• VHAC Shock Data Collection Form

    The Shock Data Collection Form is used to capture information on cardiogenic shock events for accurate reporting and analysis. This form provides centerswith the opportunity to document whether cardiogenic shock was present at the time of arrival (CPMI Detail Line #10935 – Cardiac Status) or whether it occurred as an episode after arrival (Episode Events Detail Line #10915). Collecting both perspectives ensures a complete understanding of patient status and outcomes, allowing for more precise evaluation of care and protocol effectiveness.

  • Demographics

    Collect basic demographic information to evaluate risk patterns, disparities in outcomes, and ensure equitable care delivery.
  • Age Group:
  • Sex at Birth
  • Race
  • Hispanic Ethnicity

  • Clinical Presentation

    Capture how and when the patient presented with cardiogenic shock to evaluate delays in care and early indicators of severity.
  • Date & Time of First Medical Contact
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date and Time of Right Heart Catheterization
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date and Time of Diagnosis of Cardiogenic Shock
     - -
    2 digit month, 2 digit day, 4 digit year
  • Initial Symptoms:
  • Where did the cardiac arrest occur?

  • Onset of AMI

  • Date and Time of AMI Symptoms
     - -
    2 digit month, 2 digit day, 4 digit year

  • Onset of Cardiogenic Shock

  • Date and Time of Cardiogenic Shock Diagnosis
     - -
    2 digit month, 2 digit day, 4 digit year
  • SCAI Shock Stage at Onset (first 6hrs)
  • SCAI Shock Stage Serial assessment (Assessed at 6h-12h)
  • Location of Shock Onset
  • Is Patient On Vent

  • Interventions

  • Were vasopressors/inotropes used?
  • Vasoactive Medications at time of assessment
  • Mechanical Circulatory Support Used?
  • Type of Mechanical Circulatory Support Used
  • Implant Date/Time
     - -
    2 digit month, 2 digit day, 4 digit year
  • Access to Cath Lab?

  • Standardized Metrics for Cardiogenic Shock Cases

  • Right Heart Catheterization Usage
  • Hemodynamic Support Devices Used - Initial:
  • Hemodynamic Support Devices Used - Escalation:
  • CPO, PAPI, and LVEDP Measurements
    Rows
  • Discharge Disposition

  • Complications

  • Check if yes, where applicable

  • Outcomes

  • Length of Stay
    Rows
  • Should be Empty: