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:
Under 40
40–54
55–64
>65–74
75 and older
Sex at Birth
Female
Male
Non-binary
Not disclosed
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific
Islander
White
UTD
Hispanic Ethnicity
Yes
No/UTD
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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
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and Time of Right Heart Catheterization
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and Time of Diagnosis of Cardiogenic Shock
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Initial Symptoms:
Chest Pain
Shortness of Breath
Hypotension (Low Blood Pressure)
Cold, Clammy Skin
Altered Mental Status (Confusion, Lethargy)
Cyanosis (Bluish Skin)
Rapid or Weak Pulse
Fatigue/Weakness
Sweating (Diaphoresis)
Nausea or Vomiting
Cardiac Arrest
Other
Where did the cardiac arrest occur?
In Hospital
Out of Hospital
CAPS Score (Cardiac Arrest Prognosis Score)
Onset of AMI
Date and Time of AMI Symptoms
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Initial BP (mmHG)
Systollic/Diastolic /MAP
Heart Rate (bpm)
Onset of Cardiogenic Shock
Date and Time of Cardiogenic Shock Diagnosis
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
SCAI Shock Stage at Onset (first 6hrs)
Deceased
Stage B
Stage C
Stage D
Stage E
ND/Unable to Determain
SCAI Shock Stage Serial assessment (Assessed at 6h-12h)
Deceased
Stage B
Stage C
Stage D
Stage E
ND/Unable to Determain
Heart Rate (bpm)
Initial BP (mmHG)
Systolic/Diastolic/MAP
Location of Shock Onset
ED
ICU
Cathlab
Pre-hospital
Other
PulsOx Rate (%)
SA O2
Respiratory Rate
Is Patient On Vent
Yes
No
FIO2
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Interventions
Were vasopressors/inotropes used?
Yes
No
Vasoactive Medications at time of assessment
None
Dobutamine
Dopamine
Epinephrine
Levosimendan
Milrinone
Nitroprusside
Norepinephrine
Phenylephrine
Vasopressin
Not Documented
Other
Mechanical Circulatory Support Used?
Yes
No
Type of Mechanical Circulatory Support Used
None
Impella
VA Ecmo
IABP
IVAC
TandemHeart
Temporary surgical VAD (e.g. CentriMag)
Implanted surgical assist device
Not Documented
Other
Implant Date/Time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Access to Cath Lab?
Yes
No
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Standardized Metrics for Cardiogenic Shock Cases
Right Heart Catheterization Usage
Yes
No
Not Performed
Initial Lactate Level
Peak Lactate Level
Hemodynamic Support Devices Used - Initial:
IABP
Impella
ECMO
Tandem Heart
Other
Hemodynamic Support Devices Used - Escalation:
IABP
Impella
ECMO
Tandem Heart
Other
CPO, PAPI, and LVEDP Measurements
Measurments
CPO (Cardiac Power Output):
PAPI (Pulmonary Artery Pulsatility Index):
LVEDP (Left Ventricular End-Diastolic Pressure):
Discharge Disposition
Home
Hospice – Home
Hospice – Health Care Facility
Acute Care Facility
Other Health Care Facility
Expired
Left Against Medical Advise (AMA)
Not documented or Unable to determind
Other
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Complications
Check if yes, where applicable
AKI
Stroke
Major Bleeding
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Outcomes
Length of Stay
Days
ICU LOS
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Submit
Submitted by
First Name
Last Name
Email (please complete for updates to this record)
example@example.com
Should be Empty: