STS Exceptional Risk Webform

In highly extraordinary circumstances, adult cardiac index operations with rare co-morbidities that fall outside of the current STS Risk Models for benchmark operations may be performed by STS Database participants. If you believe a case meets exceptional risk criteria and would like it reviewed by the Exceptional Risk Exclusion Committee (EREC), please complete the form below prior to the date of surgery. STS will contact you or your data manager for specific case information and documentation to determine if the case meets the exclusion requirements. You will be notified of the final decision after the date of surgery. If the case is approved by the EREC as exceptional risk, the complete in-hospital and/or 30-day data including mortality information must still be submitted to the STS Database, but it will be removed from outcome reporting.

Attestations:

I understand that the exceptional risk case review aims to adjudicate extremely high-risk patients from STS Database Analytics and is not intended to influence patient-care decision-making.

I understand that if the STS Exceptional Risk Exclusion Committee finds the case to be of exceptional risk, it will be eliminated from STS Harvest Analytics, STS Risk Adjusted Results, and STS Public Reporting.

I understand that STS may require additional information. I further understand that STS must receive a response to this request within 72 business hours (3 business days), and that failure to do so may jeopardize the candidacy of my participant site from future participation in the exceptional risk program.

I understand that the outcome of the submitted case review by the Committee is final, and no further adjudication or appeals will be accepted.

I understand that this request cannot be rescinded.

Who is submitting the form:

Surgeon Name:

Surgeon Email:

Surgeon Phone Number:

Submitter's Name:

Submitter's Email:

Submitter's Phone Number:

Name of Surgeon Performing the Surgery:

Hospital Name:

Hospital City:

Hospital State:

Brief De-identified Clinical Summary (Do not include PHI):

Planned Date of Surgery:

PID Number: