Patients Insert additional information here. 1.2 Are there any patients in your institution on extracorporeal life support (specifically a pump with an oxygenator) that are not reported to the registry and why? Insert answer here. 1.3 Check all of your specialty services available on a 24-hour/day on-call basis? (Describe plan for any services not available) ☐ ☐ Cardiology General surgery ☐ ☐ Cardiovascular surgery Neonatology ☐ Anesthesiology ☐ Neurosurgery ☐ Interventional Radiology ☐ Genetics ☐ Biomedical Engineering ☐ Social Work ☐ ☐ Neurology Nephrology ☐ ☐ Critical Care Specialist Pulmonology ☐ Hospitalist ☐ Hematology/Oncology ☐ Infectious Disease ☐ Gastroenterology ☐ Insert additional information here. 1.4 Check available support services and/or consultants that are available (Describe plan for any services and/or consultants not available) ☐ ☐ Blood gas laboratory Chemistry and hematology laboratory ☐ Blood Bank ☐ Pharmacy ☐ Cardiovascular operating room with ☐ Radiology including cranial ultrasound and cardiopulmonary bypass capabilities CAT scan ☐ Occupational and/or Physical Therapy ☐ Developmental/rehabilitation Specialist ☐ Nutritionist ☐ Pastoral Care ☐ Interpreter services Insert additional information here.
Patients Insert additional information here. 1.2 Are there any patients in your institution on extracorporeal life support (specifically a pump with an oxygenator) that are not reported to the registry and why? Insert answer here. 1.3 Check all of your specialty services available on a 24-hour/day on-call basis? (Describe plan for any services not available) ☐ Cardiology ☐ General surgery ☐ Cardiovascular surgery ☐ Neonatology ☐ Anesthesiology ☐ Neurosurgery ☐ Interventional Radiology ☐ Genetics ☐ Biomedical Engineering ☐ Social Work ☐ Neurology ☐ Nephrology ☐ Critical Care Specialist ☐ Pulmonology ☐ Hospitalist ☐ Hematology/Oncology ☐ Infectious Disease ☐ Gastroenterology ☐ Insert additional information here. 1.4 Check available support services and/or consultants that are available (Describe plan for any services and/or consultants not available) ☐ Blood gas laboratory ☐ Chemistry and hematology laboratory ☐ Blood Bank ☐ Pharmacy ☐ Cardiovascular operating room with cardiopulmonary bypass capabilities ☐ Radiology including cranial ultrasound and CAT scan ☐ Occupational and/or Physical Therapy ☐ Developmental/rehabilitation Specialist ☐ Nutritionist ☐ Pastoral Care ☐ Interpreter services Insert additional information here.
ELSOAwardApplication%202016.docx