National
Emergency Laparotomy
Audit
Prospective Audit Dataset
Version Control
Version
1
Date
0.4
0.5
0.6
07/11/2013
07/11/2013
11/11/13
0.7
0.8
0.9
0.10
22/11/13
05/12/13
31/01/14
28/2/14
Changes
MC - Changes post team meeting
JL – corrections to 1.3/1.4, 2.8, 5.2
DM/JL – Process numbers changed / Type column
removed
Q2.3 – wording amended
Q3.2 – 1st option text changed
Q5.3a,c,d options updated
Q3.10&6.8 range changed/Q7.6 options updated
0.11
2
7/4/14
Text after 3.5 & 6.3 changed / Wording of 3.18 &
6.16 changed / Options added for 3.22 & 6.20 /
Option added for 5.6 / 6.12 can now be amended
Dataset definitions
Master Patient Index
All items are mandatory (with the provision of “data unavailable” response where appropriate).
Type indicates whether the item is held locally (L), or nationally (N), or both (B).
Purpose: rationale for collection of that data item. PM/OM refers to the relevant process measure or outcome measure.
Value resp: indicates whether the field can take single (S) or multi (M) values.
ISB = Information Standards Board
Field IDs
D = Demographics - Section 1
A = Admission – Section 1 (cont.)
Pre = Pre-op – Section 2
PreR = Pre-op Risk stratification – Section 3
IN = Intra-op – Section 4
PRO = Procedure – Section 5
PoR = Post-op Risk stratification – Section 6
PO = Post-op – Section 7
Field
ID
D1
1.1
Data item
Question wording
Field name
Description
Purpose
NHS number
NHS number
NHSnumber
Captures
NHS/CHI
number
D2
1.2
Pseudoanonymisation
Pseudoanonymisation
Pseudo-anon
unique
database
identifier
Used for
unique
identification
to match
records from
different
service
providers
For exporting
data and
linkage
3
Format /
Options
10 digit
number
Source of
definition
NHS Data
Dictionary
ISB
Value
Resp.
S
Validation
Rules
(PID field)
Check for
duplicate
with
Admission
date
S
Automatically
generated by
the system
(PID field)
Notes
Check
structure
NI, WAL,
SCO
Field
ID
D3
1.3
Data item
Question wording
Field name
Description
Purpose
Local patient
id/hospital number
Local patient
id/hospital number
LOPATID
Local patient
ID
For monitoring
of unit data at
local level
D4
1.4
Date of birth
Date of birth
DOB
Date of birth
For calculating
age at surgery
stratification
and case-mix
adjustment,
and linkage
PM15
1.4
Age on arrival
Age on arrival
AgeOnArrival
D5
1.5
Sex
Sex
Sex
D6
1.6
Forename
Forename
Forename
D7
1.7
Surname
Surname
Surname
D8
1.8
PostcodeOut and
PostcodeIn
Postcode
4
Age on
arrival
Patient sex
The
forename or
given name
of a person.
Surname,
used to
describe
family, clan,
tribal group,
or marital
association.
To display for
no PID
For
stratification
and case-mix
adjustment,
and linkage
Used to aid
local
management
of records.
Used to aid
local
management
of records.
Geographical
stratification,
allocation of
deprivation
index and
record linkage
Format /
Options
10 digit
text
Source of
definition
e-GIF
format
‘CCYYMM-DD’
NHS Data
Dictionary
ISB
Value
Resp.
S
S
S
Validation
Rules
(PID field)
Check for
duplicate
with
Admission
date
Cannot be
less than 18
at time of
admission
(give or take
two weeks!)
(PID field)
Automatically
generated
Notes
Not
exported
1 = Male
2=
Female
NHS Data
Dictionary
ISB
S
Text
ISB
S
(PID field)
Not
exported
Text
ISB
S
Not
exported
4+3
character,
alphanumeric
field
NHS Data
Dictionary
S
(PID field)
Check for
duplicate
with DOB
and
admission
date
(Postcode
inner - PID
field)
UK only
5.2. Procedure dataset
PREOPERATIVE VALUES
Field ID Data item
Question
Wording
Field
name
A1
1.9
Admission
date
Adm_da
te
A2
1.9
Admission
time
A3
1.10
Admission
Type
Start of
section
2
If the patient is returning to theatre as an
emergency following previous elective surgery, all
answers should relate to the emergency
laparotomy, not the previous elective surgery
Date first
Date and time
Date_1s
seen by
first seen by
tsurg
consultant
consultant
surgeon
surgeon
following
following
admission/r admission/referr
eferral
al
Time first
Time_1s
seen by
tsurg
consultant
surgeon
following
admission/r
eferral
PRE1
2.1
PRE2
2.1
5
Date and time
patient admitted
to this hospital
Description
Adm_ti
me
What was the
nature of this
admission?
Adm_ty
pe
Purpose
Format / Options
For analysis of
timescales of
care
e-GIF format ‘CCYY-MMDD’
PM1
PM2
PM6
Understanding
of patient
pathway
Source
of
definitio
n
ISB
Value
Resp.
