of0
Export
 
CDE Detailed Report
This report contains detailed information about the selected CDEs.
Note: If at least one CDE was selected from a copyright- or trademark-protected instrument/scale then all of the CDEs from that instrument/scale are included in this report.
Disease: Spinal Cord Injury
SubDisease: Spinal Cord Injury
Sub-Domain: History of Disease/Injury Event
CRF: Pre-Hospital Assessment Form
Item count: 41 (41 distinct CDEs)
CDE ID
CDE Name
Variable Name
Definition / Description
Question Text
Permissible Value
Description
Data Type
Instructions
References
Population
Classification (e.g., Core)
Version #
Version Date
Aliases for Variable Name
CRF Module / Guideline
© or TM
Sub-Domain
Domain
Previous Title
Size
Input Restrictions
Min Value
Max Value
Measurement Type
LOINC ID
SNOMED
caDSR ID
CDISC ID
C14200
Emergency Medical Services (EMS) call received date and time
EMSCallRecvdDateTime
Date and time first call was received by the Emergency Medical Services (EMS) dispatcher OR date and time of EMS vehicle dispatch as recorded on the EMS trip sheet or other similar documentation.
Date and Time first call received by EMS
  
Date or Date & Time
This data element is looking to capture the date and time that EMS was first called to the scene of the stroke (and not meant to capture those patients that are transferred between hospitals via EMS). If a patient is transported by EMS from the scene of the stroke to an outside hospital and is then transferred to EMS to your hospital, enter the time when the first call was received by the EMS.
Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).
Paul Coverdell National Acute Stroke Registry
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
EMS call received date and time
 
Free-Form Entry
       
C14201
Emergency Medical Services (EMS) dispatch date and time
EMSDispatchDateTime
This refers to the date when Emergency Medical Services (EMS) transport (either by ground or air) leaves the station to pick up the patient for transport.
Date and Time of EMS dispatch
  
Date or Date & Time
Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).
No references available
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
EMS dispatch date and time
 
Free-Form Entry
       
C18153
Data unknown text
DataUnknwnTxt
The free-text field to Mark an "X" in to record if data are unknown or not available.
   
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
3.0
7/17/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
 
20
Free-Form Entry
       
C14202
Emergency Medical Services (EMS) dispatch priority type
EMSDispatchPriorityTyp
For EMS systems where there is prioritizing of calls, this item would capture what level of prioritization was assigned to the transport at dispatch.
EMS dispatch priority
High acuity;Moderate acuity;Other;Unknown;
the highest level assigned to life-threatening illnesses;the next highest level indicating urgent but not life-threatening illnesses;Other;Unknown;
Alphanumeric
Choose one.
Acuity is defined as the level of resource intensiveness of patient care.
https://ncim.nci.nih.gov/ncimbrowser/pages/concept_details.jsf?dictionary=NCI%20MetaThesaurus&code=C1553717&type=properties
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
EMS dispatch priority type
 
Single Pre-Defined Value Selected
       
C14204
Emergency Medical Services (EMS) vehicle type
EMSVehicleTyp
This refers to the Emergency Medical Services (EMS) vehicle that is used to transport the patient to the hospital. Choose one response.
Type of EMS vehicle
Ground;Air;Other;Unknown;
Ground;Air;Other;Unknown;
Alphanumeric
Choose one.
See Pre-Hospital EMS Course form
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
EMS vehicle type
 
Single Pre-Defined Value Selected
       
C14205
Emergency Medical Services (EMS) scene arrival date and time
EMSSceneArrvlDateTime
This refers to the date/time when the Emergency Medical Services (EMS) vehicle arrives on the scene to transport the patient to the hospital.
Date and Time of EMS arrival at scene
  
Date or Date & Time
This data element refers to the original scene and is not applicable to inter-facility transport or to patients arriving by means other than EMS. Note that EMS includes response by volunteer and professional paramedics, EMTs, fire, police and other municipal service officers responding to 911 calls.
Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).
See Pre-Hospital EMS Course form
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
EMS scene arrival date and time
 
Free-Form Entry
       
C14206
Emergency Medical Services (EMS) scene departure date and time
EMSSceneDepartureDateTime
Date and time the EMS vehicle departs with the patient from the scene to take the patient to the hospital.
Date and Time of EMS departure from scene
  
Date or Date & Time
Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).
See Pre-Hospital EMS Course form
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
EMS scene departure date and time
 
