Download Washington Cardiac Arrest Data Collection Form

Washington Cardiac Arrest Data Collection Form
Complete for treated, non-traumatic cardiac arrests for whom EMS initiated or continued CPR*
Responding Agency Information:
ID 1st Agency on scene
Date and time call to 911 received by dispatch center - not PSAP (leave time components blank if unknown)
Responding unit times
Earliest Dispatch
m
m
d
d
y
y
y
y
Enroute
h
h
m
m
s
Earliest arrival at scene
At patient
s
BLS unit response
hh
:
mm
:
ss
hh
:
mm
:
ss
hh
:
mm
:
ss
hh
:
mm
:
ss
ALS unit response
hh
:
mm
:
ss
hh
:
mm
:
ss
hh
:
mm
:
ss
hh
:
mm
:
ss
Patient Information:
Age in years: valid values 0 to 120, 0=< 1 year; 999 Unk.
Gender:
1. Male
Age unknown, but patient is an adult
Location (check one):
5. Assisted
living
facility
6. Medical facility
7. Ambulance
9. Unknown
facility/nursing home
Cardiac history (MI, CHF, arrhythmia, bypass surgery, etc.)
No
2.
9. Unknown
Presumed cause of cardiac arrest (check one, use all available sources):
1. Home/Residence
2. Public indoors
3. Public outdoors
4. Skilled nursing
1. Yes
2. Female
9.
1. Cardiac
4. Drowning
2. Respiratory - medical
(COPD, emphysema)
5. End-stage
3. Overdose
illness (cancer, renal)
Other medical (GI bleed, CVA, …)
9. Unknown cause
6.
/ poisoning
History of other serious medical problems (cancer, diabetes, COPD… see list)
Unknown, not stated
1. Yes
2.
No
9.
Unknown, not stated
Cardiac Arrest and Treatment Information:
Was the cardiac arrest witnessed (seen or heard) by anyone?
1. Yes
2.
No
9.
Was the cardiac arrest prior to EMS arrival?
Unknown
1. Yes
Who initiated CPR?
1. EMS
2. Citizen
3. Police
2.
No
9.
Unknown
Did the dispatcher / call taker provide CPR instructions?
4. MD/RN/Off-duty EMS/caregiver/other
1. Yes
2.
No
9.
Unknown
Did the EMS responders (BLS and / or ALS) perform CPR?
8. Unknown if CPR before EMS arrival
1. Yes
9. Unknown
if any CPR provided
0. No CPR provided by anyone
2.
No
9.
CPR onset time
(1st breath or cc)
Unknown
Cannot estimate
hh : mm : ss
Initially-analyzed cardiac arrest rhythm (only code this from the 1st analysis / 1st look after cardiac arrest, automated or manual mode)
1. AED shock advised
1st
shock by:
(use codes below)
___
2. AED no shock advised
1st shock time
3. VF
4. pulseless VT
5. Asystole
Cannot estimate
hh : mm : ss
Check all who shocked patient:
6. PEA
9.Unknown
Total all shocks (estimates OK)
0 = none, 99 = cannot estimate
___ ___
EMS interventions (check all that apply)
5.
Other medical personnel
6. Implantable device
8. Other or unknown person
9. Unknown if patient shocked
0.
No shocks delivered
1. Responding EMT
2. Responding paramedic
3. Citizen / PAD
4. Police
Public Access Defibrillator (PAD) attached and turned on?
Endotracheal intubation
Other advanced airway
Intravenous line (peripheral, central, other)
Intraosseous line
Medications
Field hypothermia
Efforts ceased due to DNAR or POLST, patient or family wishes?
Patient Outcome:
When did the patient experience an initial return of spontaneous circulation (ROSC)?
0. N/A-never had ROSC
Patient status at end of EMS care
1. Alive
(pulse and BP)
Ongoing CPR
3. Expired (efforts ceased)
9. Unknown
2.
1. After
CPR only
2. After
shock
3. After
Short-term patient outcome (hospital admission)
1. Expired
at scene
2. Expired in ED
4. Admitted
3. Transport to hospital,
9. Unknown
unknown if admitted
For Agency Use:
WACADForm_091028.doc, Revision 6.0
to hospital
ALS (meds, airway)
Hospital discharge
1.Yes
2.
No
9. Unknown
9. Unknown
Survivor neurostatus
1. CPC 1
2. CPC 2
3. CPC 3
4. CPC 4
9. Unk.
0. N/A
Washington Cardiac Arrest Data Collection Form
Complete for treated, non-traumatic cardiac arrests for whom EMS initiated or continued CPR*
Selected instructions for completing the form.
*Use all readily available sources: EMS incident report, CAD report, dispatch recording, hospital record, death certificate, medical
examiner. Trauma per se is ineligible for WACAD. Cases should be included where the initial mechanism appears to be traumatic, such as
an MVA or a fall, but the evidence suggests that the apparent “trauma” was a result of a cardiac arrest and not the cause. Cardiac arrest cases
shocked by any external defibrillator with resulting ROSC and no need for EMS CPR are also eligible for WACAD and should be included.
Times: Times are collected throughout the form in the 24 hour format hh:mm:ss. Use 0 for the hour between midnight and 1 am, 23 for the
hour between 11 pm and midnight. Leave time components blank if unknown or not applicable (e.g. leave seconds blank if unknown).
Responding unit times: BLS and ALS unit type is defined by the level of care that can be provided by the unit staff. Units carrying staff
who can only provide CPR and shock are BLS. Units carrying staff who can provide ALS care (meds, ett/advanced airway, lines) are ALS.
