Data Collection Form
(Version 3.1)
ICNARC © 2015
Doc.version 3.1.0
ICMPDS V3.1: Data Form
Admission - prior to or at admission to your unit
Admission number:
CMP number:
1
NHS number:
Identifiers
2
2
0
Residence prior to admission to acute hospital:
Postcode:
2
Residence
Home
M
Residential place of work/education
R
Nursing home or equivalent
U
Hospice or equivalent
P
Health-related institution
H
Non-health-related institution
O
No fixed address/abode or temporary abode
3
N
Ethnicity:
White - British
A
Asian or
Asian British Bangladeshi
K
White - Irish
B
Asian or Asian
British - any other
L
White - any other
C
Black or black
British - Caribbean
M
D
Black or black
British - African
N
Mixed - white and
black African
E
Black or black
British - any other
P
Mixed - white
and Asian
F
Other ethnic group
- Chinese
R
Mixed - any other
G
Any other
ethnic group
S
Asian or Asian
British - Indian
H
Not stated
Z
Asian or Asian
British - Pakistani
J
Date of birth:
D
3
Socio-demographics
D
M
M
C
C
IF DATE OF BIRTH = 01/01/CCYY
Date of birth estimated:
Yes
Doc.version 3.1.0
Y
Y
No
N
Y
Mixed - white and
black Caribbean
Body composition
Height (cms):
Height estimated:
Sex:
Yes
Y
No
N
Weight (kg):
Female
F
4
Male
M
9
Weight estimated:
Yes
Y
No
N
ICMPDS V3.1: Data Form 1
4
5
Obstetric critical
illness
Admission currently/recently
pregnant:
Currently pregnant
C
5
Recently pregnant
R
6
Not known to be pregnant
N
9
Current pregnancy
Gestation of current pregnancy:
Expected date of delivery of current pregnancy:
OR
9
D
weeks
6
Recent pregnancy
Previous pregnancies
M
Gestation at delivery of recent
pregnancy:
Y
Recent pregnancy
outcome
2
0
Y
Y
No
N
Unknown
U
Molar pregnancy associated
with recent pregnancy:
Actual date of delivery of recent pregnancy:
D
weeks
D
M
M
2
0
Y
Y
Yes
Y
No
7
N
Number of live births (babies) and/or
stillbirths from previous pregnancies:
8
Number of previous Caesarean
sections excluding most recent
pregnancy:
8
M
Assisted conception used
for recent pregnancy:
Yes
7
D
Outcome of recent pregnancy:
Termination of pregnancy
T
Ectopic pregnancy
E
Caesarean section
C
Assisted vaginal
A
Spontaneous vaginal
S
9
Doc.version 3.1.0
Number of births from
recent pregnancy:
Number of live births (babies)
Number of babies
in NICU following
recent pregnancy:
Hysterectomy at/since
delivery of recent
pregnancy:
Yes
Y
No
9
N
Number of stillbirths
ICMPDS V3.1: Data Form 2
Date of admission to your hospital:
9
10
11
Prior to
admission
Date/time of
admission
CPR
D
D
M
0
Y
Date of admission to your unit:
D
D
Time of admission to your unit:
H
Source
H
Y
H
M
:
M
Timely
T
Delayed
2
Y
Y
0
M
C
No CPR
Prior location (in):
12
N
N
O
N
T
R
A
N
S
I
E
N
T
T
R
A
N
S
I
E
N
T
N
O
N
T
R
A
N
S
I
E
N
T
19
Hospital housing
transient location (in):
Accident &
emergency
E
Recovery only
R
Imaging department
G
Specialist
treatment area
S
Clinic
C
Theatre & recovery
T
Level 3 bed in adult
ICU or ICU/HDU
I
Level 2 bed in adult
ICU or ICU/HDU
H
Adult HDU
U
Same hospital
S
Classification
of surgery:
Emergency
M
Urgent
U
Scheduled
S
Elective
L
13
Other acute hospital
Paediatric/
neonatal ICU/HDU
P
Obstetrics area
B
Other intermediate
care area
M
Ward
W
Non-acute hospital
Level 3 bed in adult ICU or ICU/HDU
I
Level 2 bed in adult ICU or ICU/HDU
H
