Tick if Yes and Other advanced therapies e.g. ECMO, 13 Other Invasive Therapy comment oscillation, MARS Written documentation in history that 14 Not for Resuscitation Order Tick if Yes patient is not for Resuscitation, CPR, etc Written or verbal order that patient will 15 Not for Return to ICU Tick if Yes not be readmitted to ICU in the event of deterioration Written that patient should not have 16 Not for cardiac arrest team Tick if Yes the cardiac arrest team called in the event of deterioration Written that patient should not have Not for emergency (MET) 17 Tick if Yes MET call in the event of deterioration Call where a MET service exists Tracheostomy in place on discharge 18 Tracheostomy Tick if Yes from ICU Ventilation via nasal or full face mask on discharge from ICU. Excludes CPAP 19 Non-invasive ventilation Tick if Yes for sleep apnoea, high flow nasal oxygen Infusions of inotropes for augmentation 20 Inotrope Infusion Tick if Yes of blood pressure or cardiac output on discharge from ICU On discharge from ICU, it is planned 21 Ongoing Renal Replacement Tick if Yes that the patient will continue with dialysis (HD, PD, HF etc) On discharge, patient continues or will 22 TPN Tick if Yes receive TPN On discharge, any departure from 23 Altered conscious state Tick if Yes normal conscious state (GCS=15). Includes confusional state Total GCS around time of discharge. If Glasgow Coma on patient has tracheostomy, estimate if 24 Number discharge from ICU they can talk normally for full verbal points On discharge, a written medical Written Medical Discharge 25 Tick if Yes discharge summary is in the medical Summary record On discharge, a written nursing Written Nursing Discharge 26 Tick if Yes discharge summary is in the medical Summary record Medical Handover On discharge, written documentation of 27 Tick if Yes Documented handover to medical on ward
13 Other Invasive Therapy Tick if Yes and comment Other advanced therapies e.g. ECMO, oscillation, MARS 14 Not for Resuscitation Order Tick if Yes Written documentation in history that patient is not for Resuscitation, CPR, etc 15 Not for Return to ICU Tick if Yes Written or verbal order that patient will not be readmitted to ICU in the event of deterioration 16 Not for cardiac arrest team Tick if Yes Written that patient should not have the cardiac arrest team called in the event of deterioration 17 Not for emergency (MET) Call Tick if Yes Written that patient should not have MET call in the event of deterioration where a MET service exists 18 Tracheostomy Tick if Yes Tracheostomy in place on discharge from ICU 19 Non-invasive ventilation Tick if Yes Ventilation via nasal or full face mask on discharge from ICU. Excludes CPAP for sleep apnoea, high flow nasal oxygen 20 Inotrope Infusion Tick if Yes Infusions of inotropes for augmentation of blood pressure or cardiac output on discharge from ICU 21 Ongoing Renal Replacement Tick if Yes On discharge from ICU, it is planned that the patient will continue with dialysis (HD, PD, HF etc) 22 TPN Tick if Yes On discharge, patient continues or will receive TPN 23 Altered conscious state Tick if Yes On discharge, any departure from normal conscious state (GCS=15). Includes confusional state 24 Glasgow Coma on discharge from ICU Number Total GCS around time of discharge. If patient has tracheostomy, estimate if they can talk normally for full verbal points 25 Written Medical Discharge Summary Tick if Yes On discharge, a written medical discharge summary is in the medical record 26 Written Nursing Discharge Summary Tick if Yes On discharge, a written nursing discharge summary is in the medical record 27 Medical Handover Documented Tick if Yes On discharge, written documentation of handover to medical on ward
CCM_45_2_2016_07_22_SANTAMARIA_CCMED-D-16-00194_SDC1.docx