Form #7 Postoperative wound dehiscence abstraction tool

Form Approved

OMB No. 0935-0124

Exp. Date XX/XX/20XX

Public reporting burden for this collection of information is estimated to average 60 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Form Approved: OMB Number 0935-0124  Exp. Date xx/xx/20xx. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0124) AHRQ, 540 Gather Road, Room #5036, Rockville, MD 20850.

Section 1: Pre-programmed section

1.1 Date abstraction completed

_ _ / _ _ /_ _ _ _

1.2 Abstractor identification number

_ _ _ _ _ _ _ _ _

Section 2: Record identification/validation

2.1 AHRQ Study identification number

_ _ _ _ _ - _ _ _ _

2 Medical record number/Patient control number

_ _ _ _ _ _ _ _ _

2.3 Date of birth

_ _ / _ _ / _ _ _ _

2.4 Gender

• Male

• Female

2.5 Date of admission

_ _ / _ _ / _ _ _ _

6. Date of discharge

_ _ / _ _ / _ _ _ _

Section 3: Ascertainment of Event(s)

3.1 Did the patient undergo an operation involving the abdomen or pelvis?

1. Yes

2. No

3. Critical documentation missing

If Q3.1= NO, explain the reason why this chart was most likely flagged for review in the TEXT BOX provided and END the abstraction.

3.2 Was pregnancy or a condition related to pregnancy the patient’s primary admitting diagnosis?

• Yes

• No

If Q3.2=Yes, explain the reason why this chart was most likely flagged for review in the TEXT BOX provided and END the abstraction.

3. Did the patient have a wound dehiscence that occurred during this hospitalization?

• Yes

• No

If Q3.3=No, explain the reason why this chart was most likely flagged for review in the TEXT BOX provided and END the abstraction.

3.4 Did the patient have any of the following immunosuppressive conditions on admission? Select all that apply.

.

	yes	no
HIV/AIDS
Severe malnutrition – (e.g., Kwashiorkor or nutritional marasmus )
Chronic kidney disease (e.g., end stage renal failure)
Immunoglobulin deficiency – (e.g. selective IG deficiency)
Transplant- any “ major” organ transplantation and complications
Other immunodeficiency specified in appendix? of the PSI Technical Specifications–(e.g., Digeorges syndrome, Nezelofs syndrome or Wiscott-Aldrich syndrome)

If the patient had any of the above immunosuppressive conditions, briefly explain why the chart was most likely flagged for review in the TEXT BOX provided below and then END the abstraction.

Section 4: Risk Factors

4.1 Did the patient have any of the following conditions as listed below at the time of admission? Select all that apply.

	yes	no
Sickle cell disease
Short gut syndrome
Systemic steroids on admission

If answered YES to systemic steroids on admission state the indication in the TEXT BOX below.

4.2 Height on admission:

[_ _ _ ._ _](cm) or [_ _] ft {[ _ ] inches

4.3 Weight on admission:

[_ _ _ ._ _](kg) or [_ _ _ ._ _ ] pounds(lbs)

Section 5: Evaluation and Treatment

5.1 How many operations involving the abdomen or pelvis occurred during this hospital stay?

• 1

• 2

• 3

• 4

• 5

• More than 5

For each separate visit to the operating room photocopy pages 4- 7, answer Q 5.2- 5.12 Do only the MOST significant procedures that were performed in that particular trip to the operating room.

For each visit to the operating room complete pages 4-7 (Q5.2—5.12).

Visit# __

5.2 Specify the date and time of the procedure:

Date: _ _ / _ _ /_ _ _ _ Time: _ _ : _ _

5.3 State the primary procedure names(s) and associated ICD-9CM codes(s):

ICD-9-CM code -	Look-up box for procedure names
1.	1.
2.	2.
3.	3.
4.	4.
5.	5.

5.4 Using physician notes or operative notes, describe the indication for the procedure.

5.5 Indicate the type of incision used:

4. Extension of previous incision

5. Local right lower quadrant (e.g., McBurney or Rocky-Davis)

6. Midline vertical (partial or full extent)

7. Oblique flank (e.g., retroperitoneal approach)

8. Oblique iliac fossa (e.g., kidney transplant approach)

9. Paramedian vertical

10. Transverse subcostal

11. Transverse (rectus-transecting)

12. Transverse (rectus-sparing) (e.g.,Pfannenstiel)

13. No incision

14. Critical documentation missing

15. Other – describe in the text box below:

5.6 Did the procedure involve repair of a defect (or hole) in the abdominal wall fascia that existed prior to this procedure?

