User Manual Web Data Collection Tool

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User Manual Web Data Collection Tool

  1. 1. Handbook for Using the PSRC Web-based Data Collection Tool Joseph P. Cravero MD Introduction: This manual is meant to be used as a reference guide when answering questions for the PSRC on line data collection tool. It obviously can not be thought to have information to answer all questions. Please email Joseph.Cravero@Hitchcock.org for any further help – generally I can get back to you in a very short period of time- minutes to hours. The following text is meant as a guideline and is printed in the order that the questions appear on the data collection tool. When the question are completely obvious in nature I have not addressed them. On the other hand I have tried to give some detail on the intent of the questions if there is any way the question could be misinterpreted in my opinion. 1. Select age in months for less than 36 months or in years for any age GREATER than 36 monts. 2. Enter the weight in kilograms. Decimals are allowed. Enter -999 if data is not available. 3. Enter gender of the patient. If the gender is unknown or ambiguous, enter “data not available”. 4. Enter the ASA status: Standard references generally refer to these entities as referenced in the table below: ASA Class Description Examples 1 A normal, healthy patient, without Healthy with good exercise organic, physiologic, or psychiatric tolerance disturbance 2 A patient with controlled medical Controlled hypertension, conditions without significant controlled diabetes mellitus systemic effects without system effects, cigarette smoking without evidence of COPD, anemia, mild obesity, age less than 1 or greater than 70 years, pregnancy 3 A patient having medical conditions Controlled CHF, stable angina, old with significant systemic effects MI, poorly controlled intermittently associated with hypertension, morbid obesity, significant functional compromise bronchospastic disease with intermittent symptoms, chronic
  2. 2. renal failure 4 A patient with a medical condition Unstable angina, symptomatic that is poorly controlled, associated COPD, symptomatic CHF, with significant dysfunction and is a hepatorenal failure potential threat to life 5 A patient with a critical medical Multiorgan failure, sepsis condition that is associated with little syndrome with hemodynamic chance of survival with or without the instability, hypothermia, poorly surgical procedure controlled coagulopathy 6 A patient who is brain dead and undergoing anesthesia care for the purposes of organ donation E This modifier is added to any of the above classes to signify a procedure that is being performed as an emergency and may be associated with a suboptimal opportunity for risk modification The next screen asks about the problem the child has – in order to organize the myriad of possible choices we have organized the choices (generally) under system headings. You must choose a general system and this will allow you to navigate to a more detailed list of choices. If (at any time) you can not find a choice that is applicable for your patient – just choose “other” and describe the problem for your child in text. 5. Select the PRIMARY problem – this question is asking for the primary problem for which the patient has come in for an examination. For instance if a child with congenital heart disease and seizures is coming in for an MRI of the head to investigate the cause of the seizures – the PRIMARY problem would be found under the “Neurological Tab” and click “Seizures”. a. If the child has had a burn injury and requiring care for that injury – click “burn injury” b. Under cardiovascular disease: If the child has had cyanotic congenital heart disease that is not corrected – please click “congenital heart disease cyanotic”. If the child has had non-cyanotic congenital heart disease OR if he/she has had cyanotic congenital heart disease that has been corrected, click “congenital heart disease non-cyanotic”. If the child has had ongoing problems with hypotension – click “hypotension”. If the child has had ongoing problems with hypertension – or if the child is currently under treatment for hypertension – click “hypertension”. c. Under craniofacial – if the child has microagnathia for any reason but does not have Pierre Robin Sequence – click “microagnathia”. If the child has P-R
  3. 3. sequence, click Pierre Robin Sequence and move on to the next question. If the child has had a general anesthetic and an operating room procedure to repair a craniofacial anomaly (not craniosynostosis) – please click s/p craniofacial surgery. If the child has an unusual facies condition that does NOT specifically involve microagnathia and is not Pierre Robin Sequence please click “unusual facies”. Note: this may be a judgment call in many cases but any condition that results in a face that clearly does not look “normal” should be noted here. d. Under gastrointestinal problems – if a child has been diagnosed with GERD and is currently under treatment for the disorder – click “GERD”. Do not click this button if the parents were at some time informed the child had reflux but there are no current problems. Click “GI bleed” if there is evidence for ongoing GI blood loss that is thought to be active and problematic. This should refer to significant bleeding – not that associated with minor blood loss such as that from a polyp that is oozing some blood. If the test is being performed because of a history of chronic vomiting – or if vomiting is ongoing – please click “vomiting” e. Under “Heme/Onc” – If the child has any type of brain tumor – click “brain tumor”. Any other type of solid tumor can come under the heading of “solid tumor”. Please click “mediastinal tumor” only if there is currently a tumor that is clinically significant. A tumor that has been removed and currently is not a significant issue (perhaps a follow-up study) should not be considered a current mediastinal mass. Other categories are self explanatory. f. Under infections – please click “fever of unknown origin” only if there has been a fever for 5 days or more and work-up to date has not revealed a source. Please only click meningitis if there is a proven CNS infection. If a child is having a procedure to rule out sepsis or meningitis – please click on “rule out sepsis/meningitis”. Click “HIV” if the procedure is being done to evaluate a child who is HIV positive or has AIDS. If the procedure is being done for another reason (i.e. pneumonia) in a child with HIV – please click “pneumonia” and click “HIV” as a coexisting problem. g. Metabolic Problems: Click “dehydration” if the primary problem being treated is strictly related to dehydration. Click “Diabetes” if the procedure relates to acute or chronic sequellae of diabetes. Please click “inborn error of metabolism” for any child with a known defect in metabolism (ie. Mitochondrial problem, urea cycle defect etc). Click “metabolic disorder” for any child who is having a workup for a problem that is thought to relate to metabolism but is not known to be a specific inborn error of metabolism. Obesity will have to be left as a judgment call. If the provider believes that the health of the child is impacted by his/her weight – and the procedure is being done for this reason – click “obesity”. Please click “renal failure” only if this is a current problem and that renal function is impaired
