* 1. The following questions are required reporting of STEMI data in your Trauma Service Area
Person entering the STEMI data

* 2. Email address of person entering data

* 3. Phone # of person entering data

* 4. Your professional title:

* 5. Hospital Name

* 6. Hospital County

* 7. Urban or Rural

* 8. “Total number of confirmed STEMI cases.”

* 9. Number arriving via EMS/ambulance AND not a transfer

* 10. Number arriving via private transportation/walk in/family/self AND not a transfer

* 11. Number arriving via other transport (mobile ICU or air) AND not a transfer

* 12. Number arriving via transfer. Transfer mode may include ambulance, mobile ICU, air transport, or unknown. (Can include transfers to a STEMI referral hospital)

* 13. Number with arrival mode not documented or unknown AND not a transfer

* 14. “Total number of confirmed STEMI cases transferred for percutaneous coronary intervention (PCI) treatment to a STEMI receiving hospital.”

* 15. ”Of all the STEMI transfers reported in Item 3, how many received primary PCI within 120 minutes of arrival at the STEMI referral hospital?”

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

* 17.  “Of all the STEMI cases reported in Item 1, how many revived thrombolytic therapy as an urgent treatment for STEMI at STEMI referral hospital?”

* 18.  “Of the STEMI cases reported in Item 6, how many received thrombolytic therapy within 30 minutes of arrival at STEMI referral hospital?”

* 19.  Number of cases with any health insurance

* 20.  Number of cases without health insurance

* 21.  Number of cases with health insurance not documented or unknown.

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