PCNASP Pre-Hospital Data Elements

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Instructions for Paul Coverdell National Acute Stroke Program (PCNASP) Pre-Hospital Data Elements

Public reporting of this collection of information is estimated to average 30 minutes/hours per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

1	EMS Agency	<EMSName>	What is the EMS Agency Name	Text, 25 characters
2	Run Sheet Number	<EMSRunNo>	What is the run sheet number given to the hospital?	Text, 15 characters
3	Scene Arrival	<ScnArrD>	_ _/ _ _/ _ _ _ _	Date MMDDYYYY
		<ScnArrT>	___: ____	Time HHMM
4	Scene Departure	<ScnDptD>	_ _/ _ _/ _ _ _ _	Date MMDDYYYY
		<ScnDptT>	___: ____	Time HHMM
5	Hospital Arrival	<HospArrD>	_ _/ _ _/ _ _ _ _	Date MMDDYYYY
		<HospArrT>	___: ____	Time HHMM
6	Patient Age	<Age>	Age |__|__|__| years	Numeric ### = 3-digit	0 < age < 125
7	Patient Gender	<Gender>	Gender	Numeric # = 1-digit	1 - Male; 2 - Female; 3 - Unknown	Select only 1 gender
8	EMS Diagnosis Impression	<EMSDiagn>	Did EMS think this was a possible stroke?	Numeric # = 1-digit	1 - Yes; 0 - No
9	Hospital pre-notification Performed	<EMSPreNt>	Did EMS call the hospital to notify them of a possible stroke patient?	Numeric # = 1-digit	1 - Yes; 0 - No
10	Pre-hospital stroke screen performed	<StkScnYN>	Did EMS perform a pre-hospital stroke scrreen?	Numeric # = 1-digit	1 - Yes; 0 - No
11	Last Known Well	<LKWD>	_ _/ _ _/ _ _ _ _	Date MMDDYYYY		Leave blank if unknown or did not ask
		<LKWT>	___: ____	Time HHMM
12	Time of discovery	<DiscD>	_ _/ _ _/ _ _ _ _	Date MMDDYYYY
		<DiscT>	___: ____	Time HHMM
13	Thrombolytic Checklist	<tPAChk>	Was a thrombolytic checklist done for possible tPA eligibility?	Numeric # = 1-digit	1 - Yes; 0 - No/ND
14	Glucose Checked	<GluChkYN>	Was glucose checked?	Numeric # = 1-digit	1 - Yes; 0 - No
		<EMSGlu>	Glucose level	Numeric # = 3-digit		mg/dL
15	Destination Decision	<DestDscn>	How did EMS make the decision to come to this hospital?	Numeric # = 1-digit	1 = Protocol to nearest stroke center; 2 = protocol to nearest hospital; 3 = patient/family choice; 4 = enroute medical direction; 5 = nearest hospital; 6 = other or unknown;
16	Follow-up		Did EMS receive hospital follow-up	Numeric # 1-digit	1 = Yes; 0 = No
			If yes, did EMS diagnosis of a stroke agree with hospital diagnosis?	Numeric # 1-digit	1 = EMS & Hospital both diagnosed a stroke; 2 = EMS called a stroke and Hospital did not diagnose a stroke; 3 = EMS did not call a stroke and Hospital diagnosed a stroke