Get With The Guidelines® - Resuscitation PMT® Coding Instructions

Last Updated January 2024

Print Coding Instructions

Table of Contents

Admission & Discharge

CPA Event

ARC Event

MET Event

PCAC

Optional Fields

Scoring Definitions

IHCA Site Characteristics

Highlighted Text = Updated since last version of document

Note about sampling:

Sampling is not permitted as part of the data entry process.  Sites may choose whether or not to enter CPA events, ARC events, MET events or a combination of the three, however, within each module, 100% data capture is required.

Note about optional data elements:

Optional data points appear in the Get With The Guidelines-Resuscitation Patient Management Tool (PMT) as dark grey shaded areas. These areas of the PMT contain data abstraction elements that may be left blank, yet the record may be closed and identified as complete without an error message. If these data elements contain information that your facility is not interested in evaluating, you may elect to not complete them in order to decrease your data abstraction burden.  It is important that you remain consistent in your decision over time so as to assure the highest degree of data accuracy. It is recommended that the decision, whether or not to abstract optional data points, should be made after some thought and consensus by facility quality improvement staff and should remain in effect for no less than 3 months at a time.

Date/Time Precisions: Date and Time fields have an additional "Precision" drop-down right above the MM/DD/YYYY HH:MI blanks. The Precision is used to indicate how much of the Date and Time data is known and can be abstracted.

Admission & Discharge

Select MET only check box if entering a patient who only had one or more MET events.  If the MET event resulted in an ARC / CPA event or if an ARC or CPA event occurred at another time during the admission, the MET check box should be unchecked and the remaining Admission and Discharge information should be entered.

1.1 Admit

System Entry Date/Time

Enter the date and time the patient entered the system, based on subject type (below). If the time is not available, select “Time Not Documented.”

Notes for Abstraction:

 *Note: Some hospitals have Rehab, Skilled Nursing and/or Mental Health areas or adjacent facilities to which patients are admitted (separate from hospital admission) where the code team responds.

Date of Birth

Enter the patient’s date of birth. If unknown, select “Unknown/Not Documented.”

Date/Time of Birth

Enter the patient’s date and time of birth. If DOB unknown or not documented, select “DOB Unknown/Not Documented", if time is unknown select "Time Not Documented." Note: In the online form, time is only available for response if the patient is "born this admission (or transferred from birth hospital)."

Age at System Entry

Enter the age of the patient at the time of system entry and indicate “minute(s)”, “hours(s)”, “day(s)”, “week(s)”, “month(s)”, or “year(s)”. If “Date of Birth” and “System Entry Date” have been provided, the age will be automatically derived.

Estimated

Select if age is estimated by hospital staff. If age is not documented and CANNOT be estimated, select “Age Unknown/Not Documented.”

Born this admission or transferred from birth hospital?

Was patient born during this admission or transferred from the hospital where birth occurred.

Note: This question is asked when patient is ≤ 1 year of age at system entry.

Patient Gender Identity

The gender identity, self-identified by the patient. This may or may not match sex assigned at birth.

Notes for Abstraction:

Suggested Data Sources:

Patient-Identified Sexual Orientation

The self-reported sexual orientation of the patient. Also defined as the gender(s) to which a person is physically attracted.

Notes for Abstraction:

Suggested Data Sources:

  • Admission Notes
  • Referral notes

    • Race

    Select the patient’s self-assessed race/ethnicity, or if not available, the physician or institution’s assessment. Assumptions should not be made based on physical characteristics. This data allows for analysis of race-related patterns of care. If patient is multi-racial, select each race they designate. Select all that apply from the list provided. Select all that apply from the list provided. If the patient is Asian or Native Hawaiian/Pacific Islander, select the specific sub-category (or sub-categories) of race if known. Selection of a race sub-category is optional. 

    Options include:

  • Monitoring (specify):
  • Vascular Access
  • None – Select this option when no "Part A" interventions were in place when the need for chest compressions and/or defibrillation was first recognized.

    • OPTIONAL: Part B:

    Table of Contents

    3.1 Event

    Age at Event

    Enter the age of the patient at the time of the event and indicate "hour(s)", "day(s)", "week(s)", "month(s)", or year(s). If Date of Birth and Event Date have been provided, the age will be automatically derived.

    Estimated

    Select if age is estimated by hospital staff.

    Note: If age is not documented and CANNOT be estimated, select "Age Unknown/Not Documented."

    Subject Type

    Enter the subject’s relationship with the hospital at the time of the event onset. Valid entries:

    Note: Some hospitals have rehab, SNF, mental health units or adjacent facilities to which patients are ‘admitted’ (separate from acute care hospital admission) where the code team responds. In these instances, Rehab Facility Inpatient, SNF Inpatient or Mental Health Facility inpatient should be selected. If the event occurs on a rehab or skilled nursing or mental health 'ward' (acute care admission), then Hospital Inpatient should be selected.

    Illness Category

    Enter the most appropriate illness category at the time of the event onset.

     Event Location (area)

    Select the patient’s location (or type of area) in the hospital when the need for emergency assisted ventilation was recognized.

    Note: Some hospitals have Rehab, Skilled Nursing or Mental Health areas or adjacent facilities to which patients are ‘admitted’ (separate from acute care hospital admission) where the code team responds.

    Event Location (name)

    Type or select the hospital-specific unit or area name or number where the patient was located at the time of the ARC event. Some examples of unit names include: Surgical ICU, Medical ICU, CVT ICU, CCU-acute, CCU-step-down, Neonatal CCN, Neonatal ICU, Newborn Nursery East, 3West, Angiography, CT scan, Cardiac Catheterization lab, Ambulatory Unit A, on-campus rehab facility.

    Note: This is a dynamic list of location names that is specific to the selected location area. As new names are added (manually entered), they become available in the menu for that particular “location area” for future records. For example, if “CCU #1” is typed in and saved in record 1, it will appear in the list for record 2.

    Event Witnessed?

    Indicate if the onset of the acute respiratory compromise event was directly observed by someone (family, lay bystander, employee or health care professional). This differs from “monitored.”

    Was the patient conscious when the need for emergency assisted ventilation was first identified?

    Indicate if the patient was conscious at the onset of the acute respiratory compromise.

    Was the patient breathing when the need for emergency assisted ventilation was first identified?

    Was the patient breathing when the need for emergency assisted ventilation was first identified?

    Rhythm when the need for emergency assisted ventilation was first identified

    What was the first documented rhythm when the need for emergency assisted ventilation was first identified? The rhythm can be documented by anyone who identifies or records rhythm, not necessarily team or ALS provider. For the unmonitored patient, select the first rhythm identified when monitor applied.

    Was a hospital-wide resuscitation response activated?

    Did patient become apneic or respirations agonal at ANY time during the ARC event?

    Date and time patient became apneic or respirations became agonal

    If the patient became apneic or respirations agonal at any time during the resuscitation event, enter the date and time apnea or agonal respirations were first recognized. If the time is not documented, select “Time Not Documented.”

    Table of Contents

    4.1 Ventilation

    Type(s) of Ventilation/Airway(s) USED During the event, including those already in place (check all that apply).

    Select each type of ventilation/airway used during the event. There is no limit on the number of types that may be selected.

    Date and Time of FIRST emergency assisted ventilation during the event (non-invasive or invasive)

    Enter the date and time of the first emergency assisted ventilation during the event. If the time is not documented, select “Time Not Documented.”

    Was any Endotracheal Tube (ET) or Tracheostomy Tube inserted/re-inserted during the event?

    Note: If insertion attempted, but not achieved, select "No" and you may indicate this in section ARC 7.1 Resuscitation Related Events and Issues

    Note: If initial Intubation and/or Reintubation is selected, the following are required/enabled:

    Date and Time Endotracheal Tube (ET) or Tracheostomy Tube inserted if not already in place and/or re-inserted during event

    If an Endotracheal Tube (ET) or Tracheostomy Tube was inserted or reinserted during the event, enter the date and time of achievement, not when the first attempt was made. If the time is not documented, select “Time Not Documented.”

    Method(s) of confirmation used to ensure correct placement of Endotracheal Tube (ET) or Tracheostomy Tube (check all that apply):

    Table of Contents

    5.1 Other Interventions

    Drug Interventions

    Select all drug interventions that were used during the event.

    There is no limit to the number of interventions that may be selected.

     Note: Check all drug interventions that were initiated, or, if already in place immediately prior to an event, were continued during the event.

     Note: Because drug interventions in place immediately prior to an event are often stopped at the onset of an event, they are not automatically carried forward from the “Interventions in place just prior to the event” screen(s).

    Non-Drug Interventions

    Select each non-drug intervention that was employed during the resuscitation event.

    Table of Contents

    6.1 Event Outcome

    Note: Return of spontaneous ventilation questions are activated only when patient experiences apnea or agonal respirations.

    Was ANY return of spontaneous respiration documented during the event (excluding agonal or gasping respiration)?

    Select either “Yes” or “No/Not Documented ” to indicate if there was any return of spontaneous respiration achieved during the event – including through invasive airway. Agonal and gasping respirations are excluded.

    Date and time of FIRST return of spontaneous respiration

    Enter the date and time of the first return of respiratory effort (excluding agonal or gasping respirations) in a patient previously apneic or with agonal breathing. If the time is not documented, select “Time Not Documented.”

    Reason Acute Respiratory Compromise event ended

    Select the reason that the event ended.

    1. Return of spontaneous ventilation (ROSV) (no further need for assisted ventilation) that is sustained for >20 min.

    OR

    1. Control of ventilation with assisted ventilation that is sustained for >20 min

    a. Non-invasively (includes mask CPAP/BiPAP, nasal CPAP/BiPAP, negative pressure ventilation; excludes manual bag-valve-mask ventilation)

    OR

    b. Via an invasive airway (e.g.,endotracheal/tracheostomy tube).

    OR

    1. With transfer of newborn out of the delivery room (usually to Newborn Nursery [NBN], Neonatal ICU [NICU] or Operating Room), when transfer occurs prior to 20 minutes of spontaneous ventilation (ROSV) or controlled ventilation.

    OR

    1. Progressed to Cardiopulmonary Arrest (CPA); or ARC interventions terminated because of advance directive.

    Note: Any event that follows after ROSV/ or control of ventilation > 20 min is defined as a new event.

    Example: ARC event begins at 1725. Endotracheal tube is successfully placed at 1730. At 1755 endotracheal tub becomes dislodged. Patient is reintubated at 1757. At 1755 when endotracheal tube became dislodged, ventilation had been controlled for 25 min; this event therefore ends at 1730. When endotracheal tube becomes dislodged at 1755 this starts a new event.

    Does CPA Portion of Event Meet Get With The Guidelines® - Resuscitation Inclusion Criteria (i.e., received chest compressions and/or defibrillation of VF or Pulseless VT)?

    Date and time ARC event ended by any of the reasons listed above

    Enter date and time of the BEGINNING of sustained ROSV or control of ventilation , or need for chest compression and/or defibrillation (CPA) first identified , or ARC interventions terminated because of advance directive . If the time is not documented, select “Time Not Documented.”

    1. Example: Control of ventilation with assisted ventilation begins at 1500 that is sustained at 1521, > 20 min. Event ends at 1500.
    2. Example: Emergency assisted ventilation begins at 1720 for ARC. CPA follows at 1725. Event ends at 1725.
    3. Example: Neither sustained ROSV nor sustained control of ventilation has occurred at 0835, but efforts terminated because of advance directive. Event ends at 0835.

    Table of Contents

    7.1 Resuscitation Related Events and Issues

    Quality Improvement Issue(s)

    Indicate the specific issues encountered in each category from the selections below and enter written comments with respect to the event.

    Universal Precautions

    Documentation

    Airway

    Vascular Access

    Medication(s):

    Leadership:

    Protocol Deviation:

    Equipment:

    Comments

    Use this field to document event-related notes.

    Note: Do not include any personal health information/protected health information or other confidential information in the comments section.

    Table of Contents

    Medical Emergency Team (MET) Event

    MET Inclusion Criteria

    All patients*, visitors, employees, and staff within the facility (in inpatient areas and ambulatory areas adjacent to the hospital and surrounding areas) for whom the Medical Emergency Team (MET) is activated. The MET may also be called by other names, such as Medical Emergency Team, Medical Emergency Response Team, Rapid Response Team, Critical Care Outreach Team, or Condition Critical Team. It is an assigned team that often consists of a critical care / emergency nurse and physician, and a respiratory care practitioner. The team response is triggered by abnormalities in patient physiology, a subjective concern on the part of the staff, or family/visitor concerns as defined by a facility’s activation policies or procedures.

    MET Exclusion Criteria

    No MET responses are excluded.

    Table of Contents

    OPTIONAL: Local Event ID

    This field provided for those facilities using pre-numbered event records or another internal event numbering system who wish to include that reference in their Get With The Guidelines® - Resuscitation record. Do not enter any personal health information/protected health information (PHI) into this field.