Validation
Rules
S
Cannot be
future date
HH:MM (24 hour clock)
ISB
S
Cannot be
future time
1= Elective
2=Non-elective
N/A
S
Notes
PM1
Text to appear
on screen
Standard:
patients
should be
reviewed by a
senior surgeon
according to
clinical
urgency
(within 12
hours of
admission)
PM1
e-GIF format ‘CCYY-MMDD’
Date not known
Not seen
S
≥A1/A2
Must be
equal to or
after
admission
(1.9)
HH:MM (24 hour clock)
Time not known
S
≥A1/A2
Must be
equal to or
after
admission
(1.9)
if some
patients
have
poor
outcom
e, it
might
be due
to late
r/v by
cons
followin
g
admissi
on
Field ID
Data item
Question
Wording
Field
name
PRE3
2.2
Date
decision
taken to
operate
Date and time
decision taken
to operate
Date_de
cop
PRE4
2.2
Time
decision
taken to
operate
A5
2.3
Responsibl
e
Consultant
Name
A6
2.3
Responsibl
e
Consultant
GMC
number
6
Description
Timedecop
Consultant
responsible for
surgical care at
the time the
decision was
made to operate
(this may be
different to the
operating
consultant)"
Resp_c
ons
Name of
Consultant
with
responsibility
for patient
Resp
_consG
MC
GMC number
of Consultant
with
responsibility
for patient
Purpose
Format / Options
For analysis of
timescales of
care, including
whether there
are delays to
surgery, and
analysis of
timescales
according to
clinical
urgency
PM5
For local
reporting
Value
Resp.
Validation
Rules
e-GIF format ‘CCYY-MMDD’
Date not known
S
HH:MM (24 hour clock)
Time not known
S
≥A1/A2
Must be
equal to or
after
admission
(1.9)
≥A1/A2
Must be
equal to or
after
admission
(1.9)
Populated from look-up
file created by local
administrator
7-digit numerical
Source
of
definitio
n
GMC
number
prepopulate
d when
surgeon
s
register
ed on
databas
e
S
S
Possibly in
the wrong
location
(08/10/13)
Notes
User
will
select
name
from
dropdo
wn –
will
have
GMC
automa
tically
associa
ted with
it
Field ID
Data item
Question
Wording
PRE5
2.4
Grade of
most senior
person
making
decision to
operate
What was the
grade of the
most senior
person making
the decision to
operate?
PRE6
2.5
Patient
reviewed in
person by
the senior
clinician
making
decision to
operate
Date
booked for
theatre
Did this clinician
personally
review the
patient at the
time of this
decision?
PRE7
2.6
PRE8
2.6
7
Time
booked for
theatre
What was the
date and time
that the patient
was first booked
for theatre?
Field
name
Description
Purpose
Format / Options
Standard:
Consultant
surgeon
should have
direct input
into high risk
patients, as
defined by
NCEPOD
urgency or
formal risk
assessments
1 = Consultant
2 = Post-CCT nonconsultant
3 = SAS grade
4 = Research Fellow /
Clinical Fellow
5 = Specialty trainee /
registrar
6 = Core trainee / SHO
9 = Other
Unknown?
0 = No
1 = Yes
9 = Unknown
S
e-GIF format ‘CCYY-MMDD’
Date not known
S
HH:MM (24 hour clock)
Time not known
S
PM3
Date_bo
oked
Time_b
ooked
For analysis of
timescales of
care, including
whether there
are delays to
surgery, and
analysis of
timescales
according to
clinical
urgency
Source
of
definitio
n
Value
Resp.
Validation
Rules
S
≥A1/A2
≥PRE3/4
Must be
equal to or
after
admission(
1.9)
≥A1/A2
≥PRE3/4
Must be
equal to or
after
admission
(1.9)
Notes
Field ID
Data item
Question
Wording
PRE9
2.7
Pre-op CT
performed
Was an
abdominal CT
scan performed
in the preoperative period
as part of the
diagnostic workup?
PRE10
2.8
CT
reporting
If performed,
was this CT
reported preoperatively by a
consultant
radiologist?
Field
name
Description
Purpose
Format / Options
Abdominal CT
aids diagnosis
and can
prevent
inappropriate
surgery.
Hospitals need
to develop
referral
pathways that
do not cause
delay in
getting to
theatre
PM7
Reporting by a
consultant
radiologist
improves the
accuracy of a
CT as a
diagnostic aid
and may
prevent
inappropriate
surgery
PM8
8
Source
of
definitio
n
Value
Resp.
Validation
Rules
1 = Yes
0 = No
9 = Unknown
S
≥A1/A2
≤IN3/4
1 = Yes
0 = No
9 = Unknown
S
Only
enable if
Previous
question is
Yes
Notes
Field ID
Data item
Question
Wording
PRE11
2.9
Date first
seen by
consultant
anaesthetis
t prior to
surgery
Date and time
first seen by
consultant
anaesthetist
prior to surgery
PRE12
2.9
Time first
seen by
consultant
anaesthetis
t prior to
surgery
Field
name
Description
Purpose
Format / Options
Standard:
Consultant
anaesthetist
should have
direct input
into high risk
patients, as
defined by
NCEPOD
urgency or
formal risk
assessments
Source
of
definitio
n
Value
Resp.
Validation
Rules
e-GIF format ‘CCYY-MMDD’
Date not known
Not seen
S
≥A1/A2
Must be
equal to or
after
admission
(1.9)
≤IN3/4
validation
moved to
IN3/4
HH:MM (24 hour clock)
Time not known
S
≥A1/A2
Must be
equal to or
after
admission
(1.9)
≤IN3/4
validation
moved to
IN3/4
PM4
9
Notes
Field ID
Data item
Question
Wording
Field
name
PRE13
2.10
Date of
administrati
on of first
dose of
antibiotics
following
admission
What was the
date and time of
the first dose of
antibiotics
following
admission
Abx_dat
e
PRE14
2.10
Time of
administrati
on of first
dose of
antibiotics
following
admission
Identified
as high risk
pre-op
Description
Purpose
Format / Options
Standards of
care for
treatment of
sepsis state
that patients
should have
prompt
antibiotic
administration.
Clear evidence
base for
improved
survival with
early antibiotic
administration
e-GIF format ‘CCYY-MMDD’
Date not known
Not administered
Source
of
definitio
n
ISB
Value
Resp.
Validation
Rules
S
≥A1/A2
Must be
equal to or
after
admission
(1.9)
ISB
S
≥A1/A2
Must be
equal to or
after
admission
(1.9)
PM2
PreR1
3.1
Abx_tim
e
What risk of
death was the
patient
documented as
having?
