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Daily Care Processes Data Collection Tool

AHRQ Safety Program for Mechanically Ventilated Patients

Hospital # ___________     Unit # ___________    

Date (mm/dd/yyyy) ___________

Fill out for all beds Complete if patient is intubated or has tracheostomy and is mechanically ventilated
Bed # Intub / Trach & Mech Vent Date of Intubation
(mm/dd/yyyy)		 SSD- ETT SSD- ETT Contra Location of Intub HOB @ ≥30o Hob Contra Sedation Scale
RASS/ SAS/ Not Used in Unit Target Actual
If RASS – 5 to 4, NS or X, NK
If SAS – 1 to 7, NS or X, NK
  Y  N  E /    / Y  N  C     Y  N  C   RASS SAS NU    
  Y  N  E /    / Y  N  C     Y  N  C   RASS SAS NU    
  Y  N  E /    / Y  N  C     Y  N  C   RASS SAS NU    
  Y  N  E /    / Y  N  C     Y  N  C   RASS SAS NU    
  Y  N  E /    / Y  N  C     Y  N  C   RASS SAS NU    
  Y  N  E /    / Y  N  C     Y  N  C   RASS SAS NU    
  Y  N  E /    / Y  N  C     Y  N  C   RASS SAS NU    

Continued:

Fill out for all beds Complete if patient is intubated or has tracheostomy and is mechanically ventilated
Bed # Intub / Trach & Mech Vent Delirium Assessment SAT SAT Contra SBT SBT Contra SBT With Seds Off?
CAM-ICU/ ASE/ ICDSC/ NU CAM-ICU P, N, X, UTA, NK ASE 0–10, X, UTA, NK ICDSC P, N, X, UTA, NK
  Y  N  E C A I NU       NS  Y  N  C/NI   Y  N  C/NI   Y  N  NK
  Y  N  E C A I NU       NS  Y  N  C/NI   Y  N  C/NI   Y  N  NK
  Y  N  E C A I NU       NS  Y  N  C/NI   Y  N  C/NI   Y  N  NK
  Y  N  E C A I NU       NS  Y  N  C/NI   Y  N  C/NI   Y  N  NK
  Y  N  E C A I NU       NS  Y  N  C/NI   Y  N  C/NI   Y  N  NK
  Y  N  E C A I NU       NS  Y  N  C/NI   Y  N  C/NI   Y  N  NK
  Y  N  E C A I NU       NS  Y  N  C/NI   Y  N  C/NI   Y  N  NK

C = Contraindicated; E = Empty; Intub = Intubation; Mech Vent = Mechanical Ventilation; N = Negative/No; NK = Not Known; NU = Not Used in this Unit; P = Positive; Trach = Tracheostomy; UTA = Unable to Assess; X = Not Performed; Y = Yes

Note: A glossary of additional acronyms can be found on the last page of this tool.

Contraindications and Locations

Select the appropriate number from below and enter it in the correct contraindications column above. If you have marked C or C/NI, indicate which contraindication is present.

Subglottic Secretion Drainage Endotracheal Tube (SSD-ETT) Contraindications Location of Intubation Head of Bed (HOB) Contraindications
  1. Other.
  2. Tracheostomy.
  1. Your intensive care unit (ICU).
  2. Another ICU in your hospital.
  3. Outside hospital.
  4. Operating room.
  5. Rapid response team.
  6. Emergency department.
  7. Cardiovascular and interventional laboratory.
  8. During a code on the floor.
  9. Another location not listed above.
  1. Other.
  2. Hypotension.
  3. Unstable physiological status.
  4. Low cardiac index.
  5. Cervical, thoracic, or lumbar surgery or instability.
  6. Left ventricular assist device.
  7. Right ventricular assist device.
  8. Intra-aortic balloon pump.
  9. Open abdomen.
  10. Patient refusal.

 

Spontaneous Awakening Trial (SAT) Contraindications Spontaneous Breathing Trial (SBT) Contraindications  
  1. Other.
  2. Sedatives for active seizures or objective evidence of active alcohol withdrawal.
  3. Escalating sedative doses due to ongoing agitation.
  4. Neuromuscular blockers.
  5. Active myocardial ischemia in the previous 24 hours.
  6. Increased intracranial pressure in the previous 24 hours.
  7. High-frequency oscillation ventilation.
  1. Other.
  2. No adequate oxygenation [SpO2 <88% on an FiO2 of ≥50% and a positive end-expiratory pressure (PEEP) of ≥8 cm H2O].
  3. No spontaneous inspiratory effort in a 5-minute period.
  4. Acute agitation requiring escalating sedative doses.
  5. Significant vasopressors or inotropes.
  6. Evidence of increased intracranial pressure in the previous 24 hours.

 

Instructions for Daily Care Processes Tool

Please complete this form once a day, every day. If possible, complete it around the same time each day, ideally during patient rounds.

Patients are considered mechanically ventilated on a specific day if they are mechanically ventilated at the time of observation.

All of the contraindications are listed on page 2 of the data collection tool. Print the data collection sheet with the contraindications on the back of the sheet for easier data collection.

DATA FIELD DIRECTIONS
Hospital Enter the name of your hospital.
ICU Enter the name of your unit.
Date Enter today’s date as MM/DD/YYYY format (e.g. 01/31/2014).
Bed # Enter all the bed numbers on the tool, whether the patient is on mechanical ventilation or not. Include empty beds.
Intub/Trach & Mech Vent: Is the patient currently receiving mechanical ventilation? Enter for all patients. If the bed is empty, leave blank. Mechanical ventilation is defined as receiving ventilator support via an endotracheal or tracheostomy tube for the 24-hour day (except for SBT). Tracheostomy patients should be included starting at the time of positive pressure ventilation initiation.
  • Patients treated with noninvasive ventilation are counted as N.
  • Circle Y if the patient is currently intubated/trached and mechanically ventilated.
  • Circle N if the patient is NOT currently intubated/trached and mechanically ventilated.
  • Enter E if there is no patient in the bed.
For any specific patient, if the patient is not currently intubated or has a tracheotomy AND is on mechanical ventilation, STOP. Do not enter any more information regarding that bed for this date.
Date of Intubation: Enter the date that the patient was intubated using MM/DD/YYYY format (e.g. 06/01/2012).

Evaluate daily for patients receiving full vent support.
  • DO NOT use dates from reintubation immediately following self-extubation.
If the patient is reintubated less than 24 hours after extubation, use first intubation date.

Subglottic Secretion Drainage Endotracheal Tubes

DATA FIELD DIRECTIONS
SSD-ETT:
Does the patient have a subglottic secretion drainage endotracheal tube?		 Evaluate daily for patients receiving mechanical ventilation.
  • Enter Y if the patient has an SSD-ETT.
  • Enter N if the patient does not have an SSD-ETT.
  • Enter C if the use of an SSD-ETT is contraindicated.
SSD-ETT Contra: 
Why is the use of a subglottic secretion drainage endotracheal tube contraindicated?   		 Evaluate daily for patients receiving mechanical ventilation AND with C entered in SSD-ETT.

If C was entered in the SSD-ETT column, answer this question. Enter the number associated with the answer in the box. For example, enter 1 for tracheostomy.

Contraindications are listed on page 2 of the data collection tool.
  1. Other.
  2. Tracheostomy.
Location of Intub:
Where was the patient intubated? Patient must be extubated for 1 or more calendar days to consider this a new intubation. If patient is extubated for less than 1 calendar day, use the original location for subsequent data collection.		 Evaluate daily for patients receiving full ventilator support.

Locations are listed on page 2 of the data collection tool.
  1. Your intensive care unit (ICU).
  2. Another ICU in your hospital.
  3. Outside hospital.
  4. Operating room.
  5. Rapid response team.
  6. Emergency room.
  7. Cardiovascular and interventional laboratory.
  8. During a code on the floor.
  9. Another location not listed above.

Head of Bed

DATA FIELD DIRECTIONS
HOB @ ≥30°: 
Is the head of the bed at least 30 degrees from the horizontal position?		 Evaluate daily for patients receiving mechanical ventilation.
  • Enter Y if the head of the patient’s bed is elevated at least 30 degrees at the time of observation.
  • Enter N if the head of the patient’s bed is not elevated at least 30 degrees at the time of observation and before correction.
  • Enter C if having the head of the patient’s bed elevated at least 30 degrees is contraindicated.
HOB Contra: 
Why is placing the head of the bed at an angle of 30 degrees or more, when compared to a horizontal surface, contraindicated? 		 Evaluate daily for patients receiving full ventilator support AND with C entered in the column labeled HOB @≥30°.

If C was entered in the column labeled HOB @ ≥30°, answer this question. Enter the number associated with the answer into the box. For example, enter 1 for Hypotension.

Contraindications are listed on page 2 of the data collection tool.
  1. Other.
  2. Hypotension.
  3. Unstable physiological status.
  4. Low cardiac index.
  5. Cervical, thoracic, or lumbar surgery or instability.
  6. Left ventricular assist device.
  7. Right ventricular assist device.
  8. Intra-aortic balloon pump.
  9. Open abdomen.
  10. Patient refusal.

