Please answer the following questions �

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					                                           PRODUCT EVALUATION
                           FARRELL VALVE GASTRIC DECOMPRESSION SYSTEM


Name/Title: ____________________________________ Dept: NICU / PICU                     Date: ____________________


INSTRUCTIONS: COMPLETE ONE EVALUATION FORM PER SHIFT. SUBMIT COMPLETED FORM TO <ENTER
NAME> OR UNIT MANAGER.


Patient Demographics

        Feeding Tube Fr Size / Length: ________ Fr ________ Inches

        Feeding Method / Volume:        Gravity    / Intermittent Pump / Continuous Pump (circle one)

                                Rate: ________ mL/Hr            Total Volume Delivered in 24H: ________ mL

        Adjunctive Therapies: O2: ________ / CPAP: ________ cmH2O

        Mech Ventilation: Pressure Support / Volume Support Comments: _____________________________

Feedback – Farrell Valve

1) Were the instructions easy to follow? Yes / No (circle one) If No, please explain further : __________________

     __________________________________________________________________________________________

2) Did you have difficulty priming the Farrell Valve? Yes / No (circle one) If Yes, please explain further : _________

     __________________________________________________________________________________________

3)   Did the Farrell Valve perform as expected? Yes / No (circle one) If No, please explain further : _______________

     __________________________________________________________________________________________

4) Do you recommend that the hospital use the Farrell Valve for patients in need of gastric decompression?

                                                     Yes / No (circle one) If No, please explain further : _________

     __________________________________________________________________________________________

5) General Comments

     __________________________________________________________________________________________

     __________________________________________________________________________________________

     __________________________________________________________________________________________

     __________________________________________________________________________________________

     __________________________________________________________________________________________



     Facility Name: ___________________________          City/State: _____________

JKillam Feb 2012

				
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