    Date/Time the MET was activated

    Enter the date and time that the MET was activated.

    Note: If the time is not documented, select the MM/DD/YYY option in the online dropdown and check off "Time Not Documented."

    Table of Contents

    2.1 Pre-Event Data

    Was patient discharged from an Intensive Care Unit (ICU) at any point during this admission and prior to this MET call?

    Notes for Abstraction:

    Note: ICU includes all Critical Care areas (e.g., ICU, CCU, NICU, PICU, etc.)

    Was patient discharged from an Intensive Care Unit (ICU) within 24 hrs prior to this MET call?

    Notes for Abstraction:

    Was patient discharged from a Post-Anesthesia Care Unit (PACU) within 24 hours prior to this MET call?

    Was patient in the ED within 24 prior to this MET call?

    Did patient receive conscious/procedural sedation or general anesthesia within 24 hours prior to this MET call?

    Enter all vital signs taken in the last 4 hours prior to this MET event (Date, Time, Heart Rate, Blood Pressure, Respiratory Rate, SpO2 (select either 'Room Air' or 'Supplemental O2 (oxygen)'), Temperature).

     Note: If no vital signs were taken in the 4 hours prior to the MET activation, enter the last documented set of vital signs with date and time prior to the MET activation. If no vital signs are available, select "Pre-Event VS Unknown/None Documented." If select vital signs are available, enter the available data and select "ND" for only those vital signs that are not documented.

     Note: If blood pressure was obtained via Doppler or pulse, leave the diastolic blood pressure field blank and override the data quality edit check.

    Neurological Assessment – AVPU Scale (most recent within last 4 hours prior to this MET event):

    Enter the most recent AVPU Scale recorded within the last 4 hours prior to this MET event.

    Notes for Abstraction:

    Table of Contents

     2.2 Pre-Existing Conditions

    Required: Active or Suspected bacterial or viral infection at admission or during hospitalization

    Definition: Indicate if the patient was confirmed or suspected to have Active or Suspected Bacterial or Viral infection at admission or during hospitalization.

    Format: Multi-Select (check box)

    Allowable Values:

    Notes for Abstraction:

    Select Emerging Infectious Disease when the patient was confirmed or suspected to have:

    Select one of the Allowable Values options when a confirmed or suspected diagnosis is documented by the provider or when a test result is documented in the patient medical record.

    Optional: Additional Personal Protective Equipment (PPE) donned by the responders?

    Definition: Indicate if Additional Personal Protective Equipment (PPE) was donned by the responders to prevent Transmission-based Precautions. These precautions are designed for patients with confirmed or suspected infections with pathogens for which additional precautions beyond Standard Precautions are needed.

    Format: Single Select

    Allowable Values:

    Notes for Abstraction:

    Optional: Pre-Existing Conditions

    Format: Single Select

    Allowable Values:

    Notes for Abstraction:

    Vaping and e-cigarette use includes electronic nicotine delivery system or electronic cigarettes (e-cigarettes), which are battery-operated devices that heat a liquid containing nicotine, propylene glycol, and/or vegetable glycerin and flavorant chemicals to generate an aerosol that the user inhales, or heat-not-burn tobacco products, which are tobacco products that heat tobacco to a lower temperature than required for combustion.

    Reference: Dehmer GJ, Badhwar V, Bermudez EA, Cleveland JC Jr, Cohen MG, D'Agostino RS, Ferguson TB Jr, Hendel RC, Isler ML, Jacobs JP, Jneid H, Katz AS, Maddox TM, Shahian DM. 2020 AHA/ACC key data elements and definitions for coronary revascularization: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Clinical Data Standards for Coronary Revascularization). Circ Cardiovasc Qual Outcomes. 2020;13:e000059. doi: 10.1161/HCQ.0000000000000059

    Table of Contents

     3.1 Event

    Date/Time of Birth

    This field will be auto-populated in the online form from data entered into the Admission and Discharge form.

    Enter the patient's date and time of birth. If DOB unknown or not documented, select "DOB Unknown/Not Documented", if time is unknown select "Time Not Documented." Note: In the online form, time is only available for response if the patient is "born this admission (or transferred from birth hospital)."

    Age at Event

    Enter the age of the patient at the time of the event and indicate “hour(s)”, “day(s)”, “week(s)”, “month(s)”, or “year(s)”. If Date of Birth and Event Date have been provided, the age will be automatically derived.

    Estimated

    Select if age is estimated.

    Note: If age is not documented and cannot be estimated, select “Age Unknown/Not Documented.”

    Date/Time 1st MET Team Member Arrived

    Enter the date and time the first MET team member arrived. If the time is not available, select “Time Not Documented.”

    Date/Time Last MET Team Member Departed

    Enter the date and time the last MET team member departed regardless of their role in caring for the patient. If the time is not available, select "Time Not Documented."

    Example:

    Subject Type

    Enter the subject's relationship with the hospital at the time of the event onset. Valid entries:

    Note: Some hospitals have rehab, SNF, mental health units or adjacent facilities to which patients are 'admitted' (separate from acute care hospital admission) where the code team responds. In these instances, Rehab Facility Inpatient, SNF Inpatient or Mental Health Facility inpatient should be selected. If the event occurs on a rehab or skilled nursing or mental health 'ward' (acute care admission), then Hospital Inpatient should be selected.

    Illness Category

    Enter the most appropriate illness category at the time of the event onset.

    Event Location (area)

    Select the patient's location (or type of area) in the hospital when the need for chest compression and/or defibrillation was recognized.

    Note: Some hospitals have Rehab, Skilled Nursing or Mental Health areas or adjacent facilities to which patients are 'admitted' (separate from acute care hospital admission) where the code team responds.

    Event Location (name)

    Type or select the hospital-specific unit or area name or number where the patient was located at the time of the event. Some examples of unit names include: CCU-step-down, Newborn Nursery East, 3West, Angiography, CT scan, Cardiac Catheterization lab, Ambulatory Unit A, on-campus rehab facility.

    Note: This is a dynamic list of location names that is specific to the selected location area. As new names are added (manually entered), they become available in the menu for that particular “location area” for future records. For example, if “3 West” is typed in and saved in record 1, it will appear in the list for record 2.

    Vital Signs at Time of Event

    Enter patient’s heart rate, blood pressure, respiratory rate, SpO 2 (select either 'Room Air' or 'Supplemental O2' (oxygen)) and temperature at the time the MET was activated. If one or all vital signs at the time of the event are not documented, select "Unknown/Not documented."

    Table of Contents

    3.2 MET Activation Triggers

    Triggers Initiating MET Activation (record all that apply)

    Based on your hospitals pre-defined set of MET triggers/conditions, select the most appropriate triggers/conditions from the list below. There is no limit to the number of conditions that may be selected.

    Respiratory:

    Cardiac:

    Neurological:

    Medical:

    Other:

    Table of Contents

    4.1 Interventions

    Check all interventions initiated during the MET event.

    Table of Contents

    4.2 Non-Drug Interventions

    Note: Check all interventions that were initiated, or, if already in place immediately prior to the event, were continued during the event.

    Respiratory Management:

    If Endotracheal Tube (ET) or Tracheostomy tube placed during MET event, method(s) of confirmation used to ensure correct placement of ET or Tracheostomy Tube (check all that apply):

    Monitoring:

    For response selected, also indicate if "continued," meaning the intervention was already in place immediately prior to the event and continued during the event OR "initiated," during the event.

    Vascular access:

    For each response selected, also indicate if "already in place" meaning the intervention was already in place immediately prior to the event and continued during the event OR "place during the MET event."

    Stat Consult:

    Other Interventions initiated during the event:

    Note: Only select other interventions from the list below if the intervention was initiated during the MET event.

    Table of Contents

    5.1 MET Outcome

    Did patient require emergency assisted ventilation for acute respiratory compromise (ARC) or chest compressions and/or defibrillation for cardiopulmonary arrest (CPA) during the MET event?

    Did the ARC event meet Get With The Guidelines® - Resuscitation Inclusion Criteria?

    Did the CPA event meet Get With The Guidelines® - Resuscitation Inclusion Criteria?

    Patient Transferred To:

    Did patient die during event?

    Was MET response scope limited by patient/family end of life decisions or physician decision of medical futility?

    Indicate if therapy was limited by patient/family end of life decisions or medical futility.

    Was patient made DNAR during MET event?

    Table of Contents

    6.1 Review of MET Response

    Select the specific issues encountered during the MET response.

    Table of Contents

    7.1 Comments

    Use this memo field to document event-related notes.

    Note: Do not include any confidential information or patient identifiers in the comments section.

    Table of Contents

    Post Cardiac Arrest Care (PCAC)

    General Information

    This form is intended to capture post cardiac arrest care provided to both out of hospital and in-hospital cardiac arrest event patients.  Sites are encouraged to enter 100% of appropriate patients. 
    The following can be included:


    If more than 1 cardiac arrest event occurred, the data from the initial/first event (requiring chest compressions and/or defibrillation) should always be used when completing this form. This holds true for both cooled and non-cooled patients with multiple arrest events.  Note, if completing this form on an out of hospital arrest patient that then re-arrests in the hospital the data entered here should be for the initial/first event and will differ from that entered on the CPA form. 


    Example:  A patient with pre-hospital CPA is stabilized in the field with ROSC at 10:00.  The patient arrives to your ED at 10:10.  The patient again requires chest compressions and/or defibrillation in the ED at 10:30.  Data collection should be based off of the initial pre-hospital CPA event.

    Example:  A patient with an in-hospital CPA is stabilized with ROSC at 13:00 and again requires chest compressions and/or defibrillation at 13:36.  Data collection should be based off of the initial in-hospital CPA event.

    Example:  A patient with an out of hospital CPA is stabilized with ROSC at 15:00.  Active cooling is not initiated.  The patient again requires chest compressions at 17:00 for a repeat event at which point a therapeutic hypothermia protocol is initiated.  Data collection should be based off of the initial out of hospital CPA event (ROSC at 15:00)


    Intro

    Where did the event occur?

    Select where the FIRST event requiring chest compressions and/or defibrillation occurred.

    Notes for Abstraction:

    Did patient have subsequent cardiac arrest event(s) during the course of hospitalization? 

    Notes for Abstraction:


    Example: A patient with pre-hospital CPA is stabilized with ROSC at 12:00. At 12:12, 7 minutes after ED arrival, patient requires additional CPA resuscitation interventions (chest compression and/or defibrillation). ROSC was not sustained > 20 min. This would be considered a single, ongoing out of hospital event.
    Example: A patient with pre-hospital CPA is stabilized with ROC at 10:00 and requires no additional CPA resuscitation interventions in ED, with ROSC sustained > 20 min at 10:21. This out of hospital event has ended and would be considered the first (index) event. If patient again requires chest compression and/or defibrillation in the ED at 10:30, 9 min after ROSC sustained for >20 minutes, that event would be considered a repeat cardiac arrest event.

    System Entry Date/Time
    Enter the date and time the patient entered the system, based on subject type (below).

    Notes for Abstraction:

    *Note: Some hospitals have Rehab, Skilled Nursing and/or Mental Health areas or adjacent facilities to which patients are admitted (separate from hospital admission) where the code team responds. 

    Table of Contents

    PCAC 2.1 Pre-Existing Conditions

    This field is provided for those facilities using pre-numbered event records or another internal event numbering system who wish to include that reference in their Get With The Guidelines® - Resuscitation Post Cardiac Arrest Care record. Do not include any personal health/protected health information (PHI) in this field.

    Pre-existing conditions at time of the event (check all that apply)

    Select only conditions that existed prior to the event. For those conditions where there is a time interval indicated, only respond affirmatively if the diagnosis is made prior to the CPA event for which you are completing the event form. There is no limit on the number of conditions that you can select, so you should select all of the conditions that apply.

    Note: The following list is specific to certain conditions of particular interest to Get With The Guidelines® - Resuscitation and is not meant to be an exhaustive list of all possible pre-existing conditions. Additionally, where a time interval is indicated, it is NOT limited to the current admission. Example: If EMS identifies Hypotension at 1:00 at a patient’s home, arrives at the ED at 1:30 and the patient arrests at 2:00, “Hypotension” should be selected from the list below (within 4 hours).

    Table of Contents

    PCAC 3.1 Cardiac Arrest Event

    Date/Time of Birth (Will be auto-populated from Admission/Discharge Form)

    Event Witnessed?

    Did patient receive chest compressions (including open chest cardiac massage)?

    Date/Time compressions started
    Enter the date and time compressions were first started by EMS personnel, hospital staff, or bystander.

    Duration of CPR (in minutes):

    If the FIRST event requiring chest compressions and/or defibrillation occurred out-of-hospital, enter the total time that CPR was performed.  You should be looking for notes documenting estimated or actual CPR time. 
    If duration of CPR is not documented, select the “Not documented” checkbox. 

    Notes for Abstraction:

    Sustained Return of Spontaneous Circulation (ROSC) achieved? 

