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): ………………………………….