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Instruction Manual

International Nutrition Survey 2009

Table of Contents

Table of Contents 2

Introduction 3

Study Contacts 5

Acronyms 6

General Guidelines 6

Critical Care Nutrition Website 8

Survey Login Page and Registration 9

Welcome ‘Home’ Page 12

Patient Status Page 14

Screening 15

Patient Baseline Form 17

APACHE II 20

Baseline Nutrition Assessment 23

Daily Nutrition Data 25

Enteral Nutrition Data 27

Parenteral Nutrition Data 30

60-day Outcomes 32

Finalizing Data Entry 34

Appendices 35

Introduction

International Nutrition Survey

This project involves a period-prevalence survey of nutrition therapies in critically ill patients in intensive care units (ICUs) across the world. This survey is to be conducted on 16 September 2009 or the nearest date practically possible.

Dietitians (or other healthcare practitioners) at the respective ICUs will collect data such as site characteristics, patient demographics, direct observational data (i.e. head of the bed elevation), baseline APACHE II variables, length of stay, duration of ventilation and mortality. In addition, nutrition practices such as route of nutrition, kilocalories and protein levels prescribed and received, interruptions, supplementation, blood sugars, insulin, etc will also be collected on a daily basis from ICU admission to ICU discharge, death, or for a maximum of 12 days (whichever comes first).

It is projected that the results of this survey will identify differences, highlight strengths and weaknesses, and hopefully illuminate opportunities to improve nutrition practices in Canada and throughout the world.

Benchmarked Site Report

In lieu of remuneration for participating in this project, you will be provided with a benchmarked site report. This site report summarizes your site’s performance and will allow you to compare your nutrition practices to other ICUs within your own country or region (‘Sister Sites’) and all the ICUs in the database (‘All Sites’). You will also be able to compare your performance to the recommendations of the Canadian Critical Care Nutrition (CCN) Clinical Practice Guidelines (CPGs).

Best of the Best 2009

Although the hard work and dedication of all ICUs who participate in the international nutrition survey is recognized, in 2009, the top ten sites that meet the award eligibility criteria will be awarded the ‘Best of the Best’ plaque. The top three sites will also be awarded $1000 towards travel and expenses to attend the American Society of Parenteral and Enteral Nutrition’s (ASPEN’s) Clinical Nutrition Week 2010, where their excellence in nutrition practice will be recognized at a session in which Dr Heyland personally presents the awardees with their plaques.

To be considered for this award, participating ICUs must meet the following criteria:

1. Entered data on a minimum of 20 critically ill patients.

2. Must have a feeding protocol in place.

3. Completion of a baseline nutrition assessment (i.e. nutrition prescription).

4. No missing data or outstanding queries.

5. Prepared to permit CCN to source verify the entered data.

Instruction Manual

The Instruction Manual functions as a resource for successful completion of electronic case report forms (eCRFs) for the International Nutrition Survey.

The manual is formatted to provide written instruction for each CRF. A webshot of the actual web page will follow written instructions.

eCRFs are the primary mode of data capture used in the International Nutrition Survey. The dietitian (or other healthcare practitioner) is expected to enter data online as soon as it becomes available. Paper CRFs and worksheet templates are available as tools to assist in capturing the required data elements prior to online data entry. Copies of these paper CRFs/worksheets can be downloaded from our website ().

In the event that additional clarification is required; please contact the Project Assistant (PA) or the Project Leader (PL).

Study Contacts

▪ Principal Investigator

Dr Daren Heyland

Clinical Evaluation Research Unit

Kingston General Hospital

Angada 4, 76 Stuart Street

Kingston

ON Canada

K7L 2V7

Tel: 613 549 6666 ext. 3339

Fax: 613 548 2428

Email: dkh2@queensu.ca

▪ Project Leader

Naomi Cahill

Clinical Evaluation Research Unit

Kingston General Hospital

Angada 4, 76 Stuart Street

Kingston

ON Canada

K7L 2V7

Tel: 613 549 6666 ext. 2812

Fax: 613 548 2428

Email: cahilln@kgh.

