The following pages require reporting of stroke data in your Trauma Service Area.
Person entering stroke data

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* 1. The following pages require reporting of stroke data in your Trauma Service Area.
Person entering stroke data

Email address of person entering date

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* 2. Email address of person entering date

Phone # of person entering data

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* 3. Phone # of person entering data

Your professional title:

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* 4. Your professional title:

Hospital represented by person entering data

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* 5. Hospital represented by person entering data

County of Hospital

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* 6. County of Hospital

Urban or Rural

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* 7. Urban or Rural

 “Total number of stroke cases.”

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* 8.  “Total number of stroke cases.”

 Number of Ischemic Strokes

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* 9.  Number of Ischemic Strokes

 Number of Intracerebral Hemorrhages

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* 10.  Number of Intracerebral Hemorrhages

Number of Subarachnoid Hemorrhages

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* 11. Number of Subarachnoid Hemorrhages

Number of Transient Ischemic Attack (<24 hours) (TIA)

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* 12. Number of Transient Ischemic Attack (<24 hours) (TIA)

 Number of stroke not otherwise specified

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* 13.  Number of stroke not otherwise specified

Number arriving via EMS from home/scene

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* 14. Number arriving via EMS from home/scene

 Number arriving via private transport/taxi/other from home/scene

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* 15.  Number arriving via private transport/taxi/other from home/scene

Number arriving via transfer from other hospital

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* 16. Number arriving via transfer from other hospital

Number with arrival mode not documented or unknown

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* 17. Number with arrival mode not documented or unknown

“Of the ischemic stroke cases reported in Item 9, how many had an NIH stroke scale performed?”

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* 18. “Of the ischemic stroke cases reported in Item 9, how many had an NIH stroke scale performed?”

“ Of the ischemic stroke cases reported in Item 9, how may received tPA therapy?”

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* 19. “ Of the ischemic stroke cases reported in Item 9, how may received tPA therapy?”

“Of all the cases reported in Item 9, how many received tPA within 60 minutes or less from the time of arrival?”

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* 20. “Of all the cases reported in Item 9, how many received tPA within 60 minutes or less from the time of arrival?”

“Of the ischemic stroke cases reported in Item 9, how many had health insurance.”

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* 21. “Of the ischemic stroke cases reported in Item 9, how many had health insurance.”

“Of the ischemic stroke cases reported in Item 9, how many did not have health insurance.”

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* 22. “Of the ischemic stroke cases reported in Item 9, how many did not have health insurance.”

Of the ischemic stroke cases reported in Item 9, with health insurance not documented or unknown

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* 23. Of the ischemic stroke cases reported in Item 9, with health insurance not documented or unknown

“Of the ischemic stroke cases reported in Item 9, how many received endovascular therapy?”

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* 24. “Of the ischemic stroke cases reported in Item 9, how many received endovascular therapy?”

 “Of the endovascular therapy cases reported in Item 9, how many received endovascular therapy within 60 minutes?”

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* 25.  “Of the endovascular therapy cases reported in Item 9, how many received endovascular therapy within 60 minutes?”

Number of ischemic stroke cases discharged to home

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* 26. Number of ischemic stroke cases discharged to home

Number of ischemic stroke cases discharged to inpatient rehabilitation

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* 27. Number of ischemic stroke cases discharged to inpatient rehabilitation

Number of ischemic stroke cases discharged to skilled nursing facility

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* 28. Number of ischemic stroke cases discharged to skilled nursing facility

Number of ischemic stroke cases discharged to hospice care (home hospice or facility hospice)

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* 29. Number of ischemic stroke cases discharged to hospice care (home hospice or facility hospice)

Number of ischemic stroke cases transferred to higher level of care

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* 30. Number of ischemic stroke cases transferred to higher level of care

Number of ischemic stroke cases expired

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* 31. Number of ischemic stroke cases expired

Number of ischemic stroke cases discharged to “other” or not known/reported

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* 32. Number of ischemic stroke cases discharged to “other” or not known/reported

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