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 D D / M M / Y Y
Baby’s date of birth: 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) 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 If Yes, please specify below Date sample taken 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
D D / M M / Y Y
h h : m m
No
Site
Name of organism
3. Were steroids given at any time during this baby’s stay in this unit? Yes 4. Was a head ultrasound performed at any time in this unit? a) If Yes, was there evidence of haemorrhage? If Yes, was this: (tick all that apply) Left side Intraventricular Parenchymal Posterior fossa b) Was there evidence of other parenchymal damage? If Yes, please specify side: and site: c) evidence of cerebral atrophy Yes Yes Left Yes Yes
No No No Right side
No Right
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): 7. Did the baby achieve full oral sucking feeds before leaving this unit? Yes If Yes, what date did the baby achieve full oral sucking feeds? 8. What was the baby’s head circumference at discharge? 9. Has an MRI brain scan been performed while in this unit? If Yes, what date was it performed? If No, has an MRI scan been requested? Yes Yes D D No
D D / M M / Y Y
.
cm No No
D D / M M / Y Y
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
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*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 No Was this baby discharged home on anticonvulsant medication? Yes b) Transferred Date of transfer to another hospital: Address of hospital D D / M M / Y Y
Name of consultant at receiving hospital
c) Died Date of death: Is an autopsy planned/already performed? What was the cause of death recorded on the death certificate? D D / M M / Y Y Yes No
Contact details
Contact details: Mother First Name Surname Address Contact details: Father First Name Surname Address
Telephone Email Contact details: Grandparent/other First Name Surname Address
Telephone Email Contact details: Family Doctor Name Surgery Address
Telephone Email
Telephone Email
Form completed by: Date:
PRINT NAME
Signature D D / M M / Y Y
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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 Coordinating 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 University of Oxford Old Road Campus Oxford OX3 7LF
tel: 01865 289737 fax: 01865 289740 email: nest@npeu.ox.ac.uk www.npeu.ox.ac.uk/nest