▪ Project Assistant

Lauren Murch

Clinical Evaluation Research Unit

Kingston General Hospital

Angada 4, 76 Stuart Street

Kingston

ON Canada

K7L 2V7

Tel: 613 549 6666 ext. 4146

Fax: 613 548 2428

Email: murchl@kgh.

▪ Technical Support

Fernando Ferrer

Kingston General Hospital

Angada 4, 76 Stuart Street

Kingston

ON Canada

K7L 2V7

Tel: 613 549 6666 ext. 3695

Fax: 613 548 2428

Email: ferrerf@kgh.

Acronyms

ABGs Arterial Blood Gases

APACHE II Acute Physiology and Chronic Health Evaluation II

CCN Critical Care Nutrition

CERU Clinical Evaluation Research Unit

CRF Case Report Form

eCRF Electronic Case Report Form

EN Enteral Nutrition

FTE Full time equivalent

GCS Glasgow Coma Score

ICU Intensive Care Unit

PA Project Assistant

PL Project Leader

PN Parenteral Nutrition

QI Quality Improvement

RD Registered Dietitian

RT Respiratory Technician/Therapist

General Guidelines

Ethics

As this is a quality improvement (QI) project, ethical committee approval is not usually required. We have received ethics approval from Queen’s University, Kingston, Ontario, Canada to conduct this survey and publish the results. However, you may still want to contact your local ethics committee to check if additional approval is needed. For more information please refer to the document ‘Preparing for Ethics Submission’ available on our website.

Accessing the Website

▪ The Clinical Evaluation Research Unit (CERU) will provide a username and password only to individuals who have registered to participate in the International Nutrition Survey 2009, and to those that have been granted access by these registrants.

▪ The Web Based Data Capturing System for the International Nutrition Survey can be accessed by following the International Survey login link on the website, or directly at .

▪ All users must log onto the website using their own username and password prior to data entry.

▪ Prior to accessing the website, first ensure that your browser is configured appropriately. For more information please refer to the help document on our website and on the login page.

▪ When you log in, you will be taken to the appropriate page based on the ICUs that you have access to. If you are registered for more than one ICU, you will be taken to the ‘My ICUs’ page. If you are registered for a single ICU, you will be taken to the appropriate ICU status page.

▪ Your user profile and password can be changed at any time by clicking the appropriate links on the International Nutrition Survey home page.

Completion of Electronic Case Report Forms

▪ All data collection activities will be completed on the web.

▪ Only patients meeting inclusion criteria should be entered on the web. See page 14.

▪ Dates are entered using YYYY/MM/DD format i.e. 2009/09/16. To ensure that proper date format is obtained, click on the calendar icon and select the appropriate date. The date field will automatically be completed for you.

▪ Enter all times using the 24-hour period format i.e. 22:37. To ensure a proper time format the web system will automatically enter a colon for you or you can manually enter a colon or semi-colon.

o Midnight (24:00 hours) should be entered as 00:00

o Enter all times as four digit codes (e.g. 7:26AM must be entered as 07:26)

▪ To access eCRFs single click the appropriate link using the left side of your mouse.

▪ The data field only supports numerical data and will not recognize a unit suffix (e.g. Kg, Kcal, mmol). Enter all data without units. All units are displayed next to the appropriate data field.

▪ To expand a menu or taxonomy click on ‘+’ next to the title of the menu/taxonomy. To collapse the menu or taxonomy click on ‘-‘.

▪ Do not press ‘enter’ on your keyboard to skip to the next field on an eCRF; this could cause you to be directed to the next page of data entry, and the current page may not be saved. Please use the ‘tab’ key or simply click on the field for which you wish to enter data for.

▪ The RESET form button will take you back to the last saved version.

▪ The EXIT form button will take you back to the ICU or Patient Status page.

Edit data entered on the web

To edit previously saved information, access the appropriate eCRF, change the appropriate field(s) and save the form. To ensure Good Clinical Practice is maintained, all changes will be tracked and logged by the computer program. You cannot delete patients. Please contact technical support if you need to delete a date, or contact the Project Assistant if you have any other queries regarding editing or deleting data.

