Big Country Regional Advisory Council TSA-D

Performance Improvement Form

~ First Responder ~

Date:

Name of Entity:

Person

Completing Report:

Performance Improvement Criteria / Indicators
1 / Number of trauma-related patients pronounced dead on scene this quarter.
2 / Number of occurrences of prolonged wait times for EMSprovider response to scene this quarter.
Specific Occurrence Report
Age: / Gender: / Chart Identification #:
Mechanism of Injury:
Identified injuries and pertinent information:
Patient Outcome:
Provider Discussion:
Contributing Factors: □ Inadequate system guidelines/ protocols □ Multiple patients □ Extrication
□ Hospital diversion □ Other:______
Please do not fill in this section – For RAC-D PI Committee Review
___ No negative outcome
___ Minor negative outcome
___ Significant system performance error
___ Major deviation from desired system
performance
___ Unable to determine / Standard of Care Met? Yes / No
___ RAC-D guidelines followed
___ Minor deviation from RAC-D guidelines
___ Significant deviation form RAC-D
guidelines
___ Major deviation from RAC-D guidelines
___ Unable to determine
Action Plan
___ No action needed ___Hospital / EMS action plan requested
___ Review with hospital or EMS provider ___ Refer to Texas DSHS
___ Track and Trend ___ Assign to workgroup
___ Education ___ Request closed Executive Committee review
___ RAC-D guideline review ___ Other: ______

CARDIAC data points:

ITEM 1: “Total number of confirmed STEMI cases.” ______

ITEM 2: “Arrival method for the confirmed STEMI cases reported in item 1.” ______

  • 2a. number arriving via EMS/ambulance AND not a transfer______
  • 2b. Number arriving via private transportation/walk in/family/self AND not a transfer______
  • 2c. Number arriving via other transport (mobile ICU or air) AND not a transfer______
  • 2d. Number arriving via transfer. Transfer mode may include ambulance, mobile ICU, air transport, or unknown. (Can include transfers to a STEMI referral hospital) ______
  • 2e. Number with arrival mode not documented or unknown AND not a transfer______

ITEM 3: “Total number of confirmed STEMI cases transferred for percutaneous coronary intervention (PCI) treatment to a STEMI receiving hospital.” ______

ITEM 4:”Of all the STEMI transfers reported in Item 3, how many received primary PCI within 120 minutes of arrival at the STEMI referral hospital?” ______

ITEM 5: “Total number of confirmed STEMI cases transferred to percutaneous coronary intervention (PCI) treatment that had a door in door out (DIDO) time of less than 30 minutes at STEMI referral facility.” ______

ITEM 6: “Of all the STEMI cases reported in Item 1, how many revived thrombolytic therapy as an urgent treatment for STEMI at STEMI referral hospital?” ______

ITEM 7: “Of the STEMI cases reported in Item 6, how many received thrombolytic therapy within 30 minutes of arrival at STEMI referral hospital?” ______

ITEM 8: “Indicate the health insurance status for cases with confirmed STEMI or STEMI equivalent.” ______

  • 6a. Number with any health insurance______
  • 6b. Number without health insurance______
  • 6c. Number with health insurance not documented or unknown.______

STROKE data points:

ITEM 1: “Total number of stroke cases.” ______

  • 1a. Number of Ischemic Strokes______
  • 1b. Number of Intracerebral Hemorrhages______
  • 1c. Number of Subarachnoid Hemorrhages______
  • 1d. Number of Transient Ischemic Attack (<24 hours) (TIA)______
  • 1e. Number of stroke not otherwise specified______

ITEM 2: “Arrival method for the stroke cases reported in Item 1.” ______

  • 2a. Number arriving via EMS from home/scene______
  • 2b. Number arriving via private transport/taxi/other from home/scene______
  • 2c. Number arriving via transfer from other hospital ______
  • 2d. Number with arrival mode not documented or unknown______

ITEM 3: “Of the ischemic stroke cases reported in Item 1a, how many had an NIH stroke

scale performed?” ______

ITEM 4: “ Of the ischemic stroke cases reported in Item 1a, how may received tPA therapy?” ______

ITEM 5: “Of all the cases reported in Item 4, how many received tPA within 60 minutes or less from the time of arrival?” ______

ITEM 6: “Of the ischemic stroke cases reported in Item 1a, indicate the health insurance status

for these cases.” ______

  • 6a. Number with any health insurance______
  • 6b. Number without health insurance______
  • 6c. Number with health insurance not documented or unknown______

ITEM 7: “Of the ischemic stroke cases reported in Item 1a, how many received endovascular therapy?” ______

ITEM 8: “Of the endovascular therapy cases reported in Item 7, how many received endovascular therapy within 60 minutes?” ______

ITEM 9: “Of the total ischemic stroke cases reported in Item 1a, how many met the following

disposition categories?” ______

  • 9a. Number discharged to home______
  • 9b. Number discharged to inpatient rehabilitation______
  • 9c. Number discharged to skilled nursing facility______
  • 9d. Number discharged to hospice care (home hospice or facility hospice)______
  • 9e. Number expired______
  • 9f. Number discharged to “other” or not known/reported______