appendix vii. charlson comorbidity index (reference
Post on 04-Apr-2022
7 Views
Preview:
TRANSCRIPT
Pan-Asian Trauma Outcomes Study Clinical Research Network
65
Appendix VII. Charlson Comorbidity Index (Reference: Charlson, M.E. 1994)
Pan-Asian Trauma Outcomes Study Clinical Research Network
69
Appendix VIII. Structured interview for Glasgow Outcome Scale (GOS) (Reference: Wilson, J.T. et al., 1998)
Pan-Asian Trauma Outcomes Study Clinical Research Network
71
Appendix IX. Modified Rankin Scale (Reference: Bruno, A., et al. 2010)
Pan-Asian Trauma Outcomes Study Clinical Research Network
72
Appendix X. Structured interview for Glasgow Outcome Scale - Extended (GOSE) (Refrence: Wilson, J.T. et al., 1998)
Pan-Asian Trauma Outcomes Study Clinical Research Network
75
Appendix XI. Structured interview for EQ5D (Refrence: EuroQol Research Foundation)
Pan-Asian Trauma Outcomes Study Clinical Research Network
77
PATOS CASE REPORT
core **; comprehensive *
A. DEMOGRAPHIC
1 Research institute
**
2 Site ID ** □□□ 3 Country ** □□□
4 EMS district or
city **
□□□ 5 Case ID ** □□□□□□
(PATOS use only)
6 Date of birth ** □□ □□ □□□□
Mo. Day Year
7 Age **
□□□
(only if DOB is missing)
8 Gender ** □ 1 Male
□ 2 Female
9 Residential postal
code *
10 Citizenship * □ 1 Citizenship □ 2 No citizenship □ 99 Unknown
B. INJURY EPIDEMIOLOGY
11 Date/time of
injury **
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
12 Weather
(check all that apply)
□ 1 Wet
□ 2 Dry
□ 3 Snow
□ 4 Ice
□ 5 Dark
□ 6 Light
□ 7 Fog
□ 99 Unknown
13 Incident site
address *
(Province, city, district) 14 Incident site
postal code *
15 Intent **
□ 1 Unintentional (accidental)
□ 2 Intentional self-harm (suicide, attempted
suicide)
□ 3 Assault (interpersonal violence)
□ 4 Undetermined (awaiting results of
investigation)
(check one)
□ 5 Legal interventions
□ 6 Operations of war and civil insurrection
□ 99 Unknown
16 Mechanism of
injury **
□ 1 Traffic injury
□ 2 Sexual assault
□ 3 Fall
□ 4 Struck/hit by person or object
□ 5 Stab or cut
□ 6 Gun shot
□ 7 Fire, flames or heat
□ 8 Choking or hanging
□ 9 Drowning or near-drowning
(check one)
8X Other
□ 80 Physical over-exertion
□ 81 Cooling
□ 82 Exposure to (effect of) weather, natural
disaster or other force of nature
□ 83 Complications of health care
□ 84 Corrosion by chemical or other
substance
□ 88 Other mechanism of injury
Pan-Asian Trauma Outcomes Study Clinical Research Network
78
□ 10 Poisoning □ 99 Unknown
17 Location of
injury **
□ 1 Head
□ 2 Face
□ 3 Neck
□ 4 Thorax
□ 5 Abdomen and pelvic contents
(check all that apply)
□ 6 Spine
□ 7 Upper extremity
□ 8 Lower extremity (including bony pelvis)
□ 9 External (skin)
□ 88 Other (non-anatomical inury)
18 Type (Nature) of
injury **
□ 1 Fracture
□ 2 Sprain, strain or dislocation
□ 3 Cuts, bites or open wound
□ 4 Bruise or superficial injury
□ 5 Burns
(check all that apply)
□ 6 Concussion
□ 7 Organ system injury
□ 88 Other
□ 99 Unknown
19 Place of injury **
□ 1 Home, including garden and out buildings
□ 2 School, including kindergarten and
schoolyard
□ 3 Street/highway
□ 4 Residential institution
□ 5 Sports and athletics area
□ 6 Other transport area
□ 7 Industrial/construction
□ 8 Farm, excluding home
(check one)
□ 9 Commercial
□ 10 Countryside, water, sea
8X Other
□ 80 Medical service area
□ 81 Recreational and cultural area and
public building
□ 88 Other place of occurrence
□ 99 Unknown
20 Work-related
injury *
□ 1 Yes □ 0 No □ 99 Unknown
21 Activity **
□ 1 Work, including travel for work (e.g. truck
driving)
□ 2 Education, including school sports
□ 3 Sports
□ 4 Leisure/play
