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NCDR® ACTION Registry®- GWTG™ v2.4 (Limited)
Acute Coronary Treatment and Intervention Outcomes Network Registry
A. DEMOGRAPHICS
Last Name2000:
□SSN N/A2031
SSN2030:
Birth Date2050:
Race:
(check all that apply)
Middle Name2020:
Patient ID2040:
Other ID2045:
Sex2060: O Male
mm / dd / yyyy
□ White2070
First Name2010:
□ Black/African American2071
O Female
□ Zip Code N/A3001
Patient Zip Code3000:
□ American Indian/Alaskan Native2073
□ Asian2072 à If Yes, □ Asian - Indian2080 □ Chinese2081 □ Filipino2082 □ Japanese2083 □ Korean2084 □ Vietnamese2085 □ Other2086
□ Native Hawaiian/Pacific Islander2074 à If Yes, □ Native Hawaiian2090 □ Guamanian or Chamorro2091 □ Samoan2092 □ Other Island2093
Hispanic or Latino Ethnicity2076 :
O No
à If Yes, Ethnicity Type:
O Yes
□ Mexican, Mexican-American, Chicano
(check all that apply)
□ Puerto Rican
2100
□ Cuban2102
2101
□ Other Hispanic, Latino or Spanish Origin2103
B. ADMISSION
Means of Transport to First Facility3100:
O Self/Family
O Ambulance
O Air
à If Ambulance or Air, EMS 1st Med. Contact Date/Time3105, 3106: ___________
à If Self/Family, Non-EMS 1st Med. Contact Date/Time3111, 3112:
EMS Dispatch Date/Time3152, 3153: ___________
EMS Agency Number3156: ___________
3158, 3159
Cath Lab Activation Date/Time
___________
(STEM or STEMI Equiv.)
(STEM or STEMI Equiv.)
□ Time Estimated3107 □ Non-System Reason for Delay3108
□ Time Estimated3113
(STEM or STEMI Equiv.)
EMS Leaving Scene Date/Time3154, 3155: ___________
EMS Run Number3157: ___________
: ___________ (STEM or STEMI Equiv.)
Transferred from Outside Facility3110: O No O Yes
à If Yes, Means of Transfer3115:
à If Yes, Arrival at Outside Facility Date/Time3120, 3121:
____________________
à If Yes, Transfer from Outside Facility Date/Time3125, 3126:
____________________
3150, 3151
Your Facility
à If Yes, Name of Transferring Facility/AHA Number
Admission Date
Insurance Payors:
(check all that apply)
O Ambulance
O Air
□ Time Estimated3122
□ Time Estimated3127
: _________________________________________________________
Location of First Evaluation3220:
Arrival Date/Time3200, 3201:
3210
(STEM or STEMI Equiv.)
O ED
O Cath Lab
O Other
3221, 3222
à If ED, Transfer Out Date/Time
:
: ____________________
□ Private Health Insurance
□ Medicare
□ Medicaid
□ Military Health Care3303
□ State-Specific Plan (non-Medicaid)3304 □ Indian Health Service3305 □ Non-US Insurance3306 □ None3307
3300
Provider Name3310-3312:
3301
3302
Provider NPI3315:
HIC #3320:
C. CARDIAC STATUS ON FIRST MEDICAL CONTACT
□ Time Estimated4002
Symptom Onset Date/Time4000, 4001:
□ Time Not Available4003
First ECG Obtained4010: O Pre-Hospital (e.g. ambulance) O After 1st hosp. arrival
□ Non-System Reason for Delay4022
First ECG Date/Time4020, 4021:
STEMI or STEMI Equivalent4030: O No
4040
à If Yes, ECG Findings
O Yes
: O ST elevation O LBBB (new or presumed new)
à If Yes, STEMI or STEMI Equivalent First Noted4041: O First ECG
O Isolated posterior MI
O Subsequent ECG
à If Subsequent ECG, Subsequent ECG with STEMI or STEMI Equivalent Date/Time4042, 4043: ______________________
à If No, Other ECG Findings4044:
(demonstrated within first 24 hours of medical contact)
O New or presumed new ST depression
O Transient ST elevation lasting < 20 minutes
Heart Failure4100:
O No
O Yes
