County of Santa Clara Emergency Medical Services System

Transcription

1 County of Santa Clara Emergency Medical Services System Reference # 803 STEMI Data Dictionary STEMI DATA DICTIORY Effective: October 28, 2013 Replaces: January 2009 Review: October 2016 Resources: Policy 414: STEMI Registry Standards I. Purpose The purpose of this policy is to provide the data points which STEMI Receiving Centers must document for all patients meeting inclusion criteria. II. Data See below. Santa Clara County Emergency Medical Services Page 1 of 38

2 COMMON NULL VALUES SCC County Element National Element Unknown is used for information that is requested but not available at time of registry entry. Page 2 of 38

3 Demographics/Episode of Care SCC County Element SR1.1 Hospital National Element This three letter code is assigned to each participating facility that collects STEMI data. This facility code is assigned by the Santa Clara County EMS Agency. ECH GSH KSC KSJ OCH RSJ SUH VMC El Camino Hospital Mountain View Good Samaritan Hospital Kaiser Permanente Medical Center Santa Clara Kaiser Permanente Medical Center San Jose O Connor Hospital Regional Medical Center of San Jose Stanford University Hospital and Clinics Santa Clara Valley Medical Center Select from pick list Identifies the treating facility Page 3 of 38

4 Demographics/Episode of Care SCC County Element SR1.2 Mode of Arrival National Element How the patient arrives at the hospital EMS If the patient arrived via emergency ambulance or helicopter Pvt. Veh. /Law enforcement/walk in If the patient self transported to the ED or if brought by non-emergent means. IFT if the patient came by ambulance or helicopter as a transfer from another Acute Care facility. Select from pick list Allows data to be sorted by mode of arrival Page 4 of 38

5 Demographics/Episode of Care SCC County Element SR1.3 Hospital Unique ID number National Element Any hospital specific number that identifies patient to that facility A field with alpha and numeric capability with 15 available digits Can be the patient s medical record number Correlates that patient s hospital record with the STEMI Registry record Page 5 of 38

6 Demographics/Episode of Care SCC County Element SR1.4 EMS Unique ID Number National Element Auto generated sequential number which includes the month and year A field with alpha and numeric capability Identifies the patient in the registry for that episode of care Page 6 of 38

7 Demographics/Episode of Care SCC County Element SR1.5 Birthdate National Element PCI 250 Patient s verified date of birth Fill in two digit month, two digit date and four digit year ( XX/XX/XXXX) For demographic data collection Page 7 of 38

8 Demographics/Episode of Care SCC County Element SR1.11 Age National Element Patient s age at last birthday Numeric field For demographic data collection Page 8 of 38

9 Demographics/Episode of Care SCC County Element SR1.6 Gender National Element PCI 260 Patient s gender at birth Select M for Male and F for Female For demographic data collection Page 9 of 38

10 Demographics/Episode of Care SCC County Element SR1.7 Race National Element PCI 270 Patient s race as determined by the patient/family White-having origins in any of the original peoples of Europe, the Middle East or North Africa Black- having origins in any of the black racial groups of Africa Asian/Pacific Islander- having origins in any of the peoples of the far East, Southeast Asia, or the Indian subcontinent including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. OR Having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands Native American- having origins in any of the original peoples of North and South America including Central America and who maintain tribal affiliation or community attachment. Other/Unknown If patient does not or cannot declare race. Using the pick list select as many as indicated by the patient For demographic data collection Page 10 of 38

11 Demographics/Episode of Care SCC County Element SR1.8 Hispanic or Latino Ethnicity National Element PCI 270 A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race Y-Yes N-No For demographic data collection Page 11 of 38

12 Demographics/Episode of Care SCC County Element SR1.9 Arrival Date National Element PCI 310 The date that the patient arrives at the facility for the current procedure Use the two digit month, two digit date and four digit year (XX/XX/XXX) Data collection based on date Page 12 of 38

13 Demographics/Episode of Care SCC County Element SR1.10 Arrival Time National Element PCI 311 The first documented time that the patient presented to the facility. Using military time (the 24 hour clock) indicate the hour and minutes. (XX:XX) Calculations for time intervals base on arrival time. Page 13 of 38

14 Procedure Information at your site SCC County Element SR2.1 Death in ED National Element The patient expires in the Emergency Department prior to any cardiac intervention Y-Yes N-No If yes is selected, the registry input automatically defaults to Section E. Assists with understanding mortality rates in this patient population Page 14 of 38

15 Procedure Information at your site SCC County Element SR2.2 Medical Management only National Element The patient will be treated medically only, no planned mechanical interventions. Y-Yes N-No This patient is counted as a STEMI patient if STEMI is documented however no mechanical intervention is done. If yes is selected, the registry input automatically defaults to Section E. Identifies those patients for whom no mechanical intervention is done. Page 15 of 38

16 Procedure Information at your site SCC County Element SR2.3 Thrombolytics National Element The patient received intravenous thrombolytics (tpa, TNK) in the ED Y-Yes N-No Thrombolytic Date: (XX/XX/XXXX) Thrombolytic Time: (XX:XX) If Y is selected, fill in the date and time that the thrombolytic drug was administered. Identifies those patients who receive thrombolytics Page 16 of 38

