Data Collection Tool - Eastern Association for the Surgery ...

Data Collection Tool

Standard Study Questions: Admission Date: Admission Time: Age: Gender:

Specifics of Injury: Time of Injury: Mechanism of Injury

Blunt vs Penetrating? Injury Severity Score? Injuries: Chest Abbreviated Injury Score: Initial GCS:

Intubation: Time of Intubation: Location of Intubation: Initial Ventilator Settings Prior to Initiation of Protocol: Date/Time of Initiation of Protocol:

Volume: Volume of crystalloid infused prior to Initiation of Protocol: Blood products Infused Prior to Initiation of Protocol:

PRBC Volume: FFP Volume: Platelet Volume: Total crystalloid infused while intubated: Total blood products infused while intubated PRBC volume: FFP volume: Platelet Volume:

Admission Values Hemoglobin: ABG: Lactate: Base Deficit: BUN: Creatinine: Vitals: PF Ratio:

Hospital Course:

Ventilator Settings and Changes: Date/Time Pulse Ox EtCO2 ABG

Ventilator Settings (per protocol)

Vasopressor and Inotrope Usage:

Date/Time

Vasopressor/Inotrope

Dose

Renal Function Date/Time

BUN/Cr

UOP6 hours in previous 24 hours

Complications Hospital Acquired Pneumonia? Ventilator Associated Pneumonia? Blood Stream Infection? Catheter Associated Urinary Tract Infection? Sepsis? DVT/PE? Acute renal Failure? Acute Renal Failure Requiring Renal Replacement Therapy? Acute Respiratory Distress Syndrome?

Mild/Moderate/Severe?

Tracheostomy required? Number of ventilator days? Number of ICU Days? Number of hospital days? Mortality within 28 days of admission? Mortality within 48 hours of admission? Extubation within 48 hours of admission?

Neurologic Assessment: GCS at time of extubation: GCS at time of transfer out of ICU: GCS at hospital discharge:

East Multicenter Study Data Dictionary

Preemptive APRV Study-Data Dictionary

Entry Space

Definition/Instructions

Standard Study Questions: Admission Date Admission Time Age Gender

Admission date of the patient enrolled Admission time of the patient enrolled Age of the patient enrolled Gender of the patient enrolled

Specifics of Injury: Time of Injury Mechanism of Injury

Blunt

Estimated time the injury occurred

Single choice for best description of blunt mechanism MVC (motor vehicle collision) Auto vs Pedestrian Fall Assault MCC (motorcycle collision) Machinery Other

Penetrating

ISS Injuries AIS Chest Initial GCS

Single choice for best description of penetrating mechanism GSW (gunshot wound) Shotgun wound Stab wound Other Numerical value for calculated ISS (Injury Severity Score) All documented injuries discovered throughout hospitalization Numerical value for AIS of chest (Abbreviated Injury Score) GCS at time of presentation to facility (Glascow Coma Score)

Intubation: Time of Intubation Location of Intubation

Initial Ventilator Settings Date/Time of Initiation

Time the patient enrolled was intubated Single choice for best description of location of intubation On scene Ambulance/Helicopter Trauma Bay ICU Ventilator settings prior to initiation of protocol Date/Time of initiation of protocol

Volume:

Volume of crystalloid prior Volume of crystalloid infused prior to initiation of protocol

Blood products prior

Blood products infused prior to initiation of protocol

pRBC Volume

Volume of pRBCs prior to initiation of protocol

FFP Volume

Volume of FFP prior to initiation of protocol

Platelet Volume

Volume of Platelets prior to initiation of protocol

Total Crystalloid infused

Total volume of crystalloid infused while patient was intubated

Total Blood Products Infused Total volume of blood product infused while intubated

Total pRBC Volume

Total volume of pRBCs infused while intubated

Total FFP Volume

Total volume of FFP infused while intubated

Total Platelet Volume

Total volume of platelets infused while intubated

Admission Values: Hemoglobin ABG Lactate Base Deficit BUN Creatinine Vitals

P/F Ratio

Admission hemoglobin (g/dL) Admission ABG (pH/PCO2/PO2/HCO3) Admission Lactate (mmol/L) Admission Base Deficit (mmol/L) Admission BUN (mg/dL) Admission Creatinine (mg/dL) Admission Vitals (temperature/heart rate/blood pressure/respiratory rate/SpO2) Admission PO2/FiO2 ratio

Hospital Course

Ventilator Settings and Changes

Date/Time

Date and time of ventilator changes per protocol

Pulse Ox

Pulse oximetry at time of each ventilator change

EtCO2

End Tidal CO2 at time of each ventilator change

ABG

ABG (if obtained) at time of each ventilator change

Ventilator Settings

Change made at that time to the ventilator, per protocol

Vasopressors and Inotrope Usage

Date/Time

Date and time of initiation of change in drip settings

Vasopressor/Inotrope

Name of vasopressor and or inotrope used

Dose

Dose at time of change of each vasopressor and inotrope

Renal Function Date/Time BUN/Cr UOP

Date and time of lab draw The value of both BUN and Creatinine at time of lab draw On the date specified, did urine ouput drop to less than 0.5mL/kg/hr for more than 6 consecutive hours? Yes/No

Compliations: Hospital Acquired Pneumonia

Ventilator Associated Pneumonia Blood Stream Infection Catheter Associated Urinary Tract Infection

Sepsis

DVT/PE Acute Renal Failure

Yes/No Confirmed by the presence of the following 48 hours after hospitalization 1. Purulent sputum 2. Associated systemic evidence of infection

a. WBC >11 or 38 C 3. 2 or more serial CXR with new or progressive and persistent infiltrates, consolidation, or cavitation 4. BAL, mini BAL, or sterile endotracheal specimen with a. Limited number of epithelial cells b. WBC (2-3+) c. Dominant organism(s) identified on gram stain or

culture with quantitative culture>100,000 cfu/mL Yes/No Hospital acquired pneumonia (as defined above) in a patient who was intubated and ventilated at the time of or within 48 hours of onset of pneumonia Yes/No Positive blood cultures obtained from blood culture

Yes/No All of the following must be met 1. Patient has had an indwelling catheter within 7 days

before urinary culture 2. Positive urine culture, that is 105 microorganisms/mL of

urine with no more than two species of microorganisms 3. Urine culturehas 10wbc/hpf Yes/No Confirmed infectious process AND 2 or more of the following 1. Body temperature 38 C 2. Heart rate > 100bpm 3. Respiratory rate >20 breaths per minute or, on blood gas,

PaCO2 of less than 32 mm Hg 4. White blood cell count 12 or greater than 10%

immature WBCs Yes/No Deep vein thrombosis or pulmonary embolism with radiographic confirmation (ultrasound, computed tomography, venography) Yes/No Defined as one of the following 1. An increase in serum creatinine by >0.3mg/dL within 48

hours 2. An increase in SCr to >1.5 times baseline which has

occurred in the previous 7 days 3. Urine volume ................
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