VHAC Incident Report

VHAC Incident Report
Click Here for Instructions

Reporting Schedule:

March-Q3 PY | June-Q4 PY | September-Q1 CY | December-Q2 CY

PY=Prior Year CY=Current Year

Schedule was developed to align with public reporting and registry harvest dates.

Who is completing this form?*

Regional LeadVHAC Partcipanting Site/Facility
Region
Date of Last Meeting

MonthDayYear
Date
Date of NEXT Meeting

MonthDayYear
Date
Number of Attendees
Any Additional Notes/Comments

FIRST MEDICAL CONTACT

	Site A	Stie B	Site C	Site D	Site E	Site F	Site G	Site H
First Medical Contact to Balloon Median Time - Metric 13443
First Medical Contact to Balloon Percent - Metric 13441

FIRST MEDICAL CONTACT (New Format)

	First Medical Contact to Device Median Time	First Medical Contact to Device Percent	Registry	Notes
Site A
Site B
Site C
Site D
Site E
Site F
Site G

SHOCK METRICS (TO BE PROVIDED BY ALL PROGRAMS)

	Site A	Stie B	Site C	Site D	Site E	Site F	Site G	Site H
Number of shock patients per last quarter available (NCDR)
Number and % with Lactate Measured
Number and % with CPO Calculated

SHOCK METRICS

	Number of shock patients per last quarter (NCDR)	Number and % with Lactate Measured	Number and % with CPO Calculated
Site A
Site B
Site C
Site D
Site E
Site F
Site G
Site H

Names of Hospitals Involved

EMS Education Sessions

	Date	Time	Location	Registration Link	Add to VHAC Site
Education Session 1
Education Session 2
Education Session 3
Education Session 4

Name of person completing form*

First NameLast Name
Site/Facility*
Email address of person completing the form*
example@example.com
Please verify that you are human*

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