    Notes for Abstraction:                                                                                                         

    For out-of-hospital events, ROSC attained?

    For out-of-hospital cardiac arrest events, enter location where ROSC was obtained. 


    Date/Time sustained ROSC began (lasting > 20 min) OR resuscitation efforts were terminated (End of event):

    Enter date and time chest compressions stopped and did not resume because it was either the beginning of the sustained return of circulation lasting > 20 min (Example: ROSC begins, chest compressions stopped at 1300 and not resumed; ROSC is sustained for > 20 min at 1321. Time event ends is 1300), or because of other reasons indicated under “Reason resuscitation ended.” Example: Resuscitation stopped at 2301.) If the time is not documented, select “Time Not Documented.” 

    If time is estimated by EMS personnel, select “Time Estimated”

    Table of Contents

    PCAC 4.1 Arrival Information

    Arrival Date/Time

    Enter the earliest documented month, day, and year, and the time the patient arrived at this hospital (emergency room, on the floor for inpatient care).

    If the time is not documented, select “Time Not Documented.”

    Notes for Abstraction:

    Neurological Assessment Findings:

    If not assessed or assessment findings are not documented, select "Not documented".

    Are pupils fixed and dilated 

    Status of patient (if not sedated/paralyzed)?

    Glasgow Coma Scale (GCS) within 1-hr of ROSC? Do not complete this section if the patient is paralyzed.

    Record the GCS performed within 1 hour of ROSC.

    If you record GCS scores for motor, eye and verbal response, the total score will automatically be generated. 

    If only a total score is documented (and not the individual components), only fill in the "Total GCS" score response option.

    If assessment of any individual component of the GCS or total GCS is limited or unable to be performed due to sedation or paralytic drug received within 1 hour prior to exam select "Sedation/Paralytic"

    If the score for the individual components of the GCS are not documented or the GCS was not done, select "Unknown/Not Documented"  

    Glasgow Coma Scale (Adults)

    Motor Response

    Obeys commands for movement

    6 points

    Purposeful movement to painful stimulus

    5 points

    Withdraws from pain

    4 points

    Abnormal (spastic) flexion, decorticate posture

    3 points

    Extensor (rigid) response, decerebrate posture

    2 points

    None

    1 point

    Eye Opening Response

    Spontaneous--open with blinking at baseline

    4 points

    Opens to verbal command, speech, or shout

    3 points

    Opens to pain, not applied to face

    2 points

    None

    1 point

    Verbal Response

    Oriented

    5 points

    Confused conversation, but able to answer questions

    4 points

    Inappropriate responses, words discernible

    3 points

    Incomprehensible speech

    2 points

    None

    1 point


    Glasgow Coma Scale and Modification for Children

    Sign

    Glasgow Comas Scale

    Modification for children

    Score

    Eye Opening

    Spontaneous

    Spontaneous

    4

    To Command

    To sound

    3

    To pain

    To pain

    2

    None

    None

    1

    Verbal Response

    Oriented

    Age appropriate verbalization, orients to sound, fixes and follows, social smile

    5

    Confused

    Cries, but consolable

    4

    Disoriented - Inappropriate words

    Irritable, uncooperative, aware of environment - Irritable, persistent cries, inconsistently consolable

    3

    Incomprehensible sounds

    Inconsolable crying, unaware of environment or parents, restless, agitated

    2

    None

    None

    1

    Motor Response

    Obeys commands

    Obeys commands, spontaneous movement

    6

    Localizes pain

    Localizes pain

    5

    Withdraws

    Withdraws

    4

    Abnormal flexion to pain

    Abnormal flexion to pain

    3

    Abnormal extension

    Abnormal extension

    2

    None

    None

    1

    Best Total Score

     

     

    15

    Notes for Abstraction:

     

    Table of Contents
    PCAC 4.2 Targeted Temperature Management


    Was targeted temperature management (TTM) utilized?

    Notes for Abstraction:

    Initial patient temp

    If yes, what was the targeted temperature (choose one)?

    Select the documented targeted temperature from the following list.

    ADULT

    PEDIATRIC/INFANT

    Notes for Abstraction:

    Temperature control method (select all that apply):

    If Targeted Temperature Management (TTM) was used for the first or initial cardiac arrest event, select all cooling methods that were used.  

    Duration of continuous hypothermia:

    Date/Time targeted temperature management initiated

    If the date and time are unknown or not documented, select “Unknown/Not Documented"
    If the time is not documented, select “Time Not Documented.”

    Was goal temperature met?


    (REQUIRED for patients that are not treated with targeted temperature management) Clinical rationale documented by medical team why targeted temperature management was not initiated (check all that apply):

    If Targeted Temperature Management (TTM) was not utilized for the first or initial cardiac arrest event, select the reason(s) why it was not initiated.

    Notes for Abstraction:

    For all patients:

    Was there ever a documented temperature of ≥38 degrees Celsius?
    Is there a recorded temperature of greater than or equal to 38 degrees Celsius (100.4 degrees Fahrenheit) documented in the medical record any time during the hospitalization?

    This data element needs to be answered for both patients in whom active cooling is initiated and also those that are not cooled. 

    If yes, when was a temperature of ≥38 degrees Celsius documented? (Check all that apply)
    If a temperature of greater than or equal to 38 degrees Celsius (100.4 degrees Fahrenheit) was documented any time during the hospitalization, indicate on what day(s) a temperature of greater than or equal to 38 degrees Celsius was recorded. 

    If the time is not documented, select "Time Not Documented"

    Table of Contents

    PCAC 5.1 Measurements & Medications

    On invasive mechanical ventilator?

    If not documented, select "Not Documented."


    Was there a PaO2 in the first 24 hours of >300mmHg?
    Was there a PaO2 after the initial value and within 24 hours of ROSC that was greater than 300 mm Hg?

    Notes for Abstraction:

    If yes, FiO2 at time PaO2 assessed(%)
    If there was a PaO2 value of greater than 300 mm Hg, what was the FiO2 at the time of blood gas draw closest to when the PaO2 value was obtained? 

    Was there a PaO2 in the first 24 hours of <60mmHg?
    Was there a PaO2 after the initial value and within 24 hours of ROSC that was less than 60 mm Hg?

    Notes for Abstraction:

    If yes, FiO2 at time PaO2 assessed(%)
    If there was a PaO2 value of less than 60 mm Hg, what was the FiO2 at the time of blood gas draw closest to when the PaO2 value was obtained? 

    Serial Measurements

    Serial Blood Pressure Measurements:

    Enter lowest Systolic BP for each of the following time periods:

    Notes for Abstraction:

    Was the patient on vasopressors/inotropes during the first 0-6 hours post ROSC:

    Was the patient on vasopressors/inotropes during the first 6-12 hours post ROSC:

    Was the patient on vasopressors/inotropes during the first 12-24 hours post ROSC:

    Was the patient on vasopressors/inotropes during the first 24-72 hours post ROSC:

     

    Table of Contents

    PCAC 5.2 Clinical Study Data

    Did patient go to the cath lab at any time during this admission?   

    Notes for Abstraction:


    Date/Time at Cath lab
    Enter the date/time that the patient arrived at the Cath lab. 

    If the time is not documented, select “Time Not Documented.”

    Notes for Abstraction:

    Reason went to Cath lab:
    Select the reason(s) the patient went to the Cath lab.  Select all that apply.   

    Notes for Abstraction:

    Cath lab interventions:
    Select the intervention(s) the patient received in the cath lab.

    Notes for Abstraction:

    Implantable cardioverter-defibrillator (ICD) placed during this admission?
    Did the patient have an implantable cardiac defibrillator placed during this admission? 

    Notes for Abstraction:

     

    For Comatose/Encephalopathic Patients Only

    EEG (spot) performed within the first 24 hours post ROSC?

    If yes, Start Date/Time of EEG (spot):


    EEG (continuous) performed within the first 24 hours post ROSC?

    If yes, Start Date/Time of EEG (continuous):

    If yes, End Date/Time of EEG (continuous):


    Brain imaging (CT/MRI) performed within the first 5 days post ROSC?

    Notes for Abstraction:

    If yes, or at any point within 10 days, Date/Time of CT/MRI:

    Notes for Abstraction:

    PCAC 6.1 Outcome Data


    Discharge Modified Rankin Scale:          

    If a Modified Rankin Scale (mRS) was measured, what is the scale recorded by hospital personnel closest to discharge.

    If a score is not available or unknown, check the "Not Documented” checkbox.

    Modified Rankin Scale   
    0 – No symptoms at all
    1 – No significant disability despite symptoms: ability to carry out all usual activities
    2 – Slight disability
    3 – Moderate disability: Requiring some help but able to walk without assistance
    4 – Moderate to severe disability: Unable to walk without assistance and unable to attend to own bodily needs without assistance
    5 - Severe disability: Bedridden, incontinent and requiring constant nursing care and attention
    6 – Death

    Notes for Abstraction:

    Table of Contents

    PCAC Historic

    Note: PCAC elements moved to Historic on December 14, 2022


    PCAC 2.1 Pre-Event


    OPTIONAL: Local Event ID

    This field is provided for those facilities using pre-numbered event records or another internal event numbering system who wish to include that reference in their Get With The Guidelines® - Resuscitation Post Cardiac Arrest Care record. Do not include any personal health/protected health information (PHI) in this field.

    Did pt. receive chest compressions and/or defibrillation during this event?

    Notes for Abstraction:
    Date/Time the need for chest compressions (or defibrillation when initial rhythm was VF or Pulseless VT) was first recognized.

    Enter the date and time that the need was first recognized by telemetry or direct observation, by EMS personnel, medical staff, or lay bystander. The date of the event is required. If the time is not documented, select “Time Not Documented.”

    Notes for Abstraction:

    PCAC 3.1 Cardiac Arrest Event

    Age at Event (Will be auto-populated from Admission/Discharge Form)

    Was out of hospital CPR performed? 

    Notes for Abstraction:

    If yes, out of hospital CPR performed first by:

    If CPR was performed out of hospital, select who first started CPR on the patient for the FIRST event requiring chest compressions and/or defibrillation.

    Notes for abstraction

    Condition that best describes this event:

    Choose the selection that best describes the patient when the need for chest compressions and/or defibrillation was first identified:

    Note: While chest compressions are usually provided to pulseless patients (option 1), patients sometimes require chest compressions when a poorly perfusing pulse/heart rate is present (e.g., bradycardia). This occurs more frequently in the pediatric population. For these events, option 2 or 3 should be selected

    If pulseless at ANY time during event:

    Date/Time pulselessness was first identified:

    If the time is not documented, select “Time Not Documented.”

    Notes for Abstraction:

    First documented pulseless rhythm:
    What was the first documented pulseless rhythm?

    Notes for Abstraction:

    Total time patient without a pulse prior to CPR (in minutes):

    If the FIRST event requiring chest compressions and/or defibrillation occurred out-of-hospital, enter the total Time in minutes the patient was without a pulse prior to the start of chest compressions.  If the duration of time the patient was without a pulse prior to the start of CPR is not documented or cannot be calculated, select the “Not documented” checkbox. 

    Notes for Abstraction:                                                                                                                    


    PCAC 4.1 Arrival Information

    Was patient transferred from another hospital?    

    Notes for Abstraction:

    Neurological Assessment performed within 1-hr of ROSC?

    Was a neurological assessment performed as part of the initial evaluation (within 1 hour of ROSC)?

    Notes for Abstraction:

    Date/Time initial neurological assessment:

    Enter the date and time of the first neurological assessment performed. 

    If time is unknown select the "Time Not Documented" checkbox. 

    If date and time are unknown or not documented, select the “Unknown/Not Documented", checkbox.  

    Notes for Abstraction:

    Pupils equal                         

    Left pupil reaction                

    Right pupil reaction              

    Follows commands at time of initial assessment?

    Notes for Abstraction:


    PCAC 4.2 Targeted Temperature Management

    Where was targeted temperature management initiated? 

    If Targeted Temperature Management (TTM) was initiated for the first or initial cardiac arrest event, select where it was started.

    Notes for Abstraction:

    If yes, Date/Time goal temperature met:

    If the time is not documented, select "Time Not Documented."
    If the date and time are unknown or not documented, select "Unknown/Not Documented"

    Date/Time re-warming started?

    If the time is not documented, select “Time Not Documented.”
    If the date and time are unknown or not documented, select “Unknown/Not Documented”

    Notes for Abstraction:


    Date/Time re-warming completed?

    Enter date/time a temperature of greater than or equal to 36.5 degrees Celsius was FIRST documented. 

    If the time is not documented, select “Time Not Documented.”
    If the date and time are unknown or not documented, select “Unknown/Not Documented”

    Notes for Abstraction:

    Was there a documented temperature of ≤ 31.0 degrees Celsius 6 hours after the initiation of the temperature controlled period?

    Notes for Abstraction:

    Did patient receive a paralytic drug during induction?

    Did the patient receive a paralytic drug any time between date/timeTargeted Temperature Management (TTM) was initiated and date/time the targeted temperature was first recorded (for the first or initial cardiac arrest event)?