Heart Rate4120:
(bpm)
Cardiogenic Shock4110:
O No
O Yes
Systolic BP4130:
(mmHg)
© 2007 American College of Cardiology Foundation
26-Mar-2014
O New or presumed new T-Wave inversion
O Old LBBB
O None O Other
Cardiac Arrest4135:
à If Yes, Pre-Hospital4140:
à If Yes, Outside Facility4145:
O No
O Yes
O No
O No
O Yes
O Yes
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NCDR® ACTION Registry®- GWTG™ v2.4 (Limited)
Acute Coronary Treatment and Intervention Outcomes Network Registry
D. HISTORY AND RISK FACTORS
Weight5010:
Diabetes Mellitus5070:
(kg)
Current/Recent Smoker (< 1 year)5020:
5030
Hypertension
Currently on Dialysis5050:
O Yes
O Yes
Cerebrovascular Disease5130:
O No
O Yes
O No
O Yes
5131
à If Yes, Prior Stroke
O No
O Yes
O No
O Yes
à If Yes, Prior TIA5132:
O No
O Yes
O No
O Yes
O No
:
O No
Peripheral Arterial Disease
:
5140
:
J. DISCHARGE
Discharge Date11000:
Provider Name11003-11005: __________ Provider NPI11006: ____________
Comfort Measures Only11010:
Enrolled in Clinical Trial During Hospitalization
Discharge Status11100:
11101
à If Alive, Smoking Counseling
O No
O Yes
: O No
O Yes
11020
:
O Alive
O Deceased
O No
O Yes
à If Alive, Cardiac Rehabilitation Referral11104:
O No-No Referral
O No-Medical Reason
O No-Health Care System Reason
à If Alive, Discharge Location11105:
O Home O Extended care/transitional care unit/Rehab O Other acute care hospital
O Skilled nursing facility
O Other
O Left against medical advice (AMA)
à If Other Acute Care Hospital, Transfer Time11106:
____________
à If Other Acute Care Hospital, Transfer for PCI11107:
O No
O Yes
O No
O Yes
11110
à If Alive, Hospice Care
:
O No-Pt Reason/Preference
O Yes
E. MEDICATIONS
Oral Medications
Medications Prescribed At Hospital Discharge
Medication
Medications Administered in First 24 Hours
(Up to 24 hours after first medical contact*)
(Discharge medications are not required for patients who expired or were discharged
to ‘Other acute care Hospital’, ‘AMA’ or are receiving Hospice Care)
Aspirin6010, 6020
O No
O Yes
O Contraindicated
O No
O No
O Yes
O Contraindicated
6060- 6070
à If Yes, Start Date/Time: __________________
Clopidogrel
O Yes
O Contraindicated
O No
O Yes
O Contraindicated
O No
O Yes
O Contraindicated
O No
O Yes
O Contraindicated
O No
O Yes
O Contraindicated
O No
O Yes
O Contraindicated
Dabigatran
O No
O Yes
O Contraindicated
Rivaroxaban6231
O No
O Yes
O Contraindicated
O No
O Yes
O Contraindicated
O No
O Yes
O Contraindicated
O No
O Yes
O Contraindicated
O No
O Yes
O Contraindicated
Aldosterone Blocking Agent
O No
O Yes
O Contraindicated
Statin6470
O No
O Yes
O Contraindicated
à If Yes, Dose: ___________mg
Ticlopidine6120
O No
Prasugrel6160-6170
O Yes
O Contraindicated
à If Yes, Start Date/Time: _________________
O No
Ticagrelor6185-6190
O Yes
O Contraindicated
à If Yes, Start Date/Time: __________________
Warfarin6220
6226
6241
Apixiban
Beta Blocker6260,6270
ACE Inhibitor
O No
O Yes
O Contraindicated
6320
Angiotensin Receptor Blocker6370
6420
© 2007 American College of Cardiology Foundation
26-Mar-2014
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NCDR® ACTION Registry®- GWTG™ v2.4 (Limited)
Acute Coronary Treatment and Intervention Outcomes Network Registry
E. MEDICATIONS (CONTINUED)
Intravenous and Subcutaneous Medications
Category
Medications Administered
GP IIb/IIIa
6800
Inhibitor
