USCIITG-PREP Common Data Set CRF version 3.0 Page 1 of 7
Patient Data – Common Data Set Case Report Form
1.0 PATIENT DEMOGRAPHICS
1. Gender: 1 Male 2 Female 0 N/A
2. Age (use estimate if not available): __ __ __ years 0 N/A
3. Race: 0 N/A
1 White 2 Black 3 Asian/Pacific islander
4 American Indian/Alaskan native 5 Other ____________
4. Hispanic: 1 Yes 2 No 0 N/A
5. Pregnant: 1 Yes 2 No 0 N/A
6. Height: ___ ___ ___ cm OR ___ ___ ___ in 0 N/A
7. Weight: ___ ___ ___ kg OR ___ ___ ___ lbs 0 N/A
2.0 PRE-HOSPITAL COURSE
1. Date of first patient encounter (MM/DD/YYYY): __ __ / __ __ / __ __ __ __ 0 N/A 2. Time of first patient encounter (HH:MM; 00:00 – 23:59): __ __:__ __ 0 N/A
3. Location of episode- (check only 1): 0 N/A
1 Public street 6 Home residence
2 Public buildings (school, government office) 7 Rural location (Farm/ranch)
3 Place of recreation (park, stadium, lake) 8 Healthcare facility
4 Industrial place (factory, construction site) 9 Insitutional residence (nursing home)
5 Other public _____________ 10 Other private ____________
4. Vital signs (worst recorded in pre-hospital setting)
a. Systolic Blood Pressure (SBP): ___ ___ ___ mmHg 0 N/A
b. Diastolic Blood Pressure (DBP): ___ ___ ___ mmHg 0 N/A
c. Pulse: ___ ___ ___ bpm 0 N/A
d. Respiratory Rate: ___ ___ bpm 0 N/A
e. Oxygen saturation (SpO2): ___ ___ ___ % 0 N/A
f. Fraction of Inspired oxygen (FiO2): __.__ __ OR ___ ___ LPM OR 1 Room air 0 N/A
5. Mode of transport to hospital 0 N/A
1 Ambulance 2 Air transport
3 Non-traditional (e.g. bus,) with clinical providers 4 Non-traditional with lay providers
5 Evaluated and released on scene
6. START Tag Team color (Highest color upon arrival to ED): 0 N/A
1 Green 2 Yellow 3 Red 4 Black
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3.0 EMERGENCY DEPARTMENT COURSE
1. Date of ED admission: __ __ /__ __ /__ __ __ __ 0 N/A
2. Time of ED admission (00:00 – 23:59): __ __ : __ __ 0 N/A
3. Duration of symptoms or injury prior to ED presentation: ___ ___ days OR ___ ___ . ___ hours 0 N/A
4. Location from which patient was admitted to the ED: 0 N/A
1 Home
2 Nursing home/Chronic care facility
3 Another hospital
4 Non-hospital institution
5 Other ___________________
5. Vital signs (worst recorded in ED)
a. Systolic Blood Pressure (SBP): ___ ___ ___ mmHg 0 N/A
b. Diastolic Blood Pressure (DBP): ___ ___ ___ mmHg 0 N/A
c. Pulse: ___ ___ ___ bpm 0 N/A
d. Respiratory Rate: ___ ___ bpm 0 N/A
e. Oxygen saturation (SpO2): ___ ___ ___ % 0 N/A
f. Fraction of Inspired oxygen (FiO2): __.__ __ OR ___ ___ LPM OR 1 Room air 0 N/A 6. Date of ED departure (e.g. admission, transfer, discharge): __ __ /__ __ /__ __ __ __ 0 N/A
7. Time of ED departure (00:00 – 23:59): __ __ : __ __ 0 N/A
8. ED disposition: 0 N/A
1 Remains in ED
2 Admit to ED observation
3 Admit to unmonitored hospital floor
4 Admit to monitored non-ICU hospital floor
5 Admit to ICU
6 Emergent surgery
7 Transfer to another acute care hospital
8 Other ____________________
4.0 PATIENT DIAGNOSES
1. Chief complaint: ____________________________ 0 N/A
2. Principal diagnosis: ____________________________ 0 N/A
3. Please select all classes of diagnoses for patient today (choose all that apply): 0 N/A
1 Nervous
2 Circulatory
3 Respiratory
4 Digestive
5 Infection
6 Endocrine
7 Renal
8 Toxic exposure (e.g. chemical, radiation, drug)
9 Trauma
10 Other ____________________
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3a. If Trauma, mechanism of injury (choose all that apply): 0 N/A
1 Motor Vehicle 2 Gunshot 3 Stabbing 4 Assault (non stabbing or gunshot)
5 Cyclist 6 Pedestrian vs Motor Vehicle 7 Hanging 8 Strangling/Suffocation
9 Drowning 10 Burn 11 Electrical Injury 12 Crush
13 Radiation 14 Chemical /Toxin Exposure 15 Infectious agent exposure 16 Other __________
3a.1. If burn, type of burn (choose all that apply):
1 Electrical 2 Chemical 3 Radiation 4 Flame
5 Steam 6 Other _____________
3a.2. Total Body Surface Area (TBSA) of burn: _____ %
3b.1. If infection, primary site of infection: 0 N/A
1 Central Nervous System 2 Lung 3 Abdomen 4 Urine
5 Skin /Soft Tissue 6 Blood Stream 7 Other_____________________
3b.2. If infection, organism(s) identified from cultures or other diagnostic tests: 0 N/A
1 Bacteria 2 Viruses 3 Fungi 4 Parasites 5 Other _______________
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5.0 SEVERITY OF ILLNESS 5.1 APACHE II Score
ACUTE PHYSIOLOGIC DATA
Lowest Highest Not Available
1. Temperature (F or C) _______ _______
2. Systolic BP (mmHg) _______ _______
3. Mean Arterial Pressure (mmHg) _______ _______
4. Heart Rate (beats/min) _______ _______
5. Respiratory Rate (breaths/min) _______ _______
6. Glasgow Coma Score (GCS)*** Total: _______ _______
OR GCS-Eyes: _______ _______
GCS-Verbal: _______ _______
GCS-Motor: _______ _______
***Please score patient as GCS of 15 if they are sedated but not known/suspected to have any brain injury (e.g. stroke, trauma). If patient is not sedated or is known/suspected to have brain injury, score the actual GCS.
HEMATOLOGY AND CHEMISTRY
Lowest Highest Not Available
7. HCT (%, e.g. 29.3) _______ _______
8. WBC (/mm3) _______ _______
9. Platelets (lowest) (x1000 / mm3) _______ _______
10. Serum Sodium (meq/L) _______ _______
11. Serum Potassium (meq/L) _______ _______
12. Serum Creatinine (mg/dL) _______ _______
13. Serum Bilirubin (highest; mg/dL) _______
14. Serum Bicarbonate (lowest; meq/L) _______
15. Arterial pH (most deranged) _______
16. pH (ABG on highest FiO2, mmHg) _______
17. PaCO2 (ABG on highest FiO2, mmHg) _______
18. PaO2 (ABG on highest FiO2, mmHg) _______
19. FiO2 (ABG on highest FiO2, mmHg) _______
20. Serum lactate (highest; mg/dL) _______
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CHRONIC HEALTH INFORMATION
21. Chronic organ insufficiency or immune-depression? 1 Yes 2 No 0 N/A
*** Answer the following questions (22a – 22g) if the above answer is ‘yes.’ Otherwise leave these blank.
22. Does the patient have any of the following chronic co-morbid medical conditions?
22a. Cancer 1 Yes 2 No
22b. Chronic kidney disease / ESRD 1 Yes 2 No
22c. Chronic lung disease 1 Yes 2 No
22d. Heart failure 1 Yes 2 No
22e. HIV / AIDS 1 Yes 2 No
22f. Chronic liver disease / cirrhosis 1 Yes 2 No
22g. Solid organ transplant 1 Yes 2 No
23. Is patient non-operative? 1 Yes 2 No
24. Is patient immediately post-operative from elective surgery? 1 Yes 2 No 25. Is patient immediately post-operative from emergent surgery? 1 Yes 2 No 5.2 Sequential Organ Failure Assessment (SOFA)
SCORE 0
(Best)
1 2 3 4
(Worst)
N/A
Cardiovascular Hypotension
(Mean Arterial Pressure (MAP) in mmHg)
□
MAP > 70 No pressor
□
MAP < 70 No pressor
□
Dopamine < 5*
Phenylephrine < 2 Dobutamine
□
Dopamine > 5*
Epinephrine < 0.1 Norepinephrine < 0.1
Phenylephrine> 2<4 Vasopressin0.03
□
Dopamine > 15*
Epinephrine > 0.1 Norepinephrine >0.1
Phenylephrine>4 Vasopressin > 0.03
□
Renal
Urine Output ml/day
□
< 500
□
< 200
□
* = Pressor agents administered for at least one hour (doses, except for vasopressin given in microgram/
kg/min. Vasopressin doses are in units/min). Vasopressin should only be used in calculation when not on another vasopressor agent.
