EZ-IO® Product System Evaluation Form

Evaluation Survey for Emergency Medical Personnel

Thank you for participating in our online survey. We're conducting this survey to obtain feedback regarding your experience with the EZ-IO® product system. We remind you that your participation in this ongoing project is strictly voluntary and you may refuse to participate or discontinue participation at any time without penalty. If you decide to fill out the survey, all your responses will be kept strictly confidential and will only be seen by those authorized by Vidacare®. You are welcome to contact our office at any time if you have questions about this survey.

Data gathered from the entire project will be summarized in the aggregate, excluding references to any individual responses. The aggregated results of our analysis will be shared among research personnel and others interested in providing services to educate people about EZ-IO® product system training and use. Vidacare® is looking for better ways to help emergency medical professionals feel comfortable and confident about their skill and use of the EZ-IO® product system. With your responses, we hope to identify areas of improvement and add to our services. Again, your input is important and any information we receive will be kept confidential.

The survey has five sections: LOG-IN INFORMATION, SITE INFORMATION, PATIENT INFORMATION (NON-IDENTIFIABLE), EZ-IO® PRODUCT SYSTEM EXPERIENCE, and COMMENTS. It will take about 3 minutes to complete.

Please direct any problems concerning the survey to the director of education or research coordinator.

EZ-IO® Evaluation Form

Log-in Information E-mail: City: State: Site Information Organization: Phone: Operator's Name: Date of Insertion: / / (MM/DD/YYYY) Time of Call/Patient Arrival: -- 00:01-07:00 07:01-13:00 13:01-19:00 19:01-24:00 Operator: -- EMC EMT EMT-I Military Medic EMT-P LP RT RN MD Other... Name of Facility Patient Transported to or Treated at:     Patient Information Approximate age of Patient: yrs. Sex of Patient: -- Male Female Height of Patient: Approximate GCS: -- 3 4 5 6 7 8 9 10 11 12 13 14 15 Classification: -- Medical Trauma Weight of Patient: EZ-IO® Information Number of EZ-IO® PD (less than 40 Kilos) attempts: -- 1 2 3 4 NA Number of EZ-IO® AD (40 Kilos or greater) attempts: -- 1 2 3 4 NA Number of EZ-IO® LD (Excessive Tissue) attempts: -- 1 2 3 4 NA   Number of EZ-IO® PD (less than 40 Kilos) insertions: -- 0 1 2 3 4 Number of EZ-IO® AD (40 Kilos or greater) insertions: -- 0 1 2 3 4 Number of EZ-IO® LD (Excessive Tissues) insertions: -- 0 1 2 3 4   EZ-IO® Insertion Site: -- Proximal Tibia Distal Tibia Proximal Humerus Other Other: EZ-IO® Placed: -- Yes No   How did you confirm placement? (Check all that apply): Firmly in place Blood at tip of stylet Able to Aspirate Marrow Physiologic response to medications Able to inject fluids and/or drugs X-ray or ultrasound confirmation More than one EZ-IO® placed in same patient: -- Yes No Did the Patient complain of pain during insertion? (0=no pain, 10=severe pain): -- 0 1 2 3 4 5 6 7 8 9 10 Time of insertion (seconds) -- 1-3 4-6 7-10 11-13 14-16 >17 (choose best answer) Medications/Fluids given: (Check all that apply) Cardiac Paralytic NS/LR   Sedative Glucose Other: Did the Patient complain of pain with infusion? (0=no pain, 10=severe pain): -- 0 1 2 3 4 5 6 7 8 9 10 Did Lidocaine decrease the pain of infusion? -- Yes No N/A Did the Patient receive a Syringe Bolus or Flush immdediately following inserion? -- Yes No If you applied pressure for a continuous infusion please indicate the source -- Manual Pressure Bag Pump Other What size drip set did you use? -- 60qtt set 15qtt set 10qtt set Other What was the estimated flow rate in qtts/min? qtt/min Return of spontaneous circulation (ROSC)? -- Yes No N/A Describe your experience with the EZ-IO® (1 = easy, 5 = Hard): -- 1 2 3 4 5 Did you feel you had control over the placement of the needle tip: -- Yes No Did the needle separate easily from the driver: -- Yes No Was the stylet easy to remove from the needle set: -- Yes No Complications: -- Yes No Did the EZ-IO® compromise the Patient or user’s safety? -- Yes No Do you need to speak with a Vidacare representative immediately? If yes, call 1-800-680-4911. Comments or suggestions: (We appreciate your comments, good or bad! All reports are taken seriously and the information is used to improve the EZ-IO® and its training. Thank You.)