Sedation Scale

DATA FIELD DIRECTIONS
RASS/SAS/NU 
What sedation scale do you use on your unit?		 Evaluate daily for patients receiving mechanical ventilation.
  • Circle R if your unit uses the Richmond Agitation Sedation Scale (RASS).
  • Circle S if your unit uses the Riker Sedation-Agitation Scale (SAS).
  • Circle NU if your unit either does not use a sedation scale or uses a scale other than RASS or SAS.*
*If you circled NU, skip to the Delirium Assessment column. DO NOT enter information into either the Target or Actual columns.

If you are a RASS or SAS user, please record the target and actual scores for RASS or SAS assessment closest to 10 a.m. If two scores were collected equidistant from 10 a.m., choose the earlier score.

Evaluated daily for mechanically ventilated patients with R or S entered in the RASS/SAS/Not Used in This Unit column.

The Society of Critical Care Medicine’s Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium (PAD) recommend the RASS and SAS as the most valid and reliable sedation assessment tools for measuring the quality and depth of sedation in adult ICU patients.

DATA FIELD DIRECTIONS
RASS: Target/Actual: 
What are the target and actual RASS scores for this patient?		 RASS
(Only for patients receiving mechanical ventilation and where RASS/SAS/Not Used in This Unit = R)

Enter the score closest to 10 a.m. If two scores were collected equidistant from 10 a.m., choose the earlier score.
  • Enter the target RASS sedation numeric scale value, choosing from -5 to 4.
    • Enter NS if the target RASS sedation level was not set.
    • Enter NK if a target RASS sedation level was set, but is not known.
    • Enter NK if you don’t know whether a target RASS sedation level was actually set.
  • Enter the RASS actual sedation numeric scale value, choosing from -5 to 4.
    • Enter X if an actual RASS sedation level was not scored.
    • Enter NK if an actual RASS sedation level was scored, but is not known.
    • Enter NK if you don’t know whether an actual RASS sedation level was scored.
SAS: Target/Actual: 
What are the target and actual SAS scores for this patient?		 SAS
(Only for patients receiving mechanical ventilation and where RASS/SAS/Not Used in This Unit = S)

Enter the score closest to 10 a.m. If two scores were collected equidistant from 10 a.m., choose the earlier score.
  • Enter the target SAS sedation numeric scale value, choosing from 1 to 7.
    • Enter NS if the target SAS sedation level was not set.
    • Enter NK if a target SAS sedation level was set but is not known.
    • Enter NK if you don’t know whether a target SAS sedation level was actually set.
  • Enter the actual SAS sedation numeric scale value, choosing from 1 to 7.
    • Enter X if an actual SAS sedation level was not scored.
    • Enter NK if an actual SAS sedation level was scored, but is not known.
    • Enter NK if you don’t know whether an actual SAS sedation level was scored.

Delirium Assessment

The Society of Critical Care Medicine’s Clinical Practice Guidelines for the Management (SCCM) of Pain, Agitation, and Delirium (PAD) recommend the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) as the most valid and reliable delirium screening tools, and that moderate- to high-risk patients be screened at least once per nursing shift.

ASE is the second step of the CAM-ICU. While it is not specifically recommended for use by the SCCM PAD Guidelines, it is a good tool to use while your unit is getting set up to do the full CAM-ICU. The results of the ASE may be abnormal due to disease, drugs, or other causes.

DATA FIELD DIRECTIONS
CAM-ICU/ ASE/ICDSC/NU
What delirium assessment tool do you use in your unit?		 Evaluate daily for patients receiving mechanical ventilation.
  • Circle C if your unit uses the CAM-ICU.
  • Circle A if your unit uses the Attention Screening Exam (ASE), which is feature 2 of the CAM-ICU.
  • Circle I if your unit uses the ICDSC.
  • Circle NU if your unit does not use any of the above methods to assess patient confusion.*
*If you circled NU, skip to the SAT column. DO NOT enter information into either the CAM-ICU or ASE columns.

Note: If the use of the CAM-ICU is not yet feasible in your unit, we recommend that patients at least undergo the Attention Screening Exam (ASE) once daily. The ASE is feature 2 of the CAM-ICU, and this 10- to 20-second test of attention is the cardinal feature of a delirium diagnosis.

If you are a CAM-ICU, ASE, or ICDSC user, please record the most recent CAM-ICU, ASE, or ICDSC assessment closest to 10 a.m. If two scores were collected equidistant from 10 a.m., choose the earlier score. The CAM-ICU can be done while on or off sedation/analgesics and it is up to the clinical team to interpret the results of the delirium assessment in light of the presence or absence of sedatives/analgesics.

(Evaluated daily for patients with C, A, or I entered in the CAM-ICU/ASE/ICDSC/Not Used in This Unit column).

CAM-ICU

DATA FIELD DIRECTIONS
CAM-ICU:
Is the patient positive or negative for delirium?		 (Only for patients receiving mechanical ventilation and where CAM-ICU/ASE/ICDSC/Not Used in This Unit = C)

Enter the score closest to 10 a.m. If two scores were collected equidistant from 10 a.m., choose the earlier score.
  • Enter P if the patient is positive for delirium based on CAM-ICU assessment.
  • Enter N if the patient is negative for delirium based on CAM-ICU assessment.
  • Enter UTA if unable to assess (i.e., RASS = -4 or -5 OR SAS = 1 or 2).
  • Enter X if CAM-ICU assessment was not completed.
  • Enter NK if CAM-ICU was completed, but results are not known.
  • Enter NK if CAM-ICU if you don’t know whether the exam was performed.

Attention Screening Exam (ASE)—Feature 2 of the CAM-ICU

DATA FIELD DIRECTIONS
ASE: 
What is the patient’s ability to pay attention?		 (Only for patients receiving mechanical ventilation and where CAM-ICU/ASE/ICDSC/Not Used in This Unit = A)

The goal of this 10- to 20-second test is to determine if a patient can follow a simple command (pay attention) for that period of time. Inattention is the cardinal feature of delirium and must be present to diagnose delirium. For centers not using the full CAM-ICU or ICDSC, conducting the ASE is a good barometer of the presence or absence of delirium. This test may be abnormal due to disease, drugs, or other causes.
The exam consists of the provider reading the following sequence of letters:

S A V E A H A A R T     or     C A S A B L A N C A     or     A B A D B A D D A Y

The patient is told to squeeze the provider’s hand when the letter A is stated. An error is defined as no squeeze with letter A or a squeeze on a letter other than A. The number of errors is counted. Inattention is present if the patient commits more than two errors. If the patient squeezes on every letter or doesn’t squeeze on any letter, then assign an error count of 10.

Enter the score closest to 10 a.m. If two scores were collected equidistant from 10 a.m., choose the earlier score.
  • Enter the number of errors, 0 to 10.
  • Enter UTA if unable to assess (i.e., RASS = -4 or -5 OR SAS = 1 or 2).
  • Enter X if the exam was not performed.
  • Enter NK if the exam was performed, but the number of errors is not known.
  • Enter NK if you don’t know whether the exam was performed.
Society of Critical Care Medicines 2013 pain/agitation/delirium (PAD) clinical practice guidelines recommend the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) as the most valid and reliable delirium screening tools, and that moderate to high risk patients be screened at least once per nursing shift.

Note: If this is not yet feasible in your unit, we recommend that patients at least undergo the Attention Screening Exam (ASE) once daily. The ASE is feature 2 of the CAM-ICU and this 10- to 20-second test of attention is the cardinal feature of a delirium diagnosis.

Intensive Care Delirium Screening Checklist (ICDSC)

DATA FIELD DIRECTIONS
ICDSC: 
Is the patient positive or negative for delirium?		 The ICDSC is an eight-item checklist of delirium symptoms evaluated over an 8- to 24-hour period. Patients are given one point for each symptom that manifests during the specified time frame (zero points if symptom did not manifest). The eight symptoms are: level of consciousness, inattention, disorientation, hallucinations/delusions/psychosis, psychomotor agitation or retardation, inappropriate speech or mood, sleep/wake cycle disturbances, and symptom fluctuation.
  • Enter P if the patient is positive for delirium.
  • Enter N if the patient is negative for delirium.
  • Enter UTA if unable to assess (i.e., RASS = -4 or -5 OR SAS = 1 or 2).
  • Enter X if the exam was not performed.
  • Enter NK if the exam was performed, but the results are not known.
  • Enter NK if you don’t know whether the exam was performed.

Spontaneous Awakening Trial (SAT)

Definition of an SAT: Patients on continuous sedative infusions or standing orders for sedating medications every 6 hours or more often are eligible for SAT. Credit for performing an SAT is given if a sedative infusion is stopped, or if a standing order for intermittent sedating medication is held or cancelled. Analgesics being used for pain can be continued.

