Form Approved
OMB No. 0990-0391
Exp. Date 05/31/2018
(Ongoing Collection: Up to four times annually, the voluntary panel participants will receive a standard survey that addresses potential healthcare issues, such as staffing, availability of resources, and changes in standard of care.)
SYSTEM TEST: A PULSE For U.S. Hospitals' Stress Level |
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Background: On a daily basis, we know that the healthcare system is often stretched beyond its conventional capacity and capability. Surge capacity occurs across a continuum that is often based on resource availability and demand for health services. One end of the continuum is defined by conventional responses - the maximal utilization of service usually provided in healthcare facilities; at the other end of the continuum is crisis care, when the care provided is the best possible given very limited resource availability. When disaster events or incidents occur, Hospitals and Emergency Departments may be further challenged with even more resource imbalances than their normal conventional or contingency status. To that end, it is useful to periodically query frontline clinicians to assess how stressed their current healthcare delivery setting is. The USCIIT Program for Emergency Preparedness (USCIIT-PREP) asks for your responses to the questions below.
Individual site data are not reported; only AGGREGATE DATA BY REGION are reported.
Please DO NOT forward this email.
Please complete by [DATE AND TIME]
Please provide your participant information
Institution
City
State or Territory
HHS Region (Automatically completed)
I would like to receive the results of this query:
Yes
No
Your Primary Role
What is your primary practice setting?
ED and ICU
Emergency Department (ED)
Intensive Care Unit (ICU)
Other (please select and define below, free text box will appear
Are your patients primarily pediatric?
Yes
No
Variable Questions, based on participant response to question: What is your primary practice setting?
Emergency Department (ED) Setting
TODAY, is the ED bed capacity in the primary hospital that you serve:
Under capacity
Appropriate balance
Over capacity
On diversion
TYPICALLY, is the ED bed capacity in the primary hospital that you serve:
Under capacity
Appropriate balance
Over capacity
On diversion
At the time that you are responding to this poll, what is the number of ICU patients in the ED waiting for ICU beds?
Intensive Care Unit (ICU) Setting
TODAY, what is the ICU (Med-Surg) bed capacity in the primary unit that you serve:
Under capacity
Appropriate balance
Over capacity
On diversion
TYPICALLY, what is the ICU (Med-Surg) bed capacity in the primary unit that you serve:
Under capacity
Appropriate balance
Over capacity
On diversion
At the time you are responding to this poll, is the number of patients requiring mechanical ventilation in your unit (demand versus supply):
Under capacity
Appropriate balance
Over capacity
On diversion
At the time you're responding to this poll, what is the total number of patients in your ICU on invasive mechanical ventilation?
At the time you're responding to this poll, what is the total number of patients in your ICU?
Resources
In your primary role setting, are you experiencing any of the following resource shortfalls? (If information not available, please leave blank)
Staffing
Supplies
Space
Other type of resource shortfall
No resource shortfalls
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
| File Type | application/msword |
| File Title | Form Approved |
| Author | DHHS |
| Last Modified By | Bonny Bloodgood |
| File Modified | 2015-09-29 |
| File Created | 2015-09-29 |