□ 5 Traveling not elsewhere classified
(check one)
8X Other
□ 80 Unpaid activities
□ 81 Activities of daily living
□ 82 During treatment
□ 88 Other activities, not elsewhere
classified
□ 99 Unknown
22 Alcohol use **
□ 1 Suspected (by report or observation)
□ 2 Confirmed by biological evidence
□ 3 No use – by report or observation or
biological evidence
(check one)
□ 99 No information available
23 Alcohol use of
others who were
directly involved
□ 1 Suspected (by report or observation)
□ 2 Confirmed by biological evidence
□ 3 No use – by report or observation or
biological evidence
(check one)
□ 88 Not applicable
□ 99 No information available
24 Psychoactive (check one)
Pan-Asian Trauma Outcomes Study Clinical Research Network
79
drug/substance use
**
□ 1 Suspected (by report or observation)
□ 2 Confirmed by biological evidence
□ 3 No use – by report or observation or
biological evidence
□ 99 No information available
25 Psychoactive
drug/substance use
of others who were
directly involved
□ 1 Suspected (by report or observation)
□ 2 Confirmed by biological evidence
□ 3 No use – by report or observation or
biological evidence
(check one)
□ 88 Not applicable
□ 99 No information available
26 Arrival type ** □ 1 Prehospital ambulance transport
□ 2 Interhospital ambulance transport
□ 3 Prehospital transport using other vehicles
(non-EMS)
□ 4 Interhospital transport using other
vehicles (non-EMS)
(If 1 or 3, complete section C: Prehospital Care)
(If 2 or 4, complete section D: Interhospital Transfer)
27 Prehospital care
provider **
□ 1 Non-EMT (includes volunteer)
□ 2 EMT(basic, intermediate, advanced,
paramedic)
(check all that apply)
□ 3 Doctors
□ 4 Nurses
□ 99 Unknown
C. PREHOSPITAL CARE
28 Incident no. * 29 Ambulance no. *
30 Mode of arrival
**
□ 1 Road ambulance
□ 2 Helicopter
□ 3 Ship
(check one)
□ 88 Other
□ 99 Unknown
31 Date/time call
received **
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
32 Date/time call
ambulance
departed from **
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
33 Date/time
ambulance arrived
at accident site **
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
34 Date/time
ambulance left
accident site **
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
35 Date/time
ambulance arrived
at hospital **
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
36 Prehospital CPR
**
□ 1 Yes
□ 0 No
□ 99 Unknown
37 Prehospital BP –
systolic **
□□□ Prehospital BP –
diastolic
□□□
38 Prehospital HR
**
□□□ per minute 39 Prehospital RR
**
□□□ per minute
40 Prehospital □□□ %
Pan-Asian Trauma Outcomes Study Clinical Research Network
80
O2Sat **
41 Prehospital
mental status **
□ 2 Glasgow Coma Scale □ 3 AVPU □ 1 Not measured
□ 99 Unknown Eye
□ 1 No eye opening
□ 2 Eyes open only with painful
stimuli
□ 3 Eyes open to verbal command
□ 4 Eyes open spontaneously
Verbal
□ 1 No verbal response
□ 2 Incomprehensible sounds
□ 3 Inappropriate words
□ 4 Disoriented
□ 5 Oriented
□ 6 Intubated
Motor
□ 1 No motor response
□ 2 Extension (decerebrate)
□ 3 Flexion (decorticate)
□ 4 Withdraws from pain
□ 5 Localizes pain
□ 6 Obeys verbal commands
□ 1 A
□ 2 V
□ 3 P
□ 4 U
42 Prehospital
airway *
□ 20 Oropharyngeal airway
3X Supraglottic Airway
□ 31 Combitube
□ 32 Laryngeal tube
□ 33 Laryngeal mask airway
□ 34 Other types
(check all that apply)
□ 40 Endotracheal tube
□ 88 Other
□ 10 None
□ 99 Unknown
43 Prehospital
oxygen *
□ 2 Nasal
□ 3 Venturi mask
□ 4 Facial mask (breathing or non-
rebreathing)
(check all that apply)
□ 5 BVM
□ 6 Mechanical ventilator
□ 88 Other
□ 1 None
□ 99 unknown
Amount
□□.□ litres per minute
44 Prehospital
