications after this surgery?

69a. Yes No

Sepsis

Enteric leak/fistula Intra-abdominal abscess

Wound infection/dehiscenceReturn to theatre Bleeding

Other

If No, what was the reason?67b. Not attempted Technical failure

Did the patient have intraoperative cholangiogramduring laparoscopic cholecystectomy?

67a. Yes No

Surgeon unableto perform

Lack of radiologyequipment

Lack ofradiographer Other

Did this alter the management of the patient?67c. Yes No

If Yes, how?67d.

Post-op ERCP Trans-cystic removal CBD stone Lap CBD exploration

Open CBD exploration Other

Bile duct injuryBile leak

N/A

(please specify)

(please specify)

(please specify)

If Yes, which of the following complications (please mark all that apply)?69b.

N/A

0 099388 716023

Did the patient undergo needle aspiration of necrosis?71a. Yes No Unknown

If Yes, what was the indication for this?71c.

In your opinion was this appropriate?71d. Yes No Unknown

If Yes to 71a, was this decision discussed with aspecialist centre prior to performing?

71f. Yes NoN/A, patient atspecialist centre

Did the patient undergo radiological drain insertion?72a. Yes No Unknown

If Yes, what was the indication for this?72c.

In your opinion, was this appropriate?72d. Yes No Unknown

If Yes to 72a, was this discussed with a specialistcentre prior to insertion?

72f. Yes NoN/A, patient atspecialist centre

Did the patient undergo another IR procedure?73a. Yes No Unknown

If Yes, what procedure?73b.

22

In No, please expand on this?71e.

Did the patient have any radiological intervention ordrainage?

70a. Yes No Unknown

If No, in your opinion should they have?70b. Yes No Unknown

If Yes to 70b, please explain?70c.

Was a sample sent for microbiological examination?71g.

If Yes, what organism was identifed?71h. None

I. MANAGEMENT OF PANCREATIC NECROSIS/COMPLICATIONS

h h m m 24 hr clock d d m m y y y y

Time unknown Date unknown

If Yes, please state the time and date this occurred71b.

h h m m 24 hr clock d d m m y y y y

Time unknown Date unknown

If Yes, please state the time and date:72b.

If No, please expand on this?72e.

Yes No Unknown

2 099388 71031923

Was surgery undertaken for pancreatic complications74a. YesNo, please go toquestion 87

If Yes what was the reason for surgery?74b.

Infected necrosis Sterile necrosis with worseningmultiple organ dysfuntion syndrome

Other

(please specify)

Suspected infected necrosis

Pancreatic abscess Pancreatic pseudocyst Massive haemorrhage

Gastric outflow obstructionPancreatic fistula

UnknownDate

d d m m y y

Time

h h m m

What was the date and time when surgery was considered?75a.

UnknownDate

d d m m y y

Time

h h m m

What was the date and time when surgery was performed?75b.

In your opinion was timing of surgery appropriate?75c. Yes No Unknown

What type of surgery was undertaken?76.

Percutaneous necrosectomy

Other

(please specify)

Open necrosectomy

Were any of the following considered prior tosurgical intervention?

77a.

Surgical drainage

Endoscopic drainage Radiological drainage

In your opinion should they have been?77b. Yes No

Was the case discussed with a specialist centre?78a. Yes No

Was the patient transferred for surgery?78b. Yes No

If No, please expand75d.

Bowel ischaemia

Endoscopic necrosectomy

Unknown

Unknown

N/A, patient atspecialist centre

9 099388 70973624

Was a pre-op risk assessment performed?79a. Yes No

What scoring system was used ?79b.

What was the grade of the primary surgeon?80a.

Consultant

Senior trainee (SpR or fellow)supervised by consultant (scrubbed)

Senior trainee supervised byconsultant (unscrubbed)

Senior trainee performed alone

Unknown

Was a trainee assisting?80b. UnknownYes No

What was the grade of the anaesthetist anaesthetising the patient?81.

What was the specialty of the primary surgeon?80d.Please enter the specialty codefrom the list on pg 2

Unknown

What was the sub-specialty interest of the primarysurgeon?

80e.Please enter the specialty codefrom the list on pg 2

Unknown

If the primary surgeon was not a consultant, whatwas the sub specialty interest of the supervisingconsultant?

80f.

Please enter the specialty codefrom the list on pg 2

Unknown

Consultant

Senior trainee (SpR or fellow)supervised by consultant

Senior trainee performed alone

Unknown

In your opinion was this an appropriateprocedure for the patient?

What surgical procedure was performed?82a.

82b. Yes No

If No, please expand on your answer?82c.

ASA P-Possum APACHE II

ACSNSQIP risk score Other

Were antibiotics commenced/continued at the time of surgery?83a. Yes No

In your opinion was this appropriate?83b. Yes No

If No, why not?83c.

If Yes, what was the grade of the trainee?80c.Please enter the grade from thelist on pg 2

Unknown

3 099388 70968825

To what location did the patient go immediately post recovery?84a.

