GWTG-CAD: Mission: Lifeline Focus July 2017 PMT FORM SELECTION. Pre-Hospital/Arrival

Transcription

1 GWTG-CAD: Mission: Lifeline Focus July 2017 PMT FORM SELECTION Page 1 Legend: BOLD = Required ^ = MLL Data Element Admin (Tab) ^Patient ID: Physician/Provider NPI: DOB: / / ^Arrival Date/Time: Race: Hispanic Ethnicity Cardiac Diagnosis: Pre-Hospital ^Means of transport to first facility: Gender: Male Female Unknown American Indian or Alaska Native Asian Asian Indian Chinese Filipino Japanese Korean Vietnamese Asian Yes No/UTD If yes, Mexican, Mexican American, Chicano/a Puerto Rican Confirmed AMI STEMI Confirmed AMI non-stemi Air Ambulance Walk-in Pre-Hospital/Arrival Patient Zip Code: Admission Date: Not admitted, transferred out another acute care facility. Black or African American White Native Hawaiian or Pacific Islander UTD Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander Confirmed AMI STEMI/non- STEMI unspecified Coronary Artery Disease EMS Agency name/number: Run/Sequence number: Cuban Another Hispanic, Latino or Spanish Origin Unstable Angina Pre-Hospital Time Tracker ^EMS First ^Non-EMS First Medical Contact: Medical Contact: ^EMS Non-System Reason for Delay: Yes No EMS Dispatch: EMS arrive on scene: EMS depart scene: Destination Prearrival alert or notification: Method of 1st notification: ECG Transmission Phone call Radio Transfers ^Transferred from other facility? Yes No Transferring Facility: Transfer Time Tracker ^Arrival at First Transport hospital: requested: Transport Arrived Date/Time: Transfer out: Mode of transport from Air Inter-facility transport EMS outside facility Ambulance Agency name/number: ECG 1 st ECG Date/Time: / / : 1 st ECG obtained: Prior to hospital arrival

2 ^1 st ECG Non-System Reason for Delay: Yes No ^STEMI or STEMI Equivalent? Yes No ^If yes, STEMI or STEMI equivalent first noted: First ECG Subsequent ECG Arrival Symptom onset Date/Time: Patient first evaluated: ED Cath Lab ^Patient Current Dabigatran Rivaroxaban Medications Apixaban Warfarin After first hospital arrival If subsequent ECG, Date/Time of positive ECG: / / : If ED, Transfer out Date/Time: ^Aspirin within 24 hours of arrival? Yes No Contraindicated ^Antithrombotic taken in 24hrs prior to arrival? Yes No ^Positive cardiac biomarkers in the first 24 hours? Yes No ^History of Smoking? Yes No Hospitalization Reperfusion Reperfusion Candidate? Yes No If no, primary reason: No ST Elevation/LBBB MI diagnosis unclear Yes ^If yes, Dose Start Date/Time: Page 2 Chest pain resolved MI symptoms >12hrs ST elevation resolved No chest pain ^Thrombolytics? ^Documented non-system reason No or delay- Lytics? Yes No If yes, reason (check all that apply) Cardiac Arrest Intubation Patient refusal ^Primary PCI? Yes No PCI Time Tracker Cath Lab Activation: Patient Arrival to Cath Lab: Attending Arrival to Cath Lab: Team Arrival to Cath Lab: ^First PCI Date/Time: ^PCI Indication O Primary PCI for STEMI O PCI for STEMI (stable after successful full-dose lytic) ^Non-system reason for delay- PCI? Reperfusion Contraindications O Difficult vascular access O Cardiac arrest and/or need for intubation ^Reasons for not performing PCI O PCI for STEMI (unstable, >12 hr from sx onset) O Rescue PCI for STEMI (after failed full-dose lytic) O Patient delays in providing consent O Difficulty crossing the culprit lesion O Noncompressible vascular puncture(s) O Active bleeding on arrival or within 24 hours O Quality of life decision O Spontaneous reperfusion (documented by cath only) O Patient/family refusal O DNR at time of treatment decision O Prior allergic reaction to IV contrast O PCI for STEMI (stable, >12 hr from sx onset) O PCI for NSTEMI O None O Not performed O No reason documented O Thrombolytic Administered

3 Hospitalization ^Reasons for not administering lytics ^LVF Assessment % ^CABG During This Admission: ^LDL Cholesterol: Yes No mg/dl O Anatomy not suitable to primary PCI O Known bleeding diathesis O Ischemic stroke w/in 3 months except acute ischemic stroke w/in 3hrs O Recent bleeding within 4 weeks O Any prior intracranial hemorrhage O Suspected aortic dissection Discharge Page 3 Obtained: O Recent surgery/trauma O Significant close head or facial trauma within previous 3 months O Active peptic ulcer O Pregnancy O Intracranial neoplasm, AV malformation, or aneurysm O Prior allergic reaction to thrombolytics This Admission W/in the last year > 1 year ago Planned After Discharge O Severe uncontrolled hypertension O DNR at time of treatment decision O Traumatic CPR that precludes thrombolytics O Expected DTB < 90 minutes O No reason documented Discharge Date/Time: 1 - Home 2 - Hospice-Home 3 - Hospice-Healthcare Facility ^Discharge Status: 4 - Acute Care Facility 5 Other Health Care Facility 6 - Expired 7 Left Against Medical Advice/AMA 8 Not Documented or Unable to Determine (UTD) ^Comfort Measures Only Yes No ^Patient Referred to Cardiac Rehab? Yes No-Referral No-Medical Reason No-Pt No-Health Care System Reason Reason/Preference ^Smoking Cessation Counseling? Yes No ^ACEI at ^ARB at ^Aspirin at ^Clopidogrel at ^Prasugrel at

4 ^Ticagrelor at ^Ticlopidine at ^Anticoagulation at ^Beta Blocker at If yes, Class: Medication: Dose: Frequency: ^Statin at Optional Field-1 Optional Field-2 Optional Field-3 Page 4

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