Pre-Hospital Care Data - PCNASP Awardee -EMS respondents

DRAFT 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 xx 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 (xxxx-xxxx)

EMS Agency	<EMSName>	What is the EMS Agency Name	Text, 100 characters		Provide unique identifier for EMS agency *In GWTG the character limit for this text field may be less than the CDC character length	Required
	<EMSNameU>	EMS agency name is unknown		1- Yes; 0- No		Required
Run Sheet Number	<EMSRunNo>	What is the run sheet number given to the hospital?	Text, 100 characters		*In GWTG the character limit for this text field may be less than the CDC character length	Required
	<EMSRuNoU>	EMS run sheet number is unknown		1- Yes; 0- No		Required
Scene Arrival	<ScnArrD>		_ _/ _ _/ _ _ _ _	Date MMDDYYYY		Optional
	<ScnArDND>	Scene arrival date not documented		1 – Yes; 0 – No		Optional
	<ScnArrT>		___: ____	Time HHMM		Optional
	<ScnArTND>	Scene arrival time not documented		1 – Yes; 0 – No		Optional
Arrives at Patient (NOTE: this item is provided secondary to scene arrival times; both can be provided if available)	<FstMdCtD>		_ _/ _ _/ _ _ _ _	Date MMDDYYYY Time HHMM		Optional
	<FstMdCtT>		___: ____			Optional
Scene Departure	<ScnDptD>		_ _/ _ _/ _ _ _ _	Date MMDDYYYY		Optional
	<ScnDpDND>	Scene departure date not documented		1 – Yes; 0 - No		Optional
	<ScnDptT>		___: ____	Time HHMM		Optional
	<ScnDpTND>	Scene departure time not documented		1 – Yes; 0 - No		Optional
Hospital Arrival	<HospArrD>		_ _/ _ _/ _ _ _ _	Date MMDDYYYY	*In GWTG this variable will be prepopulated from in-hospital ED triage date and time as of Winter release 2018	Optional
	<ArrDDND>	Hospital arrival date not documented		1 – Yes; 0 - No		Optional
	<HospArrT>		___: ____	Time HHMM		Optional
	<ArrDTND>	Hospital arrival time not documented		1 – Yes; 0 – No		Optional
Patient Age	<Age>	Age |__|__|__| years	Numeric ### = 3-digit	0 < age < 125		Required
Patient Gender	<Gender>	Gender	Numeric # = 1-digit	1 - Male; 2 - Female; 3 - Unknown	Select only 1 gender	Required
EMS Transfer	<Transfer>	Was this an interfacility transport or transfer patient?		1 - Yes; 0 – No; 2 - Unknown		Required
EMS Diagnosis Impression	<EMSDiagn>	Did EMS think this was a possible stroke? (i.e., primary or secondary provider impression)	Numeric # = 1-digit	1 - Yes; 2 - No; 3- not documented		Required
Hospital pre-notification Performed	<EMSPreNt>	Did EMS call the hospital to notify them of a possible stroke patient?	Numeric # = 1-digit	1 - Yes; 2 – No; 3- N/A		Required
	<EMSAlert>	Was additional information provided as part of pre-notification?	Numeric # = 1-digit	1 – Blood glucose value; 2 – Blood pressure; 3 – Result of stroke screen/Severity score; 4 – LKW time per EMS; 5 – Seizure activity	*In GWTG this ems_alert is not enabled if gs_prehosp_ems is NO[1]	Optional
Pre-hospital stroke screen performed	<StkScn>	Did EMS perform a pre-hospital stroke screen?	Numeric # = 1-digit	1 - Yes; 2– No; 3 – Not documented		Required
	<ScnType>	What type of stroke screen tool did EMS preform?		14=BE FAST; 4=CPSS; 5=DPSS; 6=FAST; 8=MASS; 9=Med PACS; 15=MEND; 10=mLAPSS; 7=LAPSS 11=OPSST; 12=ROSIER; 13=Other (text field for other); 1=Stroke screen tool used, but tool used is unknown; 2=No stroke screen used; 13=Not Documented	*CDC format originally aligned with NEMSIS; since GWTG allows “other” category, we will adopt this format.	Optional
