VHAC Incident Report
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Region
Please Select
Eastern
Central
Northern
NorthWestern
Southern
Western
Date of Last Meeting
-
Month
-
Day
Year
Date
Date of NEXT Meeting
-
Month
-
Day
Year
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
NCDR Chest Pain–MI Registry
AHA GWTG / Mission: Lifeline
Internal / Validated Local Data
Not Sure/Unknown
Other (please specify)
Site B
NCDR Chest Pain–MI Registry
AHA GWTG / Mission: Lifeline
Internal / Validated Local Data
Not Sure/Unknown
Other (please specify)
Site C
NCDR Chest Pain–MI Registry
AHA GWTG / Mission: Lifeline
Internal / Validated Local Data
Not Sure/Unknown
Other (please specify)
Site D
NCDR Chest Pain–MI Registry
AHA GWTG / Mission: Lifeline
Internal / Validated Local Data
Not Sure/Unknown
Other (please specify)
Site E
NCDR Chest Pain–MI Registry
AHA GWTG / Mission: Lifeline
Internal / Validated Local Data
Not Sure/Unknown
Other (please specify)
Site F
NCDR Chest Pain–MI Registry
AHA GWTG / Mission: Lifeline
Internal / Validated Local Data
Not Sure/Unknown
Other (please specify)
Site G
NCDR Chest Pain–MI Registry
AHA GWTG / Mission: Lifeline
Internal / Validated Local Data
Not Sure/Unknown
Other (please specify)
NCDR Chest Pain–MI Registry
AHA GWTG / Mission: Lifeline
Internal / Validated Local Data
Not Sure/Unknown
Other (please specify)
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 available (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
Name of person completing form
*
First Name
Last Name
Email address of person completing the form
*
example@example.com
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