Central Okanagan QI Department
AMI DATA COLLECTION FORM
Patient Addressograph
DATE: ______Onset of Chest Pain (time):______
Arrival by: Self/SO EHS EHS(ALS) Transfer: Hospital/Facility/Home ______
Time of Arrival ______Time of Triage ______CTAS Level______
Time of Bed ______Time of ECG ______
Time Seen by Physician ______Time of Thrombolytic ______(where appropriate) For ST elevation MI patients only Thrombolysis within 30 minutes yes no contraindicated For all heart attack patients Early measures Aspirin within 24 hours yes no contraindicated ASA taken prior to arrival at hospital after arrival
Confirmation of AMI This patient had: ST elevation on ECG presumably new LBBB on ECG (see reverse for definitions) elevated troponin level (>1.0 ug/L)
History of Tobacco Use in Past Year yes no (if no, go to next section)
During hospital stay did the patient receive: Pharmacological therapy Nicotine Replacement yes no uncertain Dopamine Reuptake Inhibitor (Bupropion) yes no uncertain
Non-pharmacological therapy Smoking Cessation Counseling yes no uncertain Referral to Cardiac Rehab Program yes no uncertain
Medications at discharge This patient has been prescribed the following medications (or counseled to continue this medication if taking pre-arrival) Aspirin yes no contraindicated uncertain
Sept 12, 2007 AMI DATA COLLECTION FORM
Central Okanagan QI Department
ACE inhibitor/ ARB yes no contraindicated uncertain Beta Blocker yes no contraindicated uncertain Statins yes no contraindicated uncertain (see reverse for assistance completing this section) TRANSFER OUT to/ EXPIRY (give Location) DATE:
MEDICATIONS GUIDE
Angiotensin Converting Enzyme Inhibitors (ACE-Inhibitors): Trade Name Benazepril Lotensin Cilazapril Inhibace Enalapril Vasotec Lisinopril Zestril Perindopril Coversyl Quinapril Accupril Ramipril Altace Trandolopril Mavik
Angiotensin Receptor Blockers (ARB): Trade Name Candesartan Atacand Eprosartan Teveten Irbesartan Avapro Losartan Cozaar Telmisartan Micardis Valsartan Diovan
Beta-Blockers:
Acebutolol (Monitan, Sectral, Rhotral) Metoprolol (Lopressor) Atenolol (Tenormin) Nadolol (Corgard) Betaxolol Oxprenolol Bisoprolol (Monocor) Pindolol Bucindolol Propranolol Carvedilol Sotalol Esmolol Timolol Labetalol
HMG Co-A Reductase Inhibitors (Statins): Trade Name Atorvastatin Lipitor Lovastatin Mevacol Pravastatin Prevachol Rosuvastatin Crestor Simvastatin Zocor
2 AMI DATA COLLECTION FORM
Central Okanagan QI Department
Bupropion Trade Names: Wellbutrin, Zyban
DEFINITIONS
ECG Findings (Confirmation of AMI) – ST elevation on 12 lead ECG greater than or equal to 1mm in 2 contiguous leads; or a presumably new LBBB
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