Duration of Data Collection

▪ All daily nutrition data needs to be collected from Study day 1 and each day following until day 12 unless ICU discharge (actual) or death occurs before day 12

▪ If a patient is re-admitted to your ICU within 48 hrs of discharge, consider this to be a continuation of the previous stay. If a patient is re-admitted to your ICU after 48 hours of discharge, this is not considered to be a continuation of previous stay and patient cannot be included in the survey again.

Time frames for completion of data entry

▪ The web pages are to be completed retrospectively but it is encouraged that data is entered online as soon as possible after it is collected.

▪ Deadline for completion of data entry:

o 1st December 2009

o If you have concerns regarding this deadline date, please contact the Project Assistant

Finalizing Patients

The web based data entry system has been programmed to recognize when the patient is eligible for finalization (i.e. no outstanding queries and a minimum of three days data entered). At this point, you can access and complete the Outcomes page for this patient and the patients’ status will change to ‘Finalized’. When all 20 patients have been finalized, navigate back to the ICU status page and click on “Edit ICU Information”. Scroll down and select the box that asks ‘Is data entry finalized at your ICU?’.

Critical Care Nutrition Website

The Critical Care Nutrition website will be the gateway for accessing the web application’s login page. Go to the website and click on ‘Register / Login’ under ‘International Survey 2009’ or access the login site directly at .

Regular updates and useful information regarding the International Nutrition Survey will also be posted on this website so please check it regularly.

Webshot of

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Survey Login Page and Registration

User and ICU Site Registration can be completed any time between September 1st 2009 and September 16th 2009. We will notify all individuals that have expressed interest in participating in the survey when registration is open.

Prior to entering data for your ICU, you will first need to create a user account for your ICU. This only needs to be completed once. Although several individuals can have access and enter data for your ICU site, we ask that the individual coordinating the survey at your ICU site take responsibility for this initial registration process.

User Registration

▪ Go to survey login page and click on ‘Create a new login account’.

▪ Complete the questions about yourself (Form A, Part A).

▪ Complete your login information (i.e. select and confirm a password and complete human user verification).

▪ Click on ‘Save User’.

▪ You will be sent an e-mail confirming that you have successfully registered your ICU site and you will be provided with your username. All usernames start with the prefix ccn followed by four digits.

ICU Registration

▪ Go to the survey login page and enter your username and password.

▪ You will be asked to complete questions about your hospital and ICU (Form A, Part B).

▪ Click on ‘Save ICU’.

▪ You will be directed to the ICU status page and can begin to enter patient data.

▪ If you wish to register more than one ICU, on the ICU status page, click on ‘Register New ICU’.

o After clicking on ‘register new ICU’, you will be directed to the hospital registration page, which you must fill out for each ICU, even if ICUs are located in the same hospital. After completion of this page, you will be directed to the ICU registration page.

▪ You can edit your user profile and hospital / ICU details or change your password at any time by following the appropriate links.

Grant Permission to Other Users

▪ If you wish to grant permission for other users, on the ICU status page, click on ‘grant permissions for this ICU to other users’, enter their e-mail addresses and click on ‘grant permissions’. This will generate an e-mail to new users with a username and temporary password to access the survey.

▪ Consent to participate: Checking this box tells us that you have read the information about the study and understand its purpose. It will allow us to compute benchmarked site reports comparing your performance with other ICUs in the dataset. All data will be aggregated, so that individual patients will not be identifiable and other sites will not be able to identify your ICU. Consenting to participate also allows us to correctly acknowledge your participation on the website and other publications.

▪ Password: Select a password for your personal account. The password is case sensitive (i.e. it must be typed with the required capitalization) and must be at least 6 characters long. Do not type spaces between characters and do not use repeating characters (i.e. aaaaaa). To secure your password please select a combination of characters that will not be easily guessed by others, and don’t write down your password or share it with anyone else.

▪ Forget your Password? : If you forget your password, click on the ‘forget your password?’ tab on the login page. Enter your e-mail address and complete the human user verification. You will be sent an e-mail with your username and a temporary password. Please change your password when you next login to the survey.

▪ Human User Verification: You must type the letters or numbers you see in the box to confirm that a person is trying to access the survey and not an automated program. This helps to prevent automated programs from misusing the survey.

▪ Registration e-mail: Please be aware that your username will be sent to you by e-mail shortly after you register (or after you are granted permissions), as the source of the e-mail may not be recognized by your provider please remember to also check your junk mail in the event that the survey e-mail is diverted to this folder.

▪ ICU Registration: Although you may be aware of the answers to these questions about your hospital and ICU, we request that you ask the medical or nursing director of your ICU to answer questions related to the type of ICU and case mix.

▪ Multiple ICUs: If your hospital has multiple ICUs, please enter YES when prompted, enter your ICU name. Make sure that you select a name for your ICU that is distinct from the other ICUs in your hospital (e.g. medical, surgical, trauma, neuro)

▪ Type of Hospital: A teaching hospital is a hospital that provides training to medical student and residents. If your hospital only has occasional medical students/residents, record your hospital as a non-teaching hospital.

▪ ICU Structure: Open ICUs are sites where patients are under the care of an attending physician (e.g. internist, family physician, surgeon) with intensivists (i.e. physician with training in critical care) consulted as necessary. Closed ICUs are sites in which patients are under the care of an intensivist, or care is shared between the intensivist and another attending physician.

▪ Full Time Equivalent Dietitian: This is a measure of the amount of time the dietitian is dedicated to the ICU relative to a full-time position e.g. a FTE of 1.0 means that the dietitian works in the ICU full-time and a FTE of 0.5 means that the dietitian is in the ICU half-time, or two and a half days a week.

▪ Grant permissions: If more than one person is entering data for your ICU, the primary user will be provided with an option to authorize other users to access your ICU site account. The new users will be sent an e-mail with their own username and password.

Webshot of Login Page

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Welcome ‘Home’ Page

My ICUs

▪ This will be your ‘home’ page if you are registered for more than one ICU.

▪ This page will display a list of ICUs for which you have been granted permission to enter data. The list will include the name of the ICU, the number of patients registered and the number of patients finalized.

▪ Clicking on a specific ICU will take you to the ‘ICU Status’ page for that ICU.

▪ You can enter the ‘My ICUs’ page at any time by clicking on the appropriate links on the menu.

ICU Status Page

▪ This will be your ‘home’ page if you are registered for a single ICU.

▪ This page displays a list of all the patients registered at your ICU. The list includes the patient number, basic demographic data, and the patient’s status. The statuses are:

o In progress: The patient has less than three days of data entered, and/or there are outstanding queries. The patient is therefore not eligible for finalization.

o Eligible for finalization: The patient has no outstanding queries and has a minimum of three days of data entered, and is therefore eligible for finalization.

o Finalized: Data entry, including outcomes, is complete, with no outstanding queries.

▪ Click on the line containing details about a specific patient to navigate to the Patient Status page for that patient.

Menu

▪ My ICUs. To view a summary of all registered ICUs and the number of patients registered and finalized click on the ‘My ICUs’ left hand menu.

▪ ICU Status. To view a summary of the number of patients registered at a single ICU and the number of patients finalized click on the ‘ICU Status’ left hand menu.

▪ Register New Patient. To register a new patient, click on ‘register new patient’ on the left hand side menu.

▪ Edit User Profile. To change your personal information click on ‘edit user profile’ on the left hand side menu

▪ Change password. To change your password, click on ‘change password’ on the left hand side menu. You will then be asked to enter your old password, and you will be able to enter and confirm a new password.

▪ Contact Us. On the left hand side of the menu click on ‘contact us’ to view the contact details of the Project Assistant, Project Leader and Technical Support.

▪ Help. To access documents related to the study and how to navigate the web-based data collection tool click on ‘help’ on the left hand side menu.

▪ Log Out. To log out of the web system and return to the login page click on “Log out’ on the left hand side menu.

Webshot of ‘My ICUs’ Page

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Webshot of ‘ICU Status’ Page

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Patient Status Page

▪ After clicking on a specific patient on the ICU Status Page you will be directed to the Patient Status page.

▪ From this page you can view, enter data, or edit information for all International Nutrition Survey related eCRFs.

▪ If you ‘save’ any eCRF, you will be directed back to this page.

▪ To review or edit daily nutrition data, click on the row corresponding to the study day, or click on “new observation” to add a new study day.

