DATA COLLECTION PROFORMA
PART 1: PATIENT CARE
Anaesthesia
1. Number and grades of physician anaesthetists
Female Male Total
Consultant
MMed 4
MMed 3
MMed 2
MMed 1
Other
Number of Clinical Officers
Female Male Total
2. Number of theatres (how many in regular use?)
Phase3
Phase 5
D-block
C-block
3. Surgical specialities
4. Number of operations per year
Major:
Intermediate:
Minor:
5. Anaesthetic techniques (including regional anaesthesia):
6. Obstetric anaesthesia
Percentage of C/S performed under GA:
Percentage of C/S performed under spinal:
7. Drugs used in anaesthesia
TYPE OF DRUG MOST COMMONLY USED AVAILABLE
DRUG DRUGS
Inhalational
agent
Induction
agent
Neuromuscul
ar blocking
agent
Opioid
analgesic
Non-opioid
analgesic
Local
anaesthetic
Reversal
Cardiovascul
ar active
drugs
8. Standard Monitoring
9. Anaesthetic machines
10. ETTs and LMAs availability
11. Perioperative mortality and morbidity
12. Recovery
Staffing:
Monitoring:
Oxygen availability:
13. Basic hospital supplies water, electricity, oxygen
Water:
Electricity:
Oxygen
14. Air conditioning in the theatres
15. Hand hygiene in the theatres
Soap/disinfectant/water/ gloves availability:
Comments
Intensive Care Unit
1. Number of beds
2. Staff
Number and grades of physicians:
Daytime cover:
Night cover:
Number and grades of nurses:
3. Overall number of cases per year:
Overall mortality rate:
4. Most common diagnoses
RANK DIAGNOSIS NUMBER OF MORTALITY
ADMISSIONS RATE (%)
(%)
5. Routine patient observations
6. Drugs supply
7. Consumables:
8. Infection control
Soap/disinfectant/water/ gloves availability:
Supporting disciplines
1. Laboratory
Tests available pre-op:
Tests available intra-op:
Tests available for ICU patients:
2. Blood bank
Blood products available:
Routine blood testing:
Routine compatibility testing:
Comments:
3. Radiology
Pre-op X-ray availability:
Mobile X-ray availability:
USS availability for ICU patients:
CT scanner availability for ICU patients:
MRI availability for ICU patients:
4. Emergency medicine
Anaesthesia involvement in management of critically ill patients in the Emergency
Department:
Anaesthesia involvement in management of critically ill patients in other areas of the
hospital:
5. Availability of emergency medical supplies: cardiac arrest drugs, self inflating bag
and mask, intubation equipment, defibrillator.
Wards:
Emergency Department:
Comments
Pain therapy
1. Specialized physicians and nurses
2. Involvement of anaesthetists in pain management outside the theatres and ICU
3. Hospital guidelines
4. Available analgesics
PART 2: UNIVERSITY TEACHING AND POSTGRADUATE TRAINING
Undergraduate training
1. Curriculum
2. Length of the module
3. Comments
Postgraduate training
1. Structure of MMed Program
2. Number of trainees
3. Supervision in theatres
4. Teaching program
Clinical Officers Training
1. Undergraduate training
2. Postgraduate training courses in the last two years
Course name Date Number of Comments
participants
PART 3: RESEARCH AND CLINICAL GOVERNANCE
Audit and research:
1. Projects completed to date
2. Projects in progress
3. Posters and presentations at national and international meetings
Clinical Governance:
1. Audit and critical incidents meetings
2. Anaesthesia M&M Meetings
3. Multidisciplinary M&M Meetings
4. Hospital protocols and guidelines
5. Protocols and guidelines under development
