New Jersey Department of Health

Office of Emergency Medical Services

PO Box 360

Trenton, NJ 08625-0360

609-633-7777 (Phone) 609-633-7954 (Fax)	Quarterly Report for

Mobile Intensive Care Program
Reports are due to Office of Emergency Medical Services by the 30th of April, July, October and January.

Reporting Quarter (Check only one)

1st 2nd 3rd 4th	Year

20

Program Name

Telephone Number

Street Address

Fax Number

City, State, Zip Code

Cost Per Completed ALS Call

Name of Person Completing Report

Name of Program Director/Coordinator

Name of Medical Director

Section 1 – System-Wide MICU Information
1	MICU Dispatches
15	ALS field pronouncements (By medical command physician)
2	MICU calls cancelled (Patient not seen)
16	ALS patients admitted to a hospital
3	MICU requested and unable to respond (Program Total)
17	ALS patients treated and released from emergency department
3a	MICU unavailable, request covered by another MICU Program.
18	ALS patients transported by Volunteer Ambulances
3b	MICU unavailable, request for ALS not covered by any MICU Program
19	ALS patients transported by Licensed Ambulances
4	Patients evaluated by MICU
20	ALS patients transported by Aeromedical Service
5	Patients triaged to BLS
21	ALS patients transported by MICU
6	Patients triaged to BLS and admitted to critical care
22	ALS transported by other means (explain each situation below)
7	Patients refusing ALS Treatment
23	ALS patients treated and left at scene
8	Patients treated by MICU as completed ALS calls
24	Transport delay due to the lack of available BLS transport service
Patient Age Breakdown:
9	0 to 1 Year
Matching Totals:

Total of 15 + 16 + 17 must equal box 8

Total of 9 + 10 + 11 + 12 + 13 + 14 must equal box 8

Total of 18 + 19 + 20 + 21 + 22 + 23 must equal box 8
10	2 to 8 Years
11	9 to 20 Years
12	21 to 45 Years
13	46 to 65 Years
14	66 Years and Older
Comments (attach additional sheets if necessary):

Program Name

Reporting Quarter (Check only one)

1st 2nd 3rd 4th	Year

20
Section 2 - Vehicle Site Information
Vehicle Site

Site Recognition Number

25	MICU Dispatches
29	Number of out-of-service hours (Explain)
26	MICU calls cancelled (Patient not seen)
Comments:

27	MICU requested and unable to respond
27a	MICU requested and unable to respond, Covered by another MIC Program
27b	MICU requested and unable to respond; ALS call not covered by any MICU
28	Patients treated by MICU as completed ALS calls
Vehicle Site

Site Recognition Number

30	MICU Dispatches
34	Number of out-of-service hours (Explain)
31	MICU calls cancelled (Patient not seen)
Comments:

32	MICU requested and unable to respond
32a	MICU requested and unable to respond, Covered by another MIC Program
32b	MICU requested and unable to respond; ALS call not covered by any MICU
33	Patients treated by MICU as completed ALS calls
Vehicle Site

Site Recognition Number

35	MICU Dispatches
39	Number of out-of-service hours (Explain)
36	MICU calls cancelled (Patient not seen)
Comments:

37	MICU requested and unable to respond
37a	MICU requested and unable to respond, Covered by another MIC Program
37b	MICU requested and unable to respond; ALS call not covered by any MICU
38	Patients treated by MICU as completed ALS calls
Vehicle Site

Site Recognition Number

40	MICU Dispatches
44	Number of out-of-service hours (Explain)
41	MICU calls cancelled (Patient not seen)
Comments:

42	MICU requested and unable to respond
42a	MICU requested and unable to respond, Covered by another MIC Program
42b	MICU requested and unable to respond; ALS call not covered by any MICU
43	Patients treated by MICU as completed ALS calls
Vehicle Site

Site Recognition Number

45	MICU Dispatches
49	Number of out-of-service hours (Explain)
46	MICU calls cancelled (Patient not seen)
Comments:

47	MICU requested and unable to respond
47a	MICU requested and unable to respond, Covered by another MIC Program
47b	MICU requested and unable to respond; ALS call not covered by any MICU
48	Patients treated by MICU as completed ALS calls
Vehicle Site

Site Recognition Number

50	MICU Dispatches
54	Number of out-of-service hours (Explain)
51	MICU calls cancelled (Patient not seen)
Comments:

52	MICU requested and unable to respond
52a	MICU requested and unable to respond, Covered by another MIC Program
52b	MICU requested and unable to respond; ALS call not covered by any MICU
53	Patients treated by MICU as completed ALS calls
Vehicle Site

