36 Week Form
Please complete this form when the baby is 36 weeks and 0 days postmenstrual age or at
discharge (if baby is discharged at less than 36 weeks).
Baby’s details
First name:
Date of birth:
Surname:
D D
/
M M
/
Y Y
D D
/
M M
/
Y Y
Hospital number:
NHS number:
Study details
Baby’s study number:
Current allocated oximeter code:
Name of hospital:
Date of admission to this hospital:
When this form has been completed, please remove the top copy and keep this in the Principal
Investigator’s Data File. If the baby was not recruited to BOOST-II UK on your unit please keep
the top copy in the baby’s notes. The bottom copy should be returned to the BOOST-II UK Coordinating Centre using the FREEPOST envelope provided.
Version 2 November 2008
Section A
1.
Study number:
Please give the following measurements taken today, or give the measurements for the date closest
to today
Weight:
Head circumference:
.
g
Date of measurement:
D D
cm
Date of measurement:
D D
/
/
M M
M M
/
/
Y Y
Y Y
Section B
Part 1: Supplemental oxygen & respiratory support up to 36 weeks + 0 days or
discharge (whichever is earlier)
2.
While in this hospital, what was the total number of days the baby received
supplemental oxygen*?
days
This is a cumulative total. Any day during which oxygen (>21%) was given for
more than 12 hours counts as a “day in oxygen” (see example ‡).
3.
What respiratory support was the baby receiving at the time of the Jones test?
No support
Nasal cannula*
CPAP
.
Flow rate
l/min
†
Endotracheal ventilation
What was the most recent PCO2?
4.
No gas taken
mmHg
/M M/ Y Y
PCO2
Part 2: Result of the formal Jones test assessment at 36 weeks
Date of measurement: D D
OR
.
kPa
Instructions for performing the Jones test:
When taking a saturation reading, ensure that the baby:
• is lying supine
• is free of gross body movement
• has a good saturation waveform
If these conditions are not present the person doing the test should wait until they are.
Answer just one set of questions [A, B or C] as appropriate and, optionally, if appropriate, those in
[D]. See flow diagram on back page explaining which box to complete.
[A]
If the baby is not in oxygen:
5.
What stable oxygen saturation did the BOOST-II UK oximeter display while
%
the baby was at rest?
[B]
If the baby is in oxygen and has a stable pulse oximeter reading of 89, 90 or 91%
on the BOOST-II UK oximeter:
6.
What percentage of oxygen is needed to obtain an oxygen saturation
of 89, 90 or 91%?
7.
What saturation did the BOOST-II UK oximeter display when the baby
was in this much oxygen?
%
89 %
90 %
91 %
* See definitions and examples section
Version 2 November 2008
[C]
If it is not possible to get a stable pulse oximeter reading of 89, 90 or 91% using the
BOOST-II UK oximeter:
Place a standard oximeter on the baby and answer the following questions:
8.
9.
10.
What percentage of oxygen was needed to obtain an oxygen saturation
in the range 86-94%?
%
What saturation was displayed by the oximeter when the baby was in this
much oxygen?
%
What make of pulse oximeter was used to obtain this reading?
[D] If the baby was in more than 28% oxygen when the Jones test was done then it would
be helpful (although it is NOT a study requirement) to obtain three paired readings
using a standard oximeter, including (if possible) one oxygen percentage reading when
the saturation reading is at least 95%:
If you are able to take 3 paired readings
please record them here:
NB: The baby should have been allowed a
minimum of 5 minutes to stabilise at each
O2 percentage before a reading is taken.
[1] O2
%
SpO2
%
[2] O2
%
SpO2
%
[3] O2
%
SpO2
%
Name of person completing this form:
(Please use BLOCK CAPITALS)
Date the Jones test was performed:
D D
/
M M
/
Y Y
What to do now:
When this form has been completed, please remove the top copy and keep this in the Principal Investigator’s
Data File. If the baby was not recruited to BOOST-II UK on your unit please keep the top copy in the baby’s notes.
The bottom copy should be returned to the BOOST-II UK Co-ordinating Centre using the FREEPOST envelope
provided.
Thank you for completing this form.
Definitions
‡
Days receiving supplemental oxygen - If in your unit, a baby receives supplemental oxygen from birth (at
6pm) until day 6 (3pm) and then again from day 14 (7am) to day 21 (4pm), the total number of days receiving
supplemental oxygen is 5 + 8 = 13 (the first day is less than 12 hours so does not count as a day in oxygen)
* Nasal cannula includes vapotherm and other humidified high flow nasal cannula devices.
†
CPAP includes nasal IPPV or BiPAP
Version 2 November 2008
The Jones Test
•
•
•
Yes
Is the baby in oxygen?
Use the allocated trial oximeter
Place the child supine
Place in oxgyen* in an incubator or
headbox (unless the child is on CPAP
or ventilated or on a high flow nasal
cannula device with a blender†)
Wait until the child is quiet 30+ minutes
after the last feed
•
No
* If the baby is on a low flow nasal cannula
device (<2l/min) the device should be removed
for the test.
†
See Jones Test section in handbook.
•
•
•
•
Use the allocated trial oximeter
Place the child supine
Wait until the child is quiet 30+
minutes after the last feed
Record the stable saturation (or the
average reading over 10 mins)
Yes
Is the displayed saturation less than 89%
breathing air?
Is it possible to get a stable reading of 89,
90 or 91% using a trial oximeter?
Yes
No
•
•
No
Complete Section A of part
2 of the data collection form
Complete Section B of part
2 of the data collection form
Replace the trial oximeter with a
standard oximeter
Find what percentage oxygen is
needed to get one reading of between
86 and 94%
Complete Section C of part
2 of the data collection form
Was the percentage of oxygen > 28% and have you got time to do a full “three point” study?
If Yes, continue to Section D
[D] Optional
• Replace the trial oximeter with a standard oximeter
• Record what percentage oxygen is needed to get 2 readings of between 86 and 94%
• Note what the percentage and the saturation was each time
• Try and get a third reading with a saturation of at least 95%
• Complete Section D of the data collection form
Version 2 November 2008