Enter the earliest dispatch and arrival times by unit type dispatched by your EMS system. If multiple units of a particular level are
dispatched, enter the earliest dispatch of that unit type and the earliest arrival at the scene of that unit type, even if these times are not from
the same unit. We are tracking how long the patient is waiting for care by service type, not by individual trucks. For example, if two BLS
units are dispatched, a fire truck and an ambulance, and unit 1 is dispatched earlier than unit 2, but unit 2 is closer to the scene and arrives
sooner, enter the dispatch time for unit 1 and the arrival time for unit 2 in the BLS row. If an ALS unit (unit 3) is dispatched and replaced
two minutes later by another (unit 4), enter the dispatch time for unit 3 and the arrival time for unit 4 in the ALS row. If a private ambulance
service (not dispatched by your EMS system) is already on scene, use your system BLS unit times for the BLS dispatch and arrival times.
Presumed cause of the cardiac arrest: Use all available information to indicate the cause of the cardiac arrest. This is coded by ruling out
the non-cardiac etiologies. Presume the cause to be cardiac unless the documentation supports one of the other choices. For example, a
person with end-stage illness can still experience cardiac arrest due to a cardiac etiology, especially if their death is not expected at that time.
Location: Code the location of the patient at the time help was summoned. Use public indoors for every location that is indoors except
those shown in specific categories. Consider these to be public indoors: private office buildings, sports arenas, indoor factory or industrial
sites, grocery stores, educational institutions, churches, community centers, jail, in a nursing home if the patient is not a resident, etc. Use
public outdoors for all outdoor locations such as parking lots, playfields, outdoor work spaces, on a street, traveling outdoors in a car or bus,
etc. Check ambulance when your responding EMS units are dispatched to a patient who is in transport by an ambulance at the time of the 91-1 call, not when a patient you are transporting has a cardiac arrest during your transport in your ambulance.
Cardiac history: Check 1=yes if any pre-existing cardiac conditions are noted. These may include: coronary artery disease (CAD) or
ischemic heart disease, myocardial infarction (MI or heart attack); congestive heart failure (CHF), cardiomyopathy, bypass, CABG,
arrhythmias, prior cardiac arrest, implanted device (pacemaker or ICD), stent, valve disease. Do not include high cholesterol
(hyperlipidemia) or high blood pressure (hypertension). If the narrative specifically notes, “No history” or “No heart history”, check 2=no.
Also check 2=no if only non-cardiac medical conditions are mentioned. If nothing is stated about history, or if “unknown history” is noted,
then check 9=unknown, not stated.
History of other serious medical problems: Check 1=yes if any pre-existing non-cardiac medical conditions are noted: high blood
pressure (HTN, hypertension), diabetes, stroke (CVA), kidney disease, cancer, chronic obstructive pulmonary disease (COPD), emphysema,
or neurological problems such as dementia. If the narrative specifically states, “No history” or only mentions heart history conditions, check
2=no. If nothing is stated about a history, or if “unknown history” is noted, then check 9=unknown, not stated.
Was the cardiac arrest witnessed (seen or heard) by anyone: If anyone (including EMS) saw or heard the patient collapse in cardiac
arrest, code this 1=yes, even if there was a delay to call 911. If the patient or someone else for the patient called 911, and the patient was not
in cardiac arrest at the time of the 911 call, consider the patient to be witnessed (e.g. cardiac arrest occurred during or after the call to 911).
Who initiated CPR? Check the box that best describes the first CPR provider. Check 2=Citizen for any lay person (family member, friend,
bystander), unless you know that the CPR provider is an on-duty police officer (box 3) or one of the box 4 categories: medical professional;
off-duty firefighter, EMT, or paramedic; caregiver (paid nursing home staff, aide, home health care worker); other (non-EMS but with a duty
to respond, e.g. ski patrol, private ambulance, security, etc.). If you know that EMS did CPR, but you don’t know if it was started prior to
EMS arrival, then check box 8. If you don’t know if CPR was done at all, check box 9. If no CPR was provided by anyone, check box 0.
Did the EMS responders (BLS and / or ALS) provide CPR? The only time you should answer 2=no for WACAD-eligible cases is if the
patient was shocked first (by PAD or EMS) and had restoration of pulse, blood pressure, and respirations so quickly that EMS did not need to
perform CPR. Otherwise, the case probably should not be in the WACAD case series.
Total all shocks Add up the total number of shocks delivered by all sources (PAD, AED, manual). The “estimate” comes in when, for
example, you might be able to document 6 shocks, but you are uncertain about a 7th. Estimate the total to be 6 or 7 using your best judgment
based on the available information. Only use code 99=cannot estimate when you are unable to make a reasonably close estimate of the total.
EMS interventions: Check only if provided by your dispatched EMS responders.
When did the patient experience an initial return of spontaneous circulation (ROSC)? This is intended to capture initial ROSC after
EMS confirmation of cardiac arrest, except in the case of a PAD shock prior to EMS arrival. If the patient never regained a palpable pulse or
measureable blood pressure, check box 0=N/A. If the patient regained a palpable pulse and/or a measureable blood pressure after receiving
only CPR, check box 1. If the patient first regained ROSC after a shock (includes after a shock and CPR and after a PAD shock), check box
2=shock. If ROSC was not reported until after at least one ALS intervention (ett, line placement, medications given), check box 3. If you
can’t tell if the patient ever had ROSC, or you can’t tell when ROSC was first noted during the resuscitation, check box 9.
Survivor neurostatus: Record the CPC scores if you have them for all survivors to hospital discharge: 1=conscious and alert with normal
function or only slight disability, 2=conscious and alert with moderate disability, 3=conscious with severe disability, 4=comatose, persistent
vegetative state, 9=unknown, 0=N/A patient did not survive to hospital discharge.
WACADForm_091028.doc, Revision 6.0