	<ScrTyUnk>	If other, please specify	Text 50 characters			Optional
	<ScnReslt>			1- Positive; 2- Negative; 3- Not documented;		Optional
	<SevType>	If stroke severity scale used, what type of scale did EMS perform?		1=CPSSS/CSTAT; 2=FAST ED; 3=LAMS; 5=RACE; 6=Other (text field for other) ems_sevscaleot; 7 = Severity scale used, but tool used is unknown; 8 = No severity scale used; 9= Not Documented		Optional
	<SevTyUnk>	If other, please specify	Text 50 characters			Optional
	<SevScore>		Numeric # = 2-digit			Optional
Last Known Well	<ELKWD>		_ _/ _ _/ _ _ _ _	Date MMDDYYYY	CDC: Leave blank if unknown or did not ask	Required
	<ELKWDND>	LKW date not documented		1- Yes; 0- No		Required
	<ELKWT>		___: ____	Time HHMM		Required
	<ELKWTND>	LKW time not documented		1- Yes; 0- No		Required
Time of Onset	<OnsetD>		_ _/ _ _/ _ _ _ _	Date MMDDYYYY		Optional
	<OnsetDND>	Onset date not documented		1- Yes; 0- No		Optional
	<OnsetT>		___: ____	Time HHMM		Optional
	<OnsetTND>	Onset time not documented		1- Yes; 0- No		Optional
Thrombolytic Checklist	<tPAChk>	Was a thrombolytic checklist done for possible alteplase eligibility?	Numeric # = 1-digit	1 - Yes; 0 - No/ND		Optional
Glucose Checked	<GluChk>	Was glucose checked?	Numeric # = 3-digit	1 - Yes; 0 – No; 2- glucometer not available; 3- not documented/ not required to perform; 4-patient refused		Required
	<EMSGlu>	Glucose level	Numeric # = 3-digit		*GWTG: mg/dL; for glucometers that don’t produce a numeric value enter 600 for high and 20 for low	Required
	<BglVal>	Blood glucose value	Numeric # = 1-digit	1 – Too high; 2- Too low		Optional
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; 7- unknown/not documented		Optional
	<DesDscnO>	If other reason, specify	Text, 200 characters			Optional
Follow-up	<EMSFU>	Did EMS receive hospital follow-up	Numeric # 1-digit	1 = Yes; 0 = No		Optional
	<DiAgree>	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		Optional
Hospital Coverdell Participation	<HospCovd>	Is this patient transport to a hospital participating in the Coverdell program? (yes/no)	Numeric # =1-digit	0 = No; 1 = Yes; 2 = Unknown		Required
EMS Coverdell Participation	<EMSCovd>	Is this patient transport by an EMS agency participating in the Coverdell program?  (yes/no)	Numeric # =1-digit	0 = No; 1 = Yes; 2 = Unknown		Required

NOTES on pre-hospital elements (Updated 11/19/17):

- EMSName should be a unique identifier, not the actual name of the EMS agency, which must fit within character limit. Ensure no duplicate identifiers occur.

- EMSRunNo - use the same sequence of numbers for every run sheet if truncating. For instance, you could choose the last 7 digits or first 5 digits, as long as they are unique and will not create duplicates. In the long run, it would be best if the names can be standardized which will help analyzing in the future. Ensure no duplicates occur.

- All states are required to report the “Additional Data Elements” (i.e., listed in section 4.4.3 of the Coverdell Resource Guide) as part of each dataset – pre-hospital, in-hospital, and post-hospital. These three additional elements -- <statenam>, <hospital> and/or <EMSName>, and <patidnum> are needed to support record auditing and analysis.