Healthcare System Stress Pulse

Form Approved

OMB No. 0990-0391

Exp. Date XX/XX/20XX

DRAFT US-CIIT HEALTHCARE SYSTEM STRESS PULSE QUERY

(NORMAL SALINE)

1. Has your facility recently experienced, or is currently experiencing, difficulty in obtaining intravenous (IV) normal saline?

• Yes

  • If yes, which product(s): __________________

• No

2. Has the IV normal saline supply adversely impacted clinical care?

• Yes (Check all that apply.)

• Medication errors

• Delayed treatment

• ED or facility diversions

• Other(specify/describe)_______________________________________

• No

3. Has your facility implemented any contingency measures due to the limited amount of normal saline?

• Yes (Check all that apply.)

• Substitution

• Conservation

• Cancellation of treatment

• Other (specify/describe)_______________________________________

• No

• Not applicable (facility is not experiencing a shortage)

 

4. If your facility is conserving its saline consumption, which conservation method(s) are being utilized? (Check all that apply.)

• Recommending oral hydration over IV

• Decreasing IV flow rates

• Increasing time per IV bag

• Other (Please describe:_______________________________ )

• Not implementing saline conservation

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 0990-0391. The time required to complete this information collection is estimated to average 15/ 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 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

5. Has your facility recently experienced, or is currently experiencing, a difficulty in obtaining any other intravenous (IV) fluids?

• Yes

  • If yes, which product(s): __________________

• No

6. Has your facility engaged alternate suppliers or other facilities for normal saline products?

• Yes

• For sizes greater than 1000 cc IV bags

• For 1000 cc IV bags

• For sizes less than 1000 cc IV bags

• Other saline products: ________________________________

• No

• Unknown

7. Please list any comments or concerns regarding saline supply you have at the current time:

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