v Patient age: ……………..……….Years |
v Patient gender: Male ☐ Female ☐ |
v Patient Nationality: Jordanian ☐ Non-Jordanian ☐ |
v Year of death: 2014 ☐ 2015 ☐ 2016 ☐ |
v The confirmed diagnosis is: Heart failure ☐ Sepsis ☐ COPD ☐ |
v What is the previous medical condition (more than one response possible) DM ☐ HTN ☐ Neurology disorder ☐ Renal disorder ☐ Endocrine disorder ☐ |
v The prior area before the patient admitted to ICU is: Hospital wards ☐ Emergency department ☐ Other hospitals ☐ |
v How manytime the patient admitted to ICU during hospitalization? One time ☐ two time ☐ more than ☐ |
v The time in hours patient needed in ICU (length of ICU stay) ………..Hours. |
v The time in hours patient needed in the hospital before ICU admission (length of hospital stay) ……………..Hours. |
v Had the patient received mechanical ventilation during last ICU admission? Yes ☐ No ☐ Unknown ☐ |
v Had the patient received systematic antibiotic during last ICU admission? Yes ☐ No ☐ Unknown ☐ |
v Is the chest tube inserted for the patient during the last ICU admission? Yes ☐ No ☐ Unknown ☐ |
v Had the patient received an indwelling urethral catheter during last ICU admission? Yes ☐ No ☐ Unknown ☐ |
v Did the central venous catheter or arterial line inserted during last ICU admission? Yes ☐ No ☐ Unknown ☐ |
v Had the patient received intravenous fluid resuscitation during last ICU admission? Yes ☐ No ☐ Unknown ☐ |
v Had the patient received vasopressor drugs (dopamine, noradrenaline, dobutamine…etc) during last ICU admission? Yes ☐ No ☐ Unknown ☐ |
v Had the patient received other invasive procedure during last ICU admission? No ☐ Yes ☐ (write it): …………………………………. |