17 Procedure Information at your site SCC County Element SR2.4 Diagnostic Cath. Only National Element PCI170 No Primary Coronary Intervention (PCI) done, the cardiac catheterization was only for diagnostic purposes. Y- Yes Diagnostic Cath date: (XX:XX:XXXX) N-No Diagnostic Cath time: (XX:XX) Pick list for reasons for diagnostic cath only 1. Normal Coronaries 2. 3-Vessel disease 3. Left Main disease 4. Other Select Y if diagnostic cath only and fill in the date and time. Use the pick list to indicate the reason for the diagnostic cath. If Normal Coronaries selected the program defaults to Section E. If 3 vessel disease or Left Main disease selected the program defaults to Section D. If other is selected, indicate the reason in the text box. Define reasons that PCI is not used/indicated. Page 17 of 38

18 Procedure Information at your site SCC County Element SR2.5 PCI National Element Primary Coronary Intervention-definitive mechanical therapy for the treatment of a STEMI Y- Yes Diagnostic Cath date: (XX:XX:XXXX) N-No Diagnostic Cath time: (XX:XX) The common name for this is the Stick time. Data collection Page 18 of 38

19 Procedure Information at your site SCC County Element SR2.6 PCI Status National Element 804 The type of status related to the procedure and the reason for the procedure. Urgent: Not elective, not emergency, procedure required during same hospitalization in order to minimize the chance of further clinical deterioration. Emergent: Ischemic dysfunction, ongoing ischemia, including rest angina, despite maximal medical therapy; Acute evolving MI within 24 hours before Cardiac Cath Lab procedure or pulmonary edema requiring intubation Mechanical Dysfunction- with or without circulatory support. Salvage: procedure is a last resort. Patient is undergoing CPR enroute to the Cardiac Cath lab. Select only one status Sort by status of PCI Page 19 of 38

20 Procedure Information at your site SCC County Element SR2.7 PCI Indication National Element PCI 812 The reason for the PCI procedure Done acutely for reperfusion in the presence of a STEMI Y-Yes, Primary PCI for STEMI the patient presents to the ED with a documented STEMI on the 12 L EKG. Y-Yes Rescue PCI PCI done after failed thrombolytic therapy with continuing or recurrent myocardial ischemia Y- Yes Facilitated PCI Planned primary PCI after reduced dose of thrombolytic therapy or platelet glycoprotein IIb IIIa therapy or both administered before admission to the Cardiac Cath Lab. N-No Select the specific reason for the procedure Select only one status. If No is selected indicate the reason in the text box. Sort by indication for the PCI indication Page 20 of 38

21 Procedure Information at your site SCC County Element SR2.8 Symptom Onset National Element The time interval the patient first noticed the symptoms of cardiac ischemia < 12 hours >12 hours Unknown Sort data by symptom onset. Page 21 of 38

22 Procedure Information at your site SCC County Element SR2.9 Symptom Date and Time National Element The actual date and time of the patients onset of symptoms. Date- month date and year (MM/DD/YYYY) Time-use military time (XX:XX) Try to ascertain the clearest time of symptom onset from patient. If patient unclear, leave blank. To calculate the onset of symptoms to balloon time calculation. Page 22 of 38

23 Procedure Information at your site SCC County Element SR2.10 STEMI Noted on 12 Lead National Element The first 12 lead EKG that identified the STEMI EMS EKG 1 st ED EKG Subsequent ED EKG If the subsequent ED EKG documented the STEMI, indicate the date and time the subsequent ED EKG was done. To determine time interval to balloon if subsequent EKG identified STEMI, instead of Door to Balloon use subsequent ED EKG to balloon time Page 23 of 38

24 Procedure Information at your site SCC County Element SR2.11 First Device Activation Date and Time National Element PCI 614 The date and time of the definitive activation of the PCI device (referred to as Balloon time) Any coronary device attempting to cross one or more coronary lesions exclude wire only. Date use two digit month, two digit date, and four digit year (MM/DD/YYYY) Time- use military time (24 hour clock) XX:XX This time is part of the calculation for the door to balloon time. Page 24 of 38

25 Procedure Information at your site SCC County Element SR2.12 TIMI grade flow post procedure National Element PCI 922 Documents the amount of flow through the affected artery after the primary PCI 0=no flow/no perfusion 1=slow penetration without perfusion 2=partial flow/partial perfusion 3=complete and brisk flow/perfusion Unknown=not documented Select 0,1,2,3 or unknown as appropriate Documentation of flow rates after the procedure Page 25 of 38

26 Procedure Information at your site SCC County Element SR2.13 Transferred in for PCI National Element PCI 818 The patient was transferred from another acute care facility to the current facility for management of STEMI. Y- Yes Date: N- No Time: If patient transferred in from another acute care facility indicate the date and time patient presented at the other facility. To monitor transfer processes, and flow. Page 26 of 38