5.3 PIM II
1. Does the patient have Severe Combined Immunodeficiency (SCID)? 1 Yes 2 No 0 N/A 2. Does the patient have acute pupillary reaction? 1 Yes 2 No 0 N/A
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6.0 INTERVENTIONS AND MEDICATIONS
1. Please indicate all settings in which the patient received the following interventions today.
Pre-hospital ED ICU N/A Neurologic
a. Intracranial pressure monitoring 1 2 3 0
b. Cervical spine immobilization 1 2 3 0
c. Therapeutic hypothermia 1 2 3 0
Pulmonary
d. Non-invasive positive pressure ventilation 1 2 3 0
e. Supra-glottic airway (e.g. King LT/COMBITUBE/LMA) 1 2 3 0
f. Invasive mechanical ventilation 1 2 3 0
g. Endotracheal tube (oral or nasal) 1 2 3 0
h. Tracheostomy/cricothoracotomy 1 2 3 0
i. Any rescue ventilation methods 1 2 3 0
i.1 High PEEP/ recruitment maneuvers 1 2 3 0
i.2 High frequency oscillation 1 2 3 0
i.3 Inhaled nitric oxide 1 2 3 0
i.4 ECMO (all types venovenous, veno-arterial, ECOR) 1 2 3 0
j. Thoracostomy tube insertion 1 2 3 0
Cardiac
k. Cardiopulmonary resuscitation (CPR; includes BLS and ACLS) 1 2 3 0
l. Central line insertion (non-dialysis) 1 2 3 0
m. Cardiopulmonary bypass 1 2 3 0
n. Cardiac pacing, cardioversion 1 2 3 0
o. Tourniqets (e.g. surgical, emergency) 1 2 3 0
Renal
p. Dialysis catheter insertion 1 2 3 0
q. Dialysis / renal replacement therapy 1 2 3 0
Miscellaneous
r. Decontamination 1 2 3 0
s. Advanced diagnostic imaging (i.e. CT scan, MRI, ultrasound) 1 2 3 0
t. Interventional radiology procedure 1 2 3 0
u. Any surgical procedure 1 2 3 0
v. Plasmapheresis 1 2 3 0
w. Hyperbaric treatment 1 2 3 0
2. Please indicate all settings in which the patient received the following types of medications today.
Pre-hospital ED ICU N/A
a. Sedatives
b. Analgesics
c. Neuromuscular blocking agents
d. Anti-convulsants
e. Anti-arrythmics
f. Crystalloid resuscitation
g. Antimicrobials
h. Antidotes, specify: ____________________
3. Did the patient receive blood products today?
3a. If yes, how many units of Packed Red Blood Cells? ___ ___ units 0 N/A 3b. If yes, how many units of Platelets? ___ ___ units 0 N/A 3c. If yes, how many units of Fresh Frozen Plasma? ___ ___ units 0 N/A
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7.0 HOSPITAL DISCHARGE OUTCOMES AND FOLLOW-UP
Note: The data in this section should be collected on the day of discharge, or as son as feasible thereafter.
1. Date of hospital discharge: __ __ /__ __ /__ __ __ __ 0 N/A
2. In-hospital withdraw of life support or limitation of support? 1 Yes 2 No 0 N/A
3. Total number of ICU days: ___ ___ days 0 N/A
4. Total number mechanical ventilation days: ___ ___ days 0 N/A
5. If the patient is discharged alive, to where is the patient being discharged? 0 N/A
1 Home 2 Inpatient rehabilitation 3 Nursing home 4 Hospice
5 Long term acute care 6 Other acute care facility 7 Other _____________________
6. Ventilator dependent at time of discharge from hospital? 1 Yes 2 No 0 N/A 7. Dialysis dependent at time of discharge from hospital? 1 Yes 2 No 0 N/A
8. Did the patient die in the hospital? 1 Yes 2 No
8a. If the patient died, where died?
1 Pre-hospital
2 Emergency department
3 ICU
4 Non-ICU hospital
5 Post-discharge