Dear Committee Doctor,
kindly fill in the following data:
The sheet containing data about your centre:
AMI questionnaire: CRF Proposal (to be filled once)
السيد الدكتور عضو اللجنة
برجاء  ملأ البيانات التالية
الملف اللذى يحتوى على المعلومات الخاصة بالمركز التابع لسيادتكم
(‫يتم ملأه مرة واحدة فقط) AMI questionnaire: CRF Proposal
 

Application for pilot center Stent For Life Egypt

 
  Center Name (University/Hospital)
  Case Responsability of (Prof./Dr.)
  Operator (Prof./Dr.)
  Case Data entry by (Prof./Dr.)
 
1. Identification of the site
  Hospital
  Address
  Contact Physician
  Number of interventional cardiologists
2. Cath lab information
  Number of cath labs
  Number of IC
  Numer of cathlab nurses
  Number of cathlabs available (24/7)
3. Coronary interventional activity
  Number of coronary angiographies
  Number of total procedures/interventions
  Number of interventions just with balloon
  Number of thrombolysis
  Number of total stents used
4. Interventional Activity in AMI
  Number of total procedures/interventions Primary PCI    
    Rescue PCI     
    Facilitated PCI
  How many AMI patients undergo pPCI (%)
  Door-balloon time min (From Hospital door to Balloon)
  Number of aspirations
  Number of procedures just with balloon
  Number of procedures with stent
  # stents used # BMS
    # DES 
    # GW  
    # BDC
  # procedures without predilatation
  Security Question 1 + 7 =