Zeppos L, Patman S, Berney S, Adsett J, Bridson J, Paratz JD (2007)
Physiotherapy intervention in intensive care is safe:
an observational study.
Australian Journal of Physiotherapy 53: 279–283
Appendix 1
Data collection sheet
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Case Recording Questionnaire:
Adverse events during physiotherapy in ICU
________________________________________________________________________
Part One – About the Adverse Event
1. Based on what monitor readings or observations did you recognise the adverse event?
ECG
 ECG heart rate change (before____ after____)
 Atrial fibrillation/flutter
 Ventricular tachycardia/output maintained
 Ventricular tachycardia/output not maintained
 Ventricular fibrillation
 Asystole
 Ventricular Ectopic beat Number and type____
 Atrial Ectopic
 ST Elevation _________(mm)
 ST depression ________(mm)
 Bigeminy
 Trigeminy
Other
 EtCO2 before______after_____
 CVP before______after_____
 Shortness of breath
Blood Pressure
 SAP before ________ after ______
 DAP before _______ after_______
 MAP before _______ after_______
Oximetry
 SpO2 before________after_______
Pulmonary artery catheter
 PAP(s) before _______after_______
 PAP(d) before _______after_______
 PAP(m) before ______ after _______
Cardiac output (if continuous)
Before_______after_______method_____
Intracranial parameters
 ICP before______after______
 CPP before_____ after_______
 Colour
Cyanosis _____ Grey ______Pale ______
2. What techniques did you apply before the adverse event? (tick as many as needed)
Positioning
 Head down tilt
 Head up tilt
 Prone
 Side lying right_______left _______
 Other______
Manual techniques
 Percussion
 Vibration
Suction
 ETT ___Trache____ Open____ Closed___
Guedels _____ nasopharyngeal____
 Manual hyperinflation
Circuit type______
FiO2 ____ Flow rate____
 Manometer in circuit
PIP during MHI ______
Exercise
 Passive movements (manual)
 CPM
 Active movements
 Active/assisted movements
 SOOB_____ SOEOB______
 Tilt table ____ degrees _____
 Stand ____Manual ___ standing frame___
 Mobilize No of assist______ Aid______
 Bicycle ________
Positive pressure/NIV
 PEP Pressure_____
 Flutter
 IPPB pressure_____
 CPAP_____
 BiPAP IPAP___ EPAP____
 Other
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3. Briefly describe how the techniques were applied
(eg combination of techniques, sequence and duration of application)
4. When did the adverse event occur? Describe briefly what happened
(During or after treatment session? During which technique?)
5. Was this the patient’s 1st physiotherapy treatment since admission to ICU?
 Yes
 No
6. Had this event occurred previously with other personnel? Give details, frequency,
activity
 Yes
 No
7. Baseline haemodynamic observations prior to treatment
Blood pressure
SAP________DAP_______MAP________
ECG
Pattern ___________HR________
Other
SpO2 ________ CVP ________
8.
Pulmonary artery catheter
PAP(s)_____PAP(d)_____PAP(m)______
PAOP______CO________SVRI________
ICP monitor
ICP__________CPP__________
Sedation scale ______Scale used_______
Which of the following best describes your experience as a physiotherapist in ICU?
 New graduate  1-3 years in ICU  > 3 years in ICU  Senior in ICU
9.
How did the patient respond post adverse event?




Self recovered
Recovered after intervention (please specify intervention)____________
Died
Other (please specify)_________
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Part Two – About the Patient
10. Demographics Age ________
Gender ___________
11. Length of stay in ICU ______________days
12. Patient’s major condition(s) for admission to ICU
13. Co-morbidities
14. Conditions which arose during hospitalization
15. Patients’ airway

No artificial airway/O2 mask

NIV mask
 Nasal  Facial  Full facial  Helmet

Endotracheal tube

Tracheostomy  Surgical  Percutaneous  Minitracheostomy
16. Ventilation parameters prior to treatment
Mode (eg SIMV, PCV) ___________
RR Machine_____ Patient________
TV Machine_____ Patient________
PIP (IP if PCV)_________________
PEEP (high/low if BiLevel_________
FiO2 ___________________________
Pressure support__________________

Nitric oxide Amount _______
I:E ratio _________________________
Time on ventilation ________________
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17. Additional modalities






ECMO
Aortic balloon pump
Ventricular assist device
Dialysis
Haemofiltration
Other
18. Arterial blood gases (last reading prior to the adverse event)
pH
_____________________mmHg
PaO2 ________________________________mmHg
PaCO2 ________________________________mmHg_
HCO3 __________________________________mmol/L
BE
_______________________
FiO2 ___________________________________
19. Other physiological indicators (last readings prior to the adverse event)
[K+] __________________mmol/L
[Ca+] _________________mmol/L
[Na+] _________________mmol/L
Urine output ____________ml/24hr
Creatinine ______________mmol/L
Urea __________________mmol/L
Haematocrit _______________L/L
WCC _____________________x 109/L
Platelet count ______________ x 109/L
Albumin __________________g/L
Bilirubin __________________mol/L
Glucose __________________mmol/L
20. Medications prior to adverse event:



Inotropic/vasopressor support (please specify drug and dose)
_____________________
_____________________
_____________________
Sedation (please specify drug and dose)
______________________
______________________
______________________
Others (please specify drug and dose)
_______________________
_______________________
_______________________
_______________________
_______________________
21. Chest X-ray



Atelectasis  Right  Left  Both
Consolidation  Right  Left  Both
Pulmonary oedema
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