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?
Region
Date of Last Meeting

MonthDayYear
Date
Date of NEXT Meeting

MonthDayYear
Date
Number of Attendees
Any Additional Notes/Comments

FIRST MEDICAL CONTACT

Rows	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)

Rows	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
Site H
Site I

SHOCK METRICS (TO BE PROVIDED BY ALL PROGRAMS)

Rows	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

Rows	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

Rows	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
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