HH:MM (24 hour clock)
Time not known
Preoperative
documented
risk
Provision of
care should be
appropriate to
the predicted
risk of death
PM9
10
1=Low (<5%)
2=Medium (5-10%)
3=High (>10%)
0= Not documented
S
Notes
Field ID
Data item
Question
Wording
PreR2
3.2
Means of
risk
assessmen
t
If documented,
how was this
assessment of
risk made?
(Please select
all that apply)
Field
name
Description
Purpose
Format / Options
Means of
preoperative
risk
assessment
Risk
assessment
should be
carried out
using objective
rather than
subjective
criteria
1= Risk prediction tool
(e.g. P-POSSUM)
2= Clinical Judgement
3 = Surgical APGAR
score
4 = Physiological criteria
5= other
Source
of
definitio
n
Value
Resp.
Validation
Rules
Notes
M
Disable if
previous
question
answered
‘Not
documente
d’
Formal
eg PPOSSU
M/
SRS/
Physiol
ogical,
eg
lactate
patient
Other
criteria,
eg
hospital
protoco
l
PM9
PreR3
3.3
PreR4
3.4
PreR5
3.5
ASA
What was the
ASA score?
ASA
physiological
score
What was the most recent pre-operative value for:
Creatinine
What was the
Serum
pre-operative
Creatinine
Serum
micromol/l
Creatinine
micromol/l
PreWhat was the
Preop lactate
operative
pre-operative
mmol/l
arterial
Arterial blood
blood
lactate mmol/l
lactate
Risk
adjustment:
ASA-PS, SRS
1=No systemic disease
2=Mild systemic disease
3=Severe systemic
disease, not lifethreatening
4=Severe, life-threatening
5=Moribund patient
America
n
Society
of
Anesthe
siologists
S
Risk
stratification
Number
[2]
S
1-1200
Risk
stratification
Number
S
0-20
Pre-op P-POSSUM calculation: answers should reflect values at closest time to start of anaesthetic
Also have option for “P-POSSUM not performed” and skip PreR 6-24
11
Field ID
Data item
Question
Wording
Field
name
Description
Purpose
Format / Options
Source
of
definitio
n
Value
Resp.
Validation
Rules
Notes
P-POSSOM calculation
For questions 3.6 to 3.22 please enter values closest to time of booking for theatre in order to calculate P-POSSUM. Answers should reflect chronic and acute
pathophysiology.
PreR6
Serum
Serum Sodium
Serum sodium Risk
Numerical value
[1, 2]
S
100-180
3.6
Sodium
concentration
in mmol/l
stratification,
(mmol/l)
P-POSSUM
PreR7
Serum
Serum
Serum
Risk
Numerical value
[1] [2]
S
1-10
3.7
Potassium
Potassium
Potassium in
stratification,
concentration
mmol/l
P-POSSUM
(mmol/l)
PreR8
Serum
Serum Urea
Serum Urea in Risk
Numerical value
[1]
S
1-300
3.8
Urea
concentration
mmol/l
stratification,
(mmol/l)
P-POSSUM
PreR9
Serum
Serum
Haemoglobin
Risk
Numerical value
[1]
S
40-250
Change
3.9
Haemoglob Haemoglobin
concentration
stratification,
d from
in g/l
concentration
in g/dl
P-POSSUM
g/dl to
(g/l)
g/l
PreR10 Serum
Serum White
White cell
Risk
Numerical value
[1, 2]
S
0-100
3.10
White Cell
cell count
count
stratification,
Count
(x10^9 / l)
x1012 / l
P-POSSUM
PreR11 Pulse rate
Pulse rate (bpm)
Pulse rate
Risk
Numerical value
[1, 2]
S
10-200
3.11
prior to
stratification,
surgery
P-POSSUM
(highest) in
bpm
PreR12 Systolic
Systolic blood
Systolic BP
Risk
Numerical value
[1]
S
10-250
3.12
Blood
pressure
immediately
stratification,
Pressure
(mmHg)
prior to risk
P-POSSUM
stratification
(mmHg)
PreR13 Glasgow
Glasgow coma
Glasgow coma Risk
Numerical value
[1, 2]
S
Range:
3.13
coma scale scale
score
stratification,
3 to 15
P-POSSUM
12
Field ID
Data item
Question
Wording
PreR14
3.14
Electrocardi
ogram
PreR15
3.15
Description
Purpose
Format / Options
Select an option
that best
describes this
patient's ECG
Describe ECG
findings
Risk
stratification,
P-POSSUM
Cardiac
signs
Select an option
that best
describes this
patient's
cardiac signs
and chest xray
appearance
Cardiac
pathology
Risk
stratification,
P-POSSUM
PreR16
3.16
Respiratory
history
Select an option
that best
describes this
patient's
respiratory
history and
chest xray
appearance
Respiratory
pathology
Risk
stratification,
P-POSSUM
PreR17
3.17
Operative
severity
Select the
operative
severity of the
intended
surgical
intervention
(see help box
for examples)
Operative
severity
Risk
stratification,
P-POSSUM
1=No abnormalities
4=AF rate 60-90
8=AF rate >90/ any other
abnormal rhythm/paced
rhythm/ >5VE/min/ Q, ST
or T wave abnormalities
999=Not performed
1 = No failure
2 = Diuretic, digoxin,
antianginal or
antihypertensive therapy
4 = Peripheral oedema,
warfarin therapy or CXR:
borderline cardiomegaly
8 = Raised jugular venous
pressure or CXR:
cardiomegaly
999=Not performed
1=No dyspnoea
2=Dyspnoea on exertion
or CXR: mild COAD
4= Dyspnoea limiting
exertion to <1 flight or
CXR: moderate COAD
8=Dyspnoea at rest/rate
>30 at rest or CXR:
fibrosis or consolidation
999=Not performed
4 = Major
8 = Major+
13
Field
name
Source
of
definitio
n
[1]
Value
Resp.
[1]
S
[1]
S
[1]
S
S
Validation
Rules
Notes
Field ID
Data item
Question
Wording
PreR18
3.18
Number of
operative
procedures
PreR19
3.19
Predicted
intraop
blood loss
PreR20
3.20
Likelihood
of
peritoneal
soiling
PreR21
3.21
Presence
of
malignancy
14
Field
name
Description
Purpose
Format / Options
Source
of
definitio
n
[1]
Value
Resp.
Including this
operation, how
many operations
has the patient
had in the 30
day period prior
to this
procedure?
Based on your
clinical
experience of
the intended
surgery, please
estimate the
likely
intraoperative
blood loss (ml)
Please select a
value that best
describes the
likely degree of
peritoneal
soiling
Number of
operative
procedures
this admission
Risk
stratification,
P-POSSUM
1 =1
4=2
8 = >2
Predicted
intraop blood
loss
Risk
stratification,
P-POSSUM
1 = <100
2 = 101-500
4 = 501-1000
8 = >1000
[1]
S
Predicted
degree of
peritoneal
soiling
Risk
stratification,
P-POSSUM
1 = None
2 = Serious fluid
4 = Localised pus
8 = Free bowel content,
pus or blood
[1]
S
What severity of
malignancy is
anticipated to be
present?
malignancy
status
Risk
stratification,
P-POSSUM
1 = None
2 = Primary only
4 = Nodal metastases
8 = Distant metastases
[1]
S
Validation
Rules
S
Based on
any
imaging
prior to
commence
ment of
anaesthesi
a
Notes
Field ID
Data item
Question
Wording
PreR22
3.22
NCEPOD
urgency
PreR23
3.23
Pre-op
percentage
predicted
mortality
Pre-op
POSSUM
predicted
morbidity
What was global
impression of
the urgency of
surgery at the
time of booking
the case?
(see help notes
for additional
information,
including
equivalent
Possum
categories)
Pre-op PPOSSUM
predicted
mortality
Pre-op
POSSUM
predicted
morbidity
PreR24
3.24
3.25
15
Not all PPOSSUM
investigations
available
Field
name
Description
Purpose
Format / Options
Risk
stratification,
P-POSSUM
4=
3. Expedited (>18 hours)
2B. Urgent (6-18 hours)
2A. Urgent (2-6 hours)
8=
1. Immediate (<2 hours)
Source
of
definitio
n
NCEPO
D
(rather
than
SRS
definitio
ns)
Value
Resp.
Validation
Rules
S
Calculated from PreR622, and age derived from
D4
calculated
Calculated from PreR6-22
and age derived from D4
calculated
If ticked
disable all
PPOSSUM
field
validation
Notes
INTRAOPERATIVE VALUES
Field
Data item
Question
ID
Wording
IN3
4.1
IN4
4.1
Date of entry
into operating
theatre/anae
sthetic room
(not theatre
suite)
Time of entry
into operating
theatre/anae
sthetic room
(not theatre
suite)
Field
name
Description
Date of entry in
to operating
theatre/anaesth
etic room (not
theatre suite)
Purpose
Format / Options
For analysis of
timescales of
care, including
whether there
are delays to
surgery, and
analysis of
timescales
according to
clinical
urgency
Source
of
definitio
n
Value
Resp.
Validation
Rules
Notes
e-GIF format ‘CCYY-MMDD’
S
HH:MM (24 hour clock)
Time not known
S
≥A1/A2
≥PRE3/4
Cannot be
less than
18 years
old at time
of operation
Must be
equal to or
after
admission,
decision
taken to
operate
and first
seen by
consultant
anaesthetis
t (1.9, 2.2 &
2.8
NB
operatin
g
theatre,
not
theatre
suite
1 = Consultant
2 = Post-CCT fellow
3 = SAS grade
4 = Research Fellow /
Clinical Fellow
5 = Specialty trainee /
registrar
6 = Core trainee / SHO
9 = Other
S
PM5
PM6
OM1
OM4
OM5
IN5
4.2
Senior
surgeon
grade
Senior surgeon
grade
Surg_gr
ade
Grade of
operating
surgeon
present in
theatre for the
majority of the
surgical
procedure
Standard:
Consultant
surgeon
should have
direct input
into high risk
patients, as
defined by
NCEPOD
urgency or
formal risk
assessments
PM10
16
Field
ID
Data item
Question
Wording
IN6
4.2.a
If consultant:
Name/GMC
of operating
consultant
If consultant:
Name/GMC of
operating
consultant
IN8
4.3
Senior
anaesthetist
grade
Senior
anaesthetist
grade
IN9
4.3.a
If consultant:
Name/GMC
of
anaesthetist
If consultant:
Name/GMC of
anaesthetist
17
Field
name
Anaes_
grade
Description
Grade of most
senior
anaesthetist
present in
theatre
Anaesthetist
with primary
responsibility
Purpose
Format / Options
For local
reporting,
surgeon
revalidation
Populated from look-up
file created by local
administrator
Standard:
Consultant
anaesthetist
should have
direct input
into high risk
patients, as
defined by
NCEPOD
urgency or
formal risk
assessments
1 = Consultant
2 = Post-CCT fellow
3 = SAS grade
4 = Research Fellow /
Clinical Fellow
5 = Specialty trainee /
registrar
6 = Core trainee / SHO
9 = Other
PM11
For local
reporting
Populated from look-up
file created by local
administrator
Source
of
definitio
n
If the
surgeon
is not in
the
dropdow
n list
allow
adding
of
surgeon
Value
Resp.