Adult HDU
U
Paediatric/neonatal ICU/HDU
P
Obstetrics area
B
Other intermediate care area
M
Ward
W
Not in hospital
N
A
D
M
M
13
14
2
0
Y
19
Sector of other
hospital (in):
Date of original admission to/
attendance at acute hospital:
D
14
10
11
M
Community CPR
N
Specialty code prior to
admission to your unit :
D
Location (in):
Not in hospital
Doc.version 3.1.0
2
Cardiopulmonary resuscitation (CPR) within 24 hours prior to admission to your unit:
In-hospital CPR
12
M
Delay (hours)
Timeliness of admission to your unit:
Y
NHS
N
15
non-NHS, UK
U
non-UK
O
O
ICMPDS V3.1: Data Form 3
13
Transfers
Transferring unit identifier (in):
Transferring unit admission number:
2
0
OR
Type of adult ICU/HDU (in):
14
Source continued
General
G
Burns & plastic
B
Cardiac
C
Renal
R
Thoracic
T
Neurosciences
N
Liver
L
Medical
M
Spinal injury
S
Surgical
U
Obstetric
O
14
Adult ICU/HDU
within your
critical care
transfer group
(in):
Yes
Y
No
N
Date of original admission to ICU/HDU:
D
D
M
M
2
0
Y
Y
Hospital housing nontransient location (in):
Same hospital
S
Other acute hospital
A
Sector of other
hospital (in):
18
Date of original admission to/attendance at acute hospital:
D
Non-acute hospital
Doc.version 3.1.0
D
M
M
2
0
Y
NHS
N
non-NHS, UK
U
non-UK
O
19
Y
O
ICMPDS V3.1: Data Form 4
15
Prior location (in):
Source continued
N
O
N
T
R
A
N
S
I
E
N
T
16
Level 3 bed in adult ICU or ICU/HDU
I
Level 2 bed in adult ICU or ICU/HDU
H
Adult HDU
U
Paediatric/neonatal ICU/HDU
P
Obstetrics area
B
Other intermediate care area
M
Ward
W
Not in hospital
N
16
17
Transfers
Transferring unit identifier (in):
19
Transferring unit admission number:
2
0
OR
Type of adult ICU/HDU (in):
General
G
Burns & plastic
B
Adult ICU/HDU
within your
critical care
transfer group
(in):
Cardiac
C
Renal
R
Thoracic
T
Neurosciences
N
Liver
L
Medical
M
Yes
Y
Spinal injury
S
Surgical
U
No
N
Obstetric
O
17
Date of original admission to ICU/HDU:
D
17
Source continued
D
M
M
2
0
Y
Y
Hospital housing nontransient location (in):
Same hospital
S
19
Doc.version 3.1.0
Other acute hospital
A
Non-acute hospital
O
ICMPDS V3.1: Data Form 5
18
Prior critical care
Critical care visit prior to this admission to your unit:
Unit outreach service only
O
Unit outreach service & non-outreach staff combined
C
Unit medical staff (non-outreach service only)
M
Unit nursing staff (non-outreach service only)
U
Both unit medical & nursing staff (non-outreach service only)
B
No critical care visit prior to this admission to your unit
N
Date of last critical care visit prior to this
admission to your unit:
19
D
D
M
M
2
0
Y
Y
19
19 Type of admission
Admission type:
Doc.version 3.1.0
Unplanned local surgical or medical admission
L
Unplanned transfer in (e.g. due to lack of capacity)
U
Planned transfer in (tertiary referral)
P
Planned local surgical admission
S
Planned local medical admission
M
Repatriation
R
Admission for
pre-surgical
preparation:
Yes
Y
No
N
20
ICMPDS V3.1: Data Form 6
Admission number:
2
Reason for admission - at admission to and during the first 24 hours in your unit
0
Primary reason for admission to your unit:
20
Primary reason
for admission
.
.
.
.
21
Burns
Burned surface area (%):
RAICU1 or RAICU2=
21
Secondary reason
for admission
Secondary reason for admission to your unit:
.
.
.
.