27 Procedure Information at your site SCC County Element SR2.14 Non system reason for delay to PCI National Element 7065 Document the non-system reason for delay to procedure, Limited only to: Difficult Vascular Access Cardiac arrest and/or need for intubation before PCI Patient delays in providing consent to the procedure Difficulty crossing culprit lesion during PCI Other None If other is selected, please indicate the reason, in the comments/notes section at the end of the form. The effect on timing/delay of PCI must be documented in order to be an acceptable reason for delay. Page 27 of 38

28 Post Procedure Events SCC County Element SR3.1 Complications (through discharge) National Element PIC The problems related to the actual procedure or as a result of the procedure. General Complications: Cardiogenic Shock as a result of the procedure CVA/Stroke following the procedure Tamponade New requirement for dialysis Vascular/Bleeding complications Bleeding at percutaneous site Retroperitoneal bleeding GI Bleed Bleeding other unknown cause Access site occlusion Significant dissection grade C in presence of ischemia and grades D-F. Dissection is defined as the appearance of contrast materials outside of the expected luminal dimensions of the target vessel and extending longitudinally beyond the length of the lesion. Pseudoaneurysm- if yes- indicate one of the following treatments: none; pressure; fibrin injection; surgery or unknown. Perforation- Indicate if angiographic or clinical evidence of perforation was observed. Page 28 of 38

29 If none is selected the program will skip to Section E Quantify the number of procedural complications. Page 29 of 38

30 Coronary Artery Bypass Surgery SCC County Element SR4.1 CABG National Element PCI 1100 Coronary Artery Bypass Graft procedure done to bypass blocked artery. Can be done as a primary procedure or in combination with PCI. Y-Yes N-No Additional information: If Yes, select Y; if No select N and the program will skip to Section E. Document rates of Cardiac Surgery Page 30 of 38

31 Post Procedure Events SCC County Element SR4.2 CABG - Status National Element PCI 1100 Indicates the status of the CABG procedure Field values: Elective: The patient's cardiac function has been stable in the days or weeks prior to the operation. The procedure could be deferred without increased risk of compromised cardiac outcome. Urgent: Procedure required during same hospitalization in order to minimize chance of further clinical deterioration. Examples include but are not limited to: worsening sudden chest pain, CHF, acute myocardial infarction (AMI), anatomy, IABP, unstable angina (USA) with intravenous (IV) nitroglycerin (NTG) or rest angina Emergent: Patients requiring emergency operation will have ongoing refractory (difficulty, complicated, and unmanageable) unrelenting cardiac compromise with or without hemodynamic instability, and not responsive to any form of therapy except cardiac surgery. An emergency operation is one in which there should be no delay in providing operative intervention. The patient's clinical status includes any of the following: A. Ischemic dysfunction (any of the following): 1. Ongoing ischemia including rest angina despite maximal medical therapy (medical or IABP). Page 31 of 38

32 2. Acute Evolving Myocardial Infarction within 24hours before surgery. 3. Pulmonary edema requiring intubation. B. Mechanical dysfunction (either of the following): 1. Shock with circulatory support 2. Shock without circulatory support. C. Salvage: The patient is undergoing CPR in route to the operating room or prior to anesthesia induction. Additional information: To collect data related to CABG Status. To stratify reasons for CABG Page 32 of 38

33 Post Procedure Events SCC County Element SR 4.3 CABG - indications National Element PCI 1100 The reason for which the CABG surgery was done PCI Complication PCI Failure without clinical deterioration Treatment for CAD without PCI immediately preceding the CABG PCI /CABG Hybrid procedure Additional information: Hybrid therapy occurs when both surgical and percutaneous coronary revascularization are planned, with different lesions treated with the different techniques. To document reasons for CABG Page 33 of 38

34 Post Procedure Events SCC County Element SR 4.3 CABG - Location National Element PCI 1100 The location at which the CABG surgery was performed At your facility Transferred to other facility CABG date CABG time Facility Name Additional information: Select corresponding button. Select the three character designator for the facility if not yours. If transferred out to another facility, indicate the date and time the transfer order was written, and indicate the date and time enroute to the other facility to monitor the transfer process. Page 34 of 38

35 Discharge SCC County Element SR 5.1 Discharge Status National Element PCI 1150 Definitions: Patient is either discharged alive or dead. Field Value: Alive Deceased Discharge Date Select the button corresponding with the patient status to determine length of stay and mortality rates. Page 35 of 38

36 Discharge SCC County Element SR 5.2 Discharge Alive Location National Element PCI 1154 Definitions: Documentation of the final discharge location. Home Extended Care/TCU/Rehab Other acute care hospital SNF/Nursing Home Hospice Other Additional information: Select the appropriate button associated with the patient s discharge location. Quantify the morbidity issues related to the procedure Page 36 of 38

37 Discharge SCC County Element SR 5.3 Discharge: If deceased - Location National Element PCI 1160 the death occurred in the cath lab during or immediately after the procedure Y- Yes N-No Select yes only if the death occurred in the cath lab Documentation of cath lab mortality rates Page 37 of 38

38 Comments/Notes SCC County Element SR 6.1 National Element Free text area to clarify issues and data. Page 38 of 38