Validation
Rules
This field
only
required if
senior
surgeon is
consultant
Same list
as Q2.3
S
If the
anaesth
etist is
not in
the
dropdow
n list
allow
adding
of
anaesth
etist
This field
only
required if
senior
anaesthetis
t is
consultant
Different list
to surgeon
Notes
Field
ID
Data item
Question
Wording
Field
name
Description
Purpose
Format / Options
IN10
4.4
Intraoperative
Goal-directed
fluid therapy
How did you
provide goal
directed fluid
therapy?
Fluid_th
erapy
Goal-directed
fluid therapy
NICE
recommendati
on: use of goal
directed fluid
therapy in high
risk patients
0 = Not provided
1 = Cardiac output
monitor
2 = Other
S
PRO1
5.1
type for
procedure
1 = First surgical
procedure after admission
2 = Surgery for
complication of previous
surgical procedure within
same admission
S
PRO3
5.2
Indication for
surgery
Is this the first
surgical
procedure of
this admission,
or a
complication of
previous
surgery within
the same
admission?
What is the
indication for
surgery?
(Please select
all that apply)'











M
PM12
To allow
grouping
according to
whether
emergency
laparotomy is
a complication
of a previous
surgical
procedure.
To understand
operative
procedure and
relate to
outcomes. To
understand
pathways of
care



18
Peritonitis
Perforation
Abdominal abscess
Anastomotic leak
Intestinal fistula
Sepsis (other)
Intestinal obstruction
Haemorrhage
Ischaemia
Colitis
Abdominal wound
dehiscence
Abdominal
compartment
syndrome
Planned relook
Other (Please
specify)
Freeform text 100
characters
Source
of
definitio
n
Value
Resp.
Validation
Rules
Notes
Check
inclusio
n criteria
to check
all
covered
Field
ID
Data item
Question
Wording
Field
name
Description
Purpose
Format / Options
PRO4
5.3.a
Proc code 1
Main procedure
Proc_1
OPCS code of
procedure
performed
To understand
operative
procedure and
relate to
outcomes
1. Peptic ulcer – suture or
repair of perforation
2. Peptic ulcer oversew of
bleed
3. Gastric surgery - other
4. Small bowel resection
5. Colectomy: left
(including anterior
resection)
6. Colectomy: right
7. Colectomy: subtotal
8. Hartmann’s procedure
9. Colorectal resection
(other)
20. Abdominal wall
closure
22. Adhesiolysis
23. Drainage of
abscess/collection
24. Exploratory/relook
laparotomy only
25. Haemostasis
26. Intestinal bypass
27. Laparostomy
formation
28. Repair of intestinal
perforation
29. Resection of other
intra-abdominal tumour(s)
30. Stoma formation
31. Stoma revision
32. Washout only
88. Not amenable to
surgery
99. Other (please specify)
Freeform text 100
characters
19
Source
of
definitio
n
Value
Resp.
S
Validation
Rules
Notes
With 2
levels of
detail
(as with
3-digit
and 4digit
OPCS)
– where
full
details
are not
known
we
would
hope to
get the
less
detailed
level
Field
ID
Data item
Question
Wording
Field
name
Description
Purpose
Format / Options
PRO5
5.3.b
Proc code 2
Second
procedure (at
same
laparotomy)
Proc_2
OPCS code of
secondary
procedure
performed
To understand
operative
procedure and
relate to
outcomes
1. Peptic ulcer – suture or
repair of perforation
2. Peptic ulcer – oversew
of bleed
3. Gastric surgery - other
4. Small bowel resection
5. Colectomy: left
(including anterior
resection)
6. Colectomy: right
7. Colectomy: subtotal
8. Hartmann’s procedure
9. Colorectal resection other
10. Splenectomy
20. Abdominal wall
closure
21. Abdominal hernia
repair
22. Adhesiolysis
23. Drainage of
abscess/collection
25. Haemostasis
26. Intestinal bypass
27. Laparostomy
formation
28. Repair of intestinal
perforation
29. Resection of other
intra-abdominal tumour(s)
30. Stoma formation
31. Stoma revision
32. Washout only
33. Appendicectomy as
incidental procedure
34. Cholecystectomy as
incidental procedure
99. Other (please specify)
20
Source
of
definitio
n
Value
Resp.
S
Validation
Rules
Notes
Field
ID
Data item
Question
Wording
Field
name
Description
Purpose
Format / Options
Source
of
definitio
n
Value
Resp.
Second
procedure Not
applicable
PRO6
5.3.c
Proc code 3
Third Procedure
(at same
laparotomy)
Proc_3
OPCS code of
secondary
procedure
performed
To understand
operative
procedure and
relate to
outcomes
Freeform text 100
characters
As 5.3.b
S
Freeform text 100
characters
As 5.3.b
S
Third procedure
Not applicable
5.3.d
Proc code 4
Fourth
Procedure (at
same
laparotomy)
Proc_4
OPCS code of
secondary
procedure
performed
To understand
operative
procedure and
relate to
outcomes
Fourth
procedure Not
applicable
PRO7
5.4
21
Procedure
approach
Procedure
approach
proc_ap
proach
Type of
surgical
approach
To understand
operative
procedure and
relate to
outcomes
Freeform text 100
characters
1 = Open
2 = Laparoscopic
3 = Laparoscopic
converted to open
4 = Laparoscopic assisted
S
Validation
Rules
Notes
Field
ID
Data item
Question
Wording
Field
name
PRO8
5.5
Operative
findings
Operative
findings:
(Please tick all
that apply)
If unsure
whether this
patient is
eligible for
NELA please
refer to help box
Op_find
22
Description
Purpose
Format / Options
To understand
operative
procedure and
relate to
outcomes. To
understand
pathways of
care






Abscess
Adhesions
Anastomotic leak
Colitis
Crohn's disease
Abdominal
compartment
syndrome
 Diverticulitis
 Haemorrhage –
peptic ulcer
 Haemorrhage –
intestinal
 Haemorrhage –
postoperative
 Incarcerated hernia
 Intestinal ischaemia
 Malignancy –
localised
 Malignancy –
disseminated
 Perforation – peptic
ulcer
 Perforation – small
bowel/colonic
 Volvulus
 Normal intraabdominal findings
 Other (please specify)
Freeform text 100
characters
Source
of
definitio
n
Value
Resp.