Dry heat burns
1.11.1.5.1
2.11.1.5.1
1.5.7.1.2
2.5.7.1.2
1.13.7.1.4
2.13.7.1.4
Steam burns or scalds
1.11.1.5.2
2.11.1.5.2
1.13.7.1.5
2.13.7.1.5
Electrical burns
1.11.1.5.3
2.11.1.5.3
1.5.7.1.1
2.5.7.1.1
1.13.7.1.3
2.13.7.1.3
Chemical burns
1.11.1.5.4
2.11.1.5.4
1.13.7.1.6
2.13.7.1.6
Inhalation burns
1.1.1.28.1
2.1.1.28.1
1.1.1.30.9
2.1.1.30.9
YES
Inhalation injury:
Yes
NO
Doc.version 3.1.0
22
Y
No
N
22
ICMPDS V3.1: Data Form 7
Admission number:
Past medical history - six months prior to or at admission to your unit
22
Past medical
history
Evidence
available to
assess past
medical
history:
Past medical
history of
one or more
of listed
conditions:
Yes
Yes
Y
No
N
24
2
Severe respiratory disease:
Y
Chemotherapy:
Y
Home ventilation:
Y
Radiotherapy:
Y
Very severe cardiovascular disease:
Y
Metastatic disease:
Y
Chronic renal replacement therapy:
Y
Lymphoma:
Y
Portal hypertension:
Y
Acute myelogenous/lymphocytic
leukaemia or multiple myeloma:
Y
Biopsy proven cirrhosis:
Y
Chronic myelogenous/
lymphocytic leukaemia:
Y
Hepatic encephalopathy:
Y
Congenital immunohumoral or
cellular immune deficiency state:
Y
Steroid treatment:
Y
HIV/AIDS:
A
Y
No
N
23
HIV
H
0
23
AIDS
Dependency prior to admission
to acute hospital:
23
Past medical
history continued
Doc.version 3.1.0
Able to live without assistance in daily activities
A
Minor assistance with some daily activities
N
Major assistance with majority of/all daily activities
J
Total assistance with all daily activities
T
Other condition in past medical history:
.
.
.
.
24
ICMPDS V3.1: Data Form 8
Admission number:
Physiology - lowest/highest - during the first 24 hours in your unit
2
24 Physiology
Yes
Y
25
No
N
44
Evidence available to abstract physiology data:
Lowest
25
Highest
Central temperature (oC):
.
.
Non-central temperature (oC):
.
.
Temperature
26
Systolic
blood pressure
27
Ventricular rate
28
Respiratory rate
0
26
Systolic BP/ paired diastolic BP (mmHg):
27
Heart rate (beats min-1):
28
Non-ventilated respiratory rate (breaths min -1):
29
Ventilated respiratory rate (breaths min -1):
29
Arterial blood gases
- with lowest PaO2
PaO2 (kPa/mmHg):
.
Associated FIO2:
.
Associated PaCO2 (kPa/mmHg):
.
+
Associated pH/H (pH/nmol I ):
Associated intubation status:
Arterial blood
gases missing
.
-1
Yes
Y
No
OR
N
30
Yes
Y
- with lowest pH (highest H+)
Doc.version 3.1.0
pH/H+ (pH/nmol-1):
.
Associated PaCO2 (kPa/mmHg):
.
ICMPDS V3.1: Data Form 9
Physiology continued - lowest/highest during the first 24 hours in your unit
- pre-admission four hours prior to admission to your unit
Lowest
Serum bicarbonate
30 (mmol I-1)
31
Serum sodium
(mmol I-1)
32
Serum potassium
(mmol I-1)
.
Blood lactate
(mmol I-1)
35
Serum urea
(mmol I-1)
Pre-admission
.
OR
.
.
.
OR
.
.
.
Urine output
(ml)
38
Haemoglobin
(g dl-1)
39
Platelet count
(x109 I-1)
40
White blood
cell count
.
.
.
OR
OR
Total for first 24 hours or, if
stay less than 24 hours, total
while in unit
.
.
OR
.
OR
Missing
(tick box)
OR
31
OR
32
OR
33
OR
34
OR
35
OR
36
OR
37
OR
38
OR
39
OR
40
OR
41
WBC count (x109 I-1)
.
.
Doc.version 3.1.0
.
OR
OR
Serum creatinine
36 (µmol I-1)
37
.
OR
33 Serum glucose
(mmol I-1)
34
Highest
.
OR
Associated absolute neutrophil count
(x109 I-1)
.
.
.
