Extracorporeal Life Support Organization (ELSO)
H1N1 ECLS Registry Form Instruction Sheet
The H1N1 registry form has been developed to track H1N1 cases that have been placed on ECLS.
This form is intended to quickly gather limited H1N1 data and then join the ECLS Registry form data
that is later submitted.
If your center is not a member of ELSO be sure to submit the H1N1CenterRegistration.doc (available
on the ELSO website’s H1N1 section) to establish a center identifier.
The H1N1 registry form has been designed so that data can be quickly entered directly into a
Microsoft Word document using form fields, pull down lists and check boxes.
The form may change over time. The most recent version will be available on the ELSO web site.
Creation and navigation:
To create a new form double click ELSOH1N1RegistryForm.dot which you can download from the
ELSO website. This will create a new instance of the H1N1 ECLS registry form for you to enter data.
When you finish filling out the form, we suggest that you save it with a filename that is unique for the
patient that will enable you to identify which patient is recorded. After saving the form with a file name
that is easily identifiable you will be able to come back and edit the form as often as needed by just
opening that form as you would any other document. ELSO recommends naming the file the same
as the “Unique ID” for that patient (this field is explained in detail below).
When filling out the form in Word, navigate between fields use the Tab key or use the mouse to click
on the field you want to select. Shift-Tab will navigate to the previous field. For check boxes, clicking
on them or pressing the Space bar will select or deselect that option. Some fields have pull down
menus that you can use to scroll to your desired option and then click on to automatically enter the
data. Do not use ‘Enter’, this will cause the field to be split in two. If you do hit ‘Enter’ by mistake, just
backspace to fix.
8/1/2009 ELSO H1N1 Registry Form Instruction Sheet 1
Any field followed by an '*' below denotes a required field. Any form received without these
fields filled in will be returned to the center.
As soon as the H1N1 patient goes on ECLS submit the ECLS H1N1 Registry Form’s Initial Data
section and then update the Final Data section as the information becomes available.
Center ID number: *
Every center is assigned an ID number, enter this numeric code here. Refer to the center list
documentation for your center's ID number. Once you enter the ID number, the next field,
'Center name' will automatically be filled in. This is a required field.
Automatically appears after you enter your Center ID number.
Unique ID: *
Enter the patient's Unique ID number. The Unique ID and Center ID fields identify unique
patients within the registry. You will need to be able to identify the patient by this Unique ID.
The format that must be used for this field is a ten character identifier that has the following
First 3 characters are the Center ID. Next four characters is year they are placed on ECLS.
Next three characters is the sequence number of that patient for that year within your center.
For example, if your center ID is 8, the year the patient went on ECLS was 2009, and they are
the third ECLS patient the Unique ID would be: 0082009003.
If your center ID is 167, the year the patient went on ECLS is 2007 and they are the 34th ECLS
patient for 2007 the Unique ID would be: 1672007034.
The reason why we encode the Center ID within the Unique ID field and still have it listed as a
separate field on the form is to ensure that the form is entered to the correct center. Because
the patient name fields have been removed for confidentiality issues, this will act as a check to
make sure a center’s forms are not mistakenly entered as a different center. If you have
questions on this please contact the ELSO Office for clarification.
When later filling out the ECLS Registry Form be sure to use the exact same Unique ID.
This is a required field.
Birth Date: *
Enter the patient's birth date. This is a required field.
Sex: (M, F)
Enter 'M' for males, 'F' for females. There is a pull down list for this field.
8/1/2009 ELSO H1N1 Registry Form Instruction Sheet 2
Race: (Asian, Black, Hispanic, White, Other)
Enter 'A' for Asian, 'B' for black, 'H' for Hispanic, 'W' for white and 'O' for other. There is a pull
down list for this field.
Basal weight: kg
Enter the basal weight in kilograms.
Enter the height in centimeters.
Choose Yes, No or Unknown for all relevant risk factors.
Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle
cell disease), neurologic, neuromuscular, metabolic disorders (including diabetes mellitus); Immunosuppression (including
that caused by medications, transplant, cancer or HIV), pregnancy, persons younger than 19 years of age who are receiving
long-term aspirin therapy, and residents of nursing homes and other chronic-care facilities
Date of First Symptoms:
Enter the date the patient was first diagnosed with H1N1 symptoms.
Enter the date the patient was admitted to your center.
Enter the date the patient was intubated.
ICU Admit Date:
Enter the date the patient was admitted to the ICU.
Date/Time on ECLS:
Enter the date/time the patient was first placed on ECLS.
Enter the ECLS mode. Possible choices are: VA, VA+V, VA-VV, VV, VV-VA, VVDL, VVDL+V
or Other. There is a pull down list for this field.
8/1/2009 ELSO H1N1 Registry Form Instruction Sheet 3
Date / time off ECLS:
Enter the date and time when patient came off ECLS.
ICU Discharge Date:
Enter the date and time when patient was discharged from the ICU.
Enter the date and time the patient was extubated.
Hospital Discharge Date:
Enter the date and time when patient was discharged from the hospital.
Enter Alive or Died. There is a pull down list for this field. If the patient has died then enter the
date/time of death.
Antiviral agent start/stop Dates:
Enter the dates and time when patient started and stopped receiving antiviral agent.
Dose antiviral agent:
Enter the dose of the antiviral agent.
Diagnostics with positive results:
Choose Yes, No or Unknown for:
DFA, Culture, PCR, and H1N1 Subtype
Form completed by: and Date completed:
Enter your name (the name of the person filling out the form) and date form was filled out.
Submit electronically by e-mail attachment. Be sure to use the ‘Verify Form’ button before
Be sure to visit our web site often for updates and revisions of all documentation and software.
ELSO Registry, 1327 Jones Drive, Suite 101, Ann Arbor, MI 48105 Phone: 734-998-6601
8/1/2009 ELSO H1N1 Registry Form Instruction Sheet 4