Validation
Rules
M
If ‘Normal
findings’
clear all
other
selections
Notes
Check
inclusio
n criteria
to check
all
covered
Field
ID
Data item
5.6
Question
Wording
Field
name
Description
Purpose
Format / Options
Value
Resp.
Validation
Rules
None or reactive
serous fluid only
Free gas from
perforation +/minimal
contamination
Pus
Bile
Gastro-duodenal
contents
Small bowel contents
Faeculent fluid
Faeces
Blood/haematoma
M
If none
selected
clear all
others
selected
and vice
versa
1 = Localised to a single
quadrant of the abdomen
2 = More extensive /
generalised
1 = Yes
0 = No
S

Please
describe the
peritoneal
contamination
present (select
all that apply)








5.7
PoR1
6.1
Postoperative
risk of death
Please indicate
if the
contamination
was
Was the patient
classified as
high risk at the
end of surgery?
To understand
provision of
subsequent
levels of care.
Standard:
Patients
should have
their risk of
death
reassessed at
the end of
surgery. This
should be
carried out in a
structure
fashion.
PM13
23
Source
of
definitio
n
Notes
Classifie
d as
High
risk
post-op
Field
ID
Data item
Question
Wording
PoR2
6.2
Structured
assessment
How was this
assessment of
risk made?
(Please tick all
that apply)
Field
name
Description
Purpose
Format / Options





PoR3
6.3
Arterial blood
lactate at end
of surgery
Arterial blood
lactate at end of
surgery (mmol/l)
End op lactate
mmol/l
Source
of
definitio
n
Number
Not performed
Risk
stratification,
P-POSSUM
Risk
stratification,
P-POSSUM
Number
Number
Validation
Rules
M
Risk prediction tool
(e.g. P-POSSUM)
Clinical Judgement
Surgical APGAR
score
Physiological criteria
Other, e.g. hospital
policy
Risk
stratification,
Multivariate
analysis
Value
Resp.
Formal
eg PPOSSU
M/ SRS/
Physiolo
gical
criteria
(eg
Lactate,
oxygena
tion,
hypothe
rmia)
Other
criteria,
eg
hospital
protocol
S
0-20
[1, 2]
S
[1] [2]
S
Auto fill
from Q3.6
100-180
Auto fill
from Q3.7
1-10
Post-operative P-Possum calculation. If the values have
changed since pre-op, please enter those values closest to
the end of surgery.
If not, the pre-operative values will automatically be entered.
Also have option for “P-POSSUM not performed” and skip
PoR 6-24
Please enter values closest to the end of surgery if available,
otherwise pre-op figures will be used where appropriate (can
be from ABGs or lab investigations). Answers should reflect
chronic and acute pathophysiology.
PoR6
Sodium
Serum Sodium
Serum sodium
6.4
concentration
in mmol/l
(mmol/l)
PoR7
Potassium
Serum
Serum
6.5
Potassium
Potassium in
(mmol/l)
mmol/l
24
Notes
Field
ID
Data item
Question
Wording
PoR8
6.6
Urea
PoR9
6.7
Description
Purpose
Format / Options
Serum Urea
(mmol/l)
Serum Urea in
mmol/l
Haemoglobin
Haemoglobin
concentration in
g/l
Haemoglobin
concentration
in g/l
Risk
stratification,
P-POSSUM
Risk
stratification,
P-POSSUM
PoR10
6.8
White Cell
Count
White cell count
x10^9 / l
PoR11
6.9
Pulse
Pulse rate
(bpm)
PoR12
6.10
Systolic
Blood
Pressure
Systolic BP
(mmHg)
PoR13
6.11
Glasgow
coma score
Glasgow coma
score
White cell
count
x10^9 / l
Pulse rate
prior to
surgery
(highest) in
bpm
Systolic BP
immediately
prior to risk
stratification
(mmHg)
Glasgow coma
score
PoR14
6.12
ECG
Describe ECG
findings
Describe ECG
findings
25
Field
name
Value
Resp.
Validation
Rules
Number
Source
of
definitio
n
[1]
S
Number
[1]
S
Auto fill
from Q3.8
1-300
Auto fill
from Q3.9
40-250
Risk
stratification,
P-POSSUM
Risk
stratification,
P-POSSUM
Number
[1, 2]
S
Number
[1, 2]
S
Risk
stratification,
P-POSSUM
Number
[1]
S
Do not
autofill
10-250
Risk
stratification,
P-POSSUM
Number
[1, 2]
S
Auto fill
from Q3.13
Should
always be
the same
Range: 3 to
15
Risk
stratification,
P-POSSUM
1=No abnormalities
4=AF rate 60-90
8=AF rate >90/ any other
abnormal rhythm/paced
rhythm/ >5VE/min/ Q, ST
or T wave abnormalities
[1]
S
Auto fill
from Q3.10
0-200
Do not
autofill
10-200
Notes
Change
d from
g/dl to
g/l
Field
ID
Data item
Question
Wording
PoR15
6.13
Cardiac signs
PoR16
6.14
Description
Purpose
Format / Options
Describe
Cardiac history /
CXR
appearance
Cardiac
pathology
Risk
stratification,
P-POSSUM
Respiratory
signs
Describe
Respiratory
history/ CXR
appearance
Respiratory
pathology
Risk
stratification,
P-POSSUM
PoR17
6.15
Operative
severity
Operative
severity
Risk
stratification,
P-POSSUM
PoR18
6.16
Number of
operative
procedures
Number of
operative
procedures
this admission
Risk
stratification,
P-POSSUM
1 =1
4=2
8 = >2
PoR19
6.17
Total blood
loss (ml)
What was the
operative
severity?
(see help box
for examples)
Including this
operation, how
many
operations has
the patient had
in the 30 day
period prior to
this procedure?
Please select
this patient's
measured
intraoperative
blood loss (ml)
1 = No failure
2 = Diuretic, digoxin,
antianginal or
antihypertensive therapy
4 = Peripheral oedema,
warfarin therapy or CXR:
borderline cardiomegaly
8 = Raised jugular venous
pressure or CXR:
cardiomegaly
1=No dyspnoea
2= Dyspnoea on exertion
or CXR: mild COAD
4= Dyspnoea limiting
exertion to <1 flight or
CXR: moderate COAD
8= Dyspnoea at rest/rate
>30 at rest or CXR:
fibrosis or consolidation
4 = Major
8 = Major+
Risk
stratification,
P-POSSUM
1 = <100
2 = 101-500
4 = 501-1000
8 = >1000
26
Field
name
Act_TBL
Source
of
definitio
n
[1]
Value
Resp.
Validation
Rules
S
Auto fill
from Q3.15
Should
always be
the same
[1]
S
Auto fill
from Q3.16
Should
always be
the same
[1]
S
Do not
autofill
[1]
S
Auto fill
from Q3.18
Should
always be
the same
S
Do not
autofill
Notes
Field
ID
Data item
Question
Wording
Field
name
PoR20
6.18
Peritoneal
soiling
PoR21
6.19
Presence of
malignancy
PoR22
6.20
NCEPOD
urgency
PoR23
6.21
Post-op PPOSSUM
predicted
mortality
Post-op
POSSUM
predicted
morbidity
Please select
the option that
best describes
this patient’s
degree of
peritoneal
soiling
What was the
level of
malignancy
based on
surgical
findings?
What was
actual urgency
of surgery at the
time the
procedure was
performed?
(see help box
for additional
information,
including
equivalent
Possum
categories)
Post-op PPOSSUM
predicted
mortality
Post-op
POSSUM
predicted
morbidity
PoR24
6.22
27
Description
Purpose
Format / Options
Act_peri
tsoil
Risk
stratification,
P-POSSUM
Act_mali
g
Value
Resp.
Validation
Rules
1 = None
2 = Serious fluid
4 = Localised pus
8 = Free bowel content,
pus or blood
S
Do not
autofill
Risk
stratification,
P-POSSUM
1 = None
2 = Primary only
4 = Nodal metastases
8 = Distant metastases
S
Do not
autofill
Risk
stratification,
P-POSSUM
4=
3. Expedited (>18 hours)
2B. Urgent (6-18 hours)
2A. Urgent (2-6 hours)
8=
1. Immediate (<2 hours)
Equation incorporating
autofilled data from
PreR6-22, values from
PoR6-22 and age
Equation incorporating
autofilled data from
PreR6-22, values from
PoR6-22 and age
Source
of
definitio
n
NCEPO
D
(rather
than
SRS
definitio
ns)
S
calculated
calculated
Notes
Field
ID
Data item
6.23
PO1
6.24
6.25
28
Question
Wording
Field
name
Description
Purpose
Format / Options
Source
of
definitio
n
Value
Resp.
Not all PPOSSUM
investigations
available
Destination
Where did the
patient go for
continued postoperative care
following
surgery?
Is the patient on
a vasopressor/
inotrope?
Validation
Rules
Is ticked,
disable all
PPOSSUM
field
validation
Proc_de
st
Actual
destination /
level of care in
immediate
post-operative
phase
Post-operative
destination
should be
appropriate to
predicted risk
of death
1=Ward
2=Level 2 HDU
3=Level 3 ICU
4=Died prior to discharge
from theatre complex
1 = Yes
0 = No
S
Notes
POSTOPERATIVE VARIABLES
Field Data item
Question
ID
wording
Field
name
Description
Purpose
If Q6.4 is ‘Died prior to discharge from theatre complex’ Q7.1 – 7.5 are disabled
PO2 ICU stay
Total length of
Level3_
Days (or part
LOS calc
7.1
post-operative
stay
days) in ICU
ITU stay (days)
see help box for
additional
information
PO3 HDU stay
Total length of
Level2_
Days (or part
LOS calc
7.2
post-operative
stay
days) in HDU
HDU stay (days)
see help box for
additional
information
PO4
7.3
Geriatric postoperative
assessment
Was the patient
assessed by a
specialist from
Elderly Medicine
in the postoperative
period?
geriatric
_postop
Assessed by
specialist from
Elderly
Medicine in the
post-operative
period
Pathway of
care. Elderly
patients
should
receive
multidisciplin
ary input into
their care
PM15
29
Format / Options
Source
of
definitio
n
3-digit Number
S
3-digit Number
S
1 = Yes
0 = No
9 = Unknown
8 = Not applicable
S
Value
Resp.
Check
again
st
dates
+1
day
Check
again
st
dates
+1
day
ICU +
HDU
check
again
st
dates
+3
Validation
Rules
Notes
PO5
7.4
PO6
7.5
30
Return to
theatre within
same hospital
admission
Re-admission to
higher level of
care
Within
this
admissi
on, did
the
patient
return to
theatre
in the
postoperativ
e period
followin
g their
initial
emerge
ncy
laparoto
my?
Did the
patient
have an
unplann
ed move
from
the
ward to
a higher
level of
care
within 7
days of
surgery
? (do
not
include
moves
from
HDU to
ITU)
Comp_the
atre
Comp_lev
el
Did the
patient go
back to
theatre for
any
procedure?