O No
O Yes
O Contraindicated
à If Yes, Medication Type6801:
(any time during this
hospitalization)
6850
Anticoagulant
O Eptifibatide
O Tirofiban
O Abciximab
6802, 6803
à If Yes, Start Date/Time
O No
O Yes
: _______________
O Contraindicated
à If Yes, Medication Type(s):
□ IV Unfractionated Heparin6851 □ Enoxaparin (LMWH)6860
□ Bivalirudin6875 □ Other parenteral anticoagulants given6895
F. PROCEDURES AND TESTS
LVEF7010:
□ LVEF Not Assessed7011
%
7020
Diagnostic Coronary Angiography
PCI7100:
O No
: O No
à If Not Assessed, Planned for after discharge7012: O No
7040-7050
à If Yes, Provider Name
O Yes
: __________ Provider NPI
: ____________
à If Yes, Provider Name7113-7115: __________ Provider NPI7116: ____________
O Yes
à If Yes, Cath Lab Arrival Date/Time7101, 7102:
à If Yes, Arterial Access Site7112:
_______________________
O Femoral
7103, 7104
à If Yes, First Device Activation Date/Time
à If Yes, Stent(s) Placed7105:
O Yes
7055
:
O Brachial
O Radial
_______________________
à If Yes, Stent Type(s):
O No O Yes
O Other
□ Bare metal stent7106 □ Drug eluting stent7107 □ Other7108
à If Yes, PCI Indication7109: O Primary PCI for STEMI
O Rescue PCI for STEMI (after failed full-dose lytic)
O PCI for STEMI (stable after successful full-dose lytic) O PCI for STEMI (unstable, >12 hr from sx onset)
O PCI for STEMI (stable, >12 hr from sx onset)
O Other
O PCI for NSTEMI
à If Primary PCI for STEMI, Non-System Reason for Delay in PCI7110:
O Difficult vascular access
O Cardiac arrest and/or need for intubation before PCI
O Patient delays in providing consent for the procedure O Difficulty crossing the culprit lesion during the PCI procedure
O Other
O None
CABG7200:
O No
O Yes
à IF STEMI OR STEMI EQUIVALENT4030 = ‘YES’
G. REPERFUSION STRATEGY (IMMEDIATE REPERFUSION)
Was Patient a Reperfusion Candidate8000:
8011
à If No, Primary Reason
:
O No
O Yes
O No ST elevation/LBBB
O ST elevation resolved
à If Yes, Primary PCI8015:
O No
O Yes
à If Yes, Thrombolytics8020:
O No
O Yes
à If Yes, Dose Start Date/Time8023, 8024:
à If Yes, Non-System Reason for Delay
O MI diagnosis unclear
O MI symptoms onset >12 hours
O Chest pain resolved
O No chest pain
O Other
_______________________
8025
:
O No
O Yes
à If Yes, Lytic ineligible and requiring prolonged transfer time for primary PCI 8026:
O No
O Yes
à If Reperfusion Candiate is ‘Yes’ and Primary PCI is ‘No’, Reason Primary PCI Not Performed8030
O
O
O
O
Non-compressible vascular puncture(s)
Active bleeding on arrival or within 24 hours
Quality of life decision
Anatomy not suitable to primary PCI
O
O
O
O
Spontaneous reperfusion (documented by cath only)
Patient/family refusal
DNR at time of treatment decision
Prior allergic reaction to IV contrast
O
O
O
O
Other
Not performed (not a PCI center)
No reason documented
Thrombolytic Administered
à If Reperfusion Candiate is ‘Yes’ and Thrombolytics is ‘No’, Reason Thrombolytics Not Administered8035
O
O
O
O
O
O
O
O
O
Known bleeding diathesis
Recent bleeding within 4 weeks
Recent surgery/trauma
Intracranial neoplasm, AV malformation, or aneurysm
Severe uncontrolled hypertension
Suspected aortic dissection
Significant close head or facial trauma within previous 3 months
Active peptic ulcer
Traumatic CPR that precludes thrombolytics
© 2007 American College of Cardiology Foundation
O
O
O
O
O
O
O
O