immobilization *
□ 2 Backboard
□ 3 Scoop
□ 4 Femur traction splint
□ 5 Other extremity splint
(check all that apply)
□ 6 Bandaging
□ 7 Pelvic binder
□ 8 C-spine
□ 88 Other
□ 1 None
□ 99 Unknown
45 Prehospital fluid (check all that apply) □ 1 None
Pan-Asian Trauma Outcomes Study Clinical Research Network
81
access * □ 2 IV
□ 3 IO
□ 99 Unknown
Type (check all that apply)
□ 1 NS
□ 2 5DW
□ 3 10DW
□ 4 50DW
□ 5 HS
□ 6 Hypertonic saline
□ 88 Other
□ 99 Unknown
Amount
□□□.□ mL
46 Pain control
during prehospital
phase
□ 2 Entonox (medical nitrous oxide
and oxygen mixture)
□ 3 IM/IV NSAIDs
□ 4 IM/IV Opioids
□ 5 Penthorox (Penthrox inhaler for
self-administration of
methoxyflurane for analgesia)
(check all that apply)
□ 6 IM/IV Ketamine
□ 7 PO Paracetamol
□ 88 Other
□ 1 None
□ 99 Unknown
47 Medications
given during
prehospital phase *
Medication 1: ___________________________________
Medication 2 ___________________________________
Medication 3 ___________________________________
Medication 4 ___________________________________
Medication 5 ___________________________________
Medication 6 ___________________________________
Medication 7 ___________________________________
Medication 8 ___________________________________
Medication 9 ___________________________________
Medication 10 __________________________________
48 Prehospital
procedure for
thoracic cavity
□ 1 None
□ 2 Thoracentesis
□ 3 Thoracotomy
(check all that apply)
□ 4 Pericardiocentesis
□ 99 Unknown
49 Prehospital
diagnosis
□ 1 Superficial injuries
□ 2 Musculoskeletal injuries
□ 3 Burn and corrosion injuries
□ 4 Internal organ injuries - chest
□ 5 Internal organ injuries – abdomen
□ 6 Crushing injuries
□ 7 Open wound injuries
□ 8 Blood vessel injuries
(check all that apply)
□ 9 Nerves and spinal cord injuries
□ 10 Other and unspecified injuries
□ 11 Skull and facial bone fracture injuries
□ 12 Intracranial injuries
□ 13 Head crushing injuries
□ 14 Neck injuries
□ 15 Other multiple body injuries
□ 99 Unknown
50 Decontamination
□ 1 Yes. Dry decontamination was done.
□ 2 Yes. Wet decontamination was done.
□ 3 No. Decontamination was indicated but
not conducted.
(check one)
□ 4 No. Decontamination was not indicated.
□ 99 Unknown
D. INTERHOSPITAL TRANSFER
51 Level of (check one) 52 Name of
Pan-Asian Trauma Outcomes Study Clinical Research Network
82
referring hospital ** □ 1 Level I trauma center
□ 2 Level II trauma center
□ 3 Level III trauma center or
below
□ 99 Unknown
referring hospital
53 Date/time of
arrival at referring
hospital
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
54 Date/time of
departure from
referring hospital
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
55 Mode of
interhospital
transfer *
□ 1 Road ambulance
□ 2 Helicopter
□ 3 Ship
(check one)
□ 88 Other
□ 99 Unknown
56 Reason for
transfer *
□ 10 Insufficient availability of wards
□ 20 Insufficient availability of ICUs
□ 30 Unable to provide emergency
operations/procedure
4X Transfer for professional emergency care
□ 41 Burns
□ 42 Neurology/neurosurgery
□ 43 Cardiothoracic surgery
□ 44 Pediatrics/pediatric trauma
□ 45 Hand surgery
□ 46 Other
(check one)
□ 50 Transfer to a lower level hospital for mild
illness
□ 60 Transfer to a long-term care facility
□ 70 Personal reasons
□ 88 Other
□ 99 Unknown
57 Transfer from
where *
□ 1 ED
□ 2 ICU
(check one)
□ 3 Ward (other than ICU)
□ 99 Unknown
58 Intervention
before transfer
□ 1 ED resuscitation
□ 2 Surgery
□ 3 ICU care
(check all that apply)
□ 4 Non-specific intervention
□ 5 No intervention
□ 99 Unknown
59 GCS at referring
hospital before
transfer *