▪ To review or edit EN or PN data, click on ‘Yes’ in the appropriate column.

▪ Outstanding issues for each patient can be viewed from the patient status page; click on the ‘+’ sign beside ‘Outstanding Issues’ to view any issues for that patient. Click on ‘fix’ beside any issue to be directed to the page where the discrepancy or error exists.

Webshot of Patient Status Page

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Screening

You must begin to identify study patients on 16 September 2009 (or nearest possible date thereafter).

The Screening Log is not part of the data collection process but has been developed as a tool to help you to identify which patients in the ICU meet the inclusion criteria. We will not be asking you to enter any specific information from this forum online. As a part of the final step of your online data entry process, however, we will be asking:

• The total number of patients screened

• Of screened patients, the number intubated and ventilated within the first 48hrs of admission to ICU

• Of screened, ventilated patients, the number who stayed in the ICU ( 3 days

• Number of eligible patients (i.e. ventilated within 48hrs and stayed ( 3 days) at your site included in the survey

Eligibility Criteria

Inclusion:

• Critically ill patients that are mechanically ventilated within the first 48 hours of admission to ICU.

• Are in the ICU ( 3 days.

• Adult patients (i.e. ( 18 years).

Exclusion:

• Patients on mask ventilation.

• Patients who were not ventilated within the first 48 hours of admission to ICU but became ventilated after.

Duration of Ventilation does not matter. Patients that were ventilated within the first 48 hours of admission to the ICU, then came off the ventilator and stay in the ICU > 3 days, still meet the eligibility criteria. If the patient is ventilated prior to admission to the ICU they meet the eligibility criteria.

To identify the 20 eligible study patients, complete the following steps:

▪ Go to your ICU and record the initials of ALL patients that are currently in your unit on this day in Column 1 of the Screening Log.

▪ In Column 2, record only those patients from Column 1 that were intubated and ventilated within the first 48 hrs of admission to ICU or prior to ICU admission.

▪ In Column 3, list only those patients from Column 2 that were in ICU ( 3 days.

▪ In Column 4, number the patients from Column 3 consecutively and these are your eligible study patients.

▪ In Column 5, enter the number the patient was allocated by the web-based data capture system (if different from Column 4).

▪ If you have less than 20 patients in your cohort of study patients on 16 September 2009, continue to screen daily until you get a minimum of 20 consecutive patients.

▪ For patients that are just admitted and are ventilated, please follow them up for 72 hours to see if they stay in the ICU ( 3 days, as they will also be included.

▪ Please keep the Screening Log to help track down which patient corresponds to which patient number in case we have data queries at a later date.

Consecutive Patient: the very next patient that was admitted that meets the criteria. Please do not ‘pick and choose’ patients randomly.

Inclusion Criteria:

o Include the patient if he/she is physically in the ICU at time of screening and meets the criteria even if they are ready for discharge from the ICU and are waiting for a bed on the ward.

o If the patient has had several admissions to the ICU, use the most recent admission.

o If a patient is discharged from the ICU but re-admitted within 48 hours consider that this patient never left the ICU.

o If there is a patient in the ICU on 16 September 2009, is ventilated and was admitted less than 72 hours ago, for example 14 September 2009, please follow the patient up and see if he/she stays in the ICU > 72 hours. If so, you will need to collect daily data from date of admission onwards to a maximum of 12 days (or death or discharge from the ICU). This can be done retrospectively at the end of the 12 days if you prefer.

o If the patient is in the ICU on 16 September 2009 and was admitted 01 August 2009, you need to collect daily from 01 August 2009 onwards until 12 August 2009.

o If charts are missing and you are unable to collect the relevant data for this patient, please exclude and include the next eligible consecutive patient.

Patient Baseline Form

This page is to be filled out once for each patient.

ICU Admission: If a patient was admitted to the ICU, then discharged or transferred and then readmitted to the ICU, enter the date of the most recent admission to the ICU. If a patient is transferred from another ICU enter the date of admission to your ICU.

