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BCMCH-ED-FORM 003 EFFECTIVENESS OF CPR  IN ER
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Date of Data Collection
MM
/
DD
/
YYYY
 EMP ID of the Staff
Area
 UHID:
 AGE:
 GENDER:
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Date of Arrival
MM
/
DD
/
YYYY
 Time of Arrival:
Time
:
1.CO- MORBIDITIES
2. EARLY RECOGNITION OF CARDIAC ARREST
Yes
No
NA
Absence of Carotid pulse
Absence of Breathing
Upward rolling of Eyes
Unresponsiveness
VT
VF
Asystole
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3. EARLY INITIATION OF CPR
Yes
No
NA
Event witnessed
Scene safety Checked
Assessed Patient Response
Called for help
CPR initiated
Privacy maintained
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4. AVAILABILITY OF CONSUMABLES &  EQUIPMENT
Yes
No
NA
Monitor connected to Patient
AMBU bag connected to Wall mounted Oxygen
Defibrillator attached to the patient
Crash Cart readily available
Intubation Tray along with laryngoscope readily available
Suction tube connected to Wall mount Suction apparatus in working condition
Induction drugs readily available
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5. QUALITIES OF CPR
Yes
No
NA
Head Tilt Chin lift position Maintained
CPR started within 10 seconds of cardiac arrest
Adequate Rate of Compression given
Compression Ventilation Ratio maintained
Adequate depth of compression given
Push hard and Push fast
Chest recoiling observed
5 cycles of CPR given
Pulse checked after every 2 minutes
Interruption minimized
Provide adequate ventilation
Avoid excessive ventilation
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6. TEAM RESPONSIBILITIES
Yes
No
NA
Team Leader present
Assigned Nurse present with the patient
Staff for transcribing present
Staff to give chest compression available
Staff available at head end to maintain airway
Staff available for giving medication
Staff / Doctor available for giving shock for cardio version to patient
Bed arrangement done in ICU / HDU/ WARD
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7. TEAM DYNAMICS
Yes
No
NA
Team Leader assigned roles & responsibilities
Effective Knowledge sharing
Limitation acknowledged
Timely Constructive intervention done
Close loop communication maintained
Patient condition summarized and evaluation done
Messages were clear and audible
Maintained mutual respect
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8. MEDICATION USED
Yes
No
NA
Inj. Adrenaline administered
Inj. Amiadarone administered
Inj. Sodium Bicarbonate administered
Inj. Calcium Gluconate administered
Inj. Magnesium Sulphate administered
IV Fluid Normal Saline started
IV Dextrose 25% administered
Proper dilution of Medicine done
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9. PATIENT STATUS
Yes
No
NA
ROSC attained
Not to Escalate
Clinically Expired
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10. POST EVENT ANALYSIS
Yes
No
NA
Maintained Good Team Work
Equipment were available on time
All equipment functioning well
Consumables available in adequate quantity
All Emergency medicines were available in the crash cart
Staff efficient in providing good quality CPR
Any Training recommended
CAPA done on the basis of Analysis
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11. DOCUMENTATION
Yes
No
NA
CODE BLUE Form filled
Nurses note completed
Doctors progress sheet completed
Online Registry Form filled
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