Reducing System and Process Barriers: The RACE to Improve Door to Balloon Performance

Appendix

RACE Referring Hospitals Data Collection Form

Data Abstracter Instructions: Please pull consecutive patient records for one month (or longer) to obtain a minimum of 10 patients. Include patients from both of these two sources; discharge charts coded with ICD-9 410.X0 – .X1 all AMI patients transferred from the emergency department to another facility

Purpose: To identify the subset of ST-elevation myocardial infarction patients and new left bundle branch block AMIs from chart pull and enter this subset of de-identified individual patient data for an aggregate data set. This will be repeated one year after RACE intervention at your center.

Process: You can use this worksheet for preliminary data abstraction or enter data directly onto the electronic data capture eCRF on nrmi.outcome.com.

Arrival mode (at your hospital):O Self-transport

• O Ambulance

• O Air ambulance/helicopter

• O Other/unknown

Patient Arrival Timeline:	Month/Day/Year (mm/dd/yyyy)	Hour/min (24hr Clock)
MI symptom onset	____ ____ /____ ____ /____ ____ ____ ____ O Date N/A	____ ____:____ ____ O Time N/A
First hospital arrival	____ ____ /____ ____ /____ ____ ____ ____	____ ____:____ ____ O Time N/A

Did the patient have chest pain at presentation?   O Yes  O No   O N/A

Year of birth:  ____ ____ ____ ____ (yyyy)

Gender:  O Male O Female O Unknown

First recorded blood pressure:  _____/_____ mmHg or O N/A        (Systolic/Diastolic)

First recorded pulse:  _______ bpm or O N/A

First assessment of heart failure (HF) ( check one ) O Killip 1: No HF

• O Killip 2: Rales, JVD

• O Killip 3: Pulmonary edema

• O Killip 4: Cardiogenic shock

Was a pre-hospital 12-lead ECG obtained?  O Yes  O No   O N/A

  If yes, by EMS?  O Yes  O No   O N/A

	Month/Day/Year (mm/dd/yyyy)	Hour/min (24hr Clock)
First 12-Lead ECG date/time	____ ____ /____ ____ /____ ____ ____ ____ O Date N/A	____ ____:____ ____ O Time N/A

First 12-Lead ECG results (Select Yes or No for each item):

ST elevation > 2 leads   O Yes  O No   # of leads: ____ or O N/A

LBBB (new/unknown)   O Yes  O No

Known LBBB (old)   O Yes  O No

Normal   O Yes  O No

Other/Unknown   O Yes  O No

Was the reperfusion checklist performed by EMS?  O Yes  O No   O N/A

   (This question is not on the regular eCRF – Record this information in Section 23, Custom Field 1 on the eCRF:

   001 = Yes, 002 = No, 003 = N/A)

(This form continues on the other side of this page)

Was an IV thrombolytic administered?  O Yes  O No (When entering online, see the Instructions)

If the patient did not receive a thrombolytic, skip the thrombolytic timeline questions below.

Thrombolytic Timeline:	Month/Day/Year (mm/dd/yyyy)	Hour/min (24 hr Clock)
IV thrombolytic ordered	____ ____ /____ ____ /____ ____ ____ ____ O Date N/A	____ ____:____ ____ O Time N/A
IV thrombolytic initiated	____ ____ /____ ____ /____ ____ ____ ____ O Date N/A	____ ____:____ ____ O Time N/A

If the patient was not administered a thrombolytic, please provide the reason(s) from the list below. Please check all reasons that apply to this patient. Skip this question if the patient did not receive a thrombolytic, but was transferred for consideration for primary PCI.

• O O Reason unknown/Not documented

• O Active internal bleeding or known bleeding diathesis on arrival or within 24 hours

• O History of CVA

• O Recent surgery/trauma (< 2 weeks)

• O Intracranial neoplasm, AV malformation or aneurysm

• O Severe uncontrolled hypertension

• O No ST elevation/LBBB

• O ST elevation resolved

• O MI diagnosis unclear

• O MI symptom onset >12 hours

• O Chest pain resolved

• O No chest pain

• O Quality of life decision

• O Co-morbid disease

• O Traumatic CPR

• O Patient/family refusal

• O Do not resuscitate order in effect at time when treatment decisions being made

• O MI present, but not acutely recognized within 12 hours (Record in Section 23, Custom Field 2 on the eCRF: 001 = Yes, otherwise, leave blank.)

What was the discharge status for this patient? (Choose only one option from this list only)

01-Discharged to home care or self care (routine discharge)

02-Discharge/transferred to another short term general hospital for inpatient care

07-Left against medical advice or discontinued care

20-Expired

	Month/Day/Year (mm/dd/yyyy)	Hour/min (24hr Clock)
Discharged/Expired/Left AMA/ Transferred-out from this hospital	____ ____ /____ ____ /____ ____ ____ ____	____ ____:____ ____ O Time N/A

If the patient was transferred from your hospital (discharge status 02), was the patient transferred for consideration for primary PCIO Yes O No (Record in Section 23, Custom Field 3 on the eCRF: 001 = Yes, 002 = No)

  If yes, which hospital? _______________________________

(Record in Section 23, Custom Field 4 on the eCRF. See the Instructions for the list of RACE tertiary hospitals and the codes to be entered in the Custom Field)

Was an Acute MI Hotline used (a single call line used to activate the cath lab at the PCI center)?

  O Yes  O No (Record in Section 23, Custom Field 5 on the eCRF: 001 = Yes, 002 = No)

How was the patient transferred to the next hospital?   O EMS (dispatched locally)

     O Ground (dispatched from PCI center)

     O Air (dispatched from PCI center)

     O Other/unknown

(Record in Section 23, Custom Field 6 on the eCRF: 001 = Local EMS, 002 = Ground, 003 = Air, 004 = Other/unknown)

Form prepared by (print name):   ____________________________________________

Signature:____________________________________________ Date: _____