□ 1 Measured □ 0 Not all GCS
measured
□ 99 Unknown
Eye
□ 0 Not measured
□ 1 No eye opening
□ 2 Eyes open only with painful stimuli
□ 3 Eyes open to verbal command
□ 4 Eyes open spontaneously
Verbal
□ 0 Not measured
□ 1 No verbal response
□ 2 Incomprehensible sounds
Pan-Asian Trauma Outcomes Study Clinical Research Network
83
□ 3 Inappropriate words
□ 4 Disoriented
□ 5 Oriented
□ 6 Intubated
Motor
□ 0 Not measured
□ 1 No motor response
□ 2 Extension (decerebrate)
□ 3 Flexion (decorticate)
□ 4 Withdraws from pain
□ 5 Localizes pain
□ 6 Obeys verbal commands
E. ED AND HOSPITAL CARE
60 BP at triage -
systolic **
□□□
BP at triage –
diastolic
□□□
61 HR at triage ** □□□ per minute 62 RR at triage ** □□□ per minute
63 Temperature at
triage **
□□.□ ℃ 64 O2Sat at triage
**
□□□ %
65 Mental status at
triage (GCS) **
□ 1 Measured □ 0 Not all GCS
measured
□ 99 Unknown
Eye
□ 0 Not measured
□ 1 No eye opening
□ 2 Eyes open only with painful stimuli
□ 3 Eyes open to verbal command
□ 4 Eyes open spontaneously
Verbal
□ 0 Not measured
□ 1 No verbal response
□ 2 Incomprehensible sounds
□ 3 Inappropriate words
□ 4 Disoriented
□ 5 Oriented
□ 6 Intubated
Motor
□ 0 Not measured
□ 1 No motor response
□ 2 Extension (decerebrate)
□ 3 Flexion (decorticate)
□ 4 Withdraws from pain
Pan-Asian Trauma Outcomes Study Clinical Research Network
84
□ 5 Localizes pain
□ 6 Obeys verbal commands
66 DOA ** □ 1 Yes □ 0 No
67 Date/time of
arrival at ED **
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
68 Date/time of
disposition from ED
**
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
69 ED disposition ** (check one)
□ 1 Treated and
discharged
□ 2 Transfer to
another hospital
□ 4 Dead
□ 88 Other
□ 99 Unknown
□ 3 Admitted to hospital
70 Hospital
Discharge
disposition **
(check one)
□ 10 Treated and discharge
□ 20 Hopeless discharge
□ 30 Discharge against advice [1]
4X Transfer
□ 41 Transferred to another hospital for acute
care treatment
□ 42 Transferred to a rehabilitation center
□ 43 Transferred to a nursing home
□ 50 Dead
□ 88 Other
□ 99 Unknown
71 Date/time of
hospital discharge
**
□□ □□ □□□□ □□:□□
Mo. Day Year Time
72 Total length of
stay in ICU **
□□□ days
73 Airway
management **
□ 20 Oropharyngeal airway
3X Supraglottic Airway
□ 31 Combitube
□ 32 Laryngeal tube
□ 33 Laryngeal mask airway
□ 34 Other types
(check all that apply)
□ 40 Endotracheal tube
□ 88 Other
□ 10 None
□ 99 Unknown
74 Fluid
□ 1 Yes □ 0 No
□ 99 unknown Amount
□□□.□ mL
75 Transfusion * □ 1 Yes □ 0 No
□ 99 unknown Amount
Whole blood: □□□ cc
Packed cells: □□□ cc
FFP: □□□ cc
Platelets: □□□ cc
Platelets (apheresis): □□□ cc
Pan-Asian Trauma Outcomes Study Clinical Research Network
85
Cryoprecipitate: □□□ cc
76 Surgical airway * □ 1 Yes □ 0 No □ 99 Unknown
77 Tension
pneumothorax
decompression *
□ 1 Yes □ 0 No □ 99 Unknown
78 Non-surgical
external bleeding
control *
□ 1 Yes □ 0 No □ 99 Unknown
79 Cardiocentesis * □ 1 Yes □ 0 No □ 99 Unknown
80 Thoracostomy or
thoracotomy *
□ 1 Yes □ 0 No □ 99 Unknown
81 Positive
ventilation *
□ 1 Yes □ 0 No □ 99 Unknown
82 Non-surgical
immobilization *
□ 1 Yes □ 0 No □ 99 Unknown
83 CPR * □ 1 Yes □ 0 No □ 99 Unknown
84 Operation *
85 Operation –
date/time *
□ 1 None
□ 2 Head
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 3 Face
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 4 Neck
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 5 Thorax
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 6 Abdomen and pelvic contents
□□ □□ □□□□
Mo. Day Year
(check all that apply)
□ 7 Spine
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 8 Upper extremity