Free-Form Entry
       
C14223
Emergency Medical Services (EMS) service highest level type
EMSServiceHighestLevelTyp
Highest level of emergency medical service (EMS) provided
Highest level of EMS service
ALS;BLS;Flight nurse;MD;Paramedic;Unknown;
Advanced life support or equivalent;Basic life support or equivalent;;MD;Paramedic or equivalent;Unknown;
Alphanumeric
Choose one
BLS: Basic Life Support; ALS: Advanced Life Support
See Pre-Hospital EMS Course form
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
EMS service highest level type
 
Single Pre-Defined Value Selected
       
C14208
Pre-hospital neurological impairment scale indicator
PrehospNeuroImpairScaleInd
Whether a pre-hospital neurologic impairment scale screen was documented by EMS personnel. Pre-hospital neurologic impairment scales are defined as published validated scales or those required by state EMS agencies (e.g., GCS for suspected hemorrhagic stroke or any stroke with impaired consciousness, Los Angeles Motor Scale, etc.).
Was a pre-hospital neurologic impairment screen documented by EMS personnel
Yes;No;Unknown;
Yes;No;Unknown;
Alphanumeric
Choose one
See Pre-Hospital EMS Course form
Adult;Pediatric
Supplemental
3.0
6/21/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
Pre-hospital neurological impairment scale indicator
 
Single Pre-Defined Value Selected
       
C06003
Injury associate spinal cord injury indicator
InjAssocSCIInd
Whether any of the following pre-specified major injuries occurred at the same time as the spinal cord injury: moderate to severe traumatic brain injury (Glasgow Coma Scale 12 or below at discharge), non-vertebral fractures requiring surgery, severe facial injuries affecting sense organs, major chest injury requiring chest-tube or mechanical ventilation, traumatic amputations of an arm or leg (or injuries severe enough to require surgical amputation), severe hemorrhaging, or damage to any internal organ requiring surgery.
Associated injury
0;1;9;
0=No;1=Yes;9=Unknown;
Numeric values
Do not include other associated injuries not listed above, negative findings from exploratory surgery, and do not include injuries that pre-date the spinal cord injury.
DeVivo M, Biering-Sørensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P; Executive Committee for the International SCI Data Sets Committees. International Spinal Cord Injury Core Data Set. Spinal Cord. 2006 Sep;44(9):535-40.
Adult;Pediatric
Supplemental
3.0
7/17/2013
ASSOCINJ
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
Injury associated with spinal cord injury indicator
 
Single Pre-Defined Value Selected
       
C19333
Arrival intubation indicator
ArrivalIntubationInd
Indicator for intubation on arrival
Was patient intubated on arrival
Yes;No;Unknown;
Yes;No;Unknown;
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
1.0
6/9/2014
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
  
Single Pre-Defined Value Selected
       
C19334
Patient paralytics utilization indicator
PatientParalyticsUtilizatnInd
Indicator for the utilization of paralytics by patient
Was patient on paralytics
Yes;No;Unknown;
Yes;No;Unknown;
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
1.0
6/9/2014
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
  
Single Pre-Defined Value Selected
       
C14964
Sedation used indicator
SedationUsedInd
Whether the participant/subject was administered any sedation
Was patient sedated
Yes;No;Unknown;
Yes;No;Unknown;
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
3.0
7/14/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
Sedation used indicator
 
Single Pre-Defined Value Selected
       
C05453
Hypotensive episode indicator
HypotnsnEpiInd
Indicator of hypotensive episode. In adults, hypotensive episode is defined as systolic blood pressure < 90 mmHg. In children, it is defined as systolic blood pressure < 5th percentile for age
Did patient/participant experience hypotensive episode (systolic BP < 90 mm Hg for longer than 5 minutes) (choose one)
Yes;No;Suspected;Unknown;
Yes;No;Suspected;Unknown;
Alphanumeric
No instructions available
No references available
Adult
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
Hypotensive episode indicator
 
Single Pre-Defined Value Selected
       
C05457
Hypoxic episode indicator
HypxEpiInd
Indicator of hypoxic episode. Hypoxic episode is defined as partial pressure of oxygen in the blood (paO2) < 8kPa (60mmHg) or oxygen saturation (SaO2) < 90%
Did patient/participant experience hypoxic episode [Oxygen saturation SpO2) less than 90% for >5 minutes] (Choose one)
Yes;No;Suspected;Unknown;
Yes;No;Suspected;Unknown;
Alphanumeric
No instructions available
No references available
Adult
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
Hypoxic episode indicator
 
Single Pre-Defined Value Selected
       
C19364
Glasgow coma scale date and time
GCSDateAndTime
Date (and time, if known) of Glasgow Coma Scale assessment
Date and Time of GCS
  
Date or Date & Time
Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974 Jul 13;2(7872):81-4.
Adult
Supplemental
1.0
6/12/2014
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
  