Complication
measure
Did the
patient
have an
unplanned
moved to a
higher level
of care
within 7
days of
surgery?
Complication
measure
1 = Yes
0 = No
9 = Unknown
S
1 = Yes
0 = No
9 = Unknown
S
OM3
OM2
Unplanned = a
move from ward to
level 2 or 3 care
within 7 days of
surgery
PO7
7.6
Histology
Histolog
y
Histology
Postoperative
histological
diagnosis
To
understand
operative
procedure
and relate to
outcomes.
To
understand
pathways of
care.
PO9
7.7
Status at
discharge
Status
at
discharg
e
Status_dis
ch
Alive on
discharge
Outcome
measure
Date
discharg
ed from
hospital
Date_disc
h
PO8
7.8
Date discharged

Crohn's
disease
 Diverticulitis
 Ischaemia
 Malignancy
 Peptic ulcer
disease
 Ulcerative
colitis
 Not
applicable/
Not
available at
time of
discharge
 Other
0=Dead
1=Alive
M
e-GIF format
‘CCYY-MM-DD’
S
S
OM1
date of
discharge
LOS calc
Must be Dead if
Q6.24 = ‘Died
prior to
discharge from
theatre complex’
≥IN3/4
OM1
OM4
1.
Prytherch, D.R., et al., POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enUmeration of Mortality and
morbidity. Br J Surg, 1998. 85(9): p. 1217-20.
Rules for POSSOM:
POSSUM - Need to decide how we want these two sections are linked. Which values should be updated first? Which questions should be greyed out depending on the
answers given in section 3.
1. If filled in pre-op, appears in post op for fields 3.6-3.10 – 6.4-6.8
2. If post-op filled in, then changing pre-op does not update post-op
3. 3.13 3.14, 3.15 3.16 3.18 3.22 always same pre/post-op – defer to point 2
4. Do not autofill 6.9 6.10 6.15 6.17 6.18 6.19 with values from 3.7, 3.8, 3.13, 3.15, 3.16, 3.17
5. 6.23, can we just have a single box to tick (like 6.3-not performed), otherwise we have a double negative
31
Assigned
value = 1
Assigned value = 2
Assigned value = 4
Assigned value =
8
Question
(Section 3)
Question
(Section 6)
≤60
61-70
≥71
*
1.14
1.14
No failure
Diuretic, digoxin,
antianginal or
hypertensive therapy
Peripheral oedema or
warfarin therapy
Raised jugular
venous pressure
Not assessed:
Assigned value = 1
3.15
6.13
x
x
Borderline cardiomegaly
Cardiomegaly
Not performed:
Assigned value = 1
3.15
6.13
No dyspnoea
Dyspnoea on exertion
or
Limiting dyspnoea (one
flight) or
6.14
Mild COAD
Moderate COAD
Not assessed:
Assigned value = 1
Not performed:
Assigned value = 1
3.16
x
Dyspnoea at rest
(rate ≥30/min) or
Fibrosis or
consolidation
3.16
6.14
4. Systolic blood pressure
(mmHg)
110-130
131-170 or 100-109
≥171 or 90-99
≤89
3.12
6.10
5. Pulse rate (beats/min)
50-80
81-100 or 40-49
101-120
≥121 or ≤39
3.11
6.9
6. Glasgow coma score
15
12-14
9-11
≤8
3.13
6.11
7. Haemoglobin (g/l)
130-160
115-129 or 161-170
100-114 or 171 - 180
≤99 or ≥181
3.9
6.7
8. White cell count (x 1012/l)
4-10
10.1-20.0 or 3.1-4.0
≥20.1 or ≤3.0
*
3.10
6.8
9. Urea (mmol/l)
≤7.5
7.6-10.0
10.1-15.0
≥15.1
3.8
6.6
10. Sodium (mmol/l)
≥136
131-135
126-130
≤I25
3.6
6.4
11. Potassium (mmol/l)
3.5-5.0
3.2-3.4 or 5.1-5.3
2.9-3.1 or 5.4-5.9
≤2.8 or ≥6.0
3.7
6.5
Atrial fibrillation (rate 6090)
Any other
abnormal rhythm
or ≥5
ectopics/min, Q
waves or ST/T
wave changes
4.14
7.12
1. Age (years)
2. Cardiac signs
Chest radiograph
3. Respiratory history
Chest radiograph
12. Electrocardiogram
Normal
x
x = no dropdown option required
* = no values to include
32
Not performed:
Assigned value = 1
Assigned value = 1
Assigned value = 2
Assigned value = 4
Assigned value = 8
Question
(Section 3)
Question
(Section 6)
13. Operative severity
x
x
Major
Major +
3.17
6.15
14. Number of previous
procedures
0
x
1
≥2
3.18
6.16
15. Total blood loss (ml)
< 100
101-500
501-999
≥1000
3.19
6.17
16. Peritoneal soiling
None
Minor (serous fluid)
Local pus
3.20
6.18
17. Presence of malignancy
None
Primary only
Nodal metastases
Free bowel
content, pus or
blood
Distant metastases
3.21
6.19
18. Mode of surgery
x
x
Emergency:
resuscitation of > 2 h
possible
Emergency
(immediate surgery
<2 h needed)
3.22
6.20
PoR19 only :
Not measured =
1
x = no dropdown option required
Mortality calculation
MortalityScore = Math.round((Math.exp(-9.065 + (0.1692*PSS) + (0.155*OSS)) / (1+ Math.exp(-9.065+(0.1692*PSS) + (0.155*OSS))))*1000)/10;
Morbidity calculation
MorbidityScore = Math.round((Math.exp(-5.91 + (0.16*PSS) + (0.19*OSS)) / (1+ Math.exp(-5.91 + (0.16*PSS) + (0.19*OSS))))*1000)/10;
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