Ischemic stroke w/in 3 months except acute ischemic stroke within 3 hours
Any prior intracranial hemorrhage
Pregnancy
Prior allergic reaction to thrombolytics
DNR at time of treatment decision
Other
Expected DTB < 90 minutes
No reason documented
26-Mar-2014
Page 3 of 4
NCDR® ACTION Registry®- GWTG™ v2.4 (Limited)
Acute Coronary Treatment and Intervention Outcomes Network Registry
H. IN-HOSPITAL CLINICAL EVENTS
Reinfarction9000:
O No
O Yes
Cardiogenic Shock9010: O No
O Yes
Heart Failure
9020
:
Cardiac Arrest9035:
CVA/Stroke9030:
à If Yes, Hemorrhagic9032
Suspected Bleeding Event
9040
:
O No
O Yes
O No
9050
O Yes à If Yes, Date9037: __________ RBC/Whole Blood Transfusion :
O No
O Yes
O No
O Yes
O No
O Yes
O No
O Yes
I. LABORATORY RESULTS
Positive Cardiac Markers Within First 24 Hours10000:
O No
O Yes
CREATININE
TROPONIN
Collected10010:
Initial
O No
à If Yes, Value
10013
: _____
O Yes – I
Collected10100:
O Yes – T
(ng/mL)
à If Yes, Value
Initial
O No
10103
: _____
O Yes
(mg/dL)
à URL10014: _____
HEMOGLOBIN
LIPIDS (mg/dL)
Collected10150:
Initial
O No
à If Yes, Value10153: _____
Panel Performed10350:
O Yes
O No
□ Value Out of Range10360
O Yes
à If Yes, LDL10355: _____
(g/dL)
K. OPTIONAL ELEMENTS (FOR AMI CORE MEASURE REPORTING ONLY)
Point of Origin12000:
O Non-health care facility
O Court/law enforcement
O Clinic
O Information not available
O Transfer from a hospital (different facility)
O D: Transfer from one distinct unit of the hospital to another
distinct unit of the same hospital resulting in a separate claim
to the Payor
O Transfer from a skilled nursing facility (SNF) or
intermediate care facility (ICF)
O E: Transfer from ambulatory surgery center
O Transfer from another health care facility
O F: Transfer from hospice and is under a hospice plan of care
or enrolled in a hospice program
O Emergency room
Transfer from Another ED12010:
O No
12020
CMS Comfort Measures Timing
12090
Principal Diagnosis Code
:
O Yes
O Day 0 or 1
:
O Day 2 or after
Principal Procedure Code
O Timing unclear
12100
:
O Not documented/UTD
Date
12101
:
Other Diagnosis Code(s)12110-12:
Other Procedure Code(s)12120-21:
Date(s)12122-23:
Physician 112130:
Physician 212131:
CMS Discharge
Status12140:
O D/C – Home or self care
O D/C – Federal health care facility
O D/C – Short term general hospital
O Hospice – Home
O D/C – To a skilled nursing facility (SNF) with Medicare
certification in anticipation of covered skilled care
O Hospice – Medical facility
O D/C – Intermediate care facility
O D/C – Institution not defined elsewhere in this code list
O D/C – Home under care of organized home health service
organization in anticipation of covered skilled care
O Left against medical advice or discontinued care
O Expired
O Expired in a medical facility (e.g. hospital, SNF, ICF, or
freestanding hospice)
© 2007 American College of Cardiology Foundation
26-Mar-2014
O D/C – Hospital-based Medicare-approved swing bed
O D/C – Inpatient rehabilitation facility (IRF) including
rehabilitation-distinct part units of a hospital
O D/C – Medicare-certified long term care hospital (LTCH)
O D/C – Nursing facility certified under Medicaid but not
certified under Medicare
O D/C – To a psychiatric hospital or a psychiatric-distinct part
unit of a hospital
O D/C – Critical access hospital (CAH)
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