ICMPDS V3.1: Data Form 10
41
Pupil reactivity
42 Sedated/paralysed
Pupil reactivity (left eye):
Pupil reactivity (right eye):
Reactive
Reactive
R
R
Unreactive
U
Unreactive
U
Unable to assess
N
Unable to assess
N
Pupil reactivity missing:
OR
Yes
Y
42
Sedated or paralysed and sedated for
whole of first 24 hours in your unit:
Sedated for whole of first 24 hours*
S
Paralysed and sedated for
whole of first 24 hours*
P
43
Neurological
status:
Associated eye component:
Sedated and/or paralysed for
some of first 24 hours*
Assessed
Never sedated or paralysed
at any time in first 24 hours*
Lowest total
Glasgow Coma
Score:
N
A
Associated motor component:
Associated verbal component:
V
Associated intubation status:
* Or, if patient stays less than 24 hours,
for period while in your unit
43
Level of care
Not assessed
Highest level of care
received in the first 24 hours
in your unit:
Level 3
3
Level 2
2
Level 1
1
Level 0
0
43
N
Yes
Y
No
N
43
44
Doc.version 3.1.0
ICMPDS V3.1: Data Form 11
Admission number:
Infection - up to and after the first 48 hours in your unit
44 Unit-acquired infection
MRSA present:
2
Clostridium difficile present:
VRE present:
Admission MRSA
A
Admission VRE
A
Admission C. difficile
A
Unit-acquired MRSA
U
Unit-acquired VRE
U
Unit-acquired C. difficile
U
No MRSA
N
No VRE
N
No C. difficile
N
No samples taken
S
No samples taken
S
No samples taken
S
0
Antimicrobial
use after 48
hours in your
unit
Yes
Y
No
N
45
Main organism causing first unit-acquired infection in blood:
45
Infection in blood
Number of unitacquired infections
present in blood:
Methicillin resistant Staphylococcus aureus (MRSA)
M
Acinetobacter
I
Staphylococcus aureus (not MRSA)
U
Enterobacter
T
Vancomycin resistant enterococcus (VRE)
V
Klebsiella
K
Enterococcus (not VRE)
N
Serratia
S
Yeast (e.g. candida)
Y
Escherichia Coli (E. Coli)
C
Pseudomonas
P
Other organism
O
1 OR MORE
(Record number 0-9)
46
NONE
46
Doc.version 3.1.0
ICMPDS V3.1: Data Form 12
Admission number:
Outcome - at discharge from your or another unit
46
47
Ultimate reason for
admission
2
0
Ultimate primary reason for admission to your unit:
.
.
.
47
.
Calendar days of organ support while in your unit
Organ support
Number of Basic respiratory support days:
Levels of care
Number of Advanced respiratory support days:
Number of Level 3 days:
Number of Basic cardiovascular support days:
Number of Advanced cardiovascular support days:
Number of Level 2 days:
48
Number of Renal support days:
Number of Level 1 days:
Number of Neurological support days:
Number of Level 0 days:
Number of Gastrointestinal support days:
Number of Dermatological support days:
Number of Liver support days:
48
Treatment withheld/
withdrawn
Treatment withheld/withdrawn:
Withdrawn
W
Both withheld then withdrawn
B
Withheld
H
Date treatment first withdrawn:
D
D
M
M
2
0
Y
Y
49
Time treatment first withdrawn:
H
H
:
M
M
49
Neither
Doc.version 3.1.0
N
ICMPDS V3.1: Data Form 13
49
Unit discharge
Status at discharge
from your unit:
Alive
Dead
Still in unit,
exporting data
50
Reason/timeliness
of discharge
Date/time
of discharge
D
D
Time when fully ready to discharge:
H
H
D
53
E
END
Ending critical care
N
Repatriation
R
Comparable critical care
C
Palliative care
P
M
Self-discharge
Date of discharge from your unit:
D
D
Time of discharge from your unit:
H
H
:
M
M
M
M
2
0
Y
Y
50
Timeliness of discharge
from your unit:
Reason for discharge from your unit:
More-specialist critical care
51
Date when fully ready to discharge:
A
Fully ready
F
Delayed
D
Early
E
51
S
M
M
M
M
2
0
Y
Y
52
Level of care/
52 expected dependency
at discharge
Doc.version 3.1.0
:
Expected dependency post-acute hospital discharge:
Level of care received at
discharge from your unit:
Level 3
3
Level 2
2
Level 1
1
Level 0
0
Able to live without assistance in daily activities
A
Minor assistance with some daily activities