Date and time of mechanical ventilation in ICU: This refers to invasive mechanical ventilation i.e. intubation with mechanical ventilation or tracheostomy with mechanical ventilation. This includes any positive pressure delivered via an endotracheal tube or a tracheostomy. This does not refer to non-invasive methods of ventilation such as BI-PAP or mask-CPAP. For the patient that is mechanically ventilated prior to admission to your hospital, this is the same as the admission date and time to your hospital, including patients undergoing outpatient surgery. Simply check the box ‘ventilation initiated prior to ICU admission’.

Admission Category: Choose the most suitable from Medical or Surgical. If surgical indicate if this is elective or emergency surgery.

Admission Diagnosis: View the ICU Admission Taxonomy provided (see Appendix). This is the diagnosis that resulted in the patient’s admission to ICU. If the patient’s admission category is Medical, choose the most suitable diagnosis from the Non-Operative list of the Taxonomy (i.e. 1 to 49). If the patient’s admission category is Surgical, choose the most suitable diagnosis from the Post-Operative list of the Taxonomy (i.e. from 50-86). If the Admission Diagnosis is not present in the taxonomy, look for the appropriate condition (based on admission category) and choose “Other” and type in the diagnosis. For example, if Admission Category is Non-Operative and Admission Diagnosis is Acute Renal Failure, choose “Other Metabolic disease (#44)” and type in “Acute renal failure”. We are specifically interested in reporting on patients with sepsis, pancreatitis, bariatric surgery, ARDS, and burns, therefore if a suitable diagnosis for a patient includes one of these conditions please select in preference to other diagnoses (e.g. if a patient is admitted with pneumonia or sepsis, select sepsis).

Presence of Acute Respiratory Distress Syndrome (ARDS): ARDS is an acute lung condition characterized by PaO2:FiO2 < 200 mmHg in the presence of bilateral alveolar infiltrates on chest x-ray. You are not expected to diagnose ARDS. You only need to review the chart for the first 72 hrs from admission to the ICU for either a confirmed or suspected diagnosis of ARDS. If the chart says “? ARDS”, this is suspected ARDS, enter Yes.

Highest/Lowest Blood Sugar within first 24 hours of admission: Indicate if blood sugar recorded within the first 24 hours of admission. If yes, please record the highest and lowest values in mmol/l. If reading is in mg/dL multiply by 0.0555 to convert to mmol/L.

Head of Bed Elevation: Head of the bed should be observed at screening (i.e. when the patient is first included in the survey). For determining head of the bed elevation, use the device that the ICU bed is equipped with. If no such device is available, you will need to estimate the angle and we suggest that you do this with another team member i.e. RN, RT, etc. When you are estimating, please note if the patient has pillows under his/her head. If there are pillows, make sure that you record the angle at which the patient’s trunk meets the bed instead of the angle between the head and the pillow.

See figure below:

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Head of Bed Elevation is the only data element to be completed prospectively, consequently it is an OPTIONAL field.

APACHE II Score: If routinely calculated directly enter score, if unavailable, leave field blank and you will be directed to the Apache II Online Worksheet.

Webshot of Patient Baseline Form

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APACHE II

Note: Use values from the first 24 hours from admission to ICU.

▪ You will only need to complete this page if the patient does not have an Apache II score entered in the patient baseline form.

▪ Please note that, as in all forms, pressing the ‘enter’ key will save the form and direct you back to the patient status page. Please click on the field you would like to enter a value for, or use the ‘tab’ key to jump between fields.

▪ Enter the lowest and highest value recorded in the source documentation within the first 24 hours from admission to ICU. The value that generates the highest severity score will be selected by the web application.

▪ When you enter the values in the right-hand columns, the severity score will be automatically calculated.

▪ Note: If variables are not available from the first 24 hrs, go outside the 24-hour window and use the data closest to ICU admission. Use the Comment Box to indicate that you used data outside the 24-hour window.

▪ Age will be automatically transferred from previous web page.

▪ Temperature: Enter the value and indicate, core, oral, axilla or tympanic listed in the second drop box.

o The program will re-calculate to the appropriate core temperature.

o Rectal, tympanic, temporal, and bladder temperatures are considered as core temperature.

o For manual calculations of APACHE: To obtain the core temperature: if oral temperature is reported, add 0.5 (C to oral temperature; if axilla temperature is reported, add 1.0(C.

