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AMERICAN SOCIETY OF ELECTRONEURODIAGNOSTIC TECHNOLOGISTS, INC. ELECTRODE BURNS IN THE OR DURING INTRAOPERATIVE NEUROPHYSIOLOGIC MONITORING REPORT FORM The American Society of Electroneurodiagnostic Technologists, Inc.[ASET] is undertaking this important survey of its members and others involved in intraoperative neurophysiologic monitoring to ascertain whether there is a significant problem with electrode burns/lesions in the IONM setting. Then, if necessary, we will attempt to define the problems or parameters that contribute to burns so that they can be eliminated. This effort is part of the mission of ASET to “…promote professional excellence and quality patient care in electroneurodiagnostics,” with findings published in a future issue of the American Journal of END Technology. Please note that your participation will be held in confidence. No patient identifying data will be asked for or used. Your assistance in submitting this important information is greatly appreciated. DIRECTIONS The report form in two parts: Part I General Information Part II More Detailed Information. [We realize that the burn you are reporting may not be a recent incident with details readily available, but please complete the form as much as possible.] The report can be accessed at www.aset.org and printed out, downloaded or completed on-line. The form can also be mailed to ASET, 6501 East Commerce Avenue, Suite 120, Kansas City, MO 64120 or faxed to 816.931.1145. INCIDENT INFORMATION PART I: GENERAL INFORMATION Have you seen other burns before this incident? Yes No If so, how many incidents have you seen? ____ Were the burns you have seen before similar to the one you are reporting? If not, please report them separately using another copy of this form. Patient Information Age ____ Sex Male Female Yes No Height ____Weight ____ Type of procedure being monitored Statement of Incident Location of lesion Stimulation Site Recording Site Ground Site Other: ___________ ______________________________________________________________________________________ PART II: DETAILED INFORMATION Did the patient have existing or history of skin problems? Yes No If so, please detail. _____________________________________________________________________ _____________________________________________________________________________________ Please describe burn/lesion in as much detail as possible. Describe the color.______________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Describe the dimension/shape._____________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Describe the size. ______________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ What was the estimated depth ?_____________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ How close was the burn/lesion site to the ESU/Bovie patient return path pad? ______________________ _____________________________________________________________________________________ Was the skin at the burn/lesion intact? Was the burn site Anode Did the patient report pain? Yes Cathode Yes No Other: __________________________________________ No How was the burn treated? _______________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ What was the outcome of that treatment? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Duration of Surgery ____________________________________________________________________ Was constant current or constant voltage stimulus setting used? __________________________________ Maximal stimulus current/voltage used _____________________________________________________ Other details on stimulus current/voltage (for example, were different levels used throughout the case?) ______________________________________________________________________________________ Stimulus duration used __________________________________________________________________ Other details on stimulus duration used _____________________________________________________ ______________________________________________________________________________________ Fraction of time during the case that the electrode was stimulated [Example, 100% if all the time, 10% if only 10% of the time] ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ NEUROPHYSIOLOGY EQUIPMENT Which type of equipment was involved in the incident? EEG EP EMG/NCV Other _____________________________________________________________________________ Date of manufacture of the equipment involved_ _ _____________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Was the equipment manufactured commercially or designed and built by your facility? Commercially built Designed and built by facility When was the list time the equipment was checked by Biomed prior to the incident? __________________ The following information is information that Biomed often documents when they check equipment. If available, please document below. Value of last recorded ground resistance ___________________________________________________ Value of last reported leakage current ____________________________________________________ Electrode types involved Specialty electrodes EEG needle electrodes Hydrogel (wetgel) EEG disc Electrodes Hydrogel (solidgel) Corkscrew Electrodes Was any electrode paste/gel used? Yes No Age of the paste/gel at time of incident_____________________________________________________ _____________________________________________________________________________________ Were the electrodes Single use Reusable Disposable self-stick electrodes Please give a description of how many recording electrodes were attached to the patient. _____________ _____________________________________________________________________________________ _____________________________________________________________________________________ How long was the electrode leadwire on the electrode where the burn occurred? ______________________ ______________________________________________________________________________________ Was the leadwire connector disconnected from the neurophysiology equipment for any time period during the surgery? If so, please give details. ______________________________________________________ _____________________________________________________________________________________ ______________________________________________________________________________________ OPERATING ROOM EQUIPMENT Equipment used during the surgery Electrosurgical Unit (ESU/Bovie) Electrocautery (Bipolar) Some equipment used in the operating room operates on batteries. An example is the train of 4 twitch stimulator used by anesthesia to control the level of muscle relaxant. Was battery operated equipment used? Yes No If so, what? __________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Was the battery operated equipment connected to the patient using electrodes? Yes No If yes, please explain what type of electrodes and how long they were on during the surgery ________ ______________________________________________________________________________________ ______________________________________________________________________________________ Did you see the application of the ESU/Bovie patient return path pad? Yes No If yes, please detail how the OR staff applied the pad. [Example, did they shave the site? Did they use any type of skin preparation such as alcohol wipe?] Please be as detailed as possible. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ What was the location of the ESU/Bovie Patient Return Path Pad? Lower Back Left Buttock Right Buttock Left Thigh Right Thigh Other: _____________________________________________________________________________ Was any burn/lesion noted under the ESU/Bovie patient return path pad? Yes No If yes, please describe. ____________________________________________________________________ _______________________________________________________________________________________ ICU / ROOM / LAB EQUIPMENT Equipment in use during the procedure machine Arterial Pump Ventilator Cooling Blanket IV Pump Balloon Pump Electric Bed Blood Warmer Dialysis LVAD Other(s)____________________________________________________________________________ Were any of these devices working on battery? Yes No If yes, which?_____________________ ______________________________________________________________________________________ Where did burn occur? Hand Did the burn occur at the EMG needle stick site Arm Foot Leg EMG ground NCV “shock site” NCV ground Please be sure to include the type of electrode(s) used in the appropriate area above. Thank you for participating in this important research. Mail, fax, email or complete on-line at www.aset.org. ASET Executive Office 6501 East Commerce Avenue, Suite 120 Kansas City, MO 64120 816.931.1145 fax