Upper GI surgery ward

General surgical ward

HPB surgery ward

High dependency unit (level 2 care)

Intensive care unit (level 3 care) Other (please specify)

In your opinion, was this appropriate?84b. Yes No

If No, why not?84c.

Did the patient suffer any post-operativecomplications after this surgery?

85a. Yes No

Sepsis

Enteric leak/fistula Intra-abdominal abscess

Bleeding

Wound dehiscence

Wound infectionReturn to theatre

Other

If Yes, please mark all that apply:85b.

(please specify)

Pancreatic fistula Bile leak

Did the patient undergo further surgical, IR orendoscopic procedures for treatment of pancreaticcomplications?

86a. Yes No

If Yes please provide details below86b.

4 099388 71640126

Was a nutrition team involved with this patient?

91.

UnknownYes No

Was a nutritional assessment performed?87a. UnknownYes No

When was this performed?87b.

Who performed assessment?87c. Not specifiedQualified Nurse Healthcare Assistant

Other

Was supplemental nutrition considered?

90b. If Yes, when was supplemental nutrition started?

90c. Nasogastric feedingOral diet Build up drinks

What assessments ofnutritional status were used?

92a.

d d m m y y y y

Was the patient referred to a dietitian?88a. UnknownYes No

If Yes, what date was this?88b.

d d m m y y y y

Was the patient seen by a dietitian?88c. UnknownYes No

If Yes, what date was this?88d.

d d m m y y y y

UnknownYes No

How many days was the patient nil by mouth?

d d m m y y y y

What nutrition was used?

Nasojejunal feeding Peripheral parenteral nutrition

Parenteral nutritionvia central line

MUST score Weight BMI

Anthropometricmeasurements

Other

89.

90a.

J. NUTRITION

Were there any delays in initiating nutrition support? UnknownYes No90d.

Were these assessments carried out weeklyduring the admission?

UnknownYes No92b.

If No to 88c, in your opinion should they havebeen?

88e. UnknownYes No

If Yes, why?88f.

In your opinion, was assessment of the patient'snutritional status adequate?

UnknownYes No92c.

Other

(please specify)

(please specify)

Unknown

Not started

None Unknown

(please specify)

3 099388 70915227

Did the patient need pancreatic enzymesupplementation?

UnknownYes No

In your opinion was the blood glucoseadequately monitored?

96a. UnknownYes No

Did the patient require blood glucose control?96b.

What method was used?96c.

IV sliding scale (variablerate insulin infusion)

oral hypoglycaemics subcutaneous insulin

Other

In your opinion, was pancreatic exocrine functionadequately assessed?

In your opinion was blood glucosecontrol adequately managed?

96d. UnknownYes No

UnknownYes No

97a.

97b.

In your opinion, was this adequately treated? UnknownYes No97c.

UnknownYes No

Was the patient commenced on pancreatic enzymes? Yes No

Was the patient advised to follow a low fat diet? Yes No

93.

94.

What enteral feed was used?95.

Unknown

Unknown

(please specify)

Unknown N/A

5 099388 74178528

What was the date of discharge or death?

d d m m y y y y

Unknown98a.

What was the discharge location?98b.

Discharged to previous place of residence

Discharged to other hospital

Patient died during this admission (please go toquestion 101)

Other

K. DISCHARGE

Were further investigations or treatmentsconcerning the patients AP planned for asubsequent appointment?

100a. UnknownYes No

If Yes, what?100b.

In your opinion should the patient have undergoneany further investigations, in addition to anydetailed in 100a, regarding their AP?

100c. UnknownYes No

If Yes, whatand why?

100d.

Was the patient discharged on nutritional support?99a. UnknownYes No

If Yes, what nutritional support was given?99b.

Enteral feeding Oral supplementsParenteral feeding

(please specify)

1 099388 70904829

What was the cause of death recorded?103.

1a

1b

1c

2

Was this case reported to the coroner?104. UnknownYes No

Please return a copy of the coroners report if available

Was a hospital or coronial autopsy performed?105. UnknownYes No

Was death anticipated?101a. UnknownYes No

Was treatment limited or withdrawn?101b. UnknownYes No

Was CPR attempted?101d. Yes No

What level ward was the patient on when they died?102.

Level 3Level 0 Level 1 Level 2 Unknown

What was the patient's resuscitation status?101c. For resuscitation

Not for resuscitation Unknown

Not considered

Please see definitions on pg 2

Was the death discussed in a M & M meeting?106a. UnknownYes No

Please answer the following questions if the patient died during this admission

Please return a copy of the autopsy report if available

If Yes were remediable factors in the care of thispatient identifed?

106b. UnknownYes No

If Yes what action was taken?106c.

If the patient was not discussed at a M & Mmeeting, having now reviewed the case, in youropinion are there lessons to be learned?

107a.

Unknown

Yes No

If Yes, please describe these107b.

N/A

Thank you for taking the time to complete this questionnaire

Unknown

6 099388 709081

NCEPOD

Ground Floor, Abbey House

74 - 76 St John Street

London

EC1M 4DZ

Funding for this study was provided by The Healthcare Quality Improvement Partnership (HQIP) as part ofThe Clinical Outcome Review Programme into medical and surgical care.