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 9 Lower extremity (including bony pelvis)
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 10 Unspecified
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 99 Unknown
Pan-Asian Trauma Outcomes Study Clinical Research Network
86
□□:□□
Time
86 First
angiography scan *
87 First
angiography scan –
date/time *
□ 1 None
□ 2 Head
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 3 Face
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 4 Neck
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 5 Thorax
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 6 Abdomen and pelvic contents
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
(check all that apply)
□ 7 Spine
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 8 Upper extremity
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 9 Lower extremity (including bony pelvis)
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 10 Unspecified
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 99 Unknown
88 Embolization *
89 Embolization
date/time *
□ 1 None
□ 2 Head
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 3 Face
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
(check all that apply)
□ 7 Spine
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 8 Upper extremity
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 9 Lower extremity + bony pelvis
Pan-Asian Trauma Outcomes Study Clinical Research Network
87
□ 4 Neck
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 5 Thorax
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 6 Abdomen
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 10 Unspecified
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
□ 99 Unknown
90 Pre-existing
comorbidity *
□ 1 Yes □ 0 No
□ 99 Unknown
(check all that apply)
□ 1 Myocardial infarction
□ 2 Congestive heart failure
□ 3 Peripheral vascular disease
□ 4 Cerebrovascular disease
□ 5 Hemiplegia
□ 6 Pulmonary disease
□ 7 Diabetes
□ 1) End-organ damage
□ 2) No end-organ damage
□ 8 Moderate to severe renal disease
□ 9 Chronic liver disease
□ 1) Moderate to severe liver disease
□ 2) Mild liver disease
□ 10 Peptic ulcer disease
□ 11 Cancer
□ 1) Lymphoma
□ 2) Leukemia
□ 3) Solid tumor
□ 4) Metastatic tumor
□ 1) Breast
□ 2) Colon
□ 3) Prostate
□ 4) Lung
□ 5) Melanoma
□ 6) Other
Pan-Asian Trauma Outcomes Study Clinical Research Network
88
□ 12 Dementia
□ 13 Rheumatologic disease
□ 14 HIV/AIDS
91 Pre-existing
disability (GOS) **
(check one)
□ 1 Vegetative state: unable to move on a bed
□ 2 Severe disability: Independent activities of daily living are not possible
□ 3 Moderate disability: Independent activities of daily living are possible, but cannot resume
work/school life
□ 4 Mild or no disability; no disability reported
□ 99 Unknown
92 Modified Rankin
Scale at discharge
**
□ 0 No symptoms at all
□ 1 No significant disability despite symptoms;
able to carry out all usual duties and
activities
□ 2 Slight disability; unable to carry out all
previous activities, but able to look after
own affairs without assistance
□ 3 Moderate disability; requiring some help,
but able to walk without assistance
(check one)
□ 4 Moderately severe disability; unable to
walk without assistance and unable to
attend to own bodily needs without
assistance
□ 5 Severe disability; bedridden, incontinent
and requiring constant nursing care and
attention
□ 6 Dead
□ 99 Unknown
93 Pediatric * □ 1 Yes □ 0 No
94 Weight * □□□ kg
95 Airway * (check one)
□ 1 Normal airway
□ 2 Maintained airway
□ 3 Unmaintainable (invasive) airway (i.e.
