The UK NHS Emergency Laparotomy Network Data Collection Form
Age………… Sex: M F Hospital Number…. ……….
ASA: 1 2 3 4 5 (age >80 is ASA 2)
Date of admission: dd/mm/yyy ……../……../…….
Admitting speciality: General Surgery Orthopaedics Medicine Psychiatry
Gynae Urology Vascular Other…………(specify)
Date/time booked for theatre: dd/mm/yyyy ……../……../……. hh:mm ……/…….
NCEPOD classification: Immediate Urgent Expedited
Date/time for start of anaesthesia: dd/mm/yyyy ……../……../……. hh:mm ……/……..
Grade of most senior surgeon present in theatre whether operating or supervising:
Consultant Post-CCT Fellow SAS Grade Research Fellow
Clinical Fellow Speciality trainee/Registrar Core trainee/SHO Other…….
Specialist interest of most senior surgeon present in theatre (operating or supervising)
Colorectal Upper-GI Hepatobiliary Breast/Endocrine Vascular General Trainee
Grade of most senior anaesthetist present in theatre (delivering care or supervising)
Consultant Post-CCT Fellow SAS Grade Research Fellow
Clinical Fellow Speciality trainee/Registrar Core trainee/SHO Other…….
Goal directed fluid therapy: (eg Doppler, Lidco etc) Y N
Operation performed: must include anatomical site.
(Descriptions such as “large bowel”, “anterior resection”, “GI perforation” are insufficient.)
Primary (main) ……………………………………….…………………….…………………….
Secondary ……………………………………..Other procedures…………………….…………
Underlying pathology: Ulcerative Colitis Crohn’s Diverticular Mass
Malignancy Strangulated/incarcerated hernia Perforation Adhesions
Ischaemic bowel Obstruction Other……………………………… (specify)
Surgery a complication of surgery in last 30 days? Y N
Required level of post-op care following surgery Level 3 (ICU) Level 2 (HDU)
Level 1 (Ward) PACU
Actual level of post-op care following surgery: Level 3 (ICU) Level 2 (HDU)
Level 1 (Ward) PACU
Level 3 length of stay (round up to whole days) …………….
(8 hours = 0, 12hrs = 1 day. 36hrs = 2 days etc)
Level 2 length of stay (round up to whole days) ……………..
(8 hours = 0, 12hrs = 1 day. 36hrs = 2 days etc)
Date of discharge: dd/mm/yyy ……../……../…….
Survives 30 days post-op: Y N
Date of death: dd/mm/yyy ……../……../…….
……………………………………………………………………………………………………………
NOTES
ASA: ASA 2 defined as “Systemic disturbance caused either by the condition to be treated surgically or by other pathophysiological processes”
NCEPOD classification:
§ IMMEDIATE – Immediate life, limb or organ-saving intervention – resuscitation simultaneous with intervention. Normally within minutes of decision to operate.
§ URGENT – Intervention for acute onset or clinical deterioration of potentially life-threatening conditions. Normally within hours of decision to operate.
§ EXPEDITED – Patient requiring early treatment where the condition is not an immediate threat to life, limb or organ survival. Normally within days of decision to operate.
Required/actual level of post-op care following surgery:
If a patient spends a period (of hours) in recovery while efforts are made to facilitate admission to HDU/ICU and this eventually occurs, post-operative care is Level 2 or 3 as appropriate.
If the patient remains in recovery because of lack of Level 2/3 beds and is then transferred to the ward, post-operative care is “Ward”.
If the unit has designated Level 2/3 beds in recovery or has a designated PACU, record Level 2/3 or PACU.
Level 3/2 length of stay: round up to whole days if equal or greater than 12 hrs, round down if less than 12hrs., ie 8 hours in ICU counts as 0 days. 13hrs is one day, 35hrs is one day.
Date of discharge: If patient dies in hospital, date of death will be same as date of discharge.
Date of death: dd/mm/yyyy. If patient dies following discharge, but within 30 days of surgery, then insert date of death. Do not follow up beyond 30 days if already discharged from hospital. If patient dies in hospital, then date of death will be same as date of discharge. Follow up occurs until discharge or 30 days, whichever is later.
Updated 6-10-2010