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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

    
  1. 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