intubated)
□ 99 Unknown
96 Level of
consciousness *
(check one)
□ 1 Awake
□ 2 Obtunded or any loss of consciousness
(responsive)
□ 3 Unresponsive
□ 99 Unknown
97 Fracture * (check one)
□ 1 None
□ 2 Single and closed or suspected
□ 3 Multiple closed or open
□ 99 Unknown
98 – Wound * (check one)
□ 1 None
□ 2 Minor; contusion, abrasion, laceration
<7 cm not through fascia
□ 3 Major, penetrating, or burns >10%
Pan-Asian Trauma Outcomes Study Clinical Research Network
89
□ 99 Unknown
99 – Child abuse (check one)
□ 1 Yes □ 0 No □ 99 Unknown
100 – Sport-related
injury
(check one)
□ 1 Yes □ 0 No □ 99 Unknown
F. INJURY SEVERITY AND OUTCOME
Injury code 101 ICD-10 Diagnosis ** 102 Abbreviated injury scale **
(check one)
□ 1 ICD-10
□ 2 ICD-9
1 □□□.□ □□□□□□.□
2 □□□.□ □□□□□□.□
3 □□□.□ □□□□□□.□
4 □□□.□ □□□□□□.□
5 □□□.□ □□□□□□.□
6 □□□.□ □□□□□□.□
7 □□□.□ □□□□□□.□
8 □□□.□ □□□□□□.□
9 □□□.□ □□□□□□.□
10 □□□.□ □□□□□□.□
103 GOS at
discharge **
(check one)
□ 1 Dead
□ 2 Vegetative state: unable to move on a bed
□ 3 Severe disability: Independent activities of daily living are not possible
□ 4 Moderate disability: Independent activities of daily living are possible, but cannot resume
work/school life
□ 5 Recovering state: Mild or no disability; can resume work/school life
□ 99 Unknown
G. REHABILITATION
104 Date for first
rehabilitation
evaluation during
hospital stay *
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
105 Date for first
psychiatric
evaluation during
hospital stay *
□□ □□ □□□□
Mo. Day Year
□□:□□
Time
H. OUTCOME AT 6 MONTH
106 Current
residence at 6
month
□ 1 Home: no additional treatment and
assistance required
□ 2 Home: additional treatment and assistance
required
□ 3 General hospital
(check one)
□ 5 Nursing home
□ 6 Hospice
□ 7 Dead
□ 88 Other
□ 99 Unknown
Pan-Asian Trauma Outcomes Study Clinical Research Network
90
□ 4 Rehabilitation hospital
107 Occupational
status at 6 month
□ 1 Patient returned to the same workplace
(school) he/she was attending prior to
injury; patient is currently at the same
level(grade) as before.
□ 2 Patient returned to the same workplace
(school) he/she was attending prior to
injury; patient is currently at a different
level(grade) as before.
□ 3 Patient returned to the same
workplace(school) he/she was attending
prior to injury; patient does not know the
level(grade) he/she is in.
□ 4 Patient returned to a different
workplace(school) than the one he/she was
attending prior to injury; patient is currently
at the same level(grade) as before.
(check one)
□ 5 Patient returned to a different
workplace(school) than the one he/she was
attending prior to injury; patient is currently
at a different level(grade) as before.
□ 6 Patient returned to a different
workplace(school) than the one he/she was
attending prior to injury; patient does not
know the level(grade) he/she is in.
□ 7 Patient never worked or attended school
prior to injury.