    Notes for Abstraction:

    If a temperature of greater than or equal to 38 degrees Celsius was documented, was patient following commands at time of fever?

    For each day a temperature of greater than or equal to 38 degrees Celsius (100.4 degrees Fahrenheit) was documented, answer whether or not the patient was following commands at the time of the fever.

    Notes for Abstraction:

    Documented Adverse Events (check all that apply)

    Indicate if any adverse events were documented as a result of the post ROSC management of cardiac arrest.  Select all that apply. 

    Notes for Abstraction:

    PCAC 5.1 Measurements & Medications


    If patient was transferred to your hospital, vital signs prior to transfer? 

    If the patient arrived to your hospital as a transfer from another acute care hospital, is there documentation of any vital signs (temperature, heart rate, blood pressure, respiratory rate or pulse oximetry saturation) obtained at the transferring hospital prior to patient transfer available in the medical record?

    Notes for Abstraction:

    If yes, Date/Time of vital signs prior to transfer:

    If the time is not documented, select “Time Not Documented.”

    If the date and time are unknown or not documented, select “Unknown/Not Documented”

    Notes for Abstraction:


    Vital signs prior to transfer:
    Enter the first vital signs post ROSC measured at the transferring hospital. 

    Temperature:
    Enter the patient’s first temperature measurement post ROSC from transferring hospital.  Select “Celsius” or “Fahrenheit” to indicate the temperature units. If temperature prior to transfer is not documented select the “Not documented” checkbox.

    Site:
    Select the site of the initial temperature. 


    Heart Rate (bpm)   
    Enter the patient’s heart rate in beats per minute. Enter the patient’s first heart rate post ROSC obtained at the transferring hospital.  If heart rate prior to transfer is not documented select the “Not documented” checkbox.

    Systolic BP/ Diastolic BP (mmHg)   
    Enter the patient’s blood pressure (systolic/diastolic) in mmHg. Enter the patient’s first blood pressure measurement post ROSC obtained at the transferring hospital. If blood pressure prior to transfer is not documented select the “Not documented” checkbox.

    Respiratory Rate (breaths/min)       
    Enter the patient’s respiratory rate in breaths/min.  Enter the patient’s first respiratory rate post ROSC obtained at the transferring hospital.  If respiratory rate prior to transfer is not documented select the “Not documented” checkbox.

    Intubated or on mechanical ventilator? 
    If a respiratory rate is documented, select whether or not the patient was intubated and/or on a mechanical ventilator at the time the respiratory rate was recorded.

    Pulse Oximetry Saturation (SpO2): (%)
    Enter the patient’s oxygen saturation obtained from pulse oximetry as a percentage.  Enter the patient’s first SpO2 post ROSC obtained at the transferring hospital. If Sp02 prior to transfer is not documented select the “Not documented” checkbox.

    Initial Measurements

    Vital Signs:
    Enter the first vital signs measured within 1 hour of ROSC that were obtained after arrival to your hospital. 
    Ideally these should be the first vital signs measured at your hospital within 1 hour of ROSC.  If the patient is not at your hospital within 1 hour of ROSC, enter the first vital signs obtained after arrival to your hospital. 

    Date/Time of initial vital sign measurements after arrival to your hospital
    Enter the date/time the first vital signs after ROSC were measured at your hospital.

    If the time is not documented, select “Time Not Documented.”
    If the date and time are unknown or not documented, select “Unknown/Not Documented”

    Notes for Abstraction:

    Temperature:
    Enter the first temperature measured within 1 hour of ROSC at your hospital.  If the patient is not at your hospital within 1 hour of ROSC, enter first heart temperature obtained after arrival to your hospital.   Select “Celsius” or “Fahrenheit” to indicate the temperature units.  If initial temperature is not documented select the “Not documented” checkbox.

    Site:


    Heart Rate (bpm)   
    Enter the patient’s heart rate in beats per minute. Enter the first heart rate obtained within 1 hour of ROSC at your hospital. If the patient is not at your hospital within 1 hour of ROSC, enter the first heart rate  obtained after arrival to your hospital.  If initial heart rate is not documented select the “Not documented” checkbox.

    Respiratory Rate (breaths/min)       
    Enter the patient’s respiratory rate in breaths/min. Enter the first respiratory rate obtained within 1 hour of ROSC at your hospital. If the patient is not at your hospital within 1 hour of ROSC, enter first respiratory rate  obtained after arrival to your hospital.  If initial respiratory rate is not documented select the “Not documented” checkbox.

    Intubated or on mechanical ventilator? 
    If a respiratory rate is documented, select whether or not the patient was intubated and/or on a mechanical ventilator at the time the respiratory rate was recorded.

    Systolic BP/ Diastolic BP (mmHg)   
    Enter the patient’s blood pressure (systolic/diastolic) in mmHg. Enter the first blood pressure measurement with 1 hour of ROSC at your hospital. If the patient is not at your hospital within 1 hour of ROSC, enter the first BP obtained after arrival to your hospital.  If blood pressure prior to transfer is not documented select the “Not documented” checkbox.

    MAP (mmHg):  
    Enter the first  MAP measured within 1 hour of ROSC at your hospital.  If the patient is not at your hospital within 1 hour of ROSC, enter the first MAP obtained after arrival to your hospital.    If a MAP is not documented for any time period, check the "Not Documented” checkbox.

    Pulse Oximetry Saturation (SpO2): (%)
    Enter the patient’s oxygen saturation obtained from pulse oximetry as a percentage.  Enter the first oxygen saturation obtained with 1 hour of ROSC at your hospital. If the patient is not at your hospital within 1 hour of ROSC, enter the first SpO2 obtained after arrival to your hospital.  If initial SpO2 is not documented select the “Not documented” checkbox.
           
    FiO2 at time SpO2 assessed: (%)
    Enter the patient's FiO2 at the time the SpO2 was assessed. For patients without an oxygen delivery device, abstractors can input 21%.

    Electrolytes and Labs

    Date/Time of initial electrolyte & lab measurements (at your hospital):

    Enter the date/time the first serum creatinine (Scr), bicarbonate/CO2,and glucose were obtained after arrival to your hospital. 

    If the time is not documented, select “Time Not Documented.”

    If the date and time are unknown or not documented, select “Unknown/Not Documented”

    Notes for Abstraction:


    Serum Creatinine:   
    Enter the first SCr measured within 2 hours of ROSC at your hospital. Indicate whether the value is in mg/dL or µmol/L.  If the patient is not at your hospital within 2 hours of ROSC, enter the first SCr  obtained after arrival to your hospital.  If initial Scr is not documented select the “Not documented” checkbox.
       
    Bicarbonate/CO2: 
    Enter the first bicarbonate/CO2 measured within 2 hours of ROSC at your hospital.  Indicate whether the value is in mmol/L or mEq/L.  If the patient is not at your hospital within 2 hours of ROSC, enter the first bicarbonate/CO2 obtained after arrival to your hospital.  If initial bicarbonate/CO2 is not documented select the “Not documented” checkbox.

    Glucose:  
    Enter the first glucose measured within 2 hours of ROSC at your hospital.  If the patient is not at your hospital within 2 hours of ROSC, enter the first  glucose obtained after arrival to your hospital.  If a glucose is not documented for any time period, select the "Not Documented” checkbox.

    Date/Time of initial Lactate: 
    Enter the date/time that the first lactate was measured after arrival to your hospital.

    Notes for Abstraction:

    Lactate: 
    Enter the first lactate measured within 2 hours of ROSC at your hospital. Indicate whether the value is in mmol/L or mg/dL. If the patient is not at your hospital within 2 hours of ROSC, enter the lactate obtained after arrival to your hospital. If a lactate is not documented, check the "Not Documented" checkbox.

    Date/Time of initial Troponin: 
    Enter the date/time that the first troponin was measured after arrival to your hospital.

    If the time is not documented, select “Time Not Documented.”

    If the date and time are unknown or not documented, select “Unknown/Not Documented”

    Notes for Abstraction:

    Troponin: 
    Enter the first troponin measured within 2 hours of ROSC at your hospital.  Indicate whether the value is in ng/dL or mcg/L and if the tests were Troponin I or T.  If the patient is not at your hospital within 2 hours of ROSC, enter the first troponin obtained after arrival to your hospital.  If initial troponin is not documented, select the "Not Documented” checkbox.

    Date/Time of initial blood gas measurements (at your hospital)
    Enter the date/time that the first pH, pCO2, and PaO2, were measured after arrival to your hospital. 

    If the time is not documented, select “Time Not Documented.”

    If the date and time are unknown or not documented, select “Unknown/Not Documented”

    Notes for Abstraction:


    pH:  
    Enter the first pH measured within 2 hours of ROSC at your hospital.  If the patient is not at your hospital within 2 hours of ROSC, enter the pH obtained after arrival to your hospital.  If pH is not documented, select the "Not documented" checkbox.

    pCO2 (mmHg):  
    Enter the first pCO2 measured within 2 hours of ROSC at your hospital.  If the patient is not at your hospital within 2 hours of ROSC, enter the first pCO2 obtained after arrival to your hospital.  If pCO2 is not documented, select the "Not documented” checkbox.

    Was there a pCO2 in the first 24 hours of <30 or >50mmHg?
    Was there a pCO2 after the initial value and within 24 hours of ROSC that was less than 30 or greater than 50 mm Hg?

    Notes for Abstraction:

    PaO2 (mmHg):
    Enter the first PaO2 measured within 2 hours of ROSC at your hospital.  If the patient is not at your hospital within 2 hours of ROSC, enter the first PaO2 obtained after arrival to your hospital.  lf PaO2 is not documented, select the "Not documented” checkbox.
           

    Is there documentation that Central Venous Saturation (ScvO2) or mixed venous saturation was tracked within the first 24 hours?
    Was central venous saturation or mixed venous return tracked during the first 24 hours post ROSC?

    Notes for Abstraction:

    Serial Measurements

    For lactate and glucose enter the measurement obtained closest to but not after:

    Note: In the online tool, the date/time fields will autopopulate with the date and time corresponding to the specified number of hours post ROSC to help you to best identify the time period.

    Notes for Abstraction:


    Lactate:  
    Indicate whether the value is in mmol/L or mg/dL.  If a lactate is not documented for any time period, select the "Not Documented” checkbox.

    Glucose (mg/dL):  
    If a glucose is not documented for any time period, select the "Not Documented" checkbox.

    Did patient receive any sedatives in the 0-6 hour time period post ROSC?

    Notes for Abstraction:

    Did patient receive any paralytics in the 0-6 hour time period post ROSC?

    Notes for Abstraction:

    Did patient receive any sedatives in the 6-24 hour time period post ROSC?

    Notes for Abstraction:

    Did patient receive any paralytics in the 6-24hour time period post ROSC?

    Notes for Abstraction:

    Did patient receive any sedatives in the 24-48 hour time period post ROSC?

    Notes for Abstraction:

    Did patient receive any paralytics in the 24-48hour time period post ROSC?

    Notes for Abstraction:

    Did patient receive any sedatives in the 48-72 hour time period post ROSC?

    Notes for Abstraction:

    Did patient receive any paralytics in the 48-72hour time period post ROSC?

    Notes for Abstraction:

    Serial Blood Pressure Measurements:

    Were there at least two consecutive systolic blood pressure readings of <90mmHg separated by at least one hour in the first 0-6 hours post ROSC?

    MAP (mmHg):
    If a MAP is not documented for any time period, select the "Not Documented" checkbox.

    Select all vasopressors/inotropes patient was on during the first 0-6 hours post ROSC:
    Select drugs delivered by IV bolus or continuous infusion.

    Were there at least two consecutive systolic blood pressure readings of <90mmHg separated by at least one hour 6-24 hours post ROSC?

    MAP (mmHg):
    If a MAP is not documented for any time period, select the "Not Documented" checkbox.

    Select all vasopressors/inotropes patient was on during hours 6-24 post ROSC:
    Select drugs delivered by IV bolus or continuous infusion.

    Select all vasopressors/inotropes patient was on during hours 24-48 post ROSC:
    Select drugs delivered by IV bolus or continuous infusion.

    Select all vasopressors/inotropes patient was on during hours 48-72 post ROSC:
    Select drugs delivered by IV bolus or continuous infusion.

    Did patient receive any anticonvulsants in the 0-72 hour time period post ROSC?

    Notes for Abstraction:


    PCAC 5.2 Clinical Study Data


    Was a 12-lead ECG performed? 
    Was a 12-lead ECG performed at any time?

    Notes for Abstraction:


    ECG interpretation:
    Indicate which of the following findings were present on the first ECG.  Select all that apply.

    Notes for Abstraction:

    ECG interpretation must be confirmed by a physician.  Abstractors should not make interpretation based upon an ECG present in the medical record. 

    Date/Time of cath lab intervention
    Enter the date/time of the first cath lab intervention. 

    If the time is not documented, select “Time Not Documented.”