Free-Form Entry
       
C01000
Glasgow Coma Scale (GCS) - eye response scale
GCSEyeRespnsScale
Glasgow Coma Scale (GCS) - Best eye response (E). The GCS is a standardized instrument for assessing the level of consciousness. It evaluates three aspects of responsiveness: eye opening, motor response, verbal response.
Best eye response Score
1;2;3;4;
No eye opening;Eye opening to pain;Eye opening to speech/verbal command;Eyes open spontaneously;
Alphanumeric
Choose one
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. Jul 1974;2(7872):81-4. Marmarou A, Lu J, Butcher I, et al. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J Neurotrauma. Feb 2007;24(2):270-80. Stocchetti N, Pagan F, Calappi E, et al. Inaccurate early assessment of neurological severity in head injury. J Neurotrauma. Sep 2004:21(9):1131-40. Balestreri M, Czosnyka M, Chatfield DA, et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry. Jan 2004;75(1):161-2.
Adult
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
GCS Eye response
 
Single Pre-Defined Value Selected
       
C01002
Glasgow Coma Scale (GCS) - verbal response scale
GCSVerbalRspnsScale
Score that describes the participant's verbal response according to the Glasgow Coma Scale (GCS)
Best verbal response score
1;2;3;4;5;
No verbal response/sounds;Incomprehensible sound;Inappropriate words;Confused;Oriented;
Alphanumeric
Choose one
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. Jul 1974;2(7872):81-4. Marmarou A, Lu J, Butcher I, et al. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J Neurotrauma. Feb 2007;24(2):270-80. Stocchetti N, Pagan F, Calappi E, et al. Inaccurate early assessment of neurological severity in head injury. J Neurotrauma. Sep 2004:21(9):1131-40. Balestreri M, Czosnyka M, Chatfield DA, et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry. Jan 2004;75(1):161-2.
Adult
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
GCS Verbal response
 
Single Pre-Defined Value Selected
       
C01001
Glasgow Coma Scale (GCS) - motor response scale
GCSMotorRespnsScale
Glasgow Coma Scale (GCS) - Best motor response (M). The GCS is a standardized instrument for assessing the level of consciousness. It evaluates three aspects of responsiveness: eye opening, motor response, verbal response.
Best motor response Score (Choose one)
1;2;3;4;5;6;Untestable;Unknown;
No motor response;Abnormal extension/Extensor response;Abnormal flexion;Flexion withdrawal/withdraws from pain;Localizes pain;Obeys command;Untestable;Unknown;
Alphanumeric
No instructions available
Marcin J and Pollack M. (2002). Triage scoring systems, severity of illness measures, and mortality prediction models in pediatric trauma. Crit Care Med. 30:S457-S467.
Adult
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
GCS Motor response
 
Single Pre-Defined Value Selected
       
C01016
Glasgow Coma Scale (GCS) - total score
GCSTotalScore
Glasgow Coma Scale (GCS) - Total Score. The GCS is a standardized instrument for assessing the level of consciousness. It evaluates three aspects of responsiveness: eye opening, motor response, verbal response. The total score is the sum of the scores for the three response types. (3-15)
Total Score (3–15; calculated field)
3;4;5;6;7;8;9;10;11;12;13;14;15;Untestable;Unknown;
3;4;5;6;7;8;9;10;11;12;13;14;15;Untestable;Unknown;
Alphanumeric
http://www.glasgowcomascale.org/faq/ ----*Dealing with missing information: There are various different strategies for dealing with information that is missing because of factors interfering with assessment such as those described above. 1.Assess, communicate and make decisions using the remaining components. Although guidelines are often expressed in terms of a total GCS ‘score,’ the trend in whichever of the components (eye, motor or verbal) can be assessed is still valuable. 2.Do not use number ‘1’ to record missing component; use ‘NT’ (Not testable). 3.Do not report a total score when a component is Not Testable because the score will be low and this could be confusing to medical colleagues. This may also imply that the patient is more unwell than they actually are. 4.It is possible using statistical methods to estimate a missing component from the findings in the other components. This is probably more relevant to research than clinical practice.
Marcin J and Pollack M. (2002). Triage scoring systems, severity of illness measures, and mortality prediction models in pediatric trauma. Crit Care Med. 30:S457-S467.
Adult
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
GCS Total score
 
Single Pre-Defined Value Selected
       
C05450
Abbreviated Injury Scale body region score
AISBodyRegionScore
Score for the body region measured by Abbreviated Injury Scale
Abbreviated Injury Score
1;2;3;4;5;6;9;
Minor: no treatment needed;Moderate: requires only outpatient treatment;Serious: requires non-ICU hospital admission;Severe: requires ICU observation and/or basic treatment;Critical: requires intubation, mechanical ventilation or vasopressors for blood pressure support;Maximal: not survivable;Not possible to assign (in NINDS this is 'unknown');
Numeric Values
No instructions available
Copes WS, Sacco WJ, Champion HR, Bain LW, "Progress in Characterising Anatomic Injury", In Proceedings of the 33rd Annual Meeting of the Association for the Advancement of Automotive Medicine, Baltimore, MD, USA, 1993; 205-218.
Adult;Pediatric
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
Abbreviated Injury Scale body region score
 
Single Pre-Defined Value Selected
       
C19365
Abbreviated injury scale six body region category
AISSixBodyRegionCat
The six body regions assessed with the 6 point intermediate ordinal severity scale
6 body regions
Abdomen;Chest;External;Extremity;Face;Head & Neck;
Abdomen;Chest;External;Extremity;Face;Head & Neck;
Alphanumeric
No instructions available
Copes WS, Sacco WJ, Champion HR, Bain LW, "Progress in Characterising Anatomic Injury", In Proceedings of the 33rd Annual Meeting of the Association for the Advancement of Automotive Medicine, Baltimore, MD, USA, 1993; 205-218.
Adult;Pediatric
Supplemental
1.0
6/12/2014
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
  
Single Pre-Defined Value Selected
       
C19367
Abbreviated injury scale nine body region category
AISNineBodyRegionCat
The nine body regions assessed with the 6 point advanced ordinal severity scale
9 body regions
Abdomen;Chest/Thorax;External and Other;Face;Head;Lower Extremity;Neck;Spine;Upper Extremity;
Abdomen;Chest/Thorax;External and Other;Face;Head;Lower Extremity;Neck;Spine;Upper Extremity;
Alphanumeric
No instructions available
Copes WS, Sacco WJ, Champion HR, Bain LW, "Progress in Characterising Anatomic Injury", In Proceedings of the 33rd Annual Meeting of the Association for the Advancement of Automotive Medicine, Baltimore, MD, USA, 1993; 205-218.
Adult;Pediatric
Supplemental
1.0
6/13/2014
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
  
Single Pre-Defined Value Selected
       
C05451
Injury Severity Score
InjSeverScore
Score measured by injury severity score (ISS)
Injury severity score (ISS)
  
Numeric Values
Between 0-75. The element may be included if relevant to the study. For additional details like permissible values, see the data dictionary associated with this CRF.
Baker SP, O'Neill B, Haddon W Jr, et al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. Mar 1974;14(3):187-196. Medicine AftAoA. The Abbreviated Injury Scale, 1990 Revision. Association for the Advancement of Automotive Medicine. 15-24. 1990. Des Plaines, IL. http://www.sfar.org/scores2/triss2.html - ISS calculator Pediatric: Gennarelli TA, Wodzin A. AIS 2005: A contemporary injury scale. Injury 2006 37:1083-1091.
Adult;Pediatric
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
Injury Severity Score
 
Free-Form Entry
       
C21622
Hypotensive episode pediatric indicator
HypotnsnEpiPedInd
Indicator of pediatric hypotensive episode. In children, it is defined as systolic blood pressure < 5th percentile for age
Did the participant/subject experience hypotensive episode for longer than 5 minutes?
Yes;No;Suspected;Unknown;
Yes;No;Suspected;Unknown;
Alphanumeric
In children, it is defined as:
Systolic BP <60 mm Hg for term neonates (0-28 days old)
Systolic BP <70 mm Hg for infants (1 month – 12 months old)
Systolic BP <70 mm Hg + (2X age in years) in children 1 year to 10 years
Systolic BP <90 mm Hg in children = 10 years
Haque IU, Zaritsky AL. Analysis of the evidence for the lower limit of systolic and mean arterial pressure in children. Pediatr Crit Care Med. 2007 Mar;8(2):138-44. PubMed PMID: 17273118.

Zubrow AB, Hulman S, Kushner H, Falkner B. Determinants of blood pressure in infants admitted to neonatal intensive care units: a prospective multicenter study. Philadelphia Neonatal Blood Pressure Study Group. J Perinatol. 1995
Nov-Dec;15(6):470-9. PubMed PMID: 8648456.
Pediatric
Supplemental
3.0
7/20/2013
Aliases for variable name not defined
Pre-Hospital Assessment Form
History of Disease/Injury Event
Disease/Injury Related Events
  
Single Pre-Defined Value Selected
       
12-19-2018
Page 1 of 2