PCNASP Pre-Hospital Data Elements

Paul Coverdell National Acute Stroke Program (PCNASP) Reporting System

Attachment 4a_Pre-hospital data elements

Pre-Hospital Quality of Care Data - PCNASP Awardee

OMB: 0920-1108

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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

 



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