    Notes for Abstraction:


    Echo Studies

    Echo performed? 


    Date/Time of First Echo
    Enter the date and time the FIRST echo study was performed for Day 1-Day 4 post ROSC. 

    If the time is not documented, select “Time Not Documented.”

    Echo findings:
    Left Ventricular Ejection Fraction (LVEF)(%) 
    If LVEF value is not available or unknown, check the "Not Documented " checkbox.

    Notes for Abstraction:


    Head CT performed? 
    Was a head CT performed post ROSC? 

    Notes for Abstraction:

    Date/Time of initial head CT
    Enter the date and time the first head CT post ROSC was performed. 

    If the time is not documented, select “Time Not Documented.”

    Notes for Abstraction:


    Head CT findings:
    Indicate the findings present on the initial head CT.  Select all that apply.

    Notes for Abstraction:

       
    Cerebral MRI performed? 
    Was a cerebral MRI performed post ROSC?

    Notes for Abstraction:

    Date/Time of initial MRI:
    Enter the date and time the first cerebral MRI post ROSC was performed. 

    If the time is not documented, select “Time Not Documented.”

    Notes for Abstraction:


    EEG performed within the first 24 hours post ROSC? 
    Was any EEG monitoring performed from ROSC up to 24 hours post ROSC? 

    If EEG performed, was there evidence of any seizure activity? 

    Notes for Abstraction:

    If evidence of seizure activity, was their evidence of Status Epilepticus (sustained seizures)? 

    Notes for Abstraction:

    If yes, was an anticonvulsant administered?
    If there was evidence of electrographic seizures, was an anticonvulsant administered during EEG monitoring?

    Notes for Abstraction:


    PCAC 6.1 Outcome Data


    Did patient survive to hospital discharge?

    Note: This data element will autopopulate from the Admission/Discharge Form data element Discharge Disposition.

    Date/Time of discharge from ICU
    Enter the date and time the patient was discharged from the ICU. 

    If the time is not documented, select the “Time Not Documented checkbox.”

    If patient was not discharged from ICU, select the “Patient was not discharged from ICU” checkbox. 

    Notes for Abstraction:


    Did patient ever follow commands?
    Is there documentation that the patient followed commands any time during the hospital stay?

    Notes for Abstraction:

    Date/Time of first documented following of commands:
    Enter the date and time the patient first followed commands. 

    If the time is not documented, select “Time Not Documented.”

    Table of Contents

    Optional Fields

    The Optional fields can be used to track any additional information not already collected in the Patient Management Tool. To use these, your Stroke team will need to decide on consistent representations for the fields you will use. For instance, Optional 1 will always be used to track the hospital floor.Do not enter any personal health/protected health information (PHI) into the Optional Fields.

    Optional 1 through Optional 10 are text fields that can hold up to 20 alphanumeric characters.

    Optional 1
    Optional 2
    Optional 3
    Optional 4
    Optional 5
    Optional 6
    Optional 7
    Optional 8
    Optional 9
    Optional 10

    Table of Contents

    Table 1: Sedatives

    clonazepam (Klonopin)
    dexmedetomidine (Precedex)
    diazepam (Valium)
    fentanyl (Duragesic, Subsys)
    fosopropofol disoudium (Lusedra)
    haloperidol (Haldol) 
    hydromorphone hydrochloride (Dilaudid) 
    ketamine (Ketalar)
    lorazepam (Ativan)
    methadone 
    midazolam (Versed)
    morphine
    propofol (Diprivan)
    Other sedative

    Table 2: Paralytics
    Neuromuscular blockade
    atracurium (Tracrium)
    choline chloride succinate
    cisatracurium (Nimbex)
    doxacurium (Nuromax)
    pancuronium (Pavulon)

    rocuronium (Zemuron)

    succinylcoline (Anectine, Quelicin)
    vecuronium (Norcuron)
    Other paralytic


    Table 3: Inotropes/Vassopressors

    adrenaline
    amrinone (Inocor) 
    digitoxin (Crystodigin)
    digoxin (Lanoxin)
    dobutamine (Dobutrex)
    dopamine
    ephedrine sulfate
    epinepherine
    inamrinone lactate
    isoproterenol (Isuprel)
    milrinone (Primacor)
    noradrenaline
    norepinephrine (Levophed)
    phenylphrine (NeoSynephrine)
    vasopressin (Pitressin)


    Table 4: Vasodilators 

    Nitroglygerin
    amrinone (Inocor)
    ciloprost, lloprost (Ventavis)
    Fenoldopam mesylate  (Corlopam)
    Hydralazine (Apresoline)
    milrinone (Primacor)
    Nesiritide (Natrecor)
    Nicardipine (Cardene)
    Sodium Nitroprusside (Nipride)
    Other vasodilator

    Table 5: Anticonvulsants

    carbamazepine (Tegretol)
    clonazepam (Klonopin)
    diazepam (Diastat, Valium)
    phenytoin (Dilantin, Fosphenytoin)
    felbamate (Felbatol)
    gabapentin (Neurontin)
    lacosamide
    lamotrigine (Lamictal)
    levetiracetam (Keppra)
    Phenobarbital
    topiramate (Topamax)
    Trileptal
    valproate (Depakene, Depakote)
    Other anticonvulsant

    Table of Contents

    Scoring Definitions

    Cerebral Performance Categories


    Adult Cerebral Performance Categories/CPC Scale
    • Evaluate only cerebral performance capabilities, estimating potential performance if non-cerebral organ systems were (are) normal.
    • Example – a conscious, mentally active, bedridden, post-CPR patient with severe heart disease would have a CPC of 1.
    • Differences in CPC scores exist only for categories 1, 2 and 3, while categories 4 and 5 are determined solely by cerebral status.

    Note: If patient is anesthetized, or paralyzed with neuromuscular blockade, or intubated, use “as is” clinical condition to calculate scores.

    • CPC 1 : Good cerebral performance* – Conscious, alert, able to work, might have mild neurologic or psychologic deficit.
    • CPC 2 : Moderate cerebral disability* – conscious, sufficient cerebral function for independent activities of daily life. Able to work in sheltered environment.
    • CPC 3 : Severe cerebral disability – Conscious, dependent on others for daily support because of impaired brain function. Ranges from ambulatory state to severe dementia or paralysis.
    • CPC 4 : Coma or vegetative state – Any degree of coma without the presence of all brain death criteria. Unawareness, even if appears awake (vegetative state) without interaction with environment; may have spontaneous eye opening and sleep/awake cycles. Cerebral unresponsiveness.
    • CPC 5 : Brain death – Apnea, areflexia, EEG silence, etc.

    *Note: Differences between “Good Performance” and “Moderate Disability” are often too subtle to distinguish from the information in the medical record. Make the selection based on your “best guess.”

    From Table 8.6, page 178 in. Safar P. Resuscitation after Brain Ischemia, in Grenvik A and Safar P Eds – Brain Failure and Resuscitation, Churchill Livingstone, New York, 1981; 155-184.

     
    Pediatric/Neonate Cerebral Performance Categories/PCPC Scale
    • PCPC 1 : Normal - Age-appropriate level of functioning; preschool child developmentally appropriate; school-age child attends regular classes.
    • NEONATE : Normal - No obvious neurological abnormalities.
    • PCPC 2 : Mild cerebral disability - Able to interact at an age-appropriate level; minor neurological disease that is controlled and does not interfere with daily functioning (e.g., seizure disorder that is well controlled with medication); preschool child may have minor developmental delays, but more than 75% of all daily living developmental milestones are above the 10 th percentile; school-age child attends regular school, but grade is not appropriate for age, or child is failing appropriate grade because of cognitive difficulties.
    • NEONATE : Mild cerebral disability - Minor neurological abnormality; neurological disease that is controlled and does not interfere with daily functioning (e.g., seizure disorder that is well controlled with medication).
    • PCPC 3 : Moderate cerebral disability - Below age-appropriate functioning; neurological disease that is not controlled and severely limits activities; most activities of preschool child’s daily living developmental milestones are below the 10th percentile; school-age child can perform activities of daily living, but attends special classes because of cognitive difficulties and/or has a learning deficit.
    • NEONATE : Moderate cerebral disability - Neurological disease that is not controlled (e.g., breakthrough seizures despite medications which affect responsiveness to environment).
    • PCPC 4 : Severe cerebral disability - Preschool child’s activities or daily living milestones are below the 10th percentile, and child is excessively dependent on others for provision of activities of daily living; school-age child may be so impaired as to be unable to attend school; school-age child is dependent on others for provision of activities of daily living; abnormal motor movements for both preschool and school-age child may include non-purposeful, decorticate, or decerebrate responses to pain.
    • NEONATE : Severe cerebral disability - Obvious severe neurological disorder: Abnormal motor movements may include non-purposeful, decorticate or decerebrate response to pain.
    • PCPC 5 : Coma or vegetative state - Coma; unawareness.
    • NEONATE : Coma or vegetative state - Coma; unawareness.
    • PCPC 6 : Brain death
    • NEONATE : Brain death

    Table of Contents

     

    Data Dictionary for IHCA Site Characteristics

    Why are we collecting this information?

    Denomiator Data

    In 2015, the Institute of Medicine's report, "Strategies to Improve Cardiac Arrest Survival: A Time to Act (2015)", initiated a call to action, specifically Recommendation #4: Set National Accreditation Standards for Cardiac Arrest for Hospital and Health Care Systems and #5: Adopt continuous quality improvement programs. Currently, survival for in-hospital cardiac arrests (IHCA) is low at about 19%-38% (Merchant RM et al. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011;39;2401-2406).

    In order to increase the rate of survival for IHCA, we must first understand that root causes when patients do not survive the IHCA, including the impact of arrest location on survival, which requires measurement of data. Get With The Guidelines-Resuscitation provides the numerator for measurement in participating hospitals. Additionally, we need to collect the denominator in order to develop a new measure and conduct feasibility testing of an IHCA incidence measure.

    Goals

    Where can you find this information?

    The owner of this information may vary by institution. If you do not know who owns this information, we recommend starting with your Finance Office, then if not available there, contacting your Quality and/or Nursing Departments. Other departments which may have this information include but are not limited to: CFO or Finance Office, VP Quality, CNO Office, Administration, and/or Business Intelligence (BI).

    Example: The finance department may maintain this as a standard report provided to each unit for budgeting purposes.

    Example: The information is provided by Unit Managers via the midnight census to Administration.

    Example: In some institutions, this information may have been developed by HIM as part of their overall finance and billing.

    What are the data being collected?

    Note: All inpatients and observation patients should be included.

    Med/surg bed days: The number of occupied bed days in the Adult med/surg units (non-procedural, non-critical, and non-licensed beds) January 1 through December 31.

    Ped ward bed days: The number of occupied bed days in the Pediatric med/surg units (non-procedural, non-critical, and non-licensed beds) January 1 through December 31.

    Total adult admissions: Enter the total adult admissions from January 1 through December 31 for patients 18 years or older.

    Total ped admissions: Enter the total pediatric (patients ≥1 year old to <18 years old) admissions from January 1 through December 31.

    Total neonate/infant admissions: Enter the total neonate/infant (patients >24 hours old to <1 years old) admissions from January 1 through December 31.

    Total newly born admissions: Enter the total newly born (born this admission or <24 hours old) admissions from January 1 through December 31.

    Adult ICU bed days: The number of occupied bed days in all the Adult Intensive Care Units from January 1 through December 31.

    Ped ICU bed days: The number of occupied bed days in all Pediatric Intensive Care Units from January 1 through December 31.

    NICU (neonatal intensive care unit) bed days: The number of occupied bed days in all Neonatal Intensive Care Units from January 1 through December 31.

    Table of Contents

     

    Summary of Changes


    Section

    Title

    Change
        Update 04/2014: Added text stating not to enter any personal health information/protected health information (PHI) in the "Local Event ID" and "Comments" section across all forms.
    1.1 Admit System Entry Date/Time Update 5/2015: Added "Emergency Department- Date/Time the patient was admitted/registered into the Emergency Department"
    1.1 Admit Date/Time of Birth Update 4/2014: Added clarification for abstraction that stated: "Note: In the online form, time is only available for response if the patient is "born this admission (or transferred from birth hospital)."
    1.1 Admit Patient Gender Identity Update 2/2021: Added new element
    1.1 Admit Patient-Identified Sexual Orientation Update 2/2021: Added new element
    1.1 Admit Race Update 03/2016: Removed multi-select instructions
    1.1 Admit Born this admission or transferred from birth hospital? Update 12/2014: Moved data element beneath Age at System Entry
    1.1 Admit Canada Sex Update 12/2021: Element added to Admission and Discharge Form.
    1.1 Admit Canada Gender Update 12/2021: Element added to Admission and Discharge Form.
    1.1 Admit Canada Date of Birth Update 12/2021: Element added to Admission and Discharge Form.
    1.1 Admit Canada Patient Postal Code Update 12/2021: Element added to Admission and Discharge Form.
    1.1 Admit Canada Providence or Territory Update 12/2021: Element added to Admission and Discharge Form.
    1.1 Admit Canada Race Update 12/2021: Element added to Admission and Discharge Form.
    1.1 Admit Birth Weight (patients <30 days only) Update 10/2013: Element added to Admission and Discharge Form.
    1.1 Admit Weight same as birth weight Update 10/2013: Element added to Admission and Discharge Form
    1.1 Admit Weight

    Update 4/2014: Label of element updated to state Weight (required for pediatric and newborn/neonate patients only). Label update made to clarify required status of element for pediatric and newborn/neonate patients only.

