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					Transfer Hospital
Discharge Form
  Only include information
   collected after ECMO




                             version 2, April 2007
A. To be completed in the ECMO Centre prior to transfer to another hospital

Baby’s name:
                  First Name                              Surname

Baby’s date of birth:                                                     D D / M M / Y Y
NEST Study Number:
ECMO centre name:


Baby’s case notes number in ECMO centre:
Transfer hospital name:



B. To be completed on arrival at transfer hospital

Baby’s case notes number in transfer hospital:

C. Please complete the remainder of this form at the time of discharge or death
The questions on this form refer to this baby’s stay in this unit only. For example the question
 asking about the duration of ventilation or CPAP only refers to the duration of ventilation or
     CPAP in your unit (not this baby’s total duration of ventilation or CPAP since birth).

1.	 Date	and	time	of	first	extubation	lasting	at	least	24	hours
   (if intubated on arrival in your Unit)                D D / M M / Y Y          h h : m m
   Not applicable (still intubated)
2.	 During	the	baby’s	stay	in	this	unit,	was	there	a	positive	culture	for	
    blood,	CSF	or	other	usually	sterile	site?	                 	           Yes           No
      If Yes, please specify below

        Date sample taken                   Site                Name of organism

        D D / M M / Y Y

        D D / M M / Y Y

        D D / M M / Y Y

        D D / M M / Y Y

        D D / M M / Y Y

        D D / M M / Y Y

        D D / M M / Y Y

        D D / M M / Y Y


                                                                                                   
    3.	 Were	steroids	given	at	any	time	during	this	baby’s	stay	in	this	unit?	 Yes                    No
    4.	 Was	a	head	ultrasound	performed	at	any	time	in	this	unit?	                       Yes          No
          a) If Yes, was there evidence of haemorrhage?                                  Yes          No
                 If Yes, was this: (tick all that apply)
                                                                                    Left side   Right side
                                                               Intraventricular
                                                                 Parenchymal
                                                               Posterior fossa
          b) Was there evidence of other parenchymal damage?                      Yes                 No
                                      If Yes, please specify side:                Left          Right
                                      and site:


          c) evidence of cerebral atrophy                                                Yes          No
    5.	 Were	any	of	the	following	diagnosed	at	any	time	during	the	baby’s	stay	in	this	
        unit?	 (tick all that apply)
          Cardiac arrhythmia requiring intervention
          Pneumonia
          Pulmonary airleak
          Pulmonary haemorrhage
          Necrotising enterocolitis
          Jaundice requiring intervention
    6.	 Total	number	of	days	receiving	respiratory	support*	(ventilation	or	CPAP):	                    D D
    7.	 Did	the	baby	achieve	full	oral	sucking	feeds	before	leaving	this	unit?	 Yes                   No
          If Yes, what date did the baby achieve full oral sucking feeds?          D D / M M / Y Y
    8.	 What	was	the	baby’s	head	circumference	at	discharge?	                                     .        cm
    9.	 Has	an	MRI	brain	scan	been	performed	while	in	this	unit?	                        Yes          No
          If Yes, what date was it performed?                                      D D / M M / Y Y
          If No, has an MRI scan been requested?                                         Yes          No




                    It would be extremely helpful if you would send a copy of any
                       Ultrasound Scans and MR Images performed while in this
                          unit to the NEST Co-ordinating Centre with this form




2                                 *See definitions on back of this form
0. Outcome Please complete one box only a), b) or c)
   a)

         Discharged
         Date of discharge home:                                   D D / M M / Y Y
         Was this baby discharged home on anticonvulsant medication? Yes        No


   b)

        Transferred

        Date of transfer to another hospital:                      D D / M M / Y Y

          Address of hospital




          Name of consultant at receiving hospital


   c)

         Died
         Date of death:                                            D D / M M / Y Y
         Is an autopsy planned/already performed?                         Yes   No
         What was the cause of death recorded on the death certificate?




                                                                                     
    Contact details

      Contact details: Mother              Contact details: Father
      First Name                           First Name
      Surname                              Surname
      Address                              Address



      Telephone                            Telephone
      Email                                Email


      Contact details: Grandparent/other   Contact details: Family Doctor
      First Name                           Name
      Surname                              Surgery
      Address                              Address



      Telephone                            Telephone
      Email                                Email




     Form completed by:
                          PRINT NAME               Signature

     Date:                                                     D D / M M / Y Y




4
What	to	do	now
1. When all data have been collected and recorded, please take a photocopy of this
   completed booklet for your records.
2. Send the completed Transfer Hospital Discharge Form to the NEST Co-ordinating Centre
   using the FREEPOST envelope provided, to the address below.
3. In addition, if the baby is transferred to another hospital, please notify the NEST Co-
   ordinating Centre (see contact details on the back of this form).


               THANK	YOU	FOR	COMPLETING	THIS	FORM


FREEPOST RLZU-CBGL-ASSZ
NEST Study
NPEU (University of Oxford)
Old Road Campus
OXFORD
OX3 7LF




                                                                                             
    Definitions
    Respiratory support: include part of any day as 1 day.




                                    Denise Jennings, Study Co-ordinator
                                         NEST Co-ordinating Centre
    National Perinatal Epidemiology Unit                                            tel: 01865 289737
    University of Oxford                                                           fax: 01865 289740
    Old Road Campus                                                       email: nest@npeu.ox.ac.uk
    Oxford OX3 7LF                                                          www.npeu.ox.ac.uk/nest