▪ Enter the systolic and diastolic blood pressures in the appropriate box. Once these values have been entered the Mean Arterial Pressure (MAP) value will automatically be calculated and entered in the right-hand column.

▪ Heart Rate: enter the highest and lowest value.

▪ Respiratory rate: (either ventilated, or non-ventilated)

▪ Oxygenation:

o If the FiO2 is > 0.5, the PaCO2, and the PaO2 boxes appear. Enter the values into the appropriate boxes. Again, the program will calculate the A-aD02 and enter the value in the right-hand column. For the purposes of this trial the barometric pressure value will be standardized at 713.

o If the FiO2 is < 0.5, only the PaO2 box will appear. Enter the value.

o If no arterial blood gases (ABGs) are available, check the appropriate box and enter the HCO3 in place of arterial pH. Serum HCO3 should only be used if there are no ABGs available in the previous 24 hours.

o For manual calculations of APACHE: In the event that the FiO2 is > 0.5 and multiple gases are available, you will need to calculate the A-aD02 (alveolar arterial gradient) manually to obtain the highest and lowest scores. To calculate the A-aD02, you must use the variables from the same gas.

▪ Arterial pH.

▪ Serum Sodium: the unit of measure is mmol/L.

▪ Serum Potassium: the unit of measure is mmol/L.

▪ Serum Creatinine: the unit of measure is µmol/L. If you require a definition of Acute Renal Failure, click on “Explain” and definitions will be provided.

▪ Hematocrit: enter this value as a percentage.

▪ White Blood Cells (total/mm3)(in 1000’s).

▪ Glasgow Coma Score (GCS): If this patient has a GCS documented in their chart for the first 24 hours after ICU admission, directly enter the score. Otherwise, to determine the GCS choose the best eye, verbal and motor response for the first 24 hours after ICU admission. If the patient is sedated, then go back to the period when the patient was not receiving sedation or approximate what the score would be if the sedation where to be removed. See worksheet or CCN website for GCS flow sheet. If you are unable to calculate a pre-sedation GCS, assume that the GCS is normal and enter a score of 15. Enter the values in the 3 separate categories and the GCS will automatically be calculated.

Eye Opening:

4-Spontanous

3- To speech

2- To Pain

1- None

Verbal Response:

5- Oriented

4- Confused

3- Inappropriate words

2- Incomprehensible words

1- None

Best Motor Response:

6- Obeys commands

5- Localizes to pain

4- Withdraws from pain

3- Abnormal flexion

2- Extension

1- None

▪ Chronic Health Points: Choose one of the 3 categories for patients with a history of severe organ system insufficiency or immunocompromised – Click “Explain” box on the left hand side of the screen for definitions.

▪ When all the categories are completed, click on the box labeled “Save Apache II Form” and the system will automatically save and calculate your Apache Score.

Webshot of Apache II Form

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Baseline Nutrition Assessment

This form is to be filled out once for each patient.

▪ Record height in metres and weight in kilograms at time of ICU admission. If unable to obtain “actual” height or weight, use estimated height and weight or that obtained from family members and check the appropriate box to indicate that data was estimated.

▪ For weight used to determine prescribed energy requirements, choose from the list.

|Code |Weight |

|1 |Actual (ABW) (Measured or estimated) |

|2 |Ideal (IBW) based on Hamwi formula |

|3 |Ideal (IBW) based on BMI 20-25 Kg/m2 |

|4 |Adjusted by 25% (ABW x 0.25 + IBW) |

|5 |Adjusted by 40% (ABW x 0.4 + IBW) |

|6 |Adjusted average ((ABW + IBW) x 0.5) |

|7 |No weight used in calculation |

|8 |No assessment completed |

|9 |Other, please specify |

▪ For determination of energy requirements choose from the list.

|Code |Predictive Equation |

|1 |Harris Benedict Equation |

|2 |Schofield Equation with no adjustment for stress and activity |

|3 |Schofield Equation with adjustment for stress and/or activity |

|4 |Mifflin-St. Jeor Equation |

|5 |Ireton-Jones Equation |

|6 |Weight based ................
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