VHAC Incident Report
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
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
Names of Hospitals Involved
Name of person completing form
*
First Name
Last Name
Email address of person completing the form
*
example@example.com
Please verify that you are human
*
Submit
Should be Empty: