EZ-IO Regional Administration Program

This Form is intended to assisit NTRAC and the NORTEX EMS Provider's Association in surveillance of our EZ-IO program.  Please fill out this formcompletely after each insertion of a needle using this device.  Please do not place any Protected Health Information (PHI) on this form.  This information will be kept secure and used in an effort of process improvement and data collection.  A completed form will be necessary to obtain a replacement needle from the NTRAC/NREMSPA program.

Q1
Q2Expired Needle
Q3
Q4Patient Classification
 
Q5Insertion Direction
 
Q6Procedure Performance
 

Device Indicators

Patient Demographic

Q7
Q8Sex
Q9Class
Q10Body Type
Q11Site Selection check all that apply
Q12Insertions
 1 2 3 4+ 
 Attempted Insertions    

 Successful Insertions    
Q13Insertion Device
Q14Analgesic

Placement Verification (check all that apply)

Q15Prehospital
Q16ER/Hospital

Determining Factor(s)

Q17Check all that apply
 

Administration

Q18Primary Use
Q19Fluid Admin
Q20Infussion Method

Results

Q21Device Performed as Expected
Q22Training for Task
Q23
 
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