Form 1 Positive Pressure Ventilation Survey

Form Approved

OMB No. 0990-XXXX

Exp. Date XX/XX/XXXX

Positive Pressure Ventilation Survey

Demographics

Facility:	     
Person Responsible for Completing this Survey:			 
Title:	RT Director		ICU Medical Director		ICU Nursing Supervisor		Other:      
Phone:			     
Email:			     

Statement of Confidentiality

Any information that would permit identification of the individual facility completing this survey will be held strictly confidential.

PLEASE SEE THE PAGE 4 FOR EXAMPLES OF VENTILATORS AND WHICH CATEGORY THEY FIT IN TO.

DO NOT COUNT VENTILATORS MORE THAN ONCE.

(FOR EXAMPLE – THE SERVOi IS A FULL FEATURED VENTILATOR (capable of ventilating adults and neonates) - IT SHOULD BE COUNTED IN THE FULL FEATURED VENTILATOR CATEGORY (#1) ONLY, EVEN IF YOU ONLY USE IT IN NEONATAL ICU.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX. The time required to complete this information collection is estimated to average 75 minutes per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201 Attention: PRA Reports Clearance Officer.

		# of devices owned
1.Full-Featured Mechanical Ventilator (See Page 4 for examples)
Vendor & Model:       Compressor Yes No		     
Vendor & Model:       Compressor Yes No		     
Vendor & Model:       Compressor Yes No		     
Vendor & Model:       Compressor Yes No		     
Vendor & Model:       Compressor Yes No		     
Vendor & Model:       Compressor Yes No		     
Vendor & Model:       Compressor Yes No		     
2. How many of the ventilators in #1 are equipped for neonatal ventilation?		     
3. High Frequency Ventilator (See Page 4 for examples.)
Vendor & Model:      		     
Vendor & Model:      		     
4. Portable Mechanical Ventilator (pneumatically powered) (See Page 4 for examples)
Vendor & Model:      		     
Vendor & Model:      		     
Vendor & Model:      		     
		# of OWNED units
5. Portable Mechanical Ventilator (with internal gas source) (See Page 4 for examples)
Vendor & Model:      		     
Vendor & Model:      		     
Vendor & Model:      		     
6. Basic EMS Transport Ventilator. PLEASE ENTER ONLY TOTAL NUMBER. MODEL & VENDOR ARE NOT NECESSARY. (Autovent 2000, Impact 706,
Total Only:		     
7. Non-invasive devices (See Page 4 for examples.)
Vendor & Model:      		     
Vendor & Model:      		     
Vendor & Model:      		     
8. CPAP Devices (See Page 4 for examples)	Pediatrics?
Vendor & Model:      		     
Vendor & Model:      		     
9. Please indicate how many ventilators listed ABOVE IN #8 are exclusively pediatric/neonatal by manufacturer design by FILLING IN THE BOX TO THE RIGHT OF THE VENTILATOR MODEL.
10. Automatic Resuscitator (See Page 4 for examples.)
Vendor & Model:      		     
Vendor & Model:      		     
11. Pediatric and Neonatal ventilators. Ventilators which are solely for NICU of the PICU (See Page 4 for examples)		# of OWNED units
Vendor & Model:      		     
Vendor & Model:      		     
12. Please list how many ventilators you have in your facility that are not routinely used but could be made functional for ventilating a critically ill patient within 24 hours		# of OWNED units
Vendor & Model:      		     
Vendor & Model:      		     

#1 FULL FEATURED MECHANICAL VENTILATORS (examples of devices)

Bird 8400 or 6400 Bear 1000 Drager E2, E4, XL, Savina Hamilton Veolar, Amadeus, Galileo, G5, Raphael Puritan Bennett 7200, 840

Maquete/Siemens 300, Servo i Respironics Espirt Viasys Avea General Electric Engstrom Carestation

Event Inspiration LS Newport E500 or E360 Emerson IMV

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#2 How many of the ventilators in question #1 are currently equipped for neonatal ventilation ? As an example with the Drager ventilators is the neo-flow option already installed and do you have the flow sensors on site.

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#3 High Frequency ventilators (examples of devices)

Sensormedics 3100 A or B Bunnell Jet Bear Jet Accutronics Jet Percussionaire VDR

Infrasonics Ultra high frequency ventilator

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#4 Portable mechanical ventilators operating from 50 psi gas sources (examples of devices)

Biomedical Devices IC2a, Crossvent 3 or 4 Bird Avian Impact 750 Hamilton MAX Airon pNeuton Allied EPV 100,Omnivent

Smiths Medical VentiPAC or ParaPac Drager Oxylog 1000, 2000, 3000 Newport E-100 Hamilton C2

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#5 Portable ventilator with internal air source (compressor, piston, turbine). (Examples of devices)

Impact 754,731 EMV Pulmonetics LTV 1000 or 1200 Puritan Bennett LP-6, LP-10, Acheiva, PB 740, 540,760 Viasys Vela,

Bird Tbird Newport HT-50 VersaMed iVent Allied MCV100, 200

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#6 Basic EMS transport ventilators (Examples of devices)

Impact 706 AutoVent 2000 or 3000 Smiths PneuPac O-Two systems Carevent MRI, ATV _______________________________________________________________________________________________________________________________________

#7 Non-invasive ventilators (Examples of devices)

Respironics Vision, BIPAP, Focus, Synchrony, AVAPS Viasys Orion, Pegasus Healthdyne/Respironics Quantum

Resmed VPAP Series Puritan Bennett Goodknight Series Drager Carina

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#8 CPAP devices. (Examples of devices)

Resmed S8 series Respironics REMstar, BIPAP AEIOmed Everest Devilbiss RPM Airon MACS

Vital Signs Downs flow generator Caradyne Whisper flow Emergent PortO2

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#9 Please identify which of the devices in #8 are solely for neonatal use. (Examples of devices)

Hamilton Arabella Viasys Infant Flow CPAP or SiPAP

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#10 Automatic resuscitators. (Examples of devices).

Oxylator EM-100, EXM, FR 300 Vortran VTM-1 Ambu Ambumatic Impact 73x

O-Two systems Carevent BLS, EMT, Genesis, ALS, CA

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#11 Neonatal and Pediatric ventilators . (Examples of devices)

Drager Babylog Bird VIP Sechrist Millennium, Model IV-100Bv Event Inspiration Infant Ventialtor BioMed MVP-10 Bear Cub

Smiths Babypac

#12 Stand by ventilators - we realize that many institutions maintain ventilators that have been retired at the facility for use at peak ICU census. These are the ventilators we hope to capture with this question.

Puritan Bennett 7200 Siemens 900C Bear 1000 Bird 6400/8400

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