Headline: SCAMP Data Form (SDF) for the Transposition of the Great Arteries Status-

Transcription

1 Farias M, Jenkins K, Lock J, Rathod R, Newburger J, Bates DW, et al. Standardized Clinical Assessment and Management Plans (SCAMPs) provide a better alternative to clinical practice guidelines. Health Aff (Millwood). 2013;32(5). Appendix Exhibit 1A (Document) Headline: SCAMP Data Form (SDF) for the Transposition of the Great Arteries Status- Post Arterial Switch Operation (ASO) SCAMP SOURCE Authors' internal document. NOTES This represents the SCAMP data form used at the 12 month encounter for patients who have undergone the arterial switch procedure. It is filled in by the clinician at the patient encounter. 1

2 SCAMPs TM Program ASO SDF 5: Evaluation at 12 months post repair For questions, please contact the SCAMPs pager, ID 3028 Recommended Tests: ECG Echocardiogram (Sedated) Stamp with addressograph, place sticker, or fill out the following CHB MRN: Pt name: Visit Information Date: Location: Attending physician name (Please print): Fellow physician / NP name (Please print): SCAMP enrollment status (if applicable): Patient ineligible for SCAMP (SDF not completed) - If patient is ineligible, please return blank form Physician enrolling patient in SCAMP, no packet delivered at time of visit Please describe why patient is ineligible/eligible? General SCAMP Comments: Please answer the following questions about conditions or events since the previous SCAMP visit. If in doubt, write it down; include non-cardiac conditions, if necessary. Does the patient have any new cardiac conditions since the last SCAMP visit? Yes No Comments: Does the patient have any worsening of existing cardiac conditions since the last SCAMP visit? Yes No Comments: Has the patient had any adverse events? Yes No Comments: History - Clinician to Complete 1. Risk Stratification High Risk Low Risk *Please see criteria attached at end of packet. Positive family history for Yes No Unknown lipid abnormality (premature coronary disease in 1st or 2nd degree relative, men <55 or women <65 years)? Comments: Copyright 2011 Institute for Relevant Clinical Data Analytics, Inc. Page 1 of 3 All Rights Reserved. For permissions contact Last Updated :09:02

3 SCAMPs TM Program ASO SDF 5: Evaluation at 12 months post repair For questions, please contact the SCAMPs pager, ID 3028 Medications Current Medications? Yes No Unknown If yes, please list: Meds initiated today? Yes No If yes, please list: Meds discontinued today? Yes No If yes, please list: Recommended SCAMP testing: Sedated Echocardiogram and ECG 5. Echocardiogram: Done previously on: Scheduled for: Not ordered date: date: Done Today If not ordered, why? Copyright 2011 Institute for Relevant Clinical Data Analytics, Inc. Page 2 of 3 All Rights Reserved. For permissions contact Last Updated :09:02

4 SCAMPs TM Program ASO SDF 5: Evaluation at 12 months post repair For questions, please contact the SCAMPs pager, ID Action(s) Taken: No Action Nuclear Lung Perfusion Scan Cardiac Catheterization Consult Other: Did you follow the SCAMP recommendation for ECHO? Yes No If not, why? 7. Did you add other tests? Yes No If yes, please list and describe why: 8. Did you delete tests? Yes No If yes, please list and describe why: Follow-Up: Recommended at age 2 with ECG 9. Next Follow-Up? Age 2 Other: Did you follow the SCAMP follow-up recommendations? Yes No, please select a reason for the deviations: Parental / Patient Anxiety Disagree with SCAMP recommendation Concern for more rapid disease progression in this patient, explain: Other: PPSQ to enter height, weight, and date of next appointment. Copyright 2011 Institute for Relevant Clinical Data Analytics, Inc. Page 3 of 3 All Rights Reserved. For permissions contact Last Updated :09:02

5 Appendix Exhibit 2A (Table) Headline: Institutions Participating in SCAMPs SOURCE Authors' data. NOTES As of 4/1/2013. Institution Baystate Medical Center Boston Children's Hospital Boston Medical Center Brigham and Women s Hospital Child Heart Associates Children's Hospital of Wisconsin Children's National Medical Center Connecticut Children s Medical Center Dartmouth Hitchcock Medical Center Harvard Vanguard Medical Associates Hasbro Children's Hospital Lancaster General Hospital Maine Medical Center Massachusetts General Hospital Pediatric Endocrine Society The Hospital for Sick Children University of California San Francico Benioff Children's Hospital University of Massachusetts Medical Center University of Vermont Medical Center Location Springfield, MA Worcester, MA Milwaukee, WI Washington, DC Hartford, CT Manchester, NH Providence, RI Lancaster, PA Portland, ME McLean, VA Toronto, Canada San Francisco, CA Worcester, MA Burlington, VT 1

6 Appendix Exhibit 3A (Figure) Headline: Total Patient Enrollment in SCAMPs SOURCE Authors' data. NOTES Total number of patient enrolled in SCAMPs at all participating institutions as of 4/1/ Total Patients Enrolled in SCAMPs Number of patients Total Patients Enrolled /1/2009 4/1/2010 4/1/2011 4/1/2012 4/1/2013 Date 2

