Download Appendix A. Survey text. Please provide the following information

Appendix A. Survey text.
Please provide the following information. We will not share your contact information.
Name: _________________________________________________
Hospital name: __________________________________________
Hospital city/town: _______________________________________
Hospital ZIP code: _______________________________________
Your position/title: ________________________________________
Your email address: ______________________________________
Your phone number: ______________________________________
Which of the following best describes your hospital’s cardiac catheterization capabilities?
□ No cardiac catheterization lab
□ Diagnostic catheterization lab only
□ Interventional catheterization lab with limited hours
□ 24/7 Interventional catheterization lab
3.
Does your hospital have a therapeutic hypothermia protocol for adult patients who are
comatose following cardiac arrest?
□ Yes
□ No
□ I don’t know
4. When was your therapeutic hypothermia protocol introduced?
□ Before 2009
□ 2009
□ 2010
□ 2011
□ I don’t know
6.
To which of the following rhythm(s) does your protocol apply?
□ Ventricular fibrillation/ventricular tachycardia (VF/VT)
□ Pulseless electrical activity (PEA)
□ Asystole
□ Other
□ I don’t know
6.
In 2010, approximately how many out-of-hospital cardiac arrest patients that were treated in
your emergency department had return of spontaneous circulation (pulses) such that they were
admitted or transferred to another facility?
□ None
□ 1-5 patients
□ 6-10 patients
□ 11-20 patients
□ 21-40 patients
□ 41-60 patients
□ >60 patients
□ I don’t know
7.
In 2010, approximately how many out-of-hospital cardiac arrest patients who were treated in
your emergency department received therapeutic hypothermia?
□ None
□ 1-5 patients
□ 6-10 patients
□ 11-20 patients
□ 21-40 patients
□ 41-60 patients
□ >60 patients
□ I don’t know
8.
Which of the following best describes your hospital’s intensive care unit (ICU)?
□ No ICU
□ ICU, no intensivist
□ ICU with intensivist, limited in-house coverage
□ ICU with 24/7 in-house intensivist coverage
9.
Does your hospital have a cardiac arrest team including emergency medicine, nursing,
cardiology, neurology, and critical care personnel?
□ Yes
□ No
10. May we contact you at the email address and phone number you provided if we need additional
information related to this project?
□ Yes
□ No