    Update 12/2014: Replaced "weight at admission" to "weight weight at time of the first (or index) event" in first sentence of coding instructions for this element.
    1.1 Admit Patient Gender Identity Update 05/2021: New response options added
    1.1 Admit Patient-Identified Sexual Orientation Update 05/2021: Element added to Admission and Discharge Form
    1.1 Admit Length (patients <30 days old only) Update 10/2013: Element added to Admission and Discharge Form
    1.1 Admit Head Circumference (patients <30 days only) Update 10/2013: Element added to Admission and Discharge Form
    1.1 Admit COVID-19 Vaccination

    Update 01/2021: Element added to Admission and Discharge Form

    Update 06/2021: Link to element added to "Vaccinations & Testing" section
    1.1 Admit COVID-19 Vaccination Date

    Update 01/2021: Element added to Admission and Discharge Form

    Update 06/2021: Updated allowable values and notes for abstraction. Link to element added to "Vaccinations & Testing" section.
    1.1 Admit COVID-19 Vaccine Manufacturer

    Update 06/2021: Element added to Admission and Discharge Form
    1.1 Admit Did the patient receive both doses of vaccine? (if applicable) Update 06/2021: Element added to Admission and Discharge Form
    1.1 Admit Is there documentation that this patient was included in a COVID-19 vaccine trial?

    Update 01/2021: Element added to Admission and Discharge Form

    Update 06/2021: Link to element added to "Vaccinations & Testing" section
    1.1 Admit Influenza Vaccination

    Update 01/2021: Element added to Admission and Discharge Form

    Update 06/2021: Link to element added to "Vaccinations & Testing" section
    1.2 Newborns/Neonates Did mother receive prenatal care Update 10/2013: Not documented response option added
    1.2 Newborns/Neonates Fetal monitoring Update 10/2013: Unknown/Not documented response option added
    1.2 Newborns/Neonates Delivery mode Update 10/2013: Vaginal "assisted" changed to vaginal "operative." C-section response divided into scheduled and emergent
    1.2 Newborns/Neonates Apgar Scores Update 10/2013: Unknown/Not Assigned response categories added. 10, 15, and 20 minute apgar scores added
    1.2 Newborns/Neonates Special circumstances recognized at birth Update 10/2013: "Known at time of delivery" removed. Response options added: Abdominal wall defects, CCAM/CPAM, CDH. Response options to indicate if the diagnosis was made prior to brith (prenatal or antenatal) or after birth (postnatal) added

    1.3 Induced Hypothermia

    Was induced hypothermia initiated?

    Update 4/2013: Element added to Admission and Discharge Form

    Update 4/2014: Following Note for Abstraction added: If the "MET-only Admission" check box is checked off, N/A will be auto-populated in the online form for this field.
    1.4 Discharge During this admission, was a standardized health related social needs form or assessment completed? Update 01/2021: Added new element.
    1.4 Discharge If yes, identify the areas of unmet social needs (select all that apply):

    Update 01/2021: Added new element.

    Update 12/2023: Updated definition and notes for abstraction.

    Update 01/2024: Updated element.
    1.4 Discharge Was there Active or Suspected COVID-19 diagnosis in the 2 weeks prior to admission or during this hospitalization? Update 06/2020: Added new element.
    1.4 Discharge Method of Diagnosis

    Update 06/2020: Added new element.

    Update 07/2020: Updated display label. Updated allowable values and notes for abstraction.
    1.4 Discharge Date/Time of Diagnosis Update 06/2020: Added new element.
      CPA Criteria

    Update 10/2013: Neonatal Delivery CPA Event Only definition added

    Update 04/2016: Updated "Neonatal" to "Newly born"
      Neonatal delivery event Update 10/2013: Element added to create Neonatal Delivery CPA Event form group
    CPA 2.1 Pre-Event Was patient discharged from an Intensive Care Unit (ICU) within 24 hours prior to this CPA Event? Update 04/2014: Updated data element and definition to specify a time frame of 24 hours prior to the event. The change to the data element included the addition of the following: "within 24 hours prior to this CPA Event."
    CPA 2.1 Pre-Event OPTIONAL: Was patient in the ED within 24 prior to this CPA event? Update 12/2014: Added Notes for Abstraction section for this data element

    CPA 2.2 Pre-existing conditions

     

    Update 10/2012: Section changed to required
    Update 04/2013: Added new data element of Did patient have an out-of-hospital arrest leading to this admission?

    Update 04/2014:
    Added the following statement: "For those conditions where there is a time interval indicated, only respond affirmatively if the diagnosis is made prior to the CPA event for which you are completing the event form."

    Updated 'Acute Stroke' to specify that this response is meant to capture new onset strokes.

    Updated Cardiac Malformation/Abnormality – Cyanotic and Non Cardiac to note that the response can be answered for adult patients if present.

    Clarified timing of diagnosis on the response options of: Major Trauma & Myocardial ischemia.

    Update 12/2014: Added following sentence to the definition for Septicemia: "Documentation of "presumed sepsis," without confirmatory positive blood cultures, would NOT constitute septicemia."

    Update 02/2018: Added new option for "Pre-existing Conditions at Time of Event"

    Update 08/2018: Updated "septicemia" to "sepsis"
    CPA 2.2 Pre-existing conditions Active or suspected bacterial or viral infection at admission or during hospitalization

    Update 04/2020: Added new element.

    Update 07/2020: Updated allowable values and notes for abstraction.

    Update 07/2020: Updated definition and allowable values.
    CPA 2.2 Pre-existing conditions Emerging Infectious Disease

    Update 04/2020: Added new element.

    Update 06/2020: Removed the duplicated element that was labeled as "Optional"

    Update 07/2020: Added new code option "Other Emerging Infectious Disease".
    CPA 2.2 Pre-existing conditions Additional Personal Protective Equipment (PPE) donned by the responders

    Update 04/2020: Added new element.

    Update 07/2020: Updated definition. Updated notes for abstraction.
    CPA 2.2 Pre-existing conditions History of vaping or e-cigarette use in the past 12 months

    Update 04/2020: Added new element.
    CPA 2.3 Interventions Already in Place Interventions ALREADY IN PLACE when need for chest compressions and/or defibrillation was first recognized

    Update 12/2014: Added Extracorporeal membrane oxygenation (ECMO) as an option under "Part B"

    Update 2/2016: Updated code options for Part A of Interventions Already in Place

    Update 04/2017: Added note before Part A referencing CPA 4.3, updated options in Part A
    Neonatal Delivery CPA Event Only 2.3 Interventions already in place Intervention(s) ALREADY IN PLACE when the need for chest compressions and/or defibrillation was first recognized

    Update 10/2013: Definition updated for Neonatal Delivery CPA Event form group

    Update 04/2017: Added note before Part A referencing CPA 4.3, updated options in Part A
    Neonatal Delivery CPA Event Only 2.3 Interventions already in place If vascular access in place, type Update 10/2013: Element added for Neonatal Delivery CPA Event form group
    Neonatal Delivery CPA Event Only 3.1 Event If team activated, date/time resuscitation team arrival Update 10/2013: Element added for Neonatal Delivery CPA Event form group
    CPA 3.1 Event Illness Category Update 12/2014: Removed Newborn option from Illness Category
    CPA 3.1 Event Event Location Update 04/2014: Added new response option of "Pediatric Cardiac Intensive Care Unit" and included the following statement under the PICU definition: Pediatric ICU (PICU) – (includes medical, surgical, cardiovascular, trauma, burn...ICUs). As of April, 2014, this response excludes the Pediatric Cardiac Intensive Care Unit.
    CPA 3.1 Event Illness Category Update 10/2018: Removed "pre-operative or" from "Surgical-Noncardiac" section.
    Neonatal Delivery CPA Event Only 4.1 Initial Condition/Defib/Vent Does patient have a detectable heart rate Update 10/2013: Element added for Neonatal Delivery CPA Event form group
    Neonatal Delivery CPA Event Only 4.1 Initial Condition/Defib/Vent If there is a detectable heart rate, what was the heart rate Update 10/2013: Element added for Neonatal Delivery CPA Event form group
    Neonatal Delivery CPA Event Only 4.1 Initial Condition/Defib/Vent Compression method used Update 10/2013: Element responses added for Neonatal Delivery CPA Event form group
    Neonatal Delivery CPA Event Only 4.1 Initial Condition/Defib/Vent Compression to ventilation ratio used Update 10/2013: Element added for Neonatal Delivery CPA Event form group
    CPA 4.1 Initial Condition/Defib/Vent First documented pulseless rhythm

    Update 10/2013: Notes for abstraction added (five bullets)

    Update 05/2015: Added "Unknown/Un-Documented"
    CPA 4.2 AED and VF/Pulseless VT Did patient have ventricular fibrillation or pulseless ventricular tachycardia at ANY time during the resuscitation event Update 10/2013: Notes for abstraction added (two bullets)
    CPA 4.2 AED and VF/Pulseless VT Date and time of first ventricular fibrillation or pulseless ventricular tachycardia Update 10/2013: Added sentence: If patient had ventricular fibrillation or pulseless ventricular tachycardia at any time during the resuscitation event, enter the date and time that ventricular fibrillation or pulseless ventricular tachycardia was first recorded. If multiple dates and times are documented, use the earliest date and time.
    CPA 4.2 AED and VF/Pulseless VT Total Number of Shocks Update 10/2013: Added sentence: Enter the total number of shocks administered during the cardiac arrest event.
    CPA 4.2 AED and VF/Pulseless VT Documented reason(s) (patient, medical, hospital related or other) for not providing defibrillation shock for Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia (VT) in first two minutes

    Update 10/2013: Element Added

    Update 12/2014: Added "or ACLS certified nurse" to Notes for Abstraction
    CPA 4.3 Ventilation Was Bag-Valve Mask ventilation intiated during the event?

    Update: Added Bag Mask instructions

    Update 12/2016: Updated label
    Was Laryngeal Mask Airway (LMA) inserted/re-inserted during event? Update 12/2016: Added elements
    Was any Pulse Oximetry placed during the event? Update 12/2016: Added elements
    CPA 5.1 Other Interventions Was IV/IO Epinephrine bolus administered

    Update 10/2013: Element updated to add "IV/IO." Removed words "during the event." Clarity added for Yes and No/Not documented response options.

    Update 2/2017: Removed references to "Vasopressin bolus"
    Neonatal Delivery CPA Event Only 5.1 Other Interventions Was any Epinephrine BOLUS administered Update 10/2013: Element added for Neonatal Delivery CPA Event form group
    Neonatal Delivery CPA Event Only 5.1 Other Interventions Epinephrine Doses Update 10/2013: Element added for Neonatal Delivery CPA Event form group
    CPA 5.1 Other Interventions Was IV/IO Vasopressinbolus administered Update 10/2013: Element updated to add "IV/IO." Removed words "during the event." Clarity added for Yes and No/Not documented response options.
    CPA 5.1 Other Interventions If IV/IO Epinephrine or Vasopressin BOLUS was not administered within the first five minutes of the event, was there a documented patient, medical, hospital related or other reason for not providing Epinephrine or Vasopressin bolus Update 10/2013: Element Added

    CPA 5.2 Other Drug Interventions

     

    Update 4/2013: Added new response option of Vasopressin, IV/IO continuous infusion
    Neonatal Delivery CPA Event Only 5.2 Other Drug Interventions Select all drug interventions that were used during the event Update 10/2013: Element updated for Neonatal Delivery CPA Event form group
    Neonatal Delivery CPA Event Only 5.3 Other Drug Interventions Select each intervention that was employed during the resuscitation event Update 10/2013: Element updated for Neonatal Delivery CPA Event form group
    CPA 6.1 Event Outcome Was ANY documented return of adequate circulation [ROC] (in the absence of ongoing chest compressions return of pulse/heart rate by palpation, auscultation, Doppler, arterial blood pressure waveform, or documented blood pressure) achieved during the event Update 10/2013: Notes for abstraction added (three bullets)
    Neonatal Delivery CPA Event Only 6.1 Event Outcome Was ANY documented return of adequate circulation [ROC] (in the absence of ongoing chest compressions return of pulse/heart rate by palpation, auscultation, Doppler, arterial blood pressure waveform, or documented blood pressure) achieved during the event Update 10/2013: Neonatal Delivery Event Only definition added

    CPA 6.2 Post-ROC Care

     

