Template for documenting and reporting data in physician-staffed pre-hospital services: a consensus-based update

Tønsager, Kristin; Krüger, Andreas Jørstad; Ringdal, Kjetil Gorseth; Rehn, Marius

doi:10.1186/s13049-020-0716-1

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Table 3 Patient descriptors

From: Template for documenting and reporting data in physician-staffed pre-hospital services: a consensus-based update

Data variable number	Main data variable name	Type of data	Data variable categories or values	Data variable sub-categories or values	Type	Definition of data variable	How often should variable be reported
3. Patient descriptors
3.1.	Age	Continuous			Number	Patient age at the time of event	For each mission
3.2.	Gender	Categorical	3.2.1 Female		Bullet list	Patient gender	For each mission
			3.2.2 Male
			3.2.3 Unknown
3.3.	Pre-event comorbidity	Ordinal			Bullet list	Pre-event ASA-PS. The comorbidity existing before event. Derangements from present disease should not be considered	For each mission
			3.3.1 ASA-PS 1			A normal healthy patient
			3.3.2 ASA-PS 2			A patient with mild systemic disease
			3.3.3 ASA-PS 3			A patient with severe systemic disease
			3.3.4 ASA-PS 4			A patient with severe systemic disease that is a constant threat to life
			3.3.5 ASA-PS 5			A moribund patient who is not expected to survive without operation
			3.3.6 ASA-PS 6			A declared brain-dead patient whose organs are being removed for donor purposes
			3.3.7 ASA Unknown
3.4.	Chronic medications	Categorical	3.4.1 Yes		Bullet list	Does patient use medication on a regular basis?	For each mission
			3.4.2 No
			3.4.3 Unknown
3.5.	Medical problem	Categorical			Bullet list	The condition most likely to be the patient’s true medical problem, main clinical symptom or diagnosis, decided by attending p-EMS	For each mission
			3.5.1 Cardiac arrest medical aetiology
			3.5.2 Cardiac arrest traumatic aetiology
			3.5.3 Trauma
			3.5.4 Breathing difficulties
			3.5.5 Myocardial infarction (MI)			Confirmed by ECG
			3.5.6 Chest pain, MI not confirmed
			3.5.7 Stroke
			3.5.8 Acute neurology excluding stroke
			3.5.9. Reduced level of consciousness			Aetiology unknown
			3.5.10 Poisoning/Intoxication
			3.5.11 Burns
			3.5.12 Obstetrics and childbirth
			3.5.13 Infection
			3.5.14 Anaphylaxis
			3.5.15 Surgical
			3.5.16 Asphyxiation
			3.5.17 Drowning
			3.5.18 Psychiatry excluding poisoning/intoxication
			3.5.19 Other
3.6.	Glasgow Coma Scale	Ordinal	3.6.1 First		Number	First recorded pre-interventional GCS upon arrival of p-EMS	For each mission
			3.6.2 Last			GCS at end of patient care or patient handover
			3.6.3 Not recorded
		Categorical	3.6.4 Patient intubated	3.6.4.1 Yes	Bullet list
				3.6.4.2 No
3.7.	Heart rate	Continuous			Number	Documented by ECG (1st choice), palpation or SpO2 curves (3rd choice)
			3.7.1 First			First heart rate per minute measured by p-EMS upon arrival
			3.7.2 Last			Heart rate per minute at end of care or patient handover
			3.7.3 Not recorded
3.8.	Systolic blood pressure	Continuous	3.8.1 Lowest		Number	Lowest recorded systolic blood pressure measured by p-EMS (sphygmomanometer, monitor or intra-arterial line) upon arrival
			3.8.2 First			First recorded systolic blood pressure measured by p-EMS (sphygmomanometer, monitor or intra-arterial line) upon arrival
			3.8.3 Last			Systolic blood pressure at end of care or patient handover
			3.8.4 Not recordable			Not possible to record despite several attempts
			3.8.5 Not recorded
3.9.	Cardiac rhythm/ECG rhythm	Categorical	3.9.1 First	3.9.1.1 Sinus rhythm	Bullet list	First cardiac rhythm interpreted by p-EMS (minimum 3-channel lead). At primary survey/upon arrival	For each mission
				3.9.1.2. SVES, VESmono
				3.9.1.3 AF/AFL/AV-block gr II/III, VESpoly
				3.9.1.4 VF, VT, Asystole, PEA
				3.9.1.5 Not recorded
			3.9.2 Last	3.9.2.1 Sinus rhythm		Cardiac rhythm at end of care or patient handover (minimum 3-channel lead)
				3.9.2.2 SVES, VESmono
				3.9.2.3 AF/AFL/AV-block gr II/III, VESpoly
				3.9.2.4 VF, VT, Asystole, PEA
				3.9.2.5 Not recorded
3.10.	SpO2	Continuous	3.10.1 Lowest		Number	Lowest recorded oxygen saturation by p-EMS (measured with pulse oximeter or arterial blood gas (SaO2))	For each mission
			3.10.2 First			First recorded oxygen saturation by p-EMS (measured with pulse oximeter or arterial blood gas (SaO2) upon arrival)
			3.10.3 Last			Oxygen saturation at end of care or patient handover
			3.10.4 Not recordable			Not possible to record despite several attempts
			3.10.5 Not recorded
3.11.	Oxygen supplementation	Categorical	3.11.1 Oxygen supplementation at first measurement of SpO2	3.11.1.1 Yes	Bullet list	First measurement by p-EMS	For each mission
				3.11.1.2 No
			3.11.2 Oxygen supplementation at last measurement of SpO2	3.11.2.1 Yes		Last measurement by p-EMS
				3.11.2.2 No
3.12.	Respiratory rate	Continuous	3.12.1 First		Number	First respiratory rate per minute measured by p-EMS upon arrival. If mechanically ventilated; document ventilation rate	For each mission
			3.12.2 Last			Respiratory rate at end of care or patient handover
			3.12.3 Not recorded
3.13.	Pain	Categorical	3.13.1 First VAS score		Number	First VAS score assessed by p-EMS upon arrival	For each mission
			3.13.2 Last VAS score			VAS score at end of care or patient handover
			3.13.3 Not recorded
3.14.	End-tidal CO2	Continuous	3.14.1 First		Number	First end-tidal CO2 measured by p-EMS	For each mission
			3.14.2 Last			Last end-tidal CO2 measured by p-EMS
			3.14.3 Not recorded
3.15.	Temperature (core)	Continuous	3.15.1 First		Number	First core temperature measured by p-EMS upon arrival	For each mission
			3.15.2 Last			Last core temperature measured by p-EMS
			3.15.3 Not recorded
3.16	Airway at primary survey	Categorical	3.16.1 Clear		Bullet list	As rated by attending physician	For each mission
			3.16.2 Threatened
			3.16.3 Obstructed
			3.16.4 Unknown

ASA-PS American Society of Anesthesiologists physical scale, p-EMS physician-staffed emergency medical services, MI Myocardial infarction, ECG Electrocardiogram, GCS Glasgow coma score, SpO2 Peripheral capillary oxygen saturation, SVES Supraventricular extrasystole, VESmono Ventricular extrasystole, monomorphic, AF Atrial fibrillation, AFL Atrial flutter, AV-block Atrioventricular block, VESpoly Ventricular extrasystole, polymorphic, VF Ventricular fibrillation, VT Ventricular tachycardia, PEA Pulseless electrical activity, SaO2 Arterial oxygen saturation, VAS Visual analogue scale, CO2 Carbon dioxide

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