Site Recognition Number

55	MICU Dispatches
59	Number of out-of-service hours (Explain)
56	MICU calls cancelled (Patient not seen)
Comments:

57	MICU requested and unable to respond
57a	MICU requested and unable to respond, Covered by another MIC Program
57b	MICU requested and unable to respond; ALS call not covered by any MICU
58	Patients treated by MICU as completed ALS calls
Vehicle Site

Site Recognition Number

60	MICU Dispatches
64	Number of out-of-service hours (Explain)
61	MICU calls cancelled (Patient not seen)
Comments:

62	MICU requested and unable to respond
62a	MICU requested and unable to respond, Covered by another MIC Program
62b	MICU requested and unable to respond; ALS call not covered by any MICU
63	Patients treated by MICU as completed ALS calls

Program Name

Reporting Quarter (Check only one)

1st 2nd 3rd 4th	Year

20
Section 3 – Patient Classification

CARDIAC
GENERAL MEDICAL
65	General Cardiac
83	Alcohol / Drug abuse
66	Cardiopulmonary Arrest (Resuscitation attempted)
84	Anaphylaxis
67	Cardiac Total (
85	CVA / Vascular
86	Dehydration / Sepsis
TRAUMA
87	Diabetic
68	Blunt Trauma
88	Drowning / Near Drowning
69	Burn / Electrical Shock
89	Gastrointestinal problems
70	Head injury
90	Heat / Cold exposure
71	Penetrating injury
91	OB / GYN problems
72	Spinal cord injury
92	Poisoning
73	Trauma codes
93	Pronouncements, not resuscitated
74	Other (explain)
94	Psychiatric problem
75	Trauma Total (
95	Respiratory problem
96	Seizures
MECHANISM OF INJURY
97	Syncope
76	MVA
98	Unconscious (etiology unknown)
77	Stab / gunshot
99	Weakness / Malaise
78	Falls
100	Other (explain)
79	Assaults
101	Medical Total (
80	Other (explain)
MATCHING TOTALS

67 + 75 + 101 must equal box 8

76 + 77 +78 +79 +80 must equal box 75

68 + 69 + 70 + 71 + 72 + 73 +74 must equal box 75
81	Trauma patient admitted to Level 1 trauma center
82	Trauma patient admitted to Level 2 trauma center

Comments:

Program Name

Reporting Quarter (Check only one)

1st 2nd 3rd 4th	Year

20

Section 4 – Procedures

102	AV Fistula / Shunt access
110	MAST inflation
103	Central venous access
111	Nasogastric tube insertion
104	Chest decompression
112	Patients cardioverted
105	Esophageal obturator
113	Patients defibrillated
105a	Other commercial airway
114	Patients participated in a prehospital research project
106	External cardiac pacing
115	Tracheal intubation
107	Intraosseous infusion
116	12 lead ECG
108	Intravenous catheter plug
116a	Crichothrotomy
109	IV therapy initiated
116b	RSI initiated
109a	Infusion pump

Section 5 – Primary Communications with Medical Command

117	UHF (telemetry)
Matching Totals

Section Five total must equal box 8
118	VHF (Hear)
119	Cellular Phone
Comments:

119a	Satellite (Nextel( type)
120a	Telephone
121	Radio Failure Protocol
122	Other means (explain)

Section 6 – Payment Source

123	Medicare
Matching Totals

Section Six total must equal box 8
124	Medicaid
125	Blue Cross / Blue Shield
Comments:

126	Self Pay
127	Other commercial insurance
128	No Fault
129	Workman’s compensation
130	Other (explain)

Program Name

Reporting Quarter (Check only one)

1st 2nd 3rd 4th	Year

20

Section 7 – Destinations

(Record the number of patients taken to each hospital)

131 - Hospital Name	Hospital Identification Number	Number of Patients
131- Hospital Name	Hospital Identification Number	Number of Patients

Matching Totals

Box 131 must equal Box 16 and 17

Program Name

Reporting Quarter (Check only one)

1st 2nd 3rd 4th	Year

20

Section 8 – Origination of Call

(List incorporated municipalities and municipality codes. Do not use subdivision names.

Record in Box 133 the number of dispatches for your program vehicles.

In Box 134, record the number of completed ALS calls originating in each town.)

132 - Town	Municipality

Code	133 -

Number of Dispatches	134 -

Number of Completed

ALS Calls

Matching Totals

Total of 133 must equal Box 1

Total of 134 must equal Box 8

Quarterly Report for Mobile Intensive Care Program, Continued

EMS-24

AUG 12	Page 7 of 7 Pages.

AUG 12	Page 1 of 7 Pages.

EMS-24, Quarterly Report for Mobile Intensive Care Program

EMS-24, Quarterly Report, MICU, Mobile Intensive Care Program, EMS, emergency medical services

EWhite

2005-11-14

NJDOH