    Update 4/2013: Removed data element of Was induced hypothermia initiated after return of circulation (ROC) was achieved?
    CPA 7.1 CPR Quality Was continuous end tidal CO 2 monitoring (exhaled CO2) used to monitor quality of CPR Update 10/2013: Added "(exhaled CO2)". Separated out No from Not Documented to create two response options: No and Not Documented. Notes for abstraction added

    Update 4/2014: Element retired and moved to historic section.
    CPA 7.1 CPR Quality If yes, was an end tidal CO2 value of >10 mmHg achieved Update 10/2013: Separated out No from Not Documented to create two response options: No and Not Documented. Notes for abstraction added

    Update 4/2014: Element retired and moved to historic section.
    Neonatal Delivery CPA Event Only 7.1 CPR Quality If yes, (>10 mmHg achieved), was an end tidal CO2 value of >20 mmHg achieved Update 10/2013: Neonatal Delivery CPA Event only element added

    Update 4/2014: Element retired and moved to historic section.
    CPA 7.1 CPR Quality Was arterial line diastolic pressure used to monitor compression quality Update 10/2013: Separated out No from Not Documented to create two response options: No and Not Documented. Notes for abstraction added

    Update 4/2014: Element retired and moved to historic section.
    CPA 7.1 CPR Quality Was a device or technology used to monitor compression quality Update 10/2013: Separated out No from Not Documented to create two response options: No and Not Documented. Notes for abstraction added

    Update 4/2014: Element retired and moved to historic section.
    Neonatal Delivery CPA Event Only 7.1 CPR Quality If yes, device Update 10/2013: Neonatal Delivery CPA Event only element added

    Update 4/2014: Element retired and moved to historic section.
    CPA 7.1 CPR Quality Was a compression rate of greater than 100/minute maintained during CPR Update 10/2013: Changed to "greater than 100/minute" (previously had been "about 100/minute"). Separated out No from Not Documented to create two response options: No and Not Documented. Notes for abstraction added

    Update 4/2014: Element retired and moved to historic section.
    Neonatal Delivery CPA Event Only 7.1 CPR Quality Was a compression rate of at least 90/minute maintained during CPR Update 10/2013: Neonatal Delivery CPA Event only element added

    Update 4/2014: Element retired and moved to historic section.
    CPA 7.1 CPR Quality Were compressions interrupted (hand off period) for > 10 seconds at any time during CPR Update 10/2013: Removed "(other than for interventions such at ET placement)" from the definition. Separated out No from Not Documented to create two response options: No and Not Documented. Notes for abstraction added

    Update 4/2014: Element retired and moved to historic section.
    CPA 7.1 CPR Quality Were compressions interrupted >15 seconds (>30 seconds for neonates) for interventions such as invasive airway placement during CPR Update 10/2013: Updated from "20" to "30 seconds" for neonates. Separated out No from Not Documented to create two response options: No and Not Documented. Notes for abstraction added

    Update 4/2014: Element retired and moved to historic section.
    CPA 7.1 CPR Quality Did ventilation rate exceed 10/minute for ped patients (20/minute for neonates), excluding the initial confirmation of tracheal tube placement Update 10/2013: Separated out No from Not Documented to create two response options: No and Not Documented. Notes for abstraction added

    Update 4/2014: Element retired and moved to historic section.
    Neonatal Delivery CPA Event Only 7.1 CPR Quality Was a ventilation rate of about 30/minute maintained during CPR Update 10/2013: Neonatal Delivery CPA Event only element added

    Update 4/2014: Element retired and moved to historic section.

    CPA 7.1 CPR Quality

    Was performance of CPR monitored or guided using any of the following? (Check all that apply)

    Update 4/2014: Element added.

    CPA 7.1 CPR Quality

    If CPR mechanics device (e.g. accelerometer, force transducer, TFI device) used: Average compression rate

    Update 4/2014: Element added.

    CPA 7.1 CPR Quality

    If CPR mechanics device (e.g. accelerometer, force transducer, TFI device) used: Average compression depth

    Update 4/2014: Element added.

    CPA 7.1 CPR Quality

    If CPR mechanics device (e.g. accelerometer, force transducer, TFI device) used: Compression fraction

    Update 4/2014: Element added.

    CPA 7.1 CPR Quality

    If CPR mechanics device (e.g. accelerometer, force transducer, TFI device) used: Percent of chest compressions with complete release

    Update 4/2014: Element added.

    CPA 7.1 CPR Quality

    If CPR mechanics device (e.g. accelerometer, force transducer, TFI device) used: Average ventilation rate

    Update 4/2014: Element added.

    CPA 7.1 CPR Quality

    If CPR mechanics device (e.g. accelerometer, force transducer, TFI device) used: Longest pre-chick pause

    Update 4/2014: Element added.

    CPA 7.1 CPR Quality

    Was a team debriefing on the quality of CPR provided completed after the event?

    Update 4/2014: Element added.

    CPA 7.2 Resuscitation Related Events and Issues

     

    Update 4/2013:  Added new data element of Was this cardiac arrest event the patient’s index (first) event (during this hospitalization)? 

    Update 4/2014: Removed the following sentence: "Note: Written comments will not be sent to Get With The Guideline-Resuscitation registry but can be used by each institution for internal QI review."

    CPA 7.3 Maternal In-Hospital Cardiac Arrest

     

    Update 02/2018:  Added new section

    CPA 7.4 ECMO / ECPR

     

    Update 05/2020: Added new section

    CPA 7.4 ECMO / ECPR

    		 Neurologic injury or events detected during ECMO or after ECMO (Less than 6 weeks after separation from ECMO or by Hospital Discharge, which ever one comes first). (check all that apply):

    Update 06/2020: Updated element name, notes for abstraction, and suggested data sources

    CPA 7.4 ECMO / ECPR

    		 Date/Time ECMO Started

    Update 06/2020: Moved element below "Was Cannulation Successful?"

    CPA 7.4 ECMO / ECPR

    		 Date/Time ECMO Ended

    Update 06/2020: Moved element below "Was Cannulation Successful?"

    CPA 7.4 ECMO / ECPR

    		 If yes, enter ELSO Patient Record Number

    Update 06/2020: Updated definition and notes for abstraction
    ARC 2.2 Pre-existing conditions  

    Update 04/2014: Added the following statement: "For those conditions where there is a time interval indicated, only respond affirmatively if the diagnosis is made prior to the ARCevent for which you are completing the event form." Updated 'Acute Stroke' to specify that this response is meant to capture new onset strokes.

    Update 12/2014: Added following sentence to the definition for Septicemia: "Documentation of "presumed sepsis," without confirmatory positive blood cultures, would NOT constitute septicemia."

    Update 08/2018: Updated "septicemia" to "sepsis"
    ARC 2.2 Pre-existing conditions Active or suspected bacterial or viral infection at admission or during hospitalization

    Update 04/2020: Added new element.

    Update 07/2020: Updated allowable values and notes for abstraction.

    Update 07/2020: Updated definition and allowable values.
    ARC 2.2 Pre-existing conditions Emerging Infectious Disease

    Update 04/2020: Added new element.

    Update 07/2020: Added new code option "Other Emerging Infectious Disease".
    ARC 2.2 Pre-existing conditions Additional Personal Protective Equipment (PPE) donned by the responders

    Update 04/2020: Added new element.

    Update 07/2020: Updated definition. Updated notes for abstraction.
    ARC 2.2 Pre-existing conditions History of vaping or e-cigarette use in the past 12 months

    Update 04/2020: Added new element.
    ARC 2.3 Interventions Already in Place   Update 10/2018: Added "Note to Abstractors" and updated response options
    ARC 3.1 Event Illness Category Update 12/2014: Removed Newborn option from Illness Category
    ARC 3.1 Event Event Location Update 04/2014: Added new response option of "Pediatric Cardiac Intensive Care Unit" and included the following statement under the PICU definition: "Pediatric ICU (PICU) – (includes medical, surgical, cardiovascular, trauma, burn...ICUs). As of April, 2014, this response excludes the Pediatric Cardiac Intensive" Care Unit.
    ARC 4.1 Ventilation Type(s) of Ventilation/Airway(s) USED During th event, including those already in place Update 10/2018: Added "Note to Abstractors"
    ARC 4.1 Ventilation Method(s) of confirmation used to ensure correct placement of Endotracheal Tube (ET) or Trachestomy Tube Update 10/2018: Updated description for "None of the above"
    MET 2.1 Pre-Event Data Was patient discharged from an Intensive Care Unit (ICU) at any point during this admission and prior to this MET call? Update 4/2014: Element label updated to include "at any point during this admission." Two notes for abstraction added.
    MET 2.1 Pre-Event Data Was patient discharged from an Intensive Care Unit (ICU) within 24 hrs prior to this MET call? Update 4/2014: Element added.
    MET 2.1 Pre-Event Data If yes, enter the date the patient admitted to non-ICU discharge PRIOR to this MET call Update 4/2014: Element retired and moved to historic.
    MET 2.1 Pre-Event Data Pre-event vital signs Update 4/2014: Added "ND" response for each vital sign. Added selection of "Room Air" or "Supplemental O2" next to the SpO2 value.
    MET 2.1 Pre-Event Data Neurological Assessment – AVPU Scale (most recent within last 4 hours prior to this MET event) Update 4/2014: Element added.
    MET 2.2 Pre-existing conditions Active or suspected bacterial or viral infection at admission or during hospitalization

    Update 04/2020: Added new element.

    Update 07/2020: Updated allowable values and notes for abstraction.

    Update 07/2020: Updated definition and allowable values.
    MET 2.2 Pre-existing conditions Emerging Infectious Disease

    Update 04/2020: Added new element.

    Update 07/2020: Added new code option "Other Emerging Infectious Disease".
    MET 2.2 Pre-existing conditions Additional Personal Protective Equipment (PPE) donned by the responders

    Update 04/2020: Added new element.

    Update 07/2020: Updated definition. Updated notes for abstraction.
    MET 2.2 Pre-existing conditions History of vaping or e-cigarette use in the past 12 months

    Update 04/2020: Added new element.
    MET 3.1 Event Subject Type Update 4/2014: Element added.
    MET 3.1 Event Illness Category Update 12/2014: Removed Newborn option from Illness Category
    MET 3.1 Event Event Location Update 4/2014: Added new response option of "Pediatric Cardiac Intensive Care Unit" and included the following statement under the PICU definition: "Pediatric ICU (PICU) – (includes medical, surgical, cardiovascular, trauma, burn...ICUs). As of April, 2014, this response excludes the Pediatric Cardiac Intensive" Care Unit.
    MET 3.2 Activation Triggers   Update 4/2014: Retired the following response options: reversal agent without immediate response, bleeding into airway, symptomatic hypertension with end organ signs/symptoms, chest pain unresponsive to nitroglycerine, rising lactate to >4 mEq/L, >1 stat page required to summon patient's regular team for acute problem.

    Changed "uncontrolled" bleeding to "excessive" bleeding.

    Moved 'unexplained agitation or delirium' under 'mental status change.'

    Added the following response options: other respiratory & specify, hypertensive urgency/emergency, chest pain, other cardiac & specify, decreased responsiveness, other neurological & specify, critical lab abnormality, elevated risk factor score & specify, uncontrolled pain, other medical & specify, and family member/patient activated.
    MET 4.1 Drug Interventions   Update 4/2014: Changed section to state "check all NEW drug interventions initiated during MET event." Prior to 4/2014, the section stated: "check all interventions that were initiated, or if already in place immediate prior to the event, were continued during the event."

    Moved the response option of Albumin from MET 4.2 to this section.

    Retired the following response options: calcium, heparin/LMWH, magnesium, mannitol, sodium bicarbonate, thrombolytic

    Added the following response options: antibiotic IV, antihistamine IV, Epinephrine & route, sedative, steroids
    MET 4.2 Non-Drug Interventions Respiratory Management: Update 4/2014:

    Retired the response options of: elective intubation for airway protection, tracheostomy care/replacement.

    Updated section to categorize interventions as "non-invasive ventilation" and "invasive ventilation" and added response options to denote if the intervention was already in place and continued during the MET event or placed during the MET event.

    Added the following element: If Endotracheal Tube (ET) or Tracheostomy tube placed during MET event, method(s) of confirmation used to ensure correct placement of ET or Tracheostomy Tube (check all that apply):
    MET 4.2 Non-Drug Interventions Monitoring: Update 4/2014:

    Retired the response option of: non-invasive blood BP (NIBP) monitor. Removed label of "stand alone" next to the "apnea/bradycardia response."

    Updated "ECG" to "continuous ECG/Telemetry"

    Updated "pulse oximetry" to "continuous pulse oximetry"

    Added an "Other monitoring & specify" response

    Added option of "continued" or "initiated" next to each response option.

