Form 141 Adult Heart and HeartLung Status 3 Criteria 2 Extension

Adult Heart and HeartLung Status 3 Criteria 2 Extension Justification Form Medical Urgency Data
Fields to be completed by members
Form Section	Field Label	Notes
Status 3 Extension Criteria 2	Multiple inotropes or a single high dose inotrope and hemodynamic monitoring	Display Only - Cascades from database
Status 3 Extension Criteria 2	Select one of the following: Candidate has an invasive pulmonary artery catheter/Candidate has daily hemodynamic monitoring to measure cardiac output and left ventricular filling pressures	Display Only - Cascades from database
Status 3 Extension Criteria 2	Candidate is supported by either: A continuous infusion of at least one high dose intravenous inotrope/A continuous infusion of at least two intravenous inotropes	Display Only - Cascades from database
Status 3 Extension Criteria 2	Was the candidate on inotropic or mechanical support at the time cardiac index was obtained?	Display Only - Cascades from database
Status 3 Extension Criteria 2	Cardiac index	Display Only - Cascades from database
Status 3 Extension Criteria 2	Cardiac index - Test Date	Display Only - Cascades from database
Status 3 Extension Criteria 2	Cardiac index - Test Time	Display Only - Cascades from database
Status 3 Extension Criteria 2	Pulmonary capillary wedge pressure	Display Only - Cascades from database
Status 3 Extension Criteria 2	Pulmonary capillary wedge pressure - Test Date	Display Only - Cascades from database
Status 3 Extension Criteria 2	Pulmonary capillary wedge pressure - Test Time	Display Only - Cascades from database
Status 3 Extension Criteria 2	Systolic blood pressure	Display Only - Cascades from database
Status 3 Extension Criteria 2	Systolic blood pressure - Test Date	Display Only - Cascades from database
Status 3 Extension Criteria 2	Systolic blood pressure - Test Time	Display Only - Cascades from database
Status 3 Extension Criteria 2	Select one of the following: Candidate has an invasive pulmonary artery catheter/Candidate has daily hemodynamic monitoring to measure cardiac output and left ventricular filling pressures
Status 3 Extension Criteria 2	Candidate is supported by either: A continuous infusion of at least one high dose intravenous inotrope/A continuous infusion of at least two intravenous inotropes
Status 3 Extension Criteria 2	Within 48 hours prior to the status expiring, either of the following are true: Cardiac index less than 2.2 L/min/m2 on the current medical regimen/Failed attempt to wean the inotrope support documented by at least one of the following
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].