0990-0344 Data Elements

Approved OMB No. 0990-0344

Exp. Date XX/XX/XX13

Data Elements for HAvBED System

Attachment 2 Revised Data Elements for Online Data Collection

Available Beds

• Adult Intensive Care Unit;

• Adult Medical and Surgical (Med/Surge);

• Burn Care;

• Pediatric ICU;

• Pediatric Medical and Surgical;

• Psychiatric;

• Airborne Infection Isolation; and

• Operating Rooms;

Mass Decontamination Status

• Available

  • Single Lane

  • Number of lanes

• None/Unavailable

Ventilators:

• Total number of full feature ventilators available to the facility that can support patients >5kg

• Number of patients who are currently being managed on rescue therapies e.g. ECMO, High Frequency Oscillation, etc.

  • Number of adults and children >12 years of age

  • Number of children birth to 12 years of age

Facility Stress:

• Since the last reporting period has the facility seen an increased demand for patient care services, such as scheduling, triage, assessment, treatment, admission, transfer and discharge as compared to the demand typically seen during this time of year?

• Has an event triggered activation of the facility’s disaster protocol/emergency operations plan to manage the response?

According to the Paperwork Reduction Act of 1995, no persons are 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 0990-0344 . The time required to complete this information collection is estimated to average an hour 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

• Has the facility activated any of the following surge strategies?

  • Expand bed capacity within existing spaces

  • Early discharge, canceling elective surgeries, etc.

  • Augment personnel e.g. extra shifts, volunteers, change in nurse patient ratios, etc.

  • Expand or modify bed capacity within/beyond existing facility spaces (alternate care sites or mobile units)

  • Requested mutual aid

  • Other

• Does your facility anticipate staffing shortages that will affect your ability to provide services?

• Does your facility anticipate difficulty in obtaining enough general medical supplies to meet demand?

• Does your facility anticipate difficulty in obtaining enough pharmaceuticals to meet demand?

• Does your facility anticipate difficulty in obtaining enough personal protective equipment (as defined by Federal, state or local guidance) to meet demand?

• Does the facility anticipate difficulty in obtaining adequate ancillary ventilator supplies (Circuits, ET tubes, nebulizers, filters, humidification equipment, and suction catheters, etc.) to meet demand?

Facility Infrastructure (linked with CMS EPRI):

• Operational Status. Select one.

<Fully operational>

<Limited operation> <Explain>

<Closed> <Explain>

• Evacuation Status. Select one.

<Not applicable>

<Shelter in place>

<Evacuation partial>

<anticipated>

<in process>

<completed>

<Evacuation total>

<anticipated>

<in process>

<completed>

• Select which (if any) of the following utilities are compromised

  • Potable water

  • Heating and cooling

  • Sewer

  • Telephone connectivity

  • Computer/Internet connectivity

  • Vacuum system

• Does your facility anticipate difficulty obtaining enough medical gasses to meet demand?

• Is your facility currently using emergency power generation?

  • If yes, how many days of fuel supply are on site?