□ 99 Unknown
108 Extended
Glasgow Outcome
Scales (GOSE)
Interview at
6 month *
□ 1 Dead
□ 2 Vegetative State
□ 3 Lower Severe Disability
□ 4 Upper Severe Disability
(check one)
□ 5 Lower Moderate Disability
□ 6 Upper Moderate Disability
□ 7 Lower Good Recovery
□ 8 Upper Good Recovery
109 EQ5D at 6
month *
Mobility
□
□ 2 I have slight problems walking about
□ 3 I have moderate problems walking about
Self-care
□ 1 I have no problems washing or dressing
myself
□ 2 I have slight problems washing or dressing
myself
□ 3 I have moderate problems washing or
dressing myself
Usual activities
□ 1 I have no problems doing my usual
activities
□ 2 I have slight problems doing my usual
activities
□ 3 I have moderate problems doing my usual
activities
(check one)
□ 4 I have severe problems walking about
□ 5 I am unable to walking about
(check one)
□ 4 I have severe problems washing or
dressing myself
□ 5 I am unable to wash or dress myself
(check one)
□ 4 I have severe problems doing my usual
activities
□ 5 I am unable to do my usual activities
Pan-Asian Trauma Outcomes Study Clinical Research Network
91
Pain/discomfort
□ 1 I have no pain or discomfort
□ 2 I have slight pain or discomfort
□ 3 I have moderate pain or discomfort
Anxiety/depression
□ 1 I am not anxious or depressed
□ 2 I am slightly anxious or depressed
□ 3 I am moderately anxious or depressed
VAS □□□
(check one)
□ 4 I have severe pain or discomfort
□ 5 I have extreme pain or discomfort
(check one)
□ 4 I am severely anxious or depressed
□ 5 I am extremely anxious or depressed
I. OUTCOME AT 12 MONTH
110 Extended
Glasgow Outcome
Scales (GOSE)
Interview at
12 month *
□ 1 Dead
□ 2 Vegetative State
□ 3 Lower Severe Disability
□ 4 Upper Severe Disability
(check one)
□ 5 Lower Moderate Disability
□ 6 Upper Moderate Disability
□ 7 Lower Good Recovery
□ 8 Upper Good Recovery
111 EQ5D at 12
month *
Mobility
□
□ 2 I have slight problems walking about
□ 3 I have moderate problems walking about
Self-care
□ 1 I have no problems washing or dressing
myself
□ 2 I have slight problems washing or dressing
myself
□ 3 I have moderate problems washing or
dressing myself
Usual activities
□ 1 I have no problems doing my usual
activities
□ 2 I have slight problems doing my usual
activities
□ 3 I have moderate problems doing my usual
activities
Pain/discomfort
□ 1 I have no pain or discomfort
□ 2 I have slight pain or discomfort
□ 3 I have moderate pain or discomfort
(check one)
□ 4 I have severe problems walking about
□ 5 I am unable to walking about
(check one)
□ 4 I have severe problems washing or
dressing myself
□ 5 I am unable to wash or dress myself
(check one)
□ 4 I have severe problems doing my usual
activities
□ 5 I am unable to do my usual activities
(check one)
□ 4 I have severe pain or discomfort
□ 5 I have extreme pain or discomfort
Pan-Asian Trauma Outcomes Study Clinical Research Network
92
Anxiety/depression
□ 1 I am not anxious or depressed
□ 2 I am slightly anxious or depressed
□ 3 I am moderately anxious or depressed
VAS □□□
(check one)
□ 4 I am severely anxious or depressed
□ 5 I am extremely anxious or depressed
J. DEATH CERTIFICATE
112 Date/time of
death **
□□ □□ □□□□ □□:□□
Mo. Day Year Time
113 Primary cause
of death **
□ 1 Unknown diagnosis due to DOA / DNR
□ 2 Shock bleeding / hypervolemia
□ 3 Severe traumatic brain injury
□ 4 Major chest or abdominal organ injury
□ 5 Septic shock / multi-organ failure
(check one)
□ 6 Complicated medical condition (MI, Stroke,
infection etc.)
□ 88 Other
□ 99 Unknown
Pan-Asian Trauma Outcomes Study Clinical Research Network
93
Reference
1. ICECI Coordination and Maintenance Group (2004). International Classification of External Causes of Injuries (ICECI) version 1.2. Consumer Safety Institute, Amsterdam and AIHW National Injury Surveillance Unit, Adelaide.
2. Concise Medical Dictionary (8 ed.). 2010, Oxford University Press. 3. Committee on Trauma America College of Surgeons, Resources for Optimal Care of the Injured
Patient 2014 M.F. Rotondo, C. Cribari, and R.S. Smith, Editors. 2014.
4. American College of Surgeons, ACS NTDB National Trauma Data Standard: Data Dictionary. 2015.
5. Wilson, J.T., L.E. Pettigrew, and G.M. Teasdale, Structured interviews for the Glasgow Outcome
Scale and the extended Glasgow Outcome Scale: guidelines for their use. J Neurotrauma, 1998. 15(8): p. 573-85.
6. Charlson, M.E., Charlson Comorbidity Index: Chart review version 1994. 7. Bruno, A., et al., Improving modified Rankin Scale assessment with a simplified questionnaire.
Stroke, 2010. 41(5): p. 1048-50.
8. EuroQol Research Foundation, EQ-5D-5L. Sample UK English EQ-5D-SL. 2015.
top related