An SAT should last until one of the following conditions occurs:

  1. Patient becomes agitated.
  2. Patient is awake and able to follow three of four commands.
  3. Sedatives have been stopped for at least 4 hours.
DATA FIELD DIRECTIONS
SAT: 
Has the patient had an SAT today?		 Evaluate every day for patients receiving mechanical ventilation.

An overview of the decision process for the data collection portion of this measure is listed below. These are not the clinical procedures to be followed.

SAT:  Have medications for sedation been held today? (see flowchart below)
  • Circle NS if the patient is not sedated.
  • Circle Y if medications for sedation have been held today.
  • Circle N if medications for sedation have not been held today.
  • Enter C/NI if holding medications for sedation is either contraindicated or not indicated today.

SAT Data Collection Decision Flowchart. Have medications* for sedation been held today? NS (Not Sedated), Y (Yes), NO (No) C/NI (Contraindicated / Not Indicated). *Sedating Medications include Lorazepam, Midazolam, Propofol, Morphine, Demerol, Dilaudid, Fentanyl, Precedex.

SAT Contra: 
Why is an SAT inappropriate for this patient?		 Evaluate daily for patients receiving mechanical ventilation AND with C/NI entered in the SAT column.

If C/NI was entered in the SAT column, answer this question. Enter the number associated with the answer into the box. For example, enter 1 if patient is receiving sedatives for active seizures or has objective evidence of active alcohol withdrawal.

Contraindications are listed on page 2 of the data collection tool.
  1. Other.
  2. Sedatives for active seizures or objective evidence of active alcohol withdrawal.
  3. Escalating sedative doses due to ongoing agitation.
  4. Neuromuscular blockers.
  5. Active myocardial ischemia in the previous 24 hours.
  6. Increased intracranial pressure in the previous 24 hours.
  7. High-frequency oscillation ventilation.

Spontaneous Breathing Trial (SBT)

SBT definition: To conduct a trial of spontaneous breathing, ventilator support is removed and the patient is allowed to breathe through either a T-tube circuit or a ventilator circuit with low levels of pressure support (5–8 cm H2O in adults) with or without 5 cm H2O PEEP. No changes are required in the fraction of inspired oxygen or the level of PEEP.

DATA FIELD DIRECTIONS
SBT:
Has the patient had an SBT today?		 Evaluated daily for patients receiving mechanical ventilation.
  • Enter Y if the patient had an SBT.
  • Enter N if the patient did not have an SBT.
  • Enter C/NI if the use of an SBT is contraindicated/not indicated.
SBT Contra: 
Why is an SBT inappropriate for this patient?		 Evaluate daily for patients receiving mechanical ventilation AND with C entered in the SAT column.

If C/NI was entered in the SBT column, answer this question. Enter the number associated with the answer into the box.

Contraindications are listed on page 2 of the data collection tool.
  1. Other.
  2. Inadequate oxygenation [SpO2 < 88% on an FiO2 of ≥ 50% and a PEEP of >8 cm H2O].
  3. No spontaneous inspiratory effort in a 5-minute period.
  4. Acute agitation requiring escalating sedative doses.
  5. Significant vasopressors or inotropes (patients may be on dopamine or dobutamine at ≤5 µg/kg/min or norepinephrine ≤2 µg/min, but may not be receiving any vasopressin or milrinone).
  6. Evidence of increased intracranial pressure in the previous 24 hours.
SBT With Seds Off:  Was the SBT performed with the sedatives off? Evaluate daily for patients receiving mechanical ventilation AND with a Y entered in the SBT column.
  • Circle Y if the SBT was performed with the sedatives turned off.
  • Circle N if the SBT was performed with the sedatives on.
  • Circle NK if you don’t know whether the sedatives were off when the SBT was performed.

Glossary of Acronyms

ACRONYM DEFINITION
ASE Attention Screening Exam
CAM-ICU Confusion Assessment Method for the ICU
Contra Contraindication
HOB Head of bed
ICDSC Intensive Care Delirium Screening Checklist
ICU Intensive care unit
RASS Richmond Agitation Sedation Scale
SAS Riker Sedation–Agitation Scale
SAT Spontaneous awakening trial
SBT Spontaneous breathing trial
Seds Sedatives
SSD-ETT Subglottic secretion drainage endotracheal tube

Publication:
16(17)-0018-9-EF

Page last reviewed January 2017
Page originally created January 2017

Internet Citation: Daily Care Processes Data Collection Tool. Content last reviewed January 2017. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/hai/tools/mvp/modules/technical/daily-care-processes-tool.html

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