Adult Heart and HeartLung Status 3 Initial Justification Form Medical Urgency Data | ||
Fields to be completed by members | ||
Form Section | Field Label | Notes |
Status 3 Justification Form Section IV |
Dischargeable left ventricular assist device (LVAD) for discretionary 30 days | |
Status 3 Justification Form Section IV |
Multiple inotropes or a single high dose inotrope and hemodynamic monitoring | |
Status 3 Justification Form Section IV |
Select one of the following | |
Status 3 Justification Form Section IV |
Candidate is supported by either | |
Status 3 Justification Form Section IV |
A continuous infusion of at least one high dose intravenous inotrope | |
Status 3 Justification Form Section IV |
Was the candidate on inotropic or mechanical support at the time cardiac index was obtained? | |
Status 3 Justification Form Section IV |
Cardiac index | |
Status 3 Justification Form Section IV |
Cardiac index - Test Date | |
Status 3 Justification Form Section IV |
Cardiac index - Test Time | |
Status 3 Justification Form Section IV |
Pulmonary capillary wedge pressure | |
Status 3 Justification Form Section IV |
Pulmonary capillary wedge pressure - Test Date | |
Status 3 Justification Form Section IV |
Pulmonary capillary wedge pressure - Test Time | |
Status 3 Justification Form Section IV |
Systolic blood pressure | |
Status 3 Justification Form Section IV |
Systolic blood pressure - Test Date | |
Status 3 Justification Form Section IV |
Systolic blood pressure - Test Time | |
Status 3 Justification Form Section IV |
Mechanical circulatory support device (MCSD) with hemolysis | |
Status 3 Justification Form Section IV |
Two separate samples collected within 48 hours of each other confirming markers of active hemolysis as evidenced by at least two of the following | |
Status 3 Justification Form Section IV |
Mechanical circulatory support device (MCSD) with pump thrombosis | |
Status 3 Justification Form Section IV |
Mechanical circulatory support device (MCSD) with right heart failure | |
Status 3 Justification Form Section IV |
Dobutamine | |
Status 3 Justification Form Section IV |
Dobutamine - Date of Initiation | |
Status 3 Justification Form Section IV |
Dopamine | |
Status 3 Justification Form Section IV |
Dopamine - Date of Initiation | |
Status 3 Justification Form Section IV |
Epinephrine | |
Status 3 Justification Form Section IV |
Epinephrine - Date of Initiation | |
Status 3 Justification Form Section IV |
Milrinone | |
Status 3 Justification Form Section IV |
Milrinone - Date of Initiation | |
Status 3 Justification Form Section IV |
Inhaled nitric oxide | |
Status 3 Justification Form Section IV |
Inhaled nitric oxide - Date of Initiation | |
Status 3 Justification Form Section IV |
Intravenous prostacyclin | |
Status 3 Justification Form Section IV |
Intravenous prostacyclin - Date of Initiation | |
Status 3 Justification Form Section IV |
Pulmonary capillary wedge pressure | |
Status 3 Justification Form Section IV |
Pulmonary capillary wedge pressure - Test Date | |
Status 3 Justification Form Section IV |
Pulmonary capillary wedge pressure - Test Time | |
Status 3 Justification Form Section IV |
Central venous pressure | |
Status 3 Justification Form Section IV |
Central venous pressure - Test Date | |
Status 3 Justification Form Section IV |
Central venous pressure - Test Time | |
Status 3 Justification Form Section IV |
Mechanical circulatory support device (MCSD) with device infection | |
Status 3 Justification Form Section IV |
Mechanical circulatory support device (MCSD) with mucosal bleeding | |
Status 3 Justification Form Section IV |
Number of hospitalizations for mucosal bleeding within the past six months | |
Status 3 Justification Form Section IV |
Mechanical circulatory support device (MCSD) with aortic insufficiency (AI) | |
Status 3 Justification Form Section IV |
Veno-arterial extracorporeal membrane oxygenation (VA ECMO) after 7 days | |
Status 3 Justification Form Section IV |
Non-dischargeable, surgically implanted, non-endovascular left ventricular assist device (LVAD) after 14 days | |
Status 3 Justification Form Section IV |
Percutaneous endovascular circulatory support device after 14 days | |
Status 3 Justification Form Section IV |
Intra-aortic balloon pump after 14 days | |
Status 3 Justification Form Section IV |
Mechanical Circulatory Support Device (MCSD) with life threatening ventricular arrhythmia after 7 days | |
Status 3 Justification Form Section IV |
Select at least one of the following | |
Status 3 Justification Form Section IV |
Exception for status 3 | |
Status 3 Justification Form Section IV |
This exception request is specifically related to a device recall | |
Status 3 Justification Form Section IV |
Clinical Narrative | |
OMB No. 0915-0157; Expiration Date: XX/XX/20XX | ||
PUBLIC BURDEN STATEMENT: | ||
The private, non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform the following OPTN functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monitor compliance of member organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0157 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non-profit OPTN also are well protected by a number of the Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed by OMB Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments Automated Information Systems Security Program Handbook. The public reporting burden for this collection of information is estimated to average 0.27 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected]. | ||
File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |