Prolonged-ventilation Weaning - Michael Garron Hospital
3237689-81225Insert Patient ID Sticker00Insert Patient ID StickerPWC RAPID SCREENING FORMProlonged-ventilation WeaningCentre (PWC) of ExcellencePhone: 416 469 6580 ext. 6841 Fax: 416 469 7717 prolonged.Ventilation@tehn.caPlease check boxes for potential PWC candidatesQuestionYesNoRespiratoryHas been invasively mechanically ventilated (MV) FORMCHECKBOX FORMCHECKBOX Date of initiation of MVWould they be capable of spontaneous mode of ventilation? FORMCHECKBOX FORMCHECKBOX Has or is being considered for tracheostomy insertion FORMCHECKBOX FORMCHECKBOX If yes, date of insertion?If yes, are they participating in trach mask or optiflow trials? FORMCHECKBOX FORMCHECKBOX NeurologicalIs awake and able to respond appropriately to questions FORMCHECKBOX FORMCHECKBOX Would be able to operate a standard call bell FORMCHECKBOX FORMCHECKBOX If physical or chemical restraints in use, please describe indicationCardiovascularDoes not currently require vasopressors or inotropes FORMCHECKBOX FORMCHECKBOX GUDoes not require dialysis? FORMCHECKBOX FORMCHECKBOX GIHas or is being considered for a PEG tube for enteral diet? FORMCHECKBOX FORMCHECKBOX Goals of CarePatient and/or substitute decision maker consents to PWC consultation FORMCHECKBOX FORMCHECKBOX Current code status ____________________________________If you are able, please describe briefly the reason for ICU admission:162016537 020000 If you are able, please describe briefly the patient’s medical comorbidities451214930 020000 ................
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