6 448224 0017191 of 3
4.
PERI-OPERATIVE CARE
National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
Clinical form to be completed by an anaesthetist
Date of birth
5. Gender
7. ASA class 1 2 3 4 5 8a. Weight
(kg)
8b. Actual Estimated
Male Female
9a. Height
(cm)
9b. Actual Estimated
6. Ethnicity (for
calculating eGFR)
Black Other
10a. Was the patient assessed
in a pre-admission clinic?
Yes No Unknown
10b. If YES, was this: within 4 weeks of surgery 4 weeks or more prior to surgery Unknown
11. Specific
co-morbidities
arrhythmia cancer documented cirrhosis
congestive cardiac failure
- see definitions
current smoker
diabetes
(insulin)
diabetes
(non insulin)
ischaemic
heart disease -
see definitions
13. Please state the last known values within 2 weeks of surgery for the following:
13a. Creatinine
(mmol/ml)
13b. Haemoglobin
(g/dl)
.
14. Start time and date of anaesthetic
h h m m
15. Anaesthetic technique - please select all that apply: General Spinal/epidural Combined
16a.
Arterial
catheter?
Yes No 16b. CVC? Yes No 16c. Cardiac output monitoring? Yes No
17. Urgency of surgery (see DEFINITIONS) Immediate Urgent Expedited Elective
Hospital number of patient (or if not
applicable, A&E number)
NHS number (10 digits)
Date of hospital admission
0 3 1 0
1.
2.
3.
d d m m y y
d d m m y y
d d m m y y
PLEASE TURN OVER TO COMPLETE THE REMAINING QUESTIONS
Not done Unknown Not done Unknown
20a. Laparoscopic? Yes No 20b. Laparoscopic converted surgery? - see definitions Yes No
19. Procedure performed
respiratory disease prior TIA/stroke
18. Post op planning
(see definitions)
Recovery
to ward
(level 0/1)
Recovery
to HDU
(level 2)
Recovery
to ICU
(level 3)
- please do NOT
detail further
Straight to
HDU (level 2)
Straight to
ICU (level 3)
18a. Intention before surgery
Other
12. Do you consider this patient to be a high risk patient? Yes No
22a. Gut resection? Yes No 22b. If YES, primary anastomosis? Yes No
23. Intra-operative
estimated blood loss
<100ml 100 to <500ml 500 to <1000ml 1000ml
21a. Intra-abdominal? Yes No 21b. Intra-thoracic? Yes No
SITE NAME
TRUST NAME2 448224 001676
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28a. Time/date/day
into recovery
0 3Time: Date:
28b. Time/date/day
out of recovery
0 3 1 0Time: Date:
28c. First location after recovery (see definitions) Ward (level 0/1) HDU (level 2) ICU (level 3)
27.
If there are any points re the pre-operative assessment, intra-operative or post operative care of this patient or their
procedure that you would like to highlight for our clinical advisors, or anything else you would like to add, please do so here:
Thank you for contributing to this study!
d d m m y y
1 0
h h m m
ANAESTHETIST TO ASK RECOVERY STAFF TO COMPLETE Q28, AND RETRIEVE THEREAFTER
NCEPOD NUMBER
SITE NUMBER
DATE RECEIVED
25a. Actual discharge after surgery
26a. Was the actual discharge location ideal? Yes No
26b. If NO, please specify why not:
25. Post op planning
(see definitions)
Recovery
to ward
(level 0/1)
Recovery
to HDU
(level 2)
Recovery
to ICU
(level 3)
Straight to
HDU (level 2)
Straight to
ICU (level 3)
Other
24a. Was a surgical checklist used during this procedure? Yes No
24b. If YES to 24a Original WHO checklist Modified WHO checklist Other0 448224 003542
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I healthy
II mild systemic, no limitations
III severe systemic, limitations
IV severe systemic, threat to life
V moribund, not expected to survive
Immediate – immediate life, limb or organ-saving intervention – resuscitation simultaneous with intervention.
Normally within minutes of decision to operate. A) Life-saving B) Other e.g. limb or organ saving.
Urgent – intervention for acute onset or clinical deterioration of potentially life-threatening conditions, for those
conditions that may threaten the survival of limb or organ, for fixation of many fractures and for relief of pain or
other distressing symptoms. 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.
Elective – intervention planned or booked in advance of routine admission to hospital. Timing to suit patient,
hospital and staff.
ASA CLASS:
URGENCY OF SURGERY:
Level 0: Patients whose needs can be met through normal ward care in an acute hospital.
Level 1: Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care
whose needs can be met on an acute ward with additional advice and support from the critical care team.
Level 2: (e.g. HDU) Patients requiring more detailed observation or intervention including support for a single
failing organ system or post operative care, and those stepping down from higher levels of care. (NB: When
Basic Respiratory and Basic Cardiovascular support are provided at the same time during the same critical care
spell and no other organ support is required, the care is considered to be Level 2 care).
Level 3: (e.g. ICU) Patients requiring advanced respiratory support alone or basic respiratory support together
with support of at least two organs. This level includes all complex patients requiring support for multi-organ
failure. (NB: Basic Respiratory and Basic Cardiovascular do not count as 2 organs if they occur simultaneously
(see above under Level 2 care), but will count as Level 3 if another organ is supported at the same time).
LEVEL OF CARE:
Cerebrovascular disease
Cerebrovascular disease is defined as a history of transient ischemic attack or stroke.
Congestive heart failure
Congestive heart failure was defined by the presence of any of the following: history of congestive heart failure,
pulmonary edema, or paroxysmal nocturnal dyspnea; physical examination showing bilateral rales or S3 gallop;
or chest radiograph showing pulmonary vascular redistribution.
Ischaemic heart disease
Ischaemic heart disease includes any of the following: history of myocardial infarction, history of a positive
exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use of nitrate
therapy, or ECG with pathological Q waves. Patients with prior coronary revascularization procedures are
categorized as having ischaemic heart disease only if they had any of the other criteria for ischaemic heart
disease listed above.
Laparoscopic converted surgery
An incision is made larger than that simply needed to extract the specimen.
CO-MORBIDITIES AND LAPAROSCOPIC CONVERTED SURGERY: