STEMI Referral Form

O Other Hospital
Referring O SKMC O IBOH Patient's Name:-------------------------------------------------
Hospital DOB: -------------------------- MRN: ---------------------------
O SKGH O Saqr
Gender: ---------------------- Ethnicity: -----------------------
O Regular Hours Tel: ----------------------------
Event date DD / MM / YYYY
O Off Hours Address: ---------------------
ÿ National Ambulance Ÿ Self referral ÿ MI within hospital

Patient information
Weight (kg) Height (cm) Last BP Last HR
Medications Given O Aspirin 300mg O Clopidogrel 600mg O Ticagrelor 180mg O Enoxaparin/Heparin: ______ IU
O Morphine / Fentanyl______ O Metoclopramide / Ondansetron ______ O Other _________
Focused Assessment

Times
Patient Symptom
onset Date DD / MM / YYYY
Symptom onset
Time ˽ ˽ ∆˽ ˽ Write times stamp in 24h fomat
ED Arrival
(Door-IN) ˽ ˽ ∆˽ ˽ Needle Time
˽ ˽ ∆˽ ˽ (If Thrombolyzed)
If Pre-hospital
ECG insert that
time stamp
ECG Time
˽ ˽ ∆˽ ˽ STEMI
confirmed ˽ ˽ ∆˽ ˽
Departed
(Door-OUT) ˽ ˽ ∆˽ ˽ Cardiology
Contacted ˽ ˽ ∆˽ ˽
SKSH Cath Lab
Activated ˽ ˽ ∆˽ ˽ Arrival in ED
˽ ˽ ∆˽ ˽
Arrival in Cath
Lab ˽ ˽ ∆˽ ˽ Vascular access
˽ ˽ ∆˽ ˽
1* Device
(balloon time) ˽ ˽ ∆˽ ˽
Patient History
Prior Medication O Aspirin O Beta Blocker O Diuretic O Lipid Lowering O Coumadin/NOAC
O none
Cardiac Risk Factors HTN Nicotine DM HyperCholest. positive famHx
O none O Yes O No O Yes O No O Yes O No O Yes O No O Yes O No

PMHx O MI O CVA O PCI O CABG O Renal Failure

O none (Creat ˽, ˽ ˽ mg/dl)
PMH (Notes):

Findings/Action in cath-Lab
Scai Shock OA OB OC OD OE O No Shock
Cardiac Arrest O Pre hosp. O CPR O VF/Def. IABP O yes LYSIS O yes
O no
O In hosp. O CPR O VF/Def. Impella O yes ECMO O yes
ECG (STEMI O Anterior O Lateral O Inferior O LBB
site)

Angio CAD O no O 1-VD O 2-VD O 3-VD O LM

Revascularization O LAD O RCA O L-Cx O LM O Graft

TIMI flow Before PCI TIMI flow post-PCI Gp IIb/IIIa
TIMI 0 TIMI 1 TIMI 2 TIMI 3 TIMI 0 TIMI 1 TIMI 2 TIMI 3
Ο Ο Ο Ο Ο Ο Ο Ο Ο
No PCI Ο Myocarditis Ο Takotsubo Ο No target vessel Ο Cah-lab down
 Ο CABG Ο Vasospam Ο Cannot pass wire Ο Other (free text)
No CAG Ο Cardiac arrest Ο Failed access Ο Patient unstable Ο No consent given
Ο CVA Ο Cancer Ο ECG normalized Ο Other (free text)
Notes on back side
Notes
Reasons for delay Ο EMS Ο Dx initially unclear Ο Cath-lab occupied

Ο ED Ο Difficult procedure Ο Other (free-text)

Fee-text:

Term Definition
FMC/Door-in Time point when the patient is either initially assessed by a physician, paramedic, nurse or other
trained clinical personnel who can obtain and interpret the ECG, and deliver initial interventions.
ECG Time Time of recording of first ECG showing ST elevation or equivalent
STEMI diagnosis The time at which the ECG of a patient with ischemic symptoms is interpreted as presenting ST-
segment elevation or equivalent.
Cardiology Contacted Time referring hospital contact the SKSH hotline and is connected to on-call interventional cardiolo
Door-out Time of patient crossing ED door for ambulance boarding
Cath Lab Activation Time SKSH interventional cardiologist activate the Cath lab team
Arrival in SKSH ED Ambulance stop at SKSH ED entrance
Arrival in Cath-Lab Patient crosses Cath-Lab door
Vascular Access Introducer sheet in artery
Balloon time Wire crossing the lesion
Needle Time Time a thrombolytic agent is administered to the patient