  4. 4. enough to impact the child’s general health. If the study is being done strictly for follow up of a problem such as this, please click “other” and describe this. h. For neurological problems – click ADHD if this is a current problem and the child is receiving either medication or behavioral therapy. Click “autism” for any child who currently has the diagnosis of any type of autism including Asperger’s Syndrome. Children who are very high functioning and have not yet been diagnosed but are being evaluated for this problem – please click “other” and explain. Click “CP” for any child with spastic motor symptoms or other neurological problems that caries this diagnosis. Any child with developmental delay which require special accommodation in school or at home should click “developmental delay”. Click “neuromuscular disorder” for any child with the diagnosis of neuromuscular disorder who does not have CP. Click “seizure disorder” for a child with any type of seizure disorder that is active. i. Under problems related to prematurity please click “Active apnea and bradycardia issues” for a child who is followed for active apnea and bradicardia issues – with an episode in the preceding week. Click BPD if the child has a known history and diagnosis of BPD and is currently under treatment for this problem or has known limitations from this illness. DO NOT click BPD for a child who is clinically well at this point but has had the diagnosis in the past. Choose “remote history of apnea and bradycardia” if the child is a year of age or less and has been under treatment for apnea and bradycardia subsequent to discharge from the new born nursery. (for example we do not want to check this button for a child who is now 8 years old and had apnea and bradycardia as a newborn in the nursery.) j. Under renal disease please click “Glomerulonephritis, HUS, Nephrotic Syndrome” buttons if the child has one of these diagnoses and is is currently impacting the child’s health. Do not click any one of these if the problem history is remote and there is no current difficulties. Click “recurrent urinary tract infections” if there is history of this problem and the child is undergoing workup for this problem. Click renal failure if the child is currently impacted by renal impairment that is requiring dialysis or active treatment. Click vesico-ureteral reflux if the child is known to have this problem at the time of the examination. Children that have had ureteral reimplantation surgery and are thought to be well in this respect should not have this button clicked. k. For upper airway problems: Click “cough” if the child has current (acute or chronic) cough that is impacting his/her health. If the cough is associated with a current URI – click URI. Click croup if the child has current respiratory difficulty and/or stridor and has the diagnosis of croup. Click “Sleep Apnea” for any child who has had documented respiratory pauses at night in association with upper airway obstruction and has been diagnosed with sleep apnea. Click snoring for a child who has a significant history of noisy snoring at night but does not meet the
  5. 5. criteria for sleep apnea and has not been diagnosed as such. Click “Stridor” for any child with active stridor or ongoing intermittent stridor – who does not currently have known croup. Click “URI” for any child who has current symptoms of nasal discharge with or without sneezing, minor cough etc. that parents believe is due to a current infection and is not part of the child’s baseline health profile. l. For trauma: Please click abdominal for a child with a history of significant trauma to the abdomen with or without known internal injuries. Click multi-system trauma for any patient with a history of trauma to multiple areas – now undergoing treatment for significant impairment of at least one major system (ie. On a ventilator). Click “Spinal Trauma” for problems that involve trauma to the spine and have resulted in some clinical or radiological defect or finding. m. Orthopedics: Click “Ortho extremity minor” for limited extremity trauma that can be remedied with brief closed reduction. Click “Ortho extremity major” for injuries that require extensive reduction necessitating internal fixation and open reduction. 6. The next screen will ask about “coexisting medical problems”. The categories and choices will be essentially identical to those listed for the primary medical problem. As mentioned above, please only choose one of these problems if there is an ongoing medical problem that impacts on the current clinical status of the child. 7. Under procedures performed please click on all appropriate procedures that are performed during this particular sedation. Once again this list has been organized into categories to make it easier to navigate to the procedure you would like to choose. If the exact procedure to be performed is not on the list please enter the procedure under “other”. This is only a partial list of possibilities – inform Joseph.Cravero@Hitchcock.org for any glaring omissions. 8. The next question relates to where the procedure was performed. This could involve more than one location if the child is sedated in one location and taken to another location etc. Please click all locations that apply and if you sedated a child in a location that is not listed, please click “other” and list the additional location there. 9. The next series of screens asks about medications used for sedation. Once again in order to make the list easier to navigate, the list has been organized into categories of medications. You are first asked to choose a category or categories of medications that will be used. Any number of categories can be clicked. As you move to the next screen, you will asked to specify the medication(s) used in each category. Once again, you can choose any number of medications that are listed. The following screens will bring up questions on each medication as to the route of administration and the dose of medication used. Please note under the drugs
  6. 6. that have the option of a continuous infusion, we have asked you to click whether you used a “bolus” or “continuous infusion”. If you used both, click on both of these options. In addition, if you click on continuous infusion, you will be asked to give the total time of the infusion. Estimate this as best as possible. It probably does not have to be accurate to the minute. You will also be asked to give the total dose of the medication given. This would relate to the dose of the infusion PLUS the bolus. Just give us the total amount of the drug used for the sedation activity. a. Please note that there is an option for “distraction techniques”. You may click this button in addition to medications or it may be the only intervention you use. If you only use distraction techniques, the questionnaire will skip questions about dose, time, time to discharge readiness etc. b. Please not that for fentanyl there are “route” options for both intranasal and inhaled. Inhaled should only be clicked if the drug was delivered by a nebulizer.

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