16. Yes → Answer Q5.7

17. No → SKIP to Q5.8

18. Critical documentation missing → SKIP to Q5.8

For each visit to the operating room complete pages 4-7 (Q5.2—5.12)

Visit# __

For patients that had a procedure that involved repair of defect or hole in the abdominal wall fascia, continue with questions 5.7, otherwise skip to Q5.8.

5.7a On what date was this defect in the abdominal wall fascia first identified?

_ _ /_ _ /_ _ _ _

5.7b Using the operative note, describe the dimensions and nature of the defect in the fascia in the text box provided.

5.7c Was the defect in the fascia associated with evisceration of the abdominal contents prior to this procedure?

• Yes

• No

• Critical documentation missing

5.7d Using the physicians’ notes and operative notes, indicate all factors associated with the defect in the fascia. Check all that apply.

Yes = documentation indicated by the surgeon that this occurred

No = documentation indicated by the surgeon that this did not occur

Documentation insufficient = documentation insufficient to determine whether this occurred.

	Yes	No	Documentation insufficient
Breakage of suture material
Unraveling of a tied suture
Tearing of the fascia with necrosis of the fascia
Tearing of the fascia without necrosis of the fascia
Unintentional failure to close a defect in the fascia
Intentional failure to close a defect in the fascia
Infection of the abdominal or pelvic cavity or wall
Other factors related to fascial defect (describe in text box below ).

For each visit to the operating room complete pages 4-7 (Q5.2—5.12)

Visit# __

Other factors:

5.8 Did the procedure involve repair of a defect (or hole) in the abdominal skin that existed prior to this procedure?

• Yes → answer Q3.13

• No → continue with Q3.14

• Critical documentation missing →continue with Q3.14

If “Yes” to Q5.8, answer Q5.9, otherwise continue with Q5.10.

5.9a On what date was this defect in the abdominal skin first identified?

_ _ / _ _ /_ _ _ _

5.9b Did the operation involve a skin graft?

• Yes

• No

• Critical documentation missing

5.9c Was any portion of the FASCIA closed with sutures during this visit to the operating room?

• Yes → answer Q3.15

• No → answer Q3.16

• Critical documentation missing → answer Q3.16

If “Yes” to Q3.14, answer Q3.15; otherwise continue with Q3.16.

5.10a What suture size was used to close the fascia of the abdomen or pelvis? Suture size is listed from larger to smaller size in descending order. Check all that apply.

• #2

• #1

• 0

• 1.0

• 2.0

• 3.0

• Other (describe) ______________________________________

For each visit to the operating room complete pages 4-7 (Q3.6-3.16)

Visit# __

• Not specified

5.10b What was the primary suture type used to close the FASCIA of the abdomen or pelvis?

• Silk

• Vicryl

• Polysorb

• Dexon

• PDS

• Maxon

• Prolene

• Surgipro

• Tevdek

• Surgidac

• TiCron

• Other (describe)

• Not specified

If more than one suture type was used to close the FASCIA of the abdomen or pelvis, describe the other suture type(s) in the textbox below.

2^nd suture type:

3^nd suture size:

5.10c Was the entire fascial defect closed during this visit to the operating room?

• Yes

• No

• Critical documentation missing

5.11 Were retention sutures placed during this visit to the operating room?

• Yes

• No

• Critical documentation missing

Section 6: Outcomes

6.1 Did evisceration of abdominal contents occur during this hospitalization?

• Yes

• No

• Critical documentation missing

6.2 Was an abdominal or pelvic fascial defect or hernia left unrepaired during this hospitalization?

• Yes

• No

• Critical documentation missing

6.3 Does the medical record suggest that the patient suffered any adverse effects or consequences from disruption of fascia that was closed during an abdominal or pelvic operation? Check all that apply.

• Extended length of hospital stay

• Infection

• Residual disability or impairment of normal function (at discharge)

• Readmission within 30 days

• Death

• None or not specified

6.4 If there are special circumstances or comments related to this case that you feel are important that were not captured in the survey, please state in the TEXT BOX [Limit 200 characters].

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