N
Major assistance with majority of/all daily activities
J
Total assistance with all daily activities
T
Discharged with the expectation of dying
D
55
ICMPDS V3.1: Data Form 14
53
Brainstem death
Brainstem
death declared:
Yes
Date of declaration
of brainstem death:
Date of death:
No
M
M
2
0
H
H
D
D
:
M
M
M
M
2
0
N
Y
Y
Referred to
transplant coordinator for
solid organ or
tissue
donation:
Y
No
N
Y
Yes
Not approached
H
H
:
M
M
Solid organ or
tissue donor:
Assent for solid
organ or tissue
donation:
No
Yes
Y
54
Time of death:
Doc.version 3.1.0
D
54
Time of declaration
of brainstem death:
54 Organ donation
D
Y
Heartbeating solid
organ donor
Y
H
Date body removed
from your unit:
Non-heartbeating
solid organ donor
O
Tissue donor only
T
No solid organs or
tissues donated
N
N
A
D
D
M
M
2
0
Y
Y
END
Time body removed
from your unit:
H
H
:
M
M
ICMPDS V3.1: Data Form 15
55 Location (out)
56 Transfers
Hospital housing
location (out):
Location (out):
Ward
W
Obstetrics area
B
Other intermediate
care area
M
Recovery only
R
Paediatric/
neonatal ICU/HDU
P
Level 3 bed in adult
ICU or ICU/HDU
I
Level 2 bed in adult
ICU or ICU/HDU
H
Adult HDU
U
Not in hospital
N
Same
hospital
S
Other acute
hospital
A
Sector of other
hospital (out):
59
NHS
N
non-NHS, UK
U
non-UK
O
61
Sector of other
hospital (out):
Non-acute
hospital
NHS
N
non-NHS, UK
U
non-UK
O
62
O
56
62
Transferring unit identifier (out):
END
Hospital
housing
location (out):
OR
Type of adult ICU/HDU (out):
General
G
Spinal injury
S
Cardiac
C
Obstetric
O
Thoracic
T
Burns & plastic
B
Liver
L
Renal
R
Adult ICU/HDU
within your
critical care
transfer group
(out):
Same
hospital
Date of ultimate discharge from ICU/HDU:
D
Doc.version 3.1.0
Medical
M
Surgical
U
Neurosciences
N
Yes
No
S
D
M
M
2
0
Y
Sector of other
hospital (out):
Y
Y
N
57
Other acute
hospital
NHS
N
non-NHS, UK
U
non-UK
O
A
58
ICMPDS V3.1: Data Form 16
57
Ultimate
discharge
Status at ultimate
discharge from
ICU/HDU:
A
Alive
Status at discharge
from your hospital:
59
Date of discharge from your hospital:
Still in unit,
exporting data
59
Outreach
(formal and
informal)
E
D
M
M
2
0
Y
Y
D
Still in hospital,
exporting data
E
END
Status at ultimate
discharge from
ICU/HDU:
Alive
A
61
Dead
D
END
Still in unit,
exporting data
E
END
Critical care visit post-discharge from your unit:
Unit outreach service only
O
Unit outreach service & non-outreach staff combined
C
Unit medical staff (non-outreach service only)
M
Date of first critical care visit
post-discharge from your unit:
D
Doc.version 3.1.0
Dead
END
D
Ultimate
discharge
continued
A
D
Dead
58
Alive
Unit nursing staff (non-outreach service only)
U
Both unit medical & nursing staff (non-outreach service only)
B
No critical care visit post-discharge from your unit
N
D
M
M
2
0
Y
60
Y
60
ICMPDS V3.1: Data Form 17
Destination postdischarge from
your hospital:
Sector of other
hospital (out):
60 Hospital discharge
Other acute
hospital
NHS
61
Status at discharge
from your hospital:
Date of discharge from your hospital:
D
D
M
M
2
0
Y
Y
Alive
A
Dead
D
Still in hospital,
exporting data
E
N
A
non-NHS, UK
U
non-UK
O
Sector of other
hospital (out):
END
Non-acute
hospital
NHS
62
END
Not in hospital
N
O
N
non-NHS, UK
U
non-UK
O
62
Status at ultimate
discharge from
hospital:
61
Date of ultimate discharge from hospital:
Ultimate hospital
discharge
D
62
Residence
after hospital
discharge
Doc.version 3.1.0
D
M
M
2
0
Y
Alive
A
Dead
D
Still in hospital,
exporting data
E
Y
END
Residence post-discharge from acute hospital:
Home
M
Non-health-related institution
O
Nursing home or equivalent
U
Residential place of work/education
R
Health-related institution - short term rehabilitation
S
Hospice or equivalent
P
Health-related institution - long term rehabilitation
L
No fixed address/abode or temporary abode
N
Other health-related institution
H
END
ICMPDS V3.1: Data Form 18