    Moved 12 lead ECG to "Other interventions initiated during the event" section
    MET 4.2 Non-Drug Interventions Vascular access: Update 4/2014:

    Retired the response options of: Umbilical Artery (UAC) and Umbilical Vein (UAV). Added option of "already in place" or "placed during MET event" next to each response option.
    MET 4.2 Non-Drug Interventions Stat consult: Update 4/2014:

    Retired the response options of: cardiology, neurology, pulmonary, and surgery.

    Added Other stat consult & Specify
    MET 4.2 Non-Drug Interventions Transfusion: Update 4/2014:

    Retired the response options of: fresh frozen plasma, packed red blood cells, platelets. Moved Albumin to section 4.1.
    MET 4.2 Non-Drug Interventions Other interventions initiated during the event: Update 4/2014:

    Retired the response options of: bronchoscopy, chest tube, coma position, CPR, cricothyotomy, defibrillation of VF/pulseless VT, foley catheter, gastric lavage, gastrointestinal endoscopy upper GI, gastrointestinal endoscopy lower GI, hyperventilation, NG/OG tube, neonatal head ultrasound (Echo), pacemaker, pericardiocentesis, serum lactate, throacentesis.

    Added response options of: STAT labs, transfusion of blood products
    MET 5.1 MET Outcome Patient transferred to: Update 4/2014: Added: Emergency Department. Retired and moved to historic Morgue (died) response.
    MET 5.1 MET Outcome Was patient made DNAR during MET Event Update 4/2014: Element added.
    MET 6.1 Review of MET Response   Update 4/2014: Added Incorrect team activated; updated MET response delay.

    PCAC

    Form creation

    Update 10/2012: PCAC form release

    PCAC General

    Intro

    Update 02/2023: Added PCAC Intro section header

    PCAC General

    Did patient have subsequent cardiac arrest event(s) during the course of hospitalization?

    Update 02/2023: Updated response options

    PCAC General

    System Entry Date/Time

    Update 02/2023: Moved note for "Time Not Documented" to below response options

    PCAC 2.1 Pre Existing Conditions

     

    Update 04/2014:
    Added the following statement: "For those conditions where there is a time interval indicated, only respond affirmatively if the diagnosis is made prior to the CPA event for which you are completing the event form."

    Updated 'Acute Stroke' to specify that this response is meant to capture new onset strokes. Updated Cardiac Malformation/Abnormality – Cyanotic and Non Cardiac to note that the response can be answered for adult patients if present.

    Clarified timing of diagnosis on the response options of: Major Trauma & Myocardial ischemia.

    Update 12/2014: Added following sentence to the definition for Septicemia: "Documentation of "presumed sepsis," without confirmatory positive blood cultures, would NOT constitute septicemia."

    Update 02/2023:
    Added note to specify the data that should be provided in the "Pre-Existing Conditions" field.

    Added "pediatric", "newborn/neonate" notes to "Cardiac Malformation/Abnormality - Cyanotic" and "Congenital Malformation/Abnormality" response options.

    Added "non-cardiac" note to "Congenital Malformation/Abnormality" response option.

    Updated "Septicemia" response option to "Sepsis".

    Reordered response options in alphabetical order.
    PCAC 2.1 Pre-existing conditions Active or suspected bacterial or viral infection at admission or during hospitalization

    Update 04/2020: Added new element.

    Update 07/2020: Removed element.
    PCAC 2.1 Pre-existing conditions Emerging Infectious Disease

    Update 04/2020: Added new element.

    Update 07/2020: Removed element.
    PCAC 2.1 Pre-existing conditions Additional Personal Protective Equipment (PPE) donned by the responders

    Update 04/2020: Added new element.

    Update 07/2020: Removed element.
    PCAC 2.1 Pre-existing conditions History of vaping or e-cigarette use in the past 12 months

    Update 04/2020: Added new element.

    Update 07/2020: Removed element.

    PCAC 3.1 Cardiac Arrest Event

     

    Update 4/2013:  Added data element of Sustained Return of Spontanous Circulation (ROSC) achieved?
    Update 4/2013:  Added data element of For our-of-hospital events, ROSC attained?

    Update 02/2023:

    Added response option "DOB Unknown/Not Documented" to data element Date/Time of Birth.

    Updated notes for abstraction for data element Date/Time of Birth.

    Moved the note If the time is not documented select "Time Not Documented" to below response options for data element Date/Time of Birth.

    Updated response options for data element Event Witnessed?

    Moved the note If the time is not documented select "Time Not Documented" to below response options for data element Date/Time compression started.

    Moved the note If the time is not documented select "Time Not Documented" to below response options for data element Date/Time sustained ROSC began (lasting > 20 min) OR resuscitation efforts were terminated (End of event).

    PCAC 4.1 Arrival Information

     

    Update 4/2013:  Added data element of Follows commands at time of initial assessment?

    Update 12/2014:
    Changed data element Initial Neurological Assessment? to Neurological Assessment performed within 1-hr of ROSC

    Updated data element Initial Glasgow Coma Scale (GCS) to Glasgow Coma Scale (GCS) within 1-hr of ROSC? and moved element beneath Follows commands at time of initial assessment?

    Moved Are pupils fixed and dilated element above Left pupil reaction

    Removed the following data elements: Gag (under Neurological Assessment Findings:), Confounded (sedation/paralytic) exam, Sedation (within 1-hr of exam), Paralytic (within 1-hr of exam), and Other confounded exam

    Update 02/2023:
    Added descriptions to response options for data element Are pupils fixed and dilated

    Added data element Status of patient (if not sedated/paralyzed)?

    Added note to not complete "Glasgow Coma Scale (GCS) within 1-hr of ROSC?" section if the patient is paralyzed.

    Updated response options for data element Motor.

    PCAC 4.2 Targeted Temperature Management

     

    Update 4/2013:  Removed data elements of Was there ever a documented temperature of ≥ 37.5 degrees Celsius & If yes, when was a temperature of ≥ 37.5 degrees Celsius documented?
    Update 4/2013: Added new data elements For All Patients of Was there ever a documented temperature of ≥ 38 degrees Celsius & If yes, when was a temperature of ≥ 38 degrees Celsius documented? & in patients with a fever, Was patient following commands at time of fever?

    Update 12/2014:
    Updated section name from PCAC 4.2 Cooling to PCAC 4.2 Targeted Temperature Management

    Added data elements: Did you utilize targeted temperature management (TTM), and If yes, what was the targeted temperature (choose one)?, If targeted temperature was ≤36.0 degrees Celsius: Was goal temperature met?, If yes, Date/Time goal temperature met, Was there a documented temperature of ≤ 31.0 degrees Celsius 6 hours after the initiation of the temperature controlled period?

    Updated the data element Cooling method (select all that apply) to Temperature control method (select all that apply); added new response options "Antipyretics" and "None"

    Removed the following data elements: Was Active Cooling Initiated, and Treatment with induced hypothermia for a repeat event?, Was cooling initiated?, Was a temperature of ≤34.0 degrees Celsius met?, If yes, Date/Time a temperature of ≤34.0 degrees Celsius met, During the hypothermic period, was a temperature of above 34.5 degrees Celsius or a temperature below 32 degrees Celsius reached?

    Replaced all references to "active cooling" with "targeted temperature management"

    Replaced existing response options for data element Where was targeted temperature management initiated? with "Pre-hospital (by EMS)," "In-hospital (either at another hospital prior to transfer or in my hospital)," and "Unknown/Not documented"

    Added 2 new reponse options for Clinical rationale documented by medical team why targeted temperature management was not initiated (check all that apply): "Facility does not routinely treat patients with targeted temperature management" and "Clinician preference"

    Removed reponse options of "Day 4" and "Day 5 or after" for If yes, when was a temperature of ≥38 degrees Celsius documented? (Check all that apply)

    Update 02/2023:
    Updated data element Did you utilize targeted temperature management (TTM)? to Was targeted temperature management (TTM) utilized?, and updated the response options and Notes for Abstraction.

    Added new data element Initial patient temp.

    Updated response options and Notes for Abstraction for data element If yes, what was the targeted temperature (choose one)?.

    Added new element Duration of continuous hypothermia.

    Updated notes for data element Date/Time targeted temperature management initiated.

    Updated response options for data element Clinical rationale documented by medical team why targeted temperature management was not initiated.

    Updated response options and notes for data element If yes, when was a temperature of ≥38 degrees Celsius documented?.

    Update 05/2023:
    Updated Notes for Abstraction for element Was targeted temperature management (TTM) utilized?.

    PCAC 5.1 Measurements and Medications

     

    Update 4/2013: Added data elements of Did patient receive any sedatives in the 0-6/6-24/24-48/48-72 hour time period post ROSC?  & Did patient receive any paralytics in the /6-24/24-48/48-72 hour time period post ROSC?
    Update 4/2013: Added data elements of: Were there at least two consecutive systolic blood pressure readings of <90mmHg separated by at least one hour in the first 0-6/6-24 hours post ROSC?   & Select all vasopressors/inotropes patient was on during hours 0-6/6-24/24-48/48-72 post ROSC
    Update 4/2013: Removed data elements of If Systolic BP <90mmHg or < 5th percentile <calculate in tool for pediatric patients> was patient on: Vasopressor/Inotrope or Vasodilator & Did patient receive and paralytics in th 0-72 hour time period post ROSC?
    Update 12/2014: 
    Removed data elements: Sedation (within 1-hr), Paralytic (within 1-hr), Was there an SpO2 in the first 24 hours of <94% or >99%, If yes, FiO2 at time SpO2 assessed: (%), Calcium, Potassium, Date/Time of initial AST and ALT measurements (at your hospital), AST (U/L), ALT (U/L), Was there a PaO2 in the first 24 hours of >150mmHg, If yes, FiO2 at time PaO2 assessed(%)

    Added data element: FiO2 at time SpO2 assessed: (%), Date/Time of initial Lactate          

    Update 02/2023:
    Added new data element On invasive mechanical ventilator?
    PCAC 5.1 Measurements and Medications Serial Measurements Serial Blood Pressure Measurements Update 10/2013: Added a patient did not survive checkbox to each post ROSC time period

    Update 02/2023:
    Updated post ROSC time periods and notes for abstraction.

    Added new element Was the patient on vasopressors/inotropes during the first 0-6 hours post ROSC.

    Added new element Was the patient on vasopressors/inotropes during the first 6-12 hours post ROSC.

    Added new element Was the patient on vasopressors/inotropes during the first 12-24 hours post ROSC.

    Added new element Was the patient on vasopressors/inotropes during the first 24-72 hours post ROSC.
    PCAC 5.1 Measurements and Medications Initial Measurements Update 10/2018: Updated description for FiO2 at time SpO2 assessed: (%)
    PCAC 5.2 Clinical Study Data  

    Update 12/2014:
    Updated response options for ECG interpretation; removed options "Sinus rhythm," "Heart block," and "Afib/flutter."

    Removed Echo Studies Day 1-4 and RV Function sections

    Updated response options for Head CT findings; removed options of "Evidence of hypoxic ischemia, "Subdural hematoma, "Ischemic stroke (either old or new)," and "Loss of Gray/White differentiation"

    Added data elements: If EEG performed, was there evidence of any seizure activity, and If evidence of seizure activity, was their evidence of Status Epilepticus (sustained seizures)?

    Removed data elements: Cerebral MRI findings (initial), Was it continuous or routine, Was there any evidence of Status Epilepticus, Electrographic seizures?

    Removed the wording select all that apply from the data element Cath lab interventions

    Update 02/2023:
    Updated response options for data element Did patient go to the cath lab at any time during this admission?

    Updated response options for data element Reason went to Cath lab.

    Updated response options for data element Cath lab interventions.

    Updated data element from ICD placed during this admission? to Implantable cardioverter-defibrillator (ICD) placed during this admission?

    Updated response options for data element Implantable cardioverter-defibrillator (ICD) placed during this admission?

    Added section "For Comatose/Encephalopathic Patients Only".

    Added new element EEG (spot) performed within the first 24 hours post ROSC? to section "For Comatose/Encephalopathic Patients Only".

    Added new element If yes, Start Date/Time of EEG (spot) to section "For Comatose/Encephalopathic Patients Only".

    Added new element EEG (continuous) performed within the first 24 hours post ROSC? to section "For Comatose/Encephalopathic Patients Only".

    Added new element If yes, Start Date/Time of EEG (continuous) to section "For Comatose/Encephalopathic Patients Only".

    Added new element If yes, End Date/Time of EEG (continuous) to section "For Comatose/Encephalopathic Patients Only".

    Added new element Brain imaging (CT/MRI) performed within the first 5 days post ROSC? to section "For Comatose/Encephalopathic Patients Only".

    Added new element If yes, or at any point within 10 days, Date/Time of CT/MRI to section "For Comatose/Encephalopathic Patients Only".
    PCAC Historic Update 02/2023: Added new section and moved retired PCAC elements to this section.
    IHCA Site Characteristics Update 10/2018: Added new section

    NOT FOR USE WITHOUT PERMISSION - CONFIDENTIAL AND PROPRIETARY INFORMATION OF QUINTILES AND THE AMERICAN HEART ASSOCIATION, INC.