Download ER Data Definitions (January 2011)

Enhanced Recovery: Data definitions for data
recorded on the Partnership Programme’s
ERP Tool (January 2011)
(changes are shown in red from previous definitions document in Sept 2010)
The toolkit supports trusts to collect a range of data to measure the
implementation of enhanced recovery. The innovation sites have focussed on
recording the fields listed in the XXX sections below, but many sites also
collect some or all of the additional data to record risk adjusters, Postoperative Morbidity Score and POSSUM may also be recorded. The fields are
listed below:
Data Field
DEMOGRAPHICS
Audit Number
Definition
Was the operation
commenced
laparoscopically?
In order to simplify the data collection the toolkit asks
whether the operation was started laparoscopically.
This includes both total laparoscopic and
laparoscopically assisted procedures
Select from “Yes”, “No”, “Not Applicable”.
This should be selected from the list of diagnoses
It is important that the audit number is not
identifiable. For example NHS Number or Hospital
case-note number should not be used. A patient ID
generator is available on the front page of the ERP
Tool (before you login) to generate a suitable audit ID
https://www.natcansatmicrosite.net/enhancedrecover
y/Default.aspx
Date of Birth
Record in format dd/mm/yyyy (note: all dates can be
selected from a calendar)
Gender
Select either Male or Female
Note: These three data fields are the minimum data required in order to save
a new record on the toolkit
ADMISSION
Operation Group
Some trusts may find it easier to record operation at
this grouped level rather than at the “Type of
operation” level. Note that this field will be
automatically populated if “Type of Operation” is
completed.
The operation group should be selected from the
drop down list.
Type of Operation
This should be selected from the list of operations
Diagnosis (ICD10
code)
Did the patient have a
stoma?
This field records patients that have either a
colostomy or an ileostomy. This is only available for
1
colorectal patients.
Select from “Yes”, “No”
Date of Admission
Record in format dd/mm/yyyy
Date of Operation
Record in format dd/mm/yyyy
Date of Discharge
Record in format dd/mm/yyyy
ITU Bed Days Used
This is the difference in days between the date a
patient is admitted onto ITU and the date the patient
leaves ITU plus 1 (e.g. If admitted onto ITU on
23/06/2010 and left on 25/06/2010 the number of bed
days used is 3)
HDU Bed Days Used This is the difference in days between the date a
patient is admitted onto HDU and the date the patient
leaves HDU plus 1 (e.g. If admitted onto HDU on
23/06/2010 and left on 25/06/2010 the number of bed
days used is 3)
PATIENT EXPERIENCE
Is patient experience Click check box if patient experience is measured.
measured?
Leave blank if patient experience not measured
Which method of
If patient experience is measured identify which
measuring patient
method is used.
experience is used?
 Questionnaire (local or national template)
 Patient/carer diary
 Patient discussion groups
 Other (please describe in free text box)
The patient experience questions used in the ER toolkit (given below)
are taken from the 2010 NHS Inpatient Survey. For this survey patients are
sent the full questionnaire for completion after they have been discharged
from hospital. Hence for consistency, these questions should if possible be
answered by the patient after they have been discharged from the hospital.
Were you involved as
much as you wanted to
be in decisions about
your care and
treatment?
How much information
about your condition or
treatment was given to
you?
Did you feel you were
involved in decisions
about your discharge
from hospital?
Did hospital staff tell
you who to contact if
you were worried about
your condition or
treatment after you left
Select from “Yes, definitely”, “Yes, to some extent” and
“No”
Select from “Not enough”, ”The right amount”, “Too
much”
Select from “Yes, definitely”, “Yes, to some extent”,
“No”, “I did not need to be involved”
Select from “Yes”, “No”, “Don’t know / Can’t remember”
2
hospital?
READMISSSION / REOPERATION
Readmission within 28 This field identifies if the patient admitted as an
days (6 weeks for
emergency for any reason within 28 days of
MSK)?
discharge (42 days for MSK)
Select Yes, No or Don’t Know
Note: Hospital trusts routinely collect this information
and so it should be available from the trust
information department
Date of readmission
Record in format dd/mm/yyyy
Date of discharge
Record in format dd/mm/yyyy
from readmission
Re-operation within 28 This field identifies if the patient has a re-operation
days (6 weeks for
within 28 days of initial operation (42 days for MSK).
MSK)?
This may involve surgery at the same site, or at
another site for same condition or to repair a feature
from previous surgery.
Select Yes, No or Don’t Know
DEATH
Death Status
Select either Alive or Dead
Date of Death
Where patient has died record in format dd/mm/yyyy
COMPLIANCE WITH ENHANCED RECOVERY PATHWAY
Pre-operative visit?
Record “ yes” if the patient visits the preadmission
clinic in order to be informed about ER care
- providing both verbal and written information - in
order to condition expectations at and after surgery.
This process can be conducted by telephone but that
also should be accompanied by written information'
Patient assessed as fit Record “yes” if patient attends a preassessment
for surgery
clinic to ensure optimal physical preparation for
surgery and is assessed as fit for surgery. This can
occur at a preadmission clinic attendance'
Patient given written
Record “Yes” if the patient is given written and verbal
and verbal
explanation of ER pathway and related care and
explanation of ER
their role in their recovery
pathway
Preoperative stoma
Record “Yes” if the patient attends a stoma care
education until
appointment and within this appointment stoma
considered competent education is commenced with the expectation that
the patient is supported to be competent with this
skill prior to surgery.
Preoperative therapy
Record “Yes” if the patient had preoperative therapy
education eg
education/preparation (can only be recorded on ER
physiotherapy /OT
toolkit for MSK patients)
Oral bowel
Record “Yes” if oral bowel preparation (e.g. picolax)
3
preparation avoided
Patient admitted on
day of surgery
Carbohydrate drinks
given preoperatively
Avoidance of long
acting sedative premedication
Administration of
appropriate antibiotics
prior to skin incision
Epidural or regional
analgesia used
Individualised goal
directed fluid therapy
Hypothermia
prevention (intraoperative warming)
Avoidance of post
operative crystalloid
overload
Avoidance of systemic
opiates used
postoperatively
Early post operative
nutrition / solid food
intake
Targeted
individualised nausea
is not taken the day before surgery to evacuate
bowel contents. (Note that bowel prep may be used
prior to an anterior resection which includes TME
(total mesorectal excision) (for colorectal patients
only)
Most patients are suitable to be admitted on the day
of surgery;
Record “Yes” if patient admitted on day of surgery
maltodextran drinks given 12 hours prior to surgery
and up to two hours before going to the operating
theatre provided gastric emptying is not impaired.
Record “Yes” if long acting pre- medication drug such
as a temezepam / diazepam has not been given
within 24 hours of surgery
Definition within 60 minutes of knife to skin as per the
WHO/NPSA safer surgery checklist (for colorectal
patients only)
Epidural or regional analgesia used to provide
adequate analgesia in the immediate postoperative
period and to allow mobilisation (Note there is not a
consensus about whether epidurals are necessary in
laparoscopic surgery)
To prevent overloading with intravenous fluids during
surgery; this may be achieved by use of an
oesophageal Doppler or other advanced
haemodynamic monitor. Must be individualised for
each patient and administered to achieve specific
haemodynamic targets.
Patient temperature 36.0-37.5 Centigrade throughout
the operation (will usually involve using active
warming measures such as forced air warming and
fluid warmers).
Intravenous crystalloid infusion discontinued on first
postoperative day (day 1).
Analgesia that ideally does not include opiates is
recommended to prevent complications such as
constipation.
Record “yes” if no oral, intramuscular or intravenous
opiates used postoperatively.
Patients are encouraged to eat and drink on day 0
(the operating day) after surgery, as tolerated, and
this to continue subsequently. To provide further
nutrition in the immediate post-operative period,
nutritious supplement drinks are encouraged daily.
Managing the patient’s nausea and vomiting to
enable them to eat and drink as soon as appropriate
4
and vomiting control
Mobilisation within 24
hours
The avoidance of
abdominal drains
except following TME
NG Tube removed
before exit from
theatre
post operatively.
Record “yes” if prophylaxis for PONV (Postoperative
nausea and Vomiting) given during surgery and
antiemetics if nauseous postoperatively, as per
agreed written protocol.
Record “Yes” only if the patient is able to mobilise
within 24hrs. For orthopaedic patients this must be
weight bearing mobilisation.
Routine use of drains has not been shown to reduce
complications and can actually cause problems
except following total mesorectal excision. (for
colorectal patients only)
Definition not required (not applicable for MSK
patients)
Additional Fields
Additional data fields to record risk adjusters, Post-operative Morbidity Score
and POSSUM may also be recorded. These are listed below:
Data Field
Times, type of re-operation
Time of Admission
Time of Operation
Time of Discharge
Type of re-operation
Comment
Record in format hh:mm
Record in format hh:mm
Record in format hh:mm
This should be selected from the list of
operations
RISK ADJUSTERS
ASA Grade
History of Insulin Dependent
Treated with insulin before surgery.
Diabetes Melitus
History of Ischaemic Heart Disease History from the patient, family or
documentation in medical records of
angina, myocardial infarction or non-ST
elevated myocardial infarction.
History of CVA or TIA
History from the patient, family or
documentation in medical records of a
cerebrovascular accident or a transient
ischaemic attack.
History of LVF or CCF
History from the patient, family or
documentation in medical records of left
ventricular failure or congestive cardiac
failure.
5
History of COPD
Pre operative serum creatanine
Pre operative haemoglobin level
Post-operative Morbidity Score
Pulmonary (present on day 8)
Infectious (present on day 8)
Renal (present on day 8)
GI (present on day 8)
CVS (present on day 8)
Neurological (present on day 8)
Wound (present on day 8)
Haematological Requirement
(present on day 8)
Pain (present on day 8)
POSSUM
Morbidity Risk
POSSUM (Mortality) Risk
P-POSSUM (Mortality) Risk
History from the patient, family or
documentation in medical records of a
chronic obstructive pulmonary disease or
chronic obstructive airway disease.
The most recently measured serum
Creatanine (mol) before surgery.
Record the most recently measured
haemoglobin level (g/dl) before surgery
De novo requirement for supplemental
oxygen or other respiratory support (e.g.,
mechanical ventilation or CPAP)
Currently on antibiotics or temperature
38 °C in the last 24 h
Presence of oliguria (500 mL/d),
increased serum creatinine (30% from
preoperatively), or urinary catheter in
place for a nonsurgical reason
Unable to tolerate an enteral diet (either
by mouth or via a feeding tube) for any
reason, including nausea, vomiting, and
abdominal distention
Diagnostic tests or therapy within the last
24 h for any of the following: de novo
myocardial infarction or ischemia,
hypotension (requiring pharmacological
therapy or fluid therapy ??200 mL/h),
atrial or ventricular arrhythmias, or
cardiogenic pulmonary edema
Presence of a de novo focal deficit,
coma, or confusion/delirium
Wound dehiscence requiring surgical
exploration or drainage of pus from the
operation wound with or without isolation
of organisms
erythrocytes, platelets, fresh-frozen
plasma, or cryoprecipitate
Surgical wound pain significant enough
to require parenteral opioids or regional
analgesia
Possum calculator is available at:
http://www.surgicalaudit.com/riskcalc.asp
-
6
7