7 Appendix Exhibit 4A (Table) Headline: Implemented SCAMPs SOURCE Authors' data. NOTES The 49 SCAMPs in use as of 4/1/2013 span a range of pediatric and adult conditions. SCAMP name Management of Adolescents with Polycystic Ovarian Syndrome Discharge Planning and Outpatient Care for Heart Failure Patients Inpatients with Low Pretest Probability for Acute Coronary Syndrome Acute Kidney Injury in the Intensive Care Unit Post Operative Management after Posterior Lumbar Fusion Distal Radius Fracture Management Breast Reconstruction Post Mastectomy Fever of Unknown Origin Persistent Pulmonary Hypertension in the Newborn Patent Ductus Arteriosus Management in Premature Infants Food Reintroduction in Allergic Patients Reducing Blood Product Ordering in the Operating Room Sedation and Analgesia in Ventilated Patients Extracorporeal Membrane Oxygenation Wolff Parkinson White Syndrome Intraoperative Management of Tetralogy of Fallot Aortic Regurgitation Aortic Stenosis Catheterization Laboratory Management of Aortic Stenosis Coarctation of the Aorta Dilated Aortic Root Hypertrophic Cardiomyopathy Hypoplastic Left Heart Syndrome (Mitral Stenosis/Aortic Atresia) Interstage Single Ventricle Patient Management Isolated Patent Ductus Arteriosus Myocarditis Nutrition Optimization for Hospitalized Patients Pediatric Chest Pain Sedated Echocardiogram Subspecialty Management of Lipid Disorders Medical specialty Adolescent Medicine, Gynecology, and Endocrinology Adult Cardiology Adult Cardiology Adult Nephrology Adult Neurosurgery Adult Orthopedics Adult Plastic Surgery General Pediatrics, Rheumatology, and Infectious Disease Neonatology Neonatology and Pediatric Allergy and Immunology Pediatric Anesthesiology and Blood Bank Pediatric Anesthesiology and Critical Care Pediatric Cardiac Critical Care Pediatric Cardiac Electrophysiology Pediatric Cardiac Surgery 3

8 Syncope Transposition of the Great Arteries status post Arterial Switch Lipid Management for Primary Care Orthodontic Retention Practices Critical Asthma Management Simple Skin Abscess Management Immune Thrombocytopenia Secondary Hyperparathyroidism in Dialysis Patients Outpatient Concussion Management Peripherally Inserted Central Catheter Insertion and Care Pressure Ulcer Prevention Papilledema Distal Radial Fracture Pediatric Airway Management Somatoform Disorders Aspiration Pneumonia in Complex Patients Lymphatic Malformations Cytomegalovirus Prevention in Solid Organ Transplant Ureterocele Management and Primary Care Pediatric Dentistry Pediatric Emergency Medicine and Critical Care Pediatric Emergency Medicine, Surgery, and Primary Care Pediatric Hematology and Oncology Pediatric Nephrology Pediatric Neurology, Neurosurgery, and Sports Medicine Pediatric Nursing Pediatric Nursing Pediatric Opthalmology Pediatric Orthopedics and Sports Medicine Pediatric Otorhinolaryngology, Critical Care, and Pulmonology Pediatric Psychiatry Pediatric Pulmonology and Complex Care Service Pediatric Radiology Pediatric Surgery and Infectious Disease Pediatric Urology 4

9 Appendix Exhibit 5A (Table) Headline: SCAMPs in Development SOURCE Authors' data. NOTES The 24 SCAMPs in development as of 4/1/2013 span a range of pediatric and adult conditions. SCAMP name Management of Renal Colic in the Emergency Department Outpatient Management of Gastroesophageal Reflux Disease Outpatient Management of Inflammatory Bowel Disease When to Extubate in the Intensive Care Unit Early Onset Sepsis Diagnosis and Management Management of Infants who Fail Pulse Oximetry Testing Management of Neonatal Hypoglycemia Mid Aortic Syndrome Mixed Aortic Valve Disease Neonatal Supraventricular Tachycardia Post Operative Use of Inhaled Nitric Oxide in Biventricular Patients Chest Pain for Primary Care Spontaneous Pneumothorax Pediatric Graves Disease Feeding Evaluation of Infants Prior to Gastrostomy Tube Placement Pediatric Pre Syncope and Syncope Ketogenic Diet Post Operative Craniotomy Management Hospitalization of Autism Spectrum Disorder Patients Acute Agitation Management Atypical Antipsychotics Non Operative Intussusception Management Diaphragmatic Hernia Empyema Management Medical specialty Adult Emergency Medicine Adult Gastroenterology Adult Gastroenterology Adult Pulmonology and Critical Care Neonatology Neonatology Neonatology and Primary Care Pediatric Emergency Medicine, Pulmonology, Radiology, and Surgery Pediatric Endocrinology Pediatric Gastroenterology, Surgery, and Newborn Medicine Pediatric Neurology Pediatric Neurology, Gastroenterology, and Nutrition Pediatric Neurosurgery Pediatric Nursing Pediatric Psychiatry Pediatric Psychiatry, Developmental Medicine, and Neurology Pediatric Radiology and Surgery Pediatric Surgery, Neonatology, Anesthesia and Critical Care Pediatric Surgery, Pulmonology, Emergency, Critical Care, and Radiology 5