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.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Odom, Erika C. (CDC/ONDIEH/NCCDPHP) |